🩹 First Aid

The Principle: The chances of survival after cardiac arrest fall by 10% per minute. Early CPR and early defibrillation are the critical factors separating life from death.

What You Need to Know:

1. The Chain of Survival: Early recognition and calling 999 → immediate CPR → prompt defibrillation → hospital care. Each link is vital; the earlier each step happens, the better the odds.

2. CPR saves lives fast: CPR started within the first 3–4 minutes can double or triple survival chances. After 10 minutes without CPR, meaningful recovery becomes unlikely.

3. Current CPR standard (2025 Resuscitation Council UK): 30 chest compressions at a rate of 100–120 compressions per minute, followed by 2 rescue breaths. If untrained, the emergency call handler will talk you through hands-only CPR (continuous chest compressions without rescue breaths).

4. Compression depth and hand placement: Compress the chest by 5–6 cm (roughly 2 inches). Place the heel of one hand on the centre of the chest, place your other hand on top, and push hard and fast. Keep your arms straight.

5. Minimal interruption is critical: Every pause in compressions reduces survival chances. Do not stop to check if the person is breathing or to give up.

6. Public defibrillators exist everywhere: The Circuit is the UK national defibrillator database, managed by the British Heart Foundation. Search DefibFinder (defibfinder.uk) or call 999 and ask the operator to direct a bystander to the nearest defibrillator. Over 100,000 defibrillators are registered.

7. Automated External Defibrillators (AEDs) are foolproof: When you place the pads on the bare chest and turn the machine on, it analyzes the heart rhythm and talks you through the process. It will only shock if a shock will help.

8. Scene safety: Before touching the casualty, check they are unresponsive (tap shoulders, shout). Check for normal breathing. Call 999 immediately.

The Simple Process:

1. Check responsiveness and breathing. Tap the person's shoulders and shout. Look for normal breathing (not gasping). If unresponsive and not breathing normally, proceed immediately.

2. Call 999. Do this yourself or ask someone to call immediately. Tell them the location and that you are starting CPR.

3. Place the person on their back on a firm surface (floor, or remove pillows if on a bed — research shows CPR can still be effective on a bed if needed).

4. Start chest compressions. Place the heel of one hand in the centre of the chest, place your other hand on top, keep your arms straight, and push hard at 100–120 compressions per minute. (Use the beat of the song "Stayin' Alive" as a metronome, roughly 100–120 bpm.)

5. After 30 compressions, give 2 rescue breaths (if trained: tilt the head, open the airway, pinch the nose, and blow into the mouth twice). If untrained or unwilling, the call handler will direct continuous chest-compression-only CPR.

6. Continue uninterrupted CPR until:

   • Help arrives and takes over
   • The person starts breathing normally
   • You are too exhausted to continue safely
   • An AED arrives and is switched on (do not stop compressions; apply pads while continuing)

7. If an AED is available:

   • Turn it on. It will talk you through attaching the pads.
   • Expose the bare chest. Apply the two adhesive pads as instructed (one on the right upper chest, one on the left lower ribs).
   • Stand clear while the machine analyzes the rhythm.
   • Follow all instructions from the machine (if shock is needed, it will tell you to stand clear, deliver the shock, and then resume CPR).
   • Do not remove the pads; do not interrupt CPR longer than needed.

Common Mistakes:

• Checking for a pulse. Non-professionals often cannot reliably feel a pulse. If someone is unresponsive and not breathing normally, they need CPR now. Do not delay.
• Giving up too soon. Recovery from cardiac arrest can take 20–30 minutes or more of continuous CPR. Do not stop assuming the person is dead.
• Pausing compressions to check for signs of life. Every pause reduces survival chances. Assume CPR is working and do not stop unless the person breathes normally, help arrives, or you physically cannot continue.
• Shallow compressions. Compress at least 5–6 cm. Gentle compressions do not work. Push hard.
• Stopping when the AED arrives. Do not pause CPR while the pads are being applied. Minimize interruptions.
• Incorrect hand placement. The centre of the chest is essential. Compressions on the neck, abdomen, or side of the chest are ineffective.
• Fear of causing harm. A person in cardiac arrest is already dying. CPR cannot make things worse.

