Restore respiration by opening the airway, performing manual thrusts and finger sweeps to remove airway obstructions, and administering mouth-to-mouth (or mouth-to-nose) resuscitation.

Given a simulated nonbreathing casualty.

Score a GO on the performance checklist.

STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.

FM 21-11, First Aid for Soldiers.

"Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care," The Journal of the American Medical Association, Volume 268, Number 16 (October 28, 1992) pp. 2171-2302.

Mouth-to-mouth resuscitation is used to restore respiration (breathing) to an unconscious casualty who is not breathing. It is also used with a casualty who loses consciousness (passes out) while you are trying to remove an upper airway obstruction (Lesson 2). The modified abdominal and chest thrusts can also be used with a conscious casualty with poor or no air exchange who is lying on his back. Speed is critical in restoring respiration. Checking and restoring respiration takes precedence over all other injuries the casualty may have suffered. The brain can be injured if it is without oxygen for as little as four minutes.

If you come upon a person who appears to be unconscious, check for responsiveness by gently shaking the person's shoulder and calling out, "Are you OK?" If the casualty does not respond, assume mouth-to-mouth resuscitation is needed. Call for help and begin resuscitation procedures.

CAUTION: If you come upon a casualty in a dangerous area (under hostile fire, near a burning vehicle, etc.), remove the casualty (and yourself) from the danger before beginning mouth-to-mouth resuscitation.

The casualty should be positioned on his back (supine position) and on a flat, firm surface (floor, ground, etc.). If the casualty is not lying on his back, kneel at his side, position his arms above his head, grasp his clothing at his far shoulder and hip, and pull gently. This will cause the casualty's body to roll as a unit toward you. Do not twist the body since twisting could cause additional damage to any spinal (neck or back) injury. Return the casualty's arms to his sides.

CAUTION: If a spinal injury is suspected (see Lesson 10) and assistance is available, support the casualty's head and neck while one or more helpers gently turn the casualty's trunk and legs.

The sequence for treating a casualty who became unconscious while you were attempting to remove an obstruction is given in Lesson 2.

Many times, an unconscious casualty's tongue may be blocking his airway. The muscles of the tongue relax when a person loses consciousness. The tongue may then slide to the back of the mouth and cover the opening to the trachea (windpipe). If foreign material or vomitus is visible in the casualty's mouth, remove it using a quick finger sweep (paragraph 3-7), but do not spend an excessive amount of time doing so. Moving the tongue away from the trachea may cause the casualty to resume breathing on his own. Even if the casualty has not stopped breathing, the procedures for opening the airway will allow him to breathe easier.

The two preferred methods of opening the casualty's airway are the head-tilt/chin-lift method and the jaw thrust method. The head-tilt/-chin-lift method is the method normally used. The jaw thrust method is used if you suspect that the casualty has suffered a fractured neck or severe head injury (deformed appearance or major wounds visible). The jaw thrust method keeps movement of the neck to a minimum.

CAUTION: The head-tilt/neck-lift method of opening the airway is no longer recommended since lifting the neck could cause damage to the spinal cord if the casualty's neck is fractured.

a. Head-Tilt/Chin-Lift

Kneel near the casualty's shoulders.

Place one of your hands on the casualty's forehead and apply firm, backward pressure with your palm to tilt the casualty's head back.

Place the fingertips of your other hand under the tip of the bony part of the casualty's lower jaw and lift the jaw to bring the chin forward. The fingertips should not press deeply into the soft tissues under the chin since the pressure could interfere with the casualty's airway. Use your fingertips, not your thumb, to lift the chin.

Lift the chin forward until the upper and lower teeth are almost brought together. The mouth should not be closed as this may block the airway. If needed, the thumb may be used to depress the casualty's lower lip slightly to keep his mouth open.

Kneel behind the casualty's head and rest your elbows on the surface on which the casualty is lying (ground or floor).

Place one hand on each side of the casualty's head and grasp the angles of the lower jaw with your fingertips. Place your thumbs on the jaw just below the level of the teeth.

