First Aid for Soldiers FM 21-11

2-2. Assessment (Evaluation) Phase (081-831-1000 and 081-831-1042)

a. Check for responsiveness (Figure 2-1A)--establish whether the casualty is conscious by gently shaking him and asking "Are you O.K.?"

b. Call for help (Figure 2-1B).

c. Position the unconscious casualty so that he is lying on his back and on a firm surface (Figure 2-1C) (081-831-1042).

WARNING (081-831-1042)

If the casualty is lying on his chest (prone position), cautiously roll the casualty as
a unit so that his body does not twist (which may further complicate a neck, back
or spinal injury.

(2) Kneel beside the casualty with your knees near his shoulders (leave space to roll his body) (Figure 2-1B). Place one hand behind his head and neck for support. With your other hand, grasp the casualty under his far arm (Figure 2-1C).

(4) Return the casualty's arms to his side. Straighten his legs. Reposition yourself so that you are now kneeling at the level of the casualty's shoulders. However, if a neck injury is suspected, and the jaw thrust will be used, kneel at the casualty's head, looking toward his feet.

a. Step ONE (081-831-1042). Call for help and then position the casualty. Move (roll) the casualty onto his back (Figure 2-1C above).

NOTE (081-831-1042)

If foreign material or vomitus is visible in the mouth, it should be removed, but do
not spend an excessive amount of time doing so.

b. Step TWO (081-31-1042). Open the airway using the jaw-thrust or head-tilt/chin-lift technique.

(1)Perform the jaw thrust technique. The jaw thrust may be accomplished by the rescuer grasping the angles of the casualty's lower jaw and lifting with both hands, one on each side, displacing the jaw forward and up (Figure 2-4). The rescuer's elbows should rest on the surface on which the casualty is lying. If the lips close, the lower lip can be retracted with the thumb. If mouth-to-mouth breathing is necessary, close the nostrils by placing your cheek tightly against them. The head should be carefully supported without tilting it backwards or turning it from side to side. If this is unsuccessful, the head should be tilted back very slightly.² The jaw thrust is the safest first approach to opening the airway of a casualty who has a suspected neck injury because in most cases it can be accomplished without extending the neck.

(2) Perform the head tilt/chin lift technique (081-831-1042). Place one hand on the casualty's forehead and apply firm, backward pressure with the palm to tilt the head back. Place the fingertips of the other hand under the bony part of the lower jaw and lift, bringing the chin forward. The thumb should not be used to lift the chin (Figure 2-5).

NOTE

The fingers should not press deeply into the soft tissue under the chin because the
airway may be obstructed.

c. Step THREE. Check for breathing (while maintaining an airway). After establishing an open airway, it is important to maintain that airway in an open position. Often the act of just opening and maintaining the airway will allow the casualty to breathe properly. Once the rescuer uses one of the techniques to open the airway (jaw-thrust or head-tilt/chin-lift), he should maintain that head position to keep the airway open. Failure to maintain the open airway will prevent the casualty from receiving an adequate supply of oxygen. Therefore, while maintaining an open airway the rescuer should check for breathing by observing the casualty's chest and performing the following actions within 3 to 5 seconds:

(1) LOOK for the chest to rise and fall.

(2) LISTEN for air escaping during exhalation by placing your ear near the casualty's mouth.

(3) FEEL for the flow of air on your cheek (see Figure 2-6).

(4) If the casualty does not resume breathing, give mouth-to-mouth resuscitation.

NOTE

If the casualty resumes breathing, monitor and maintain the open airway. If he
continues to breathe, he should be transported to a medical treatment facility.

b. There are several methods of administering rescue breathing. The mouth-to-mouth method is preferred; however, it cannot be used in all situations. If the casualty has a severe jaw fracture or mouth wound or his jaws are tightly closed by spasms, use the mouth-to-nose method.

2-5. Preliminary Steps--All Rescue Breathing Methods (081-831-1042)

a. Step ONE. Establish unresponsiveness. Call for help. Turn or position the casualty.

b. Step TWO. Open the airway.

c. Step THREE. Check for breathing by placing your ear over the casualty's mouth and nose, and looking toward his chest:

(1) Look for rise and fall of the casualty's chest (Figure 2-6).

