(1 lecture)
Introduction to first aid. First aid management. Asphyxia and artificial respiration.
Aleksander Sipria
Clinic of Anaesthesiology and Intensive Care
University of Tartu (http://www.kliinikum.ee/aikliinik)
Tel. 7318 405
• Your check of the scene suggests that a victim has suffered an electrical shock. The first thing to do is…..
a) Cover all burns with a dry loose dressing.
b) Ask a bystander to help you move the victim.
c) Place the victim on one side with the head down.
d) Make sure the power is turned off.
• What information should you gather if you think a person has swallowed poison or taken a harmful substance?
a) What they have taken, when and how much.
b) What they have taken, when and where.
c) What they have taken, when and why.
• Which would you do when caring for a seizure victim?
a) Remove nearby objects that might cause injury.
b) Place a small object, such as a rolled up piece of cloth, between the victims teeth.
c) Try to hold the person still.
d) All of the above.
• When caring for a victim with a bloody nose you would not…… a) Apply an ice pack to the bridge of the nose.
b) Apply pressure to upper lip just beneath nose.
c) Have the victim sit with head tilted slightly forward while pinching the nostrils together.
d) Have the victim sit with head tilted slightly backward while pinching the nostrils together.
• In which order single rescuer should start CPR of victim who has sudden cardiac arrest of presumed cardiac etiology (agonal gasping exists) a) ABC.
b) BAC.
c) CAB.
d) BCA.

The most critical and visible health problems are the sudden death and disability caused by catastrophic accidents and illnesses
• Heart disease
• Accident injury
• Poisoning (alcohol and drug overdose)
• About 500 000-700 000 sudden cardiac arrest victims
• Over 150 000 people die from trauma and
400 000 receive permanent injuries
• More than 100 000 people die because of the lack of adequate and available emergency medical services
• About 700 000 sudden cardiac arrest victims
(50-60% of them die on prehospital level)
• During last 30 years survival after out-ofhospital sudden cardiac arrest did not significantly changed
• Over 3000 people die each year from sudden cardiac arrest of cardiac origin
• About 2300 people die from trauma
• About 300 people die from alcohol poisoning
• Pre-hospital emergency care
- 90 ambulances (84 ACLS units and 6 MICU-s), medical teams only, about 26% of them have a physician, as rule three team members
- 2 MICU in Tartu and 2 MICU in Tallinn operate as a first or secondary responding units
- 4 emergency dispatch centres (joint alarm call number 112 for fire-rescue and ambulance services since 1999)

EM System in Estonia
Pre-hospital emergency care
LOCALISATION OF AMBULANCE TEAMS
Time-Intervals of Management of Out-of-Hospital Cardiac Arrest
Time 0.00
Collapse/Recognition
1
3
2
Call to Dispatch Center
Call-Response Interval
Vehicle stops
First Defibrillation / ACLS
• EM is an Independent medical specialty since 2000 (residency for EM since 1998)
• In-hospital emergency care
- Most hospitals providing emergency care reorganized reception wards on ED in which EM residents or physicians work with other medical specialists
- No designated trauma centres
Out-of-Hospital Resuscitation in Estonia in
1999-2009
(6352 resuscitation attempts)
Male (n): 4492 (73%) Mean age: 57 years !!!!!
Survivors: 362 (8%)
Female (n): 1622 (26%) Mean age: 64 years
Survivors: 182 (11%)
Children ≤ 14 years (n): 149 (2%) boys 100, girls 49 Survivors: 10 boys (10%) 3 girls (6%)
An age of 86 patients was unknown
The Causes of Out-of-Hospital Cardiac Arrest in
Estonia
(6352 resuscitation attempts in 1999-2009)
Place of out-of-hospital cardiac arrest
(cardiac aetiology).
4322 resuscitation attempts in 1999-2009
How often bystanders performed CPR?

Bystander CPR Better When
More People Help
Bystander witnessed out-of-hospital cardiac arrest
(cardiac aetiology) and BCPR in Estonia (1999-2009)
Survival rate in all 9%
P <0.01
BCPR in 1999 –2009
(4844 causes of bystander witnessed out-of-hospital cardiac arrest)
The Most Important Out-of-Hospital Care
Problems in Estonia
• The weakest part in the chain of survival in Estonian
EMS system is long collapse-to-call interval. Insufficient quality of first aid.
• The likelihood of survival after call-response interval more than 10 minutes is very low (main reason of bad results in rural areas)
• Further improvement of public education, early access to the EMS system, quality of medical dispatch, early defibrillation and early ACLS country-wide are needed
CPR training of people in US
More than 560 people have already registered for free, one-hour
"Learning CPR is Easy" training. Sessions are scheduled in
Bowdon, Bremen, Carrollton, Franklin, New Georgia, Tallapoosa,
Villa Rica and Woodland. Those who register will receive a free
CPR kit from the American Heart Association. The kit includes a personal CPR manikin, training DVD, CPR training booklet and more.
First aid is the immediate or emergency assistance given on the scene to sick or injured person before professional medical care