Improvisation:

• Firm surface: If on soft furniture or a bed, push down to compress the chest by 5–6 cm. If you cannot achieve this depth, move the person to the floor (briefly) without delaying CPR start.
• Counting compressions: If you do not have a metronome, count steadily: "1-and-2-and-3..." at about 100–120 per minute. The emergency call handler can also help you maintain pace over the phone.
• Rescue breaths without training: Hands-only CPR (continuous chest compressions without breaths) is nearly as effective as full CPR. If you do not know how to give rescue breaths, continue compressions.
• AED as backup, not requirement: If an AED is not available, CPR alone still dramatically improves chances. Do not wait for an AED; start CPR immediately. The call handler or a bystander can search for a nearby defibrillator while you continue.

Historical Note:

In the early 1900s, CPR as we know it did not exist. Cardiac arrest was universally fatal. George Crile conducted experimental chest compressions in the 1890s and reported the first successful human resuscitation using external compression in 1903, but the technique remained rare and misunderstood for decades. Early British Army first aid manuals (1914 onwards) contained instructions for "artificial respiration" (mouth-to-mouth or Schafer's method — rolling the prone casualty to compress the lungs) but did not mention chest compressions. It was not until the 1960s that chest compression-based CPR became standard. A great-grandparent in 1910 would have had no effective tool for cardiac arrest; they would have applied friction to the limbs and hoped for spontaneous recovery, which was extremely rare.

Safety:

• Call 999 immediately and do not wait for an ambulance before starting CPR.
• Unconsciousness + abnormal or absent breathing = start CPR without delay.
• CPR can cause rib fractures; this is normal and acceptable if it keeps someone alive.
• If you suspect a spinal injury (e.g., from a fall), still perform CPR but try to minimize spine movement. The need for CPR overrides precautions against spine injury.
• After successful resuscitation, the person needs hospital care immediately. Do not leave them alone.

The Principle: Cooling a burn within minutes dramatically reduces tissue damage, scarring, and infection risk. The response is always the same: cool running water for 20 minutes, always.

What You Need to Know:

1. Cool, running water is the ONLY correct first response. Start cooling immediately and continue for 20 minutes. Lukewarm water (not cold or iced) is safest, but if only cold water is available, use it.

2. Why cool water works: Heat is conducted away from the burnt tissue, preventing deeper layers from being damaged. After 20 minutes, most of the heat is gone. Later cooling has minimal benefit.

3. Never use ice, iced water, butter, oil, toothpaste, or any folk remedy. These trap heat, prevent effective cooling, or cause additional injury. Ice can freeze tissue and cause frostbite. Butter and oils are greasy and prevent assessment of the burn.

4. Remove clothing and jewellery near the burn (but not if they are stuck to the skin). Synthetic fibres retain heat.

5. After 20 minutes of cooling, cover the burn loosely with cling film. Lay the film over the burn in overlapping layers; do not wrap it around a limb (this causes swelling and cuts off circulation as tissue swells). A clean, clear plastic bag is acceptable for hands.

6. Keep the person warm overall. A burnt person loses heat rapidly and can develop hypothermia even after a small burn. Wrap them in dry blankets away from the burnt area.

7. When a burn needs hospital: Any burn larger than the person's own palm (roughly 1% of body surface area), burns on the face, hands, joints, feet, or genitals, full-thickness burns (charred, white, or leathery skin), chemical or electrical burns, or burns in children under 5 or adults over 60. Also seek help if the burn was from a significant flame, explosive, or confined space fire.

8. Pain relief: Paracetamol or ibuprofen help with pain, but do not delay cooling or hospital assessment.

The Simple Process:

1. Immediately cool the burn with cool running water for 20 minutes. Check the time. Do not stop early.

2. While cooling, remove any clothing or jewellery (unless stuck to skin). If wet clothing, carefully peel it away.

3. After 20 minutes, gently dry the area with a clean cloth. Do not rub.

4. Cover loosely with cling film in overlapping layers, or use a clean, clear plastic bag for hands/feet.

5. Wrap the person in a blanket or dry clothing away from the burn to keep them warm.

6. Assess if hospital is needed (see "When a burn needs hospital" above). If any doubt, call NHS 111 or attend an urgent care centre. If severe, call 999.