(2) Listen for sounds of breathing.

(3) Feel for breath on the side of your face. If the chest does not rise and fall and no air is exhaled, then the casualty is breathless (not breathing). (This evaluation procedure should take only 3 to 5 seconds.) Perform rescue breathing if the casualty is not breathing.

2-6. Mouth-to-Mouth Method (081-831-1042)

In this method of rescue breathing, you inflate the casualty's lungs with air from your lungs. This can be accomplished by blowing air into the person's mouth. The mouth-to-mouth rescue breathing method is performed as follows:

a. Preliminary Steps.

(1) Step ONE (081-831-1048). If the casualty is not breathing, place your hand on his forehead, and pinch his nostrils together with the thumb and index finger of this same hand. Let this same hand exert pressure on his forehead to maintain the backward head-tilt and maintain an open airway. With your other hand, keep your fingertips on the bony part of the lower jaw near the chin and lift (Figure 2-7).

(2) Step TWO (081-831-1042). Take a deep breath and place your mouth (in an airtight seal) around the casualty's mouth (Figure 2-8). (If the injured person is small, cover both his nose and mouth with your mouth, sealing your lips against the skin of his face.)

(3) Step THREE (081-831-1042). Blow two full breaths into the casualty's mouth (1 to 1 1/2 seconds per breath), taking a breath of fresh air each time before you blow. Watch out of the corner of your eye for the casualty's chest to rise. If the chest rises, sufficient air is getting into the casualty's lungs. Therefore, proceed as described in step FOUR below. If the chest does not rise, do the following (a, b, and c below) and then attempt to ventilate again.

(a) Take corrective action immediately by reestablishing the airway. Make sure that air is not leaking from around your mouth or out of the casualty's pinched nose.

(b) Reattempt to ventilate.

(c) If chest still does not rise, take the necessary action to open an obstructed airway (paragraph 2-14).

NOTE

If the initial attempt to ventilate the casualty is unsuccessful, reposition the casualty's
head and repeat rescue breathing. Improper chin and head positioning is the most
common cause of difficulty with ventilation. If the casualty cannot be ventilated
after repositioning the head, proceed with foreign body airway obstruction maneuvers
(see Open an Obstructed Airway, paragraph 2-14).⁴

(4) Step FOUR (081-831-1042). After giving two breaths which cause the chest to rise, attempt to locate a pulse on the casualty. Feel for a pulse on the side of the casualty's neck closest to you by placing the first two fingers (index and middle fingers) of your hand on the groove beside the casualty's Adam's apple (carotid pulse) (Figure 2-9). (Your thumb should not be used for pulse taking because you may confuse your pulse beat with that of the casualty.) Maintain the airway by keeping your other hand on the casualty's forehead. Allow 5 to 10 seconds to determine if there is a pulse.

b. Rescue Breathing (mouth-to-mouth resuscitation) (081-831-1042). Rescue breathing (mouth-to-mouth or mouth-to-nose resuscitation) is performed at the rate of about one breath every 5 seconds (12 breaths per minute) with rechecks for pulse and breathing after every 12 breaths. Rechecks can be accomplished in 3 to 5 seconds. See steps ONE through SEVEN (below) for specifics.

2-13. Opening the Obstructed Airway--Conscious Casualty (081-831-1003)

a. Step ONE. Ask the casualty if he can speak or if he is choking. Check for the universal choking sign (Figure 2-18).

b. Step TWO. If the casualty can speak, encourage him to attempt to cough; the casualty still has a good air exchange. If he is able to speak or cough effectively, DO NOT interfere with his attempts to expel the obstruction.

c. Step THREE. Listen for high pitched sounds when the casualty breathes or coughs (poor air exchange). If there is poor air exchange or no breathing, CALL for HELP and immediately deliver manual thrusts (either an abdominal or chest thrust).

• Apply ABDOMINAL THRUSTS using the procedures below:

  o Stand behind the casualty and wrap your arms around his waist.

  o Make a fist with one hand and grasp it with the other. The thumb side of your fist should be against the casualty's abdomen, in the midline and slightly above the casualty's navel, but well below the tip of the breastbone (Figure 2-19).

o Press the fists into the abdomen with a quick backward and upward thrust (Figure 2-20).

o Each thrust should be a separate and distinct movement.

