FM 21-11 First Aid for Soldiers: Chapter 2
Headquarters, Department of the Army, Washington, D.C., October
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*2-1. Breathing Process
All living things must have oxygen to live. Through the breathing process, the lungs draw oxygen from the air and put it into the blood. The heart then pumps the blood through the body to be used by the living cells which require a constant supply of oxygen. Some cells are more dependent on a constant supply of oxygen than others. Cells of the brain may die within 4 to 6 minutes without oxygen. Once these cells die, they are lost forever since they DO NOT regenerate. This could result in permanent brain damage, paralysis, or death.
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).
a unit so that his body does not twist (which may further complicate a neck, back
or spinal injury.
2-3. Opening the Airway-Unconscious
and Not Breathing Casualty (081-831-1042)
*The tongue is the single most common cause of an airway obstruction (Figure 2-2). In most cases, the airway can be cleared by simply using the head-tilt/chin-lift technique. This action pulls the tongue away from the air passage in the throat (Figure 2-3).
|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).|
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.
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:
(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.
continues to breathe, he should be transported to a medical treatment facility.
a. If the casualty does not promptly resume adequate spontaneous breathing after the airway is open, rescue breathing (artificial respiration) must be started. Be calm! Think and act quickly! The sooner you begin rescue breathing, the more likely you are to restore the casualty's breathing. If you are in doubt whether the casualty is breathing, give artificial respiration, since it can do no harm to a person who is breathing. If the casualty is breathing, you can feel and see his chest move. Also, if the casualty is breathing, you can feel and hear air being expelled by putting your hand or ear close to his mouth and nose.
|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:
(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.
(b) Reattempt to ventilate.
(c) If chest still does not rise, take the necessary action to open an obstructed airway (paragraph 2-14).
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
(b) If a pulse is found and the casualty is not breathing, continue rescue breathing.
*(c) If a pulse is not found, seek medically trained personnel for help.
|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) Step TWO. Take a deep breath and place your mouth (in an airtight seal) around the casualty's mouth (Figure 2-8).
(3) Step THREE. Blow a quick breath into the casualty's mouth forcefully to cause his chest to rise. If the casualty's chest rises, sufficient air is getting into his lungs.
(4) Step FOUR. When the casualty's chest rises, remove your mouth from his mouth and listen for the return of air from his lungs (exhalation).
(5) Step FIVE. Repeat this procedure (mouth-to-mouth resuscitation) at a rate of one breath every 5 seconds to achieve 12 breaths per minute. Use the following count: "one, one-thousand; two one-thousand; three, one-thousand; four, one-thousand; BREATH; one one-thousand" and so forth. To achieve a rate of one breath every 5 seconds, the breath must be given on the fifth count.
*(6) Step SIX. Feel for a pulse after every 12th breath. This check should take about 3 to 5 seconds. If a pulse beat is not found, seek medically trained personnel for help.
*(7) Step SEVEN. Continue rescue breathing until the casualty starts to breathe on his own, until you are relieved by another person, or until you are too tired to continue. Monitor pulse and return of spontaneous breathing after every few minutes of rescue breathing. If spontaneous breathing returns, monitor the casualty closely. The casualty should then be transported to a medical treatment facility. Maintain an open airway and be prepared to resume rescue breathing if necessary.
Use this method if you cannot perform mouth-to-mouth rescue breathing because the casualty has a severe jaw fracture or mouth wound or his jaws are tightly closed by spasms. The mouth-to-nose method is performed in the same way as the mouth-to-mouth method except that you blow into the nose while you hold the lips closed with one hand at the chin. You then remove your mouth to allow the casualty to exhale passively. It may be necessary to separate the casualty's lips to allow the air to escape during exhalation.
If a casualty's heart stops beating, you must immediately seek medically trained personnel for help. SECONDS COUNT! Stoppage of the heart is soon followed by cessation of respiration unless it has occurred first. Be calm! Think and act! When a casualty's heart has stopped, there is no pulse at all; the person is unconscious and limp, and the pupils of his eyes are open wide. When evaluating a casualty or when performing the preliminary steps of rescue breathing, feel for a pulse. If you DO NOT detect a pulse, immediately seek medically trained personnel.