• to save life
• to provide reassurance and comfort to the ill or injured
• to prevent further injury or illness becoming worse
• to minimize or prevent infection and promote rapid recovery
• to maintain an open airway
• to maintain breathing
• to maintain circulation
During this process control bleeding and reduce or prevent shock
• Safety (vehicle accidents, electrical accidents, gas, smoke and poisonous fumes, fires and collapsing buildings)
• Mechanism of injury
• Medical information devices
• Number of casualties
• Bystanders
• Introduce yourself
• The energy source or factor that caused the original injury
• The hazards from secondary or external factors
• The hazards of rescue or first aid procedures
• Take charge of the situation
• Call to attract the attention of bystanders to assist you
• Assess the hazards at the scene
• Make the area safe for yourself and others
• Identify yourself to the casualties as First Aider and offer to help

• Quickly assess the victims for life-threatening conditions
• Give first aid for life-threatening conditions
• Send someone to call for help- ambulance, police etc.
(in Estonia 112)
• Address or location of the incident, giving cross-streets if applicable
• Telephone number from which the call is being placed
(if needed)
• What`s happened? (Circumstances of the incident: trauma, illness?) Who is calling? Number of casualties involved?
• Is victim conscious?
• Is victim breathing?
Be the last to hang up! Be prepared to act according to instructions of dispatcher
• It is vital for rescuers to get help as quickly as possible
• When more than one rescuer is available, one should start resuscitation while another rescuer goes for help
• Alone rescuer will have to decide:
Call first or call fast?
• If the victim is an adult, and the cause unconsciousness is not trauma (injury) or drowning, the rescuer should assume that the victim has a heart problem and go for help immediately when unresponsiveness is established or after the absence of breathing
• If the likely cause of unconsciousness is trauma (injury) or drowning or if the victim is an infant or child, the rescuer should perform resuscitation for about one minute before going for help
• After immediate first aid is given:
- Call emergency services if someone else has not already done so
- Monitor the casualties continuously
- Keep the casualty comfortable and warm enough to maintain normal body temperature
- Do not give the casualty anything to eat or drink because it may cause vomiting, and because of the possible need for surgery
- Protect and shelter the casualty while awaiting the arrival of medical aid

- Safeguard the casualty`s personal belongings
- Assist in the evacuation of the casualty by ambulance
- Ensure that casualties who do not require medical aid are placed in the care of friend or relatives
- Make notes of the names of the casualties and bystanders and record the first aid given
Responsibilities of First Aider and Legal Implications
• Verbal (actual) consent and implied consent
• If help is refused, remain with the person until help arrives
• If the casualty`s life is not danger and you do not know what to do, stay with him and send for help
• You use caution in giving first aid so that you do not aggravate or increase injury
• You give the help you would hope to receive if you were in similar circumstances
• History of the case
• Signs
(objective evidence, vital signs)
• Symptoms
(sensations that a person feels and describes)
Keep the casualty lying down, head level with the body, until you determine the extent and seriousness of the illness or injury.
• Ask where the injury or pain is located and examine that area first
• Ask if anything else is wrong and make sure there are no injuries that are masked by pain, numbness or drugs
- Severe external bleeding?
- Unconsciousness?
- Breathing?
- Circulation (pulse)?
Give first aid for life-threatening conditions in all victims before conducting a secondary examination
- Look: for bleeding, skin colour and condition, and deformity
- Listen: for patient responses or sounds
- Feel:
(very gently) for deformity, texture, swelling, or temperature
- Smell: the patient´s breath and other odours to form an impression of other problems the patient may have

A full body check should be carried out in the following order
Inform the casualty of what you are doing and why
During your examination, move the casualty no more than is necessary.
If you suspect head or neck injuries or are unsure of the casualty` s condition, keep them lying flat and wait for professional medical assistance
• The highest priority
- Asphyxia and breathing difficulties
- Severe bleeding
- Unconsciousness
- Shock
- Other immediate life-threatening medical emergencies
• Next in priority
Burns
- Fractures
- Back injuries
• The lowest priority
- Minor fractures
- Minor bleeding
- Behavioural problems
Do not attempt to straighten broken or dislocated bones because of the high risk of causing further injury. Splint them in the position in which they are found.
(in the circulating blood 02 ↓ , CO2 ↑ )
• Airway obstruction (unconsciousness, FBAO, allergy, trauma, drowning)
• Reduced oxygen supply (toxic gases)
• Deterioration of lung and heart functions (chest trauma, poisonings, diseases)
• Signs of abnormal breathing (irregular or restricted chest movements, noisy sounds, low or high respiratory rate, blue coloration of the skin - late sign)