7. Give pain relief (paracetamol or ibuprofen as appropriate for age/weight) if the person is conscious and able to swallow.

Common Mistakes:

• Stopping cooling too early. Twenty minutes is the minimum. Shorter cooling means deeper tissue damage and worse scarring.
• Using ice or very cold water. This can cause ice burn (frostbite) on top of the burn injury.
• Wrapping cling film around a limb. This traps swelling and cuts off circulation. Always lay it over the burn, not around.
• Applying butter, oil, or other folk remedies. These trap heat, create a barrier that prevents proper assessment, and cause infection.
• Ignoring signs that hospital is needed. Any doubt = call for advice. Hospital staff can assess depth and extent; they can also manage pain and prevent infection.
• Leaving the person alone. Burns cause shock and confusion. Keep them warm, calm, and supervised.

Improvisation:

• No cling film? A clean plastic bag, clean cloth, or even a clean plastic carrier bag will do. The goal is to protect from infection and keep the burn clean.
• No running water? Cool water in a bucket, basin, or even a clean pond (e.g., on a remote site) is acceptable. The priority is cooling; it does not have to be mains water or sterile.
• No timer? Ask someone to count minutes aloud, or count "mississippi" 120 times (roughly 2 minutes), repeating. Err on the side of longer cooling (25–30 minutes is fine; too short is the risk).
• Pain relief unavailable? Do not delay cooling for want of analgesics. Cooling itself provides some relief.

Historical Note:

In early 1900s Britain, burns were cooled with water — this part was correct — but the understanding of why was limited. Cold water immersion was often recommended, which we now know carries a frostbite risk. "Old remedies" included linseed oil, flour, and animal fat, all of which trapped heat and worsened outcomes. By the 1914 Field Service Pocket Book, British Army doctrine recommended "water dressing and rest," which is broadly correct. The key modern advance is understanding that cool (not hot, not iced) running water must be applied for at least 20 minutes, and that quick cooling in the first minutes is far more important than what happens later. A great-grandparent would likely have known to use water, but would not have understood the 20-minute standard or why other substances were harmful.

Safety:

• Cool running water is safe. You cannot over-cool a burn or cause hypothermia from 20 minutes of water cooling.
• Do not delay hospital care or cooling to find ideal materials. Start with whatever cool water is available.
• Chemical burns: Cool with water for longer (at least 20 minutes, often 30+). Do not neutralize with acid or alkali — cool with water only. Call 999 immediately.
• Electrical burns: Treat as thermal burns (cool with water) but be aware of internal damage. Call 999 immediately.
• Do not remove clothing stuck to the burn. Cool with water while wearing the stuck clothing, then let hospital staff handle removal.

The Principle: Direct pressure stops the vast majority of bleeding. Most wounds can be managed with clean cloth and time. For catastrophic limb bleeding, apply a tourniquet early — do not wait until direct pressure has clearly failed if the bleeding is severe and arterial.

What You Need to Know:

1. Direct pressure is the standard treatment. Press a clean cloth firmly onto the wound and maintain pressure. Most bleeding stops in 3–10 minutes.

2. Elevation helps. If possible, raise the injured limb above the level of the heart. This reduces blood pressure in the wound and slows bleeding.

3. Wounds that need professional attention: Bleeding that does not stop after 10 minutes of direct pressure, deep or gaping wounds, wounds with embedded glass or debris, wounds with loss of sensation or movement below the injury, jagged or severely contaminated wounds, bites, and any wound from a rusty or dirty object (tetanus risk).

4. Infection signs develop over hours or days: Increasing pain, redness, warmth, swelling, pus, streaking (red lines running up the limb), or fever. Seek professional help if these develop.

5. Tourniquets are for catastrophic limb bleeding (e.g., severe arterial bleeding from a severe laceration or amputation). Current UK guidance (2025) recommends applying a tourniquet early when bleeding is catastrophic — do not delay by persisting with ineffective direct pressure. For moderate bleeding, direct pressure remains the correct first response.

6. Tourniquet application: Place the tourniquet just above the wound (never over a joint or directly over the wound itself). Tighten until the bleeding stops completely. Once applied, do not loosen, remove, or cover it — it must stay visible and tight. Mark the time of application.