*NOTE

Continue performing abdominal thrusts until the obstruction is expelled or the casualty becomes unconscious.

o If the casualty becomes unconscious, call for help as you proceed with steps to open the airway and perform rescue breathing. See task 081-831-1042, Perform Mouth-to-Mouth Resuscitation.)

• Applying CHEST THRUSTS. An alternate technique to the abdominal thrust is the chest thrust. This technique is useful when the casualty has an abdominal wound, when the casualty is pregnant, or when the casualty is so large that you cannot wrap your arms around the abdomen. To apply chest thrusts with casualty sitting or standing:

  o Stand behind the casualty and wrap your arms around his chest with your arms under his armpits.

  o Make a fist with one hand and place the thumb side of the fist in the middle of the breastbone (take care to avoid the tip of the breastbone and the margins of the ribs).

  o Grasp the fist with the other hand and exert thrusts (Figure 2-21).

o Each thrust should be delivered slowly, distinctly, and with the intent of relieving
the obstruction.

o Perform chest thrusts until the obstruction is expelled or the casualty becomes unconscious.

o If the casualty becomes unconscious, call for help as you proceed with steps to open the airway and perform rescue breathing. (See task 081-831-1042, Perform Mouth-to-Mouth Resuscitation.)

a. Open the airway and attempt rescue breathing. (See task 081-831-1042, Perform Mouth-to-Mouth Resuscitation.)

b. If still unable to ventilate the casualty, perform 6 to 10 manual (abdominal or chest) thrusts. (Note that the abdominal thrusts are used when casualty does not have abdominal wounds; is not pregnant or extremely overweight.) To perform the abdominal thrusts:

(1) Kneel astride the casualty's thighs (Figure 2-22).

(2) Place the heel of one hand against the casualty's abdomen (in the midline slightly above the navel but well below the tip of the breastbone). Place your other hand on top of the first one. Point your fingers toward the casualty's head.

(3) Press into the casualty's abdomen with a quick, forward and upward thrust. You can use your body weight to perform the maneuver. Deliver each thrust slowly and distinctly.

(4) Repeat the sequence of abdominal thrusts, finger sweep, and rescue breathing (attempt to ventilate) as long as necessary to remove the object from the obstructed airway. See paragraph d below.

(5) If the casualty's chest rises, proceed to feeling for pulse.

c. Apply chest thrusts. (Note that the chest thrust technique is an alternate method that is used when the casualty has an abdominal wound, when the casualty is so large that you cannot wrap your arms around the abdomen, or when the casualty is pregnant.) To perform the chest thrusts:

(1) Place the unconscious casualty on his back, face up, and open his mouth. Kneel close to the side of the casualty's body.

• Locate the lower edge of the casualty's ribs with your fingers. Run the fingers up along the rib cage to the notch (Figure 2-23A).

• Place the middle finger on the notch and the index finger next to the middle finger on the lower edge of the breastbone. Place the heel of the other hand on the lower half of the breastbone next to the two fingers (Figure 2-23B).

• Remove the fingers from the notch and place that hand on top of the positioned hand on the breastbone, extending or interlocking the fingers (Figure 2-23C).

• Straighten and lock your elbows with your shoulders directly above your hands without bending the elbows rocking, or allowing the shoulders to sag. Apply enough pressure to depress the breastbone 1 1/2 to 2 inches, then release the pressure completely (Figure 2-23D). Do this 6 to 10 times. Each thrust should be delivered slowly and distinctly. See Figure 2-24 for another view of the breastbone being depressed.

(2) Repeat the sequence of chest thrust, finger sweep, and rescue breathing as long as necessary to clear the object from the obstructed airway. See paragraph d below.

(3) If the casualty's chest rises, proceed to feeling for his pulse.

d. Finger Sweep. If you still cannot administer rescue breathing due to an airway obstruction, then remove the airway obstruction using the procedures in steps (1) and (2) below.

(1) Place the casualty on his back, face up, turn the unconscious casualty as a unit, and call out for help.

(2) Perform finger sweep, keep casualty face up, use tongue-jaw lift to open mouth.

