Opening and Managing a Casualty’s Airway

TASK:  Open and manage the airway of a simulated casualty.

CONDITIONS: Given a simulated casualty and a combat lifesaver medical equipment set.

STANDARDS: Score a GO on the performance checklists. Additional injuries to the casualty are prevented.

REFERENCE: Army’s Combat Lifesaver Course: Student Self-Study (PDF)

5-1. MOVE TO SAFETY

If a casualty is not breathing, measures to restore respiration (breathing) need to be administered as soon as possible. You must be in a situation in which you and the casualty are not under hostile fire before treating breathing problems. If you are under enemy fire, only administer rescue breathing after you have moved yourself and the casualty to a safe location. This lesson assumes that you have come upon a casualty while you are not under enemy fire and the casualty does not have any life-threatening bleeding from an extremity.

5-2. CHECK THE CASUALTY FOR RESPONSIVENESS

a. If the casualty appears to be unconscious, check the casualty for responsiveness. Ask in a loud, but calm, voice, “Are you okay?” Also, gently shake or tap the casualty on the shoulder. If the casualty does not respond, you will need to position the casualty on his back and open his airway.

b. Determine the casualty’s level of consciousness using the AVPU scale (paragraphs 2-5b and 3-4c).

5-3. POSITION THE CASUALTY

If the casualty is not lying on his back, turn him onto his back. The supine position will allow you to better evaluate the casualty and provide rescue breathing, if needed.

NOTE: This method of rolling the casualty is used to minimize further injury to the casualty’s spine in case he has suffered an injury to the head, neck, or back.

a. Kneel beside the casualty with your knees near his shoulders. Leave enough space between you and the casualty so that you will be able to roll the casualty’s body toward you.

b. Raise the casualty’s arm that is nearest to you and place it above the casualty’s head.

c. Adjust the casualty’s legs so that they are together and straight or nearly straight.

d. Place one of your hands under the casualty’s head and neck. This hand will support the casualty’s head and neck when you roll the casualty.

e. With your free hand, reach across the casualty’s back and grasp the clothing under the casualty’s arm (far armpit area).

f. Pull the clothing toward yourself with a steady and even manner. Keep the casualty’s head and neck in line with his torso and you turn him.

g. Roll the casualty as a single unit, keeping the casualty’s head and neck in line.

h. Once the casualty has been rolled onto his back, place his arms at his sides.

NOTE: Do not leave an unconscious casualty on his back if you must leave him to seek medical aid or care for other casualties. If you must leave the casualty, place the casualty in the recovery position to help keep his airway open.

5-4. OPEN THE CASUALTY’S AIRWAY (HEAD-TILT/CHIN-LIFT)

When a casualty becomes unconscious, all of his muscles may relax. This relaxation may cause the casualty’s tongue to slip to the back of his mouth and block his airway. Removing the blockage (moving his tongue forward) may allow the casualty to resume breathing on his own. The normal method of opening the casualty’s airway is the head-tilt/chin-lift method described below.

NOTE: Even if the casualty is still breathing, the head-tilt/chin-lift will help to keep the airway open and help the casualty to breathe easier.

a. Kneel at the level of the casualty’s shoulders.

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

c. Place the fingertips of your other hand under the tip of the bony part of the casualty’s lower jaw and bring the chin forward. See figure 5-1.

Head tilt chin lift 5-1

d. Lift the chin forward until the upper and lower teeth are almost brought together. The mouth should not be closed as this could interfere with breathing if the nasal passages are blocked or damaged. If needed, the thumb may be used to depress the casualty’s lower lip slightly to keep his mouth open.

CAUTION: Do not use the thumb to lift the lower jaw.

CAUTION: Do not press deeply into the soft tissue under the chin with the fingers as this could close the casualty’s airway.

CAUTION: Do not completely close the casualty’s mouth.

e. If you see something in the casualty’s mouth (such as foreign material, loose teeth, dentures, facial bone, or vomitus) that could block his airway, use your fingers to remove the material as quickly as possible.

5-5. CHECK THE CASUALTY FOR BREATHING

While maintaining the open airway position (head-tilt/chin-lift), place your ear over the casualty’s mouth and nose and look toward the chest and abdomen. Figure 5-2 shows checking for breathing while maintaining the head-tilt/chin-lift.

Checking for breathing 5-2

Figure 5-2. Checking for signs of breathing while maintaining an open airway (head-tilt/chin-lift).

a. Look to see if the casualty’s chest rises and falls.

b. Listen for air escaping during exhalation.

c. Feel for the flow of air on the side of your face.

5-6. DETERMINE APPROPRIATE ACTION

a. If the casualty is conscious and breathing on his own, count the number of respirations for 15 seconds. If the casualty’s respiratory rate is less than two breaths in 15 seconds (one inhalation and one exhalation equals one breath), insert a nasopharyngeal airway (paragraph 5-8) and place the casualty in the recovery position (paragraph 5-9).

b. If the casualty is conscious and breathing on his own, but is making snoring or gurgling sounds, insert a nasopharyngeal airway (paragraph 5-8) and place the casualty in the recovery position (paragraph 5-9).

c. If the casualty is unconscious, insert a nasopharyngeal airway (paragraph 5-8) and place the casualty in the recovery position (paragraph 5-9).

d. If the casualty is not breathing and does not have a penetrating chest wound (see Lesson 6), check for a carotid pulse.

