HELMET REMOVAL

If the victim is wearing a helmet, it may be necessary to rapidly remove it to get to the airway. It is very important to do this in a way that protects the neck from twisting or bending forward or backward. It usually takes two persons to safely remove a helmet:

1. The first rescuer, positioned above the head of the victim, holds the helmeted head steady by grasping it on each side. If necessary to support the airway, the first rescuer can reach down and hold the mandible (lower jaw).

2. The second rescuer, positioned below the head of the victim, prepares the helmet for removal by loosening and removing straps, goggles, and other attachments, so long as this process does not allow for unintended head movement.

3. The second rescuer takes over head stabilization, while the first rescuer continues to hold the helmeted head, by sliding two hands along the sides of the victim’s head position; this should be done by either placing one hand behind the base of the head at its junction with the neck and the other hand under the chin or by sliding two hands along the sides of the head and up inside the helmet.

4. The first rescuer completes removal of retaining straps, then slides the helmet off the head using axial (straight up away from the feet, without any twisting) traction.

5. Head positioning and gentle traction is maintained while a cervical collar or other method (see page 37) is used to stabilize the position of the head and neck.

AIRWAY

Airway obstruction is one of the leading causes of death in victims of head injury, and a frequent complication of vomiting in an unconscious person. Adequacy of the airway and breathing must be attained rapidly in every victim. In the absence of hypothermia, an interval of four minutes in which there is a failure to oxygenate the brain can lead to irreversible damage.

Figure 2 depicts the anatomy of the respiratory system. Air enters the mouth and nose (where it is humidified), traverses the pharynx (throat), passes through the trachea (windpipe) and bronchi, and normally proceeds into the smallest air sacs of the lungs, known as the alveoli. Within these distal air spaces, inspired oxygen is exchanged for carbon dioxide, one of the end products of human metabolism. During swallowing, the epiglottis and tongue cover the entrance (via the vocal cords) to the trachea, so that food and liquid enter the esophagus and not the airway.

Figure 2 Anatomy of the respiratory system.

Obstruction of the airway at any level can interfere with the passage of air, delivery of oxygen via the lungs to the blood, and exhalation of carbon dioxide. The mouth and pharynx may fill with blood, vomitus, or secretions. With facial injury, deformation of the jaw or nose may hinder breathing. In a supine (faceup) unconscious victim, the tongue may fall back into the pharynx and occlude the opening to the trachea. Inhalation of food can obstruct the opening between the vocal cords and cause rapid suffocation.

Symptoms of airway obstruction include sudden inability to speak, an appearance of panic with bulging eyes, blue skin discoloration (cyanosis), choking gestures (hand held to the throat) (see Figure 11), harsh and raspy or “musical” and high-pitched noise (“stridor”) that comes from the throat during breathing, and difficulty with breathing as evidenced by struggling and profound agitation. Any person who collapses suddenly, particularly while eating, or who has been in an accident should be examined rapidly for airway obstruction.

Figure 11 The Heimlich maneuver. A, A hand is placed on the upper abdomen. B, The second hand interlocks to create a tight grip. A sudden, forceful squeeze (“bear hug”) causes the victim to cough.

1. Under no circumstance should the neck be manipulated if there is a possibility of injury to the spine or spinal cord. If a victim is unconscious and has suffered a fall or multiple injuries, it is safest to assume that his neck is broken. If this is the case, keep the airway open by gently but firmly lifting the jaw, either by grasping the lower teeth and jaw and pulling directly forward (away from the face), or by maintaining a forward pull on the angles of the jaw (Figure 3). Do not bend the neck forward or backward. A modified jaw thrust (Figure 4) can be performed by a single rescuer while stabilizing the neck.

2. If there is no chance of a broken neck, maintain the airway with the jaw lifts previously described or by tilting the head backward while gently lifting under the neck (Figure 5). The alignment is different for an infant, a small child, and an older child or adult in terms of where one would position a pad or pillow (Figure 6). A head tilt with chin lift may be used (Figure 7).

3. Keep the airway clear of blood, vomitus, loose dentures, and debris. This can be accomplished by sweeping the mouth with two fingers or by continuous suction with a field suction apparatus powerful enough to extract chunks. Take care not to force objects deeper into the throat. If the tongue appears to be the problem, wrap the end of the tongue in a cloth or gauze bandage, grasp firmly, and pull it out of the mouth (Figure 8). If it cannot be held in this manner, a large safety pin or sharp-pointed wire may be passed through the tongue and used to improve the grip (see Figure 8); take care to avoid the large, visible blood vessels at the base of the tongue. To keep the tongue out of the mouth, a string can be tied to the safety pin and then secured to the victim’s shirt button or jacket zipper. Fortunately, in most cases the jaw lift will carry the base of the tongue out of the airway. Another technique is to use two safety pins to attach the tongue to the face just below the lower lip (Figure 9).

4. If the victim is unconscious, and there is no chance of a broken neck or back, do not leave him lying flat on his back. Turn him on his side so that if vomiting occurs, the fluid can drain from his mouth and the victim won’t choke or drown (Figure 10).

5. Choking is a life-threatening condition in which the upper airway (above the vocal cords) is obstructed by a foreign object (tongue, broken teeth, dentures, food). The choking person is profoundly agitated (until he becomes unconscious from lack of oxygen), may appear to be panicked with bulging eyes, may grasp at his throat in a choking gesture, cannot breathe, and is unable to speak. You must respond rapidly:

Sweep the mouth with one or two fingers to remove any foreign material. Take care not to force material farther into the throat. Quickly extract loose dentures.

Using an open hand, give the victim two to four rapid, sharp blows on the back between the shoulder blades. This may be more effective if the victim is lying on his side or is bent forward at the waist. If a small child is choking, perform this maneuver while holding him facedown or upside down. If the victim is an infant, place him facedown on one of your forearms, with his head lower than his body. Support his head. Give five quick back blows, then turn the infant over and give five quick chest thrusts (similar to those given during cardiopulmonary resuscitation [CPR]—see page 32).

Perform the Heimlich maneuver (Figure 11). Position yourself behind the victim and encircle him with your arms, clasping your hands in a fist in the upper abdomen just below his ribs. Squeeze the victim suddenly and firmly (“bear hug”) two or three times, in an attempt to produce a brisk exhalation (cough) and ejection of the foreign (choking) material. If your first attempt is unsuccessful, alternate back blows with the Heimlich maneuver. If you are the victim and no one is present to help during a choking episode, you can throw yourself against a log or table edge in an attempt to perform a self Heimlich maneuver.

If the victim is lying on his back (supine), perform the Heimlich maneuver by sitting astride his thighs, facing his head (Figure 12). Place the heel of one hand on his upper abdomen and cover it with your other hand. Press into the abdomen suddenly and firmly in a direction toward the chest. Do this a few times, and then perform the chin lift (see step 1 on page 23) and sweep a finger deeply through the mouth to extract any foreign material forced up by your efforts. Take care not to push anything back into the throat.