• Open the casualty's mouth by grasping both his tongue and lower jaw between your thumb and fingers and lifting (tongue-jaw lift) (Figure 2-25). If you are unable to open his mouth, cross your fingers and thumb (crossed-finger method) and push his teeth apart (Figure 2-26) by pressing your thumb against his upper teeth and pressing your finger against his lower teeth.

• Insert the index finger of the other hand down along the inside of his cheek to the base of the tongue. Use a hooking motion from the side of the mouth toward the center to dislodge the foreign body (Figure 2-27).

WARNING

Take care not to force the object deeper into the airway by pushing it with the finger.

2-15. Clothing (081-831-1016)

In evaluating the casualty for location, type, and size of the wound or injury, cut or tear his clothing and carefully expose the entire area of the wound. This procedure is necessary to avoid further contamination. Clothing stuck to the wound should be left in place to avoid further injury. DO NOT touch the wound; keep it as clean as possible.

WARNING (081-831-1016)

DO NOT REMOVE protective clothing in a chemical environment. Apply dressings
over the protective clothing.

b. Hold the dressing directly over the wound with the white side down. Pull the dressing open (Figure 2-29) and place it directly over the wound (Figure 2-30).

d. Wrap the other tail in the opposite direction until the remainder of the dressing is covered. The tails should seal the sides of the dressing to keep foreign material from getting under it.

e. Tie the tails into a nonslip knot over the outer edge of the dressing (Figure 2-32). DO NOT TIE THE KNOT OVER THE WOUND. In order to allow blood to flow to the rest of an injured limb, tie the dressing firmly enough to prevent it from slipping but without causing a tourniquet-like effect; that is, the skin beyond the injury becomes cool blue, or numb.

a. If bleeding continues after applying the sterile field dressing, direct manual pressure may be used to help control bleeding. Apply such pressure by placing a hand on the dressing and exerting firm pressure for 5 to 10 minutes (Figure 2-33). The casualty may be asked to do this himself if he is conscious and can follow instructions.

b. Elevate an injured limb slightly above the level of the heart to reduce the bleeding (Figure 2-34).

WARNING

DO NOT elevate a suspected fractured limb unless it has been properly splinted. (To
splint a fracture before elevating, see task 081-831-1034, Splint a Suspected
Fracture.)

c. If the bleeding stops, check and treat for shock. If the bleeding continues, apply a pressure dressing.

2-19. Pressure Dressing (081-831-1016)

Pressure dressings aid in blood clotting and compress the open blood vessel. If bleeding continues after the application of a field dressing, manual pressure, and elevation, then a pressure dressing must be applied as follows:

a. Place a wad of padding on top of the field dressing, directly over the wound (Figure 2-35). Keep injured extremity elevated.

b. Place an improvised dressing (or cravat, if available) over the wad of padding (Figure 2-36). Wrap the ends tightly around the injured limb, covering the previously placed field dressing (Figure 2-37).

c. Tie the ends together in a nonslip knot directly over the wound site (Figure 2-38). DO NOT tie so tightly that it has a tourniquet-like effect. If bleeding continues and all other measures have failed, or if the limb is severed, then apply a tourniquet. Use the tourniquet as a LAST RESORT. When the bleeding stops, check and treat for shock.

2-20. Tourniquet (081-831-1017)

A tourniquet is a constricting band placed around an arm or leg to control bleeding. A soldier whose arm or leg has been completely amputated may not be bleeding when first discovered, but a tourniquet should be applied anyway. This absence of bleeding is due to the body's normal defenses (contraction of blood vessels) as a result of the amputation, but after a period of time bleeding will start as the blood vessels relax. Bleeding from a major artery of the thigh, lower leg, or arm and bleeding from multiple arteries (which occurs in a traumatic amputation) may prove to be beyond control by manual pressure. If the pressure dressing under firm hand pressure becomes soaked with blood and the wound continues to bleed, apply a tourniquet.

*The tourniquet should not be used unless a pressure dressing has failed to stop the bleeding or an arm or leg has been cut off. On occasion, tourniquets have injured blood vessels and nerves. If left in place too long, a tourniquet can cause loss of an arm or leg. Once applied, it must stay in place, and the casualty must be taken to the nearest medical treatment facility as soon as possible. DO NOT loosen or release a tourniquet after it has been applied and the bleeding has stopped.

a. Improvising a Tourniquet (081-831-1017). In the absence of a specially designed tourniquet, a tourniquet may be made from a strong, pliable material, such as gauze or muslin bandages, clothing, or kerchiefs. An improvised tourniquet is used with a rigid stick-like object. To minimize skin damage, ensure that the improvised tourniquet is at least 2 inches wide.

b. Placing the Improvised Tourniquet (081-831-1017).