*Paragraphs 2-9, 2-10, and 2-11 have been deleted. No text is provided.
In order for oxygen from the air to flow to and from the lungs, the upper airway must be unobstructed.
a. Upper airway obstructions often occur because--
(2) Foreign bodies become lodged in the throat. These obstructions usually occur while eating (meat most commonly causes obstructions). Choking on food is associated with--
(3) The contents of the stomach are regurgitated and may block the airway.
(4) Blood clots may form as a result of head and facial injuries.
b. Upper airway obstructions may be prevented by taking the following precautions:
(2) Avoid laughing and talking when chewing and swallowing.
(3) Restrict alcohol while eating meals.
(4) Keep food and foreign objects from children while they walk, run, or play.
(5) Consider the correct positioning maintenance of the open airway for the injured or unconscious casualty.
c. Upper airway obstruction may cause either partial or complete airway blockage.
(2) Complete airway obstruction. A complete obstruction (no air exchange) is indicated if the casualty cannot speak, breathe, or cough at all. He may be clutching his neck and moving erratically. In an unconscious casualty a complete obstruction is also indicated if after opening his airway you cannot ventilate him.
2-13. Opening the Obstructed Airway--Conscious Casualty (081-831-1003)
Clearing a conscious casualty's airway obstruction can be performed with the casualty either standing or sitting, and by following a relatively simple procedure.
|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).
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.)
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.)
2-14. Open an Obstructed Airway--Casualty Lying or Unconscious (081-831-1042)
The following procedures are used to expel an airway obstruction in a casualty who is lying down, who becomes unconscious, or is found unconscious (the cause unknown):
|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:
(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:
(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.
(2) Perform finger sweep, keep casualty face up, use tongue-jaw lift to open mouth.
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.
DO NOT REMOVE protective clothing in a chemical environment.
Before applying the dressing, carefully examine the casualty to determine if there is more than one wound. A missile may have entered at one point and exited at another point. The EXIT wound is usually LARGER than the entrance wound.
a. Use the casualty's field dressing; remove it from the wrapper and grasp the tails of the dressing with both hands (Figure 2-28).
|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).|
c. Hold the dressing in place with one hand. Use the other hand to wrap one of the tails around the injured part, covering about one-half of the dressing (Figure 2-31). Leave enough of the tail for a knot. If the casualty is able, he may assist by holding the dressing in place.
|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.
2-18. Manual Pressure (081-831-1016)
|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).|
splint a fracture before elevating, see task 081-831-1034, Splint a Suspected
c. If the bleeding stops, check and treat for shock. If the bleeding continues, apply a pressure dressing.
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.|
Wounded extremities should be checked periodically for adequate
dressing must be loosened if the extremity becomes cool, blue or numb.
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
c. Applying the Tourniquet (081-831-1017).
(2) Place a stick (or similar rigid object) on top of the half-knot (Figure 2-40).
out of sight of) the casualty.
(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.
2-21. Causes and Effects
a. Shock may be caused by severe or minor trauma to the body. It usually is the result of--
b. Shock stuns and weakens the body. When the normal blood flow in the body is upset, death can result. Early identification and proper treatment may save the casualty's life.
c. See FM 8-230 for further information and details on specific types of shock and treatment.
2-22. Signs/Symptoms (081-831-1000)
Examine the casualty to see if he has any of the following signs/symptoms:
2-23. Treatment/Prevention (081-831-1005)
In the field, the procedures to treat shock are identical to procedures that would be performed to prevent shock. When treating a casualty, assume that shock is present or will occur shortly. By waiting until actual signs/symptoms of shock are noticeable, the rescuer may jeopardize the casualty's life.
|a. Position the Casualty. (DO
NOT move the casualty or his limbs if suspected fractures have
not been splinted. See Chapter 4 for
(2) Lay the casualty on his back.
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.
|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).|
c. Evaluate Casualty. If necessary, continue with the casualty's evaluation.
1. American Heart Association (AHA). Instructor's Manual for Basic Life Support (Dallas: AHA, 1987), p. 37.
4. Ibid., p. 38