• Electric shock
• Drowning
• Suffocation
• Inhalation of poisonous gases
• Head injuries
• Seizures
• Airway obstruction
• Stroke
• Drug overdose
• Heart problems
• Allergy reactions
In cases of the sudden primary respiratory arrest circulation (pulse) can be present during the first 1-2 min before cardiac arrest.
Respiratory arrest is treated initially with artificial ventilation, together with treatment of the likely cause.
(P.Safar 1981)
• Triple Airway
Manoeuvre
(Esmarch,
Heiberg, Safar)
Head Tilt, Mouth Open,
Jaw Thrust
(P.Safar 1981)
Opening the airway in an unconscious person (head tilt and chin lift)
ERC 2010
Keeping the airway open, look, listen and feel for breathing
• Look for chest movement
• Listen at the victim`s mouth for breath sounds
• Feel for air on you cheek
• Decide if breathing is normal not normal or absent
• Look listen and feel for no more than 10 s to determine whether the victim is breathing normally
• If he is breathing normally: turn him into the recovery position
• Call for help, continue to assess that breathing remains normal
Recovery position
(ERC 2010)
1
2
3
Victim is unconsciousness and breathing normally

Indirect methods
(manual techniques) of artificial respiration
(historical overview)
Artificial ventilation
(expired air resuscitation)
Safar P, McMahon M.
JAMA, 1958; 1666:1459
Direct Mouth-to-mouth and
Mouth-to-nose Ventilation
(P.Safar 1981)
Mouth to mouth artificial ventilation
(ERC 2010 )
Blow steadily into victim`s mouth whilst watching for his chest to rise
Take your mouth away from the victim and watch to his chest to fall as air comes up
Give each rescue breath over about 1s
The time taken to 2 breath should not exceed 5s
The most common errors in artificial ventilation
• Loss of head tilt
- ineffective ventilation and oxygenisation
- distension of the stomach and risk of regurgitation
(silent flow of stomach contents into mouth and nose)
• Hyperventilation (over-inflation)
- increases intrathoracic pressure, decreases venous return to the heart and reduces cardiac output
- distension of the stomach and risk of regurgitation
Disease transmission and barrier devices
• The risks of diseases transmission during training and actual CPR performance is extremely low
• HIV and hepatitis have not been transmitted by resuscitation to date of publication, although transmission is theoretically possible. If the victim is known to have a serious infection (e.g. HIV, tuberculosis, hepatitis B or SARS) a barrier device is recommended.
ERC 2010

Face shield
• Ventilation with supplementary oxygen
P.Safar 1981
(expired air resuscitation)
• Response assessment
• Breathing assessment
• Airway opening and breathing reassessment
• Lung ventilation
• Pulse assessment
• If the victim has a pulse but is not breathing, rescue breathing may help, but this situation is difficult for a bystander to evaluate.
• For untrained bystanders chest- compression
- only CPR is recommended.
(in the circulating blood O2 ↓ and CO2 ↑ )
• Recognition of airway obstruction (most choking events are associated with eating, victim may clutch his neck)
• Partial airway obstruction (noisy breathing, victim can speak, cough and breath)
• Complete airway obstruction (victim unable to speak, may nod, cannot breathe, wheezy breathing, silent attempts to cough, unconsciousness)

Patients with FBAO and Out-of-Hospital
Resuscitation (n=62) in Estonia (1999-2006)
• Male (n) 44 (71%), female (n) 14 (23%), children ≤ 14 years (n) 4 (6%): 1 year, 1 year and 3 month, 8 years and 13 years. All children died
• FBAO by food 90% (61% by meat)
• Choking was bystander witnessed 80%
• Bystander CPR in 32% of patients
• Survival rate 11% (7 patients)
• Survival from cardiac arrest of FBAO etiology is strictly depending on the time interval between collapse and ACLS intervention
• First aid Manoeuvres for Choking
- Back blows
- Abdominal thrusts (Heimlich manoeuvre)
- Finger sweep to remove any solid foreign body seen in the mouth
- Chest thrusts
- Ventilations
The restoration of breathing takes precedence over all other measures
Back blows (A) and abdominal thrusts (B) for foreign body obstruction in the conscious standing or sitting victim
P.Safar 1981
Choking emergency device and first aid

Prehospital Emergency Care and Crisis Intervention
Third Edition by Brent Q. Hafen,
Keith J.Karren Brady Morton Series
1989
P.Safar 1981
ERC 2010 guidelines not recommended
The most significant difference from the adult algorithm is that abdominal thrusts should not be used for infants. Chest thrusts are similar to chest compressions but sharper and delivered at a slower rate
Manual Cleaning of the Airway
P.Safar 1981
Blind finger sweeps should be avoided and solid material in the airway removed manually only if it can be seen
• Assess obstruction severity
• Mild airway obstruction (effective cough)
Continue to check for deterioration to ineffective cough or until obstruction relived
• Severe airway obstruction (ineffective cough)
Conscious
5 back blows
5 abdominal thrusts
Unconscious
Start CPR
ERC 2010

• The head is relatively large
• The neck is relatively short
• The tongue is large
• The trachea (windpipe) is soft and easily compressed
• The adenoids may be large
• Assess obstruction severity
Effective cough
Encourage cough
Continue to check for deterioration to ineffective cough or until obstruction relieved
• Ineffective cough
Conscious
5 back blows
5 thrusts (chest for infant)
(abdominal for child >1)
Unconscious
Open airway
5 breath
Start CPR
ERC 2010