(1) Place the tourniquet around the limb, between the wound and the body trunk (or between the wound and the heart). Place the tourniquet 2 to 4 inches from the edge of the wound site (Figure 2-39). Never place it directly over a wound or fracture or directly on a joint (wrist, elbow, or knee). For wounds just below a joint, place the tourniquet just above and as close to the joint as possible.

(2) The tourniquet should have padding underneath. If possible, place the tourniquet over the smoothed sleeve or trouser leg to prevent the skin from being pinched or twisted. If the tourniquet is long enough, wrap it around the limb several times, keeping the material as flat as possible. Damaging the skin may deprive the surgeon of skin required to cover an amputation. Protection of the skin also reduces pain.

c. Applying the Tourniquet (081-831-1017).

(1) Tie a half-knot. (A half-knot is the same as the first part of tying a shoe lace.)

(2) Place a stick (or similar rigid object) on top of the half-knot (Figure 2-40).

(3) Tie a full knot over the stick (Figure 2-41).

(4) Twist the stick (Figure 2-42) until the tourniquet is tight around the limb and/or the bright red bleeding has stopped. In the case of amputation, dark oozing blood may continue for a short time. This is the blood trapped in the area between the wound and tourniquet.

(5) Fasten the tourniquet to the limb by looping the free ends of the tourniquet over the ends of the stick. Then bring the ends around the limb to prevent the stick from loosening. Tie them together under the limb (Figure 2-43A and B).

NOTE

If possible, save and transport any severed (amputated) limbs or body parts with (but
out of sight of) the casualty.

(6) DO NOT cover the tourniquet--you should leave it in full view. If the limb is missing (total amputation), apply a dressing to the stump.

(7) Mark the casualty's forehead, if possible, with a "T" to indicate a tourniquet has been applied. If necessary, use the casualty's blood to make this mark.

(8) Check and treat for shock.

(9) Seek medical aid.

CAUTION (081-831-1017)

DO NOT LOOSEN OR RELEASE THE TOURNIQUET ONCE IT HAS BEEN APPLIED BECAUSE IT COULD ENHANCE THE PROBABILITY OF SHOCK.

a. Position the Casualty. (DO NOT move the casualty or his limbs if suspected fractures have not been splinted. See Chapter 4 for details.)

(1) Move the casualty to cover, if cover is available and the situation permits.

(2) Lay the casualty on his back.

NOTE

A casualty in shock after suffering a heart attack, chest wound, or breathing difficulty,
may breathe easier in a sitting position. If this is the case, allow him to sit upright, but
monitor carefully in case his condition worsens.

(3) Elevate the casualty's feet higher than the level of his heart. Use a stable object (a box, field pack, or rolled up clothing) so that his feet will not slip off (Figure 2-44).

WARNING

DO NOT elevate legs if the casualty has an unsplinted broken leg, head injury, or abdominal injury. (See task 081-831-1034, Splint a Suspected Fracture, and task 081-831-1025, Apply a Dressing to an Open Abdominal Wound.)

(4) Loosen clothing at the neck, waist, or wherever it may be binding.

(5) Prevent chilling or overheating. The key is to maintain body temperature. In cold weather, place a blanket or other like item over him to keep him warm and under him to prevent chilling (Figure 2-45). However, if a tourniquet has been applied, leave it exposed (if possible). In hot weather, place the casualty in the shade and avoid excessive covering.

(6) Calm the casualty. Throughout the entire procedure of treating and caring for a casualty, the rescuer should reassure the casualty and keep him calm. This can be done by being authoritative (taking charge) and by showing self-confidence. Assure the casualty that you are there to help him.

b. Food and/or Drink. During the treatment/prevention of shock, DO NOT give the casualty any food or drink. If you must leave the casualty or if he is unconscious, turn his head to the side to prevent him from choking should he vomit (Figure 2-46).