Lift with both hands to move the jaw forward (upward). This action will also cause the casualty's head to tilt back somewhat. Keep the head and neck from moving more than necessary. If mouth-to-mouth resuscitation efforts are not effective, you may need to increase the backward tilt of the head slightly.

If the casualty's lips are still closed after the jaw has been moved forward, use your thumbs to retract the lower lip and allow air to enter the casualty's mouth.

Place your ear over the casualty's mouth and nose with your face toward the casualty's chest. Maintain the open airway (head-tilt/chin-lift or jaw thrust) during your check. (The examination process should take 3 to 5 seconds.)

Look for the rise and fall of the casualty's chest and abdomen.

Listen for sounds of breathing.

Feel for his breath on the side of your face.

If the casualty is breathing and has good air exchange, keep his airway open and proceed to look for life-threatening injuries (massive bleeding, etc.). If he is not breathing or if he is breathing weakly, start mouth-to-mouth resuscitation.

Keep the casualty's airway open by maintaining the head-tilt/chin-lift or jaw thrust. Keeping the casualty's lower jaw forward prevents the tongue from blocking the airway.

If you are using the head-tilt/chin-lift, use the thumb and index finger of your hand on the casualty's forehead to gently pinch the casualty's nostrils closed.

If you are using the jaw thrust, close the casualty's nostrils by placing your cheek tightly against the nose.

Open your mouth wide and take a deep breath.

Place your mouth over the casualty's mouth. Make sure that your mouth forms a good seal so that air will not escape when you blow air into the casualty's mouth. Maintaining the open airway will keep the casualty's mouth open slightly.

Blow a breath into the casualty's mouth. As you blow, observe the casualty's chest. If air is getting into the casualty's lungs, his chest will rise.

After blowing the first breath, quickly break the seal and take another deep breath. Seal your mouth over the casualty's mouth again and blow. Administering the two breaths (ventilations) should take about 2 to 3 seconds.

Break the seal over the casualty's mouth and release his nose. This will allow the casualty's body to exhale.

CAUTION: If you cannot seal off the casualty's nose or if the casualty has injuries to his mouth or jaw area that prevent you from administering mouth-to-mouth resuscitation, administer mouth-to-nose resuscitation instead. Close the casualty's mouth so air will not escape, seal your mouth over the casualty's nose, and blow the two breaths (ventilations) into his nostrils.

If the casualty begins breathing again on his own, look for injuries. (You do not need to check for a pulse. His heart will be beating if he is breathing on his own.) After treating the injuries, evacuate the casualty to a medical treatment facility. Do not leave the casualty alone since his breathing may stop again. The casualty may still require help to keep his airway open.

If air goes in and out of the casualty's lungs (chest rises and falls) but he does not start breathing on his own, check his pulse (paragraph 3-10).

If the casualty's chest did not rise and fall, then fresh air is not getting into his lungs. Try to open the casualty's airway more (lift the chin more and/or increase the tilt of the head) and administer two full breaths again. If the casualty's chest still does not rise, a foreign object is probably blocking his airway. Administer finger sweeps (paragraph

3-7) and manual thrusts (paragraphs 3-8 and 3-9) as needed to unblock his airway. Once the airway is unblocked, administer two full breaths again and reevaluate.

If you can see a foreign object in an unconscious casualty's mouth or if you strongly suspect the presence of a foreign object in an unconscious casualty's mouth, perform a finger sweep.

Open the casualty's mouth. If the casualty's mouth does not open readily, cross your finger and thumb and push his teeth apart by pushing against his upper teeth with your thumb and against the lower teeth with your finger.

Grasp the casualty's tongue and lower jaw between your thumb and fingers and lift. This tongue-jaw lift makes objects easier to locate.

Insert the index finger of your free hand down along the inside of the casualty's cheek to the base of his tongue and sweep the mouth with a "hooking" motion. If a foreign object is encountered, you may need to push the object to the side of the casualty's mouth before you can secure and remove the object.