(1) If there is no pulse, stop your rescue efforts.

(2) If there is a pulse, begin rescue breathing (paragraph 5-7).

e. If the casualty is not breathing, has a penetrating (open) chest wound (see Lesson 6), and is making no effort to breathe, do not attempt to treat the casualty.

5-7. PERFORM RESCUE BREATHING

In rescue breathing, you blow air into the casualty’s lungs and then let the
casualty expel the air. This approximates the body’s natural breathing.

NOTE: Rescue breathing is only appropriate if you have no other casualties.

a. Gently pinch the casualty’s nostrils closed.

b. Administer a full breath mouth-to-mouth and observe casualty’s chest to make sure it rises. Instructions for administering mouth-to-mouth ventilation are given below.

(1) Open your mouth wide and take a deep breath.

(2) 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 head-tilt/chin lift will keep the casualty’s mouth open slightly.

(3) 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.

(4) Release the casualty’s nostrils to allow the air to escape (chest falls).

c. Evaluate your efforts.

(1) If the casualty’s chest rises and falls, continue administering rescue
breathing (close nostrils, administer breath, release nostrils) at the rate of one breath every five seconds.

(2) If the casualty’s chest does not rise, reposition his airway again (increase the head-tilt/chin lift position) in an effort to open the airway. Check for foreign objects in the casualty’s mouth and remove any object with your fingers. Then administer another full breath using mouth-to-mouth rescue breathing.

(a) If the chest rises and falls, continue administering rescue breathing at the rate of one breath every five seconds.

(b) If the chest does not rise and fall and the casualty is not making an effort to breathe (no movement), stop your rescue efforts.

d. Check the casualty’s carotid pulse every 12 breaths or so (about every minute). (Pulse beats indicate that the heart is still pumping blood.) Observe the casualty as you check his pulse to see if he has begun breathing on his own. Procedures for checking the casualty’s carotid pulse are given below.

(1) Continue to maintain the casualty’s airway by keeping one hand
pressing on the casualty’s forehead.

(2) 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.

(3) 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).

(4) 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. See figure 5-3.

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.

Feeling for a carotid pulse

(5) Evaluate the situation and perform needed actions.

(a) If the casualty has a pulse but is still not breathing on his own, continue administering mouth-to-mouth resuscitations at the rate of one ventilation every five seconds. Continue checking the casualty’s pulse after every 12 ventilations.

(b) If the casualty does not have a pulse, stop your rescue efforts. Administering cardiopulmonary resuscitation (CPR) is not recommended and is not a combat lifesaver task.

(c) If the casualty resumes breathing on his own, insert a nasopharyngeal airway if needed. A nasopharyngeal airway is inserted if the casualty is unconscious, if his respiration rate is less than two respirations in 15 seconds, or if the casualty is making snoring or gurgling sounds.

e. Continue administering rescue breathing until the casualty begins breathing on his own or until no pulse is felt or until you are told to stop your efforts by your unit leader or by the combat medic.

5-8. INSERT A NASOPHARYNGEAL AIRWAY

A nasopharyngeal airway (see figure 5-4) provides an open (patent) airway and helps to keep the tongue from falling to the back of the mouth and blocking the airway.

Nasopharyngeal Airways 5-4

CAUTION: Do not use the nasopharyngeal airway if there is a history of head trauma and the roof of the casualty’s mouth is fractured or brain matter is exposed.

CAUTION: Do not use the nasopharyngeal airway if there is clear fluid coming from the ears or nose. This may be cerebrospinal fluid (CSF). Cerebrospinal fluid indicates a possible skull fracture.

a. Make sure the casualty is positioned on his back with his face up before inserting the airway.

b. Lubricate the tube with sterile lubricating jelly or water (figure 5-5).

Lubricating nasopharyngeal airway

Figure 5-5. Lubricating the nasopharyngeal airway tube with sterile lubricating jelly.

c. Insert the airway.

(1) Expose the opening of the casualty’s nostril (figure 5-6). The casualty’s right nostril is normally used for the initial attempt.

Exposing Opening of Nostril 5-6

(2) Insert the tip of the airway tube into the nostril.

(3) Position the tube so that the bevel (pointed end) of the airway faces toward the septum (the partition inside the nose that separates the nostrils).

(4) Insert the airway into the nostril and advance it until the flange rests against the nostril (figure 5-7.)

Airway inserted

CAUTION: Never force the airway into the casualty’s nostril. If resistance is met, pull the tube out and attempt to insert it in the other nostril. If neither nostril will accommodate the airway, place the casualty in the recovery position and seek medical aid.

(5) Secure the airway in place with a piece of tape.

d. Place the casualty in the recovery position and seek medical aid.

The following video demonstrates inserting a nasopharyngeal airway:

5-9. POSITION THE CASUALTY (RECOVERY POSITION)

The recovery position (figure 5-8) allows blood, mucus, and vomitus to drain out of the casualty’s mouth and not block the airway. It also helps to prevent the tongue From blocking the airway. To place a casualty in the recovery position:

a. Roll the casualty, as a single unit, onto his side.

b. Place the hand of the casualty’s lower arm under his chin.

c. Flex the casualty’s upper leg to help stabilize the casualty.

Casualty in the recovery position