7. Critical tourniquet safety: A tourniquet can only be safely removed by a doctor in a hospital. Removing a tourniquet outside hospital carries a high risk of sudden shock and death as accumulated toxins flood the bloodstream.

8. Wound cleaning (minor wounds only): Gentle cleaning with clean water and mild soap, then allow to air-dry or cover with a clean dressing. Hydrogen peroxide or antiseptic washes are optional and do not significantly improve outcomes.

9. Infection prevention: Keep wounds clean and dry. Watch for infection signs. Tetanus protection: anyone with a dirty wound (rust, soil, animal bites) should see a doctor, especially if their tetanus vaccination is out of date.

The Simple Process:

For minor bleeding:

1. Apply direct pressure with a clean cloth. Push firmly and continuously for 3–10 minutes. Do not lift the cloth to check — keep pressure on.

2. Elevate the limb if possible.

3. Once bleeding slows, gently clean the wound with cool water.

4. Cover with a clean dressing or let air-dry if very minor.

5. Watch for infection over the next few days.

For severe bleeding:

1. Call 999 immediately.

2. Apply direct pressure with whatever clean cloth is available. Push hard and do not stop.

3. Elevate the limb if the wound allows.

4. If bleeding does not stop after 10 minutes of direct pressure, consider a tourniquet:

   • Place the tourniquet 2–3 inches (5–8 cm) above the wound, never over a joint.
   • Tighten until the bleeding stops completely.
   • Do not loosen it.
   • Write the time of application clearly on the tourniquet or the skin.
   • Keep the tourniquet visible and tight.

5. Continue to call 999 and report the tourniquet.

6. Do not remove the tourniquet unless told by paramedics or a doctor.

Common Mistakes:

• Releasing pressure too early. Resist the temptation to check the wound. Continuous pressure is essential.
• Using a tourniquet for minor or moderate bleeding. Tourniquets cause tissue damage and are only appropriate for catastrophic limb bleeding. For moderate bleeding, direct pressure is sufficient and correct.
• Removing a tourniquet outside hospital. This can cause death. Only hospital staff should remove tourniquets.
• Ignoring signs of infection. Redness, warmth, swelling, pus, or fever within days of a wound warrants professional assessment.
• Panic over blood volume. A small wound can bleed dramatically but still be minor. Direct pressure for 10 minutes usually works.
• Using dirty cloth or not washing hands. Use whatever clean cloth is nearest; hand hygiene helps prevent infection.

Improvisation:

• No clean cloth? Use a clean piece of clothing (T-shirt, scarf, bandage, or clean paper towel). The priority is direct pressure; sterility is secondary.
• Elevating a leg wound? Lie the person down and raise their leg on pillows or a bag.
• No tourniquet (catastrophic bleeding only)? Improvise with a belt, a tight bandage, or a strip of cloth tied very tightly around the limb above the wound. Make sure it is tight enough to stop all bleeding.
• Tourniquet improvisation: A belt, rolled cloth, or even a bandage can work. Tighten it by wrapping tighter or using a stick as a lever. Mark the time clearly.
• Wound cleaning: Cool tap water is sufficient. Soap is optional. Do not delay professional help to "clean properly."

Historical Note:

By the early 1900s, direct pressure and elevation were well-established practice in British military first aid. The Field Service Pocket Book (1914) explicitly recommended "firm pressure with a clean dressing" for bleeding wounds. Tourniquets were known but less standardized; early British medical practice sometimes used improvised tourniquets (belts, cloth strips) for severe limb bleeding, though documentation is sparse. The key modern advance is understanding that tourniquets should be applied only for catastrophic bleeding when direct pressure fails, and that they must be marked clearly and left in place for hospital staff to remove. Early approaches sometimes applied tourniquets too quickly or too loose, reducing their effectiveness. A great-grandparent in 1900s Britain would have understood direct pressure and elevation, but would have been less certain about when tourniquets were appropriate or how to apply them effectively.