CAUTION: Take care to avoid forcing the object deeper into the casualty's airway.

Pull the object to the front of the casualty's mouth and remove the object.

Reopen the casualty's airway and try to administer two full breaths again. Observe the chest to see if it rises.

If the casualty begins breathing on his own, treat any major injuries and evacuate the casualty.

If the casualty's chest rises and falls but he does not breathe on his own, check the casualty's pulse (paragraph 3-10).

If you are unable to ventilate the casualty (chest does not rise), perform manual thrusts (paragraphs 3-8, and 3-9) to dislodge the obstruction.

A manual thrust acts like an artificial cough. Each thrust is performed with the intent of dislodging the obstruction without having to perform additional thrusts. The abdominal thrust used with a standing casualty is modified to use on a casualty lying down. The modified abdominal thrust is the preferred method of administering a manual thrust to an unconscious casualty.

Kneel astride the casualty's thighs.

Place the heel of one hand on the midline of the casualty's abdomen slightly above the navel (belt buckle) and well below the tip of the breastbone (xiphoid process). Do not make your hand into a fist.

Place the heel of your other hand on top of the first hand and point your fingers toward the casualty's head.

Press into the abdomen using a quick forward (inward) and upward thrust. The thrust can be delivered by locking your elbows and shifting your body weight forward.

Release the pressure on the casualty's abdomen (shift your body weight backward).

If you think the obstruction has been dislodged, perform a finger sweep and administer two full breaths. If the airway is open, check for a pulse and for spontaneous breathing (casualty breathing on his own).

If the obstruction was not dislodged, administer another modified abdominal thrust. .If you administer 6 to 10 thrusts without apparently dislodging the obstruction, call for help again, perform a finger sweep, and administer two more breaths. Repeat the cycle of thrusts, finger sweep, and breaths until the object is expelled and the casualty's airway is open (chest rises during ventilations).

CAUTION: If the casualty vomits, turn him onto his side and use a quick finger sweep to remove vomitus from his mouth.

The chest thrust used with a standing casualty is modified to use on a casualty lying down. The modified chest thrust is used to remove an airway obstruction in an unconscious casualty if the casualty has a serious abdominal wound, is noticeably pregnant, or is extremely overweight.

Kneel close beside the casualty's chest.

Locate the lower edge of the casualty's rib cage.

Run the fingers of your hand nearest the casualty's feet along the lower edge of the rib cage until you come to the notch where the rib meets the breastbone in the middle of the lower portion of the casualty's chest. Place your middle finger (same hand) on the notch; then place your index finger next to your middle finger.

FIGURE 3-8. LOCATING COMPRESSION SITE FOR CHEST THRUST

Place the heel of your other hand on the casualty's breastbone next to and above (toward the casualty's head) your two fingers. Do not form a fist. The heel of this hand is on the compression site (lower half of the sternum and above the xiphoid process).

CAUTION: Make sure the heal of your hand is on the breastbone and not resting on the ribs.

Remove your fingers from the notch area and place that hand on top of the hand on the compression site. Either extend or interlace your fingers.

Straighten your arms and lock your elbows. Position your shoulders directly above your hands.

Using the weight of your body, apply enough pressure straight down to depress the casualty's breastbone 1½ to 2 inches. (NOTE: If casualty is a child 8 years or younger, depress the breastbone 1 to 1½ inches.)

Do not remove your hands from the compression site. If you happen to remove your hands from the site, repeat the procedures for locating the compression site. Delivering a thrust at the wrong compression site can cause injury to the casualty.

If you think the obstruction has been dislodged, perform a finger sweep to remove the obstruction and administer two full breaths. If the airway is open, check for a pulse and for spontaneous breathing.

If the obstruction was not dislodged, administer another chest thrust. If you administer 6 to 10 thrusts without apparently dislodging the obstruction, call for help again, perform a finger sweep, and administer two more breaths. Repeat the cycle of thrusts, finger sweep, and breaths until the object is expelled and the casualty's airway is open (chest rises during ventilations).

