One of the keys to a successful resuscitation is a clear (‘open’) airway. This is achieved by applying backward head tilt and chin lift, and by clearing any visible foreign matter obstructing the unconscious victim’s upper airway. Good observation of and access to the victim’s airway must be achieved.
Care of the airway takes precedence over other injuries, including the possibility of spinal injury. The one exception to this guideline is the management of severe, life-threatening bleeding, which takes precedence over airway management. Once life-threatening bleeding has been managed, assess the airway. Refer to your first aid training on bleeding.
The victim should not be routinely rolled onto their side to assess for airway obstruction and breathing. Assessing the victim’s airway while they are on their back takes less time, is easier and avoids unnecessary movement. Maintain an open airway by applying backward head tilt and chin lift.
Vomiting and regurgitation often occur after drowning due to large amounts of swallowed water. If matter such as sand, debris or vomit is found on initial assessment, or at any time during resuscitation, this needs to be removed from the upper airway to prevent obstruction. In this case, follow the flowchart below:
Repeated attempts to clear frothy or blood-stained fluid that continues to accumulate in the upper airway during resuscitation is likely to be unsuccessful. Lifesavers should continue with external chest compressions and rescue breaths to minimise unnecessary interruptions.
All body tissues, especially the brain, must be supplied with adequate oxygen. All persons who are unconscious require treatment using the principles of basic life support.
Rolling a face-down victim onto their back (supine position)
Note: For the purpose of this description, you will be on the victim’s left-hand side, facing the surf. It is possible to perform the procedure on either side of the victim.
Follow the steps below to roll a face down victim onto their side.
- Kneel closely beside the victim.
- Place the victim’s right arm along their side and ensure that the left arm is extended above their head.
- Using the victim’s hip and shoulder, roll the victim onto their back.
Rolling a victim onto their side (lateral or recovery position)
You should quickly roll a victim onto their side if they are vomiting or regurgitating or showing signs of recovery during CPR.
Note: In this description you are on the victim’s right-hand side, facing the surf.
- Kneel closely beside the victim.
- Place the victim’s left arm at right-angles to their body, pointing to the surf.
- The victim’s right arm may be across their chest or along their side.
- Raise the victim’s right leg at the knee, which is closest to you.
- Use the victim’s hip and shoulder to roll them onto their side, towards the surf.
- Angle their right thigh to approximately 90 degrees to their torso to prevent them rolling onto their stomach.
- Tilt the head backwards and slightly downwards while support of the jaw is maintained. This position allows drainage of fluids and mucus from the mouth. The victim’s right arm can stay where it is or be placed under the victim’s head for added support.
Note:
- If CPR is being carried out by a single operator, the victim should be rolled away from the operator to enable them to check and clear the airway and assess breathing.
- If CPR is being carried out within a team environment, the victim should be rolled towards the person doing compressions while the airway operator continues to manage the victim’s airway.
- For larger victims, you may put one arm under the victim’s raised knee to provide extra leverage instead of using the hip to roll the victim.
- A hip and shoulder roll should be carried out quickly in an attempt to minimise the inhalation of stomach contents into the lungs.
Assessing the airway
- Look in the victim’s mouth to see if there is any material in the mouth, while maintaining backward head tilt, chin lift and drainage.
- If there is any obstruction, let go of the chin and use your gloved fingers to sweep away any material such as vomit from the victim’s mouth. If there are other visible obstructions in the victim’s mouth, reach in and remove them with your gloved fingers. False teeth (dentures) should not be removed unless they are loose and interfering with the victim’s airway.
Note: ANZCOR suggests against the use of blind finger sweeps for removing vomit/regurgitation. You should always look in the victim’s mouth before attempting to clear their airway by seizing and removing any visible items.
Establishing an open airway
A clear airway is achieved by applying backward head tilt and chin lift. This ensures that the victim’s mouth is open, the jaw is lifted forward, and the tongue and soft tissues are lifted away from the back of the throat.
Backward head tilt and chin lift is achieved by the jaw support (‘pistol grip’) or jaw thrust methods. It should be used whether the victim is lying on their back or their side. The victim’s airway should be kept open where possible. While head tilt is important for effective rescue breaths, apply with caution if a neck/spinal injury is suspected.
Where a spinal injury is suspected, commence with neutral head position and progress as necessary towards backward head tilt in order to achieve an open airway.
Backward head tilt
One hand is placed on the victim’s forehead or the top of the head. The other hand provides chin lift. The victim’s head is tilted backwards. It is important to avoid excessive force, especially where neck injury is suspected. You are encouraged to use this method in single person CPR scenarios.
Jaw support (‘pistol grip’)
Place the thumb over the chin below the lip and support the tip of the jaw with the knuckle of the middle finger. The hand is held in a ‘pistol grip’ fashion with the index finger lying along the jaw line. Care is required to prevent the ring finger from squashing the soft tissues of the neck. The jaw is held open slightly and lifted up from the chin.
Jaw thrust
Jaw thrust is a very efficient method of achieving backward head tilt and chin lift. You are encouraged to use this method in two-person or team CPR scenarios.
In the jaw thrust method, you are positioned behind the top of the victim’s head. Your middle, ring and little fingers are applied to the back part of the victim’s jaw on either side of the angle of the jaw — lifting the jawbone upwards and outwards and opening the airway.
The index finger is applied to the line of the jaw, in front of the angle of the jaw. The thumbs are applied to either side of the mouth or, when using a mask, are used to seal the mask against the face.
In learning this hold, there is no substitute for frequent practice sessions on people rather than manikins. While manikins are essential in practice, jaw holds are best taught on the human jaw, as there are great size variations both in jaws and in your hands.
Airway for children and infants
It is important to note that an infant’s airway is different from an adult’s, and is more likely to become blocked because an infant’s
- head is relatively larger
- neck is relatively shorter
- tongue is larger
- windpipe is softer and more easily compressed.
Opening an open airway for children and infants
Children’s heads should be tilted slightly backwards to maintain their airway. The level of tilt is sometimes referred to as ‘the sniffing position’.
Backward head tilt should not be used with infants, as it stretches the tissues and this may block the airway.
Instead, the head should be kept in the neutral position, with the lower jaw lifted at the point of the chin. If the neutral position does not provide a clear airway, it may be necessary to tilt the head back very slightly.
Lateral and recovery position for children and infants
Children should be rolled into the lateral or recovery position the same way as an adult.
Infants can be rolled onto their side or rolled onto your arm (slightly facing downwards) to drain regurgitation or vomit.
If a child or infant vomits or regurgitates during CPR, roll them into the lateral position away from you to allow the contents to drain and check their airway for any foreign material that needs to be cleared. After the airway is clear, check to see if the young victim is breathing normally again.
Leave infants on their back on a firm and flat surface to check their breathing and monitor their skin colour — remember to keep them warm. Continue with CPR if normal breathing does not return or if they are still not breathing.