Safety:

• Direct pressure is always safe. Push hard and maintain contact.
• Do not remove a tourniquet once applied unless instructed by a doctor.
• Clean wounds with clean water; avoid contamination during cleaning.
• Any wound from a rusty object, animal, or dirty source carries tetanus risk. Seek professional assessment if the person's tetanus protection is uncertain.
• Wounds with loss of sensation or movement suggest nerve damage. Professional assessment is essential.
• If a foreign object (glass, metal, debris) is embedded in the wound, do not remove it. Call 999. Removing it may cause severe bleeding.

The Principle: Hypothermia develops gradually but can become fatal if rewarming is done incorrectly. Gradual, gentle rewarming is essential; rapid rewarming can trigger dangerous heart rhythm changes and death.

What You Need to Know:

1. Hypothermia stages (by core body temperature):

   • Mild (32–35°C, 90–95°F): Shivering, confusion, difficulty speaking, stumbling. The person is still conscious but increasingly irrational.
   • Moderate (28–32°C, 82–90°F): Shivering may stop (dangerous sign), confusion is severe, drowsiness, slurred speech, weak pulse, slow breathing.
   • Severe (<28°C, <82°F): Loss of consciousness, barely perceptible pulse and breathing, risk of cardiac arrest. The person may appear dead but may still be resuscitable if very slowly rewarmed.

2. Never assume someone is dead until they are warm and dead. Cold bodies have survived prolonged cardiac arrest and made full recoveries. Resuscitation in severe hypothermia can continue for 1–2 hours or more.

3. Immediate rewarming principles: Remove wet clothing, move the person to a warm room, provide dry layers and blankets, give warm (not hot) drinks if conscious and able to swallow.

4. What NOT to do:

   • Never use a hot bath or hot shower. This causes rapid rewarming of the skin, which diverts blood away from the core, causes a sudden drop in core body temperature ("afterdrop"), and can trigger fatal heart rhythms.
   • Never use hot water bottles or heating lamps directly on the skin. These cause burns and rapid, dangerous rewarming.
   • Never rub limbs or apply vigorous massage. Rough handling can trigger heart rhythm changes and cardiac arrest in severe hypothermia.
   • Never give alcohol or caffeine. These increase heat loss and cause dehydration.

5. Gentle rewarming for mild hypothermia: Remove wet clothes, provide dry clothing and blankets, move to a warm room, give warm (not hot) drinks.

6. Severe hypothermia rewarming: This requires hospital care. Keep the person very still (minimize jostling), continue gentle rewarming with blankets and warm room, and prepare for prolonged CPR. Call 999 immediately.

7. Afterdrop: The core temperature can paradoxically drop further during the early stages of rewarming as cold blood from the limbs returns to the core. This is why rapid rewarming of the skin is dangerous.

The Simple Process:

Mild to moderate hypothermia:

1. Move the person to a warm room or shelter. Do so gently to avoid jostling.

2. Remove wet clothing. Replace with dry clothing or wrap in blankets.

3. Give warm (not hot) drinks — tea, warm water, or broth. Only if the person is conscious and able to swallow safely.

4. Wrap in blankets or layers to prevent further heat loss.

5. Monitor breathing and consciousness. If consciousness is lost or breathing is very slow/weak, call 999.

6. Continue gentle rewarming in the warm room. Do not rush.

7. Reassess after 30 minutes. If improving, continue gradual rewarming. If deteriorating, call 999.

Severe hypothermia:

1. Call 999 immediately.

2. Handle the person very gently. Rough handling can trigger cardiac arrest.

3. Remove wet clothing carefully.

4. Move to a warm room.

5. Dry the person and wrap in blankets. Do not apply direct heat to the skin.

6. If unconscious or in cardiac arrest, begin CPR immediately. Continue CPR during transport to hospital, even if the person appears lifeless. Hospital staff can rewarm using extracorporeal rewarming (machines that warm the blood externally).

7. Do not assume the person is dead until they have been rewarmed by hospital staff.

Common Mistakes:

• Rapid rewarming (hot bath, hot water, vigorous massage). This causes afterdrop and can trigger fatal arrhythmias. Slow, gentle rewarming is essential.
• Giving hot drinks or alcohol. Alcohol increases heat loss. Hot drinks must be warm, not scalding.
• Rough handling. Even moving the person roughly can cause cardiac arrest in severe hypothermia. Be very gentle.
• Assuming the person is