After you have ensured that the casualty's airway is open by successfully delivering two full breaths, check for a pulse. (Pulse beats indicate that the heart is still pumping blood.)

Continue to maintain the casualty's airway. If the head-tilt/chin-lift method is being used, keep one hand pressing on the casualty's forehead.

Locate the carotid artery on the side of the casualty's neck that is closest to you. One carotid artery is located in the groove on the left side of the windpipe (trachea) and another carotid artery is located in the groove on the right side of the windpipe.

Use the index and middle fingers of your free hand to feel for the artery in the groove next to the casualty's Adam's apple (larynx).

Once the artery is located, gently press on the artery with your middle and index fingers and feel for a pulse for 5 to 10 seconds. Also look for signs of spontaneous breathing (rising and falling of the casualty's chest, etc.) while checking the pulse.

CAUTION: Do not use your thumb to feel for the casualty's pulse. If you use your thumb, you may mistake the pulse in your thumb for the casualty's pulse.

Evaluate the situation and perform needed actions.

If the casualty has no pulse, cardiopulmonary resuscitation (CPR) must be begun. If you are qualified, begin administering CPR and, if possible, send a soldier to get medical help. If you are not qualified to administer CPR, seek medical help (usually the combat medic). (NOTE: Administering CPR is not a combat lifesaver task.)

If the casualty has a pulse but is not breathing on his own, continue mouth-to-mouth resuscitation (paragraph 3-12).

If the casualty resumes breathing on his own, check for injuries. Continue to monitor the casualty's breathing and be prepared to resume administering mouth-to-mouth resuscitation if needed.

If the casualty's airway is open (any obstruction removed), he has a pulse, and he is not breathing on his own, continue to administer mouth-to-mouth resuscitation. (NOTE: Mouth-to-nose resuscitation is delivered at the same rate.)

Open the casualty's airway.

Take a deep breath.

Close the casualty's nostrils (pinch nose or press cheek against nose).

Seal your mouth over the casualty's mouth.

Blow the breath into the casualty's lungs. Observe the rising of the casualty's chest to ensure that the ventilation is effective.

Break your seal over the casualty's mouth and release his nose. Observe the casualty's chest fall and listen for exhale.

CAUTION: If the chest does not rise and fall, reposition his airway (tilt head back more or lift jaw more) and try again.

Repeat ventilations at the rate of one ventilation (breath) every 5 seconds (10-12 ventilations per minute). Use the following count: "One, one-thousand; two, one-thousand; three, one-thousand; four, one-thousand; (ADMINISTER BREATH); one, one-thousand; two, one-thousand; etc.

After about one minute (10 to 12 ventilations), stop ventilating the casualty and check the carotid pulse again. Observe for spontaneous breathing (chest rising and falling) as you feel for the pulse. The procedure should take 3 to 5 seconds.

If the casualty has no pulse, CPR is needed. If you are not qualified to administer CPR, send for or seek medical aid.

If the casualty has a pulse and is breathing on his own, check for other injuries while continuing to monitor the casualty's breathing.

If the casualty has a pulse but is not breathing on his own, continue to administer ventilations at the rate of one ventilation every 5 seconds. Continue to check the casualty's pulse after every 10 to 12 ventilations.

Continue administering mouth-to-mouth resuscitation until:

The casualty begins breathing on his own.

You are relieved by a qualified person.

You must seek medical help (no pulse).

You must continue with your combat duties.

You are too exhausted to continue.

Once you have established that the casualty is breathing on his own, continue to monitor the casualty's breathing. Ensure that the casualty's airway remains open. If breathing difficulties arise, call for help and repeat the steps for clearing the airway and performing mouth-to-mouth resuscitation, as needed.

(NOTE: If the casualty is breathing on his own but is still unconscious, the combat lifesaver can insert an oropharyngeal airway to help maintain an open airway. This procedure is covered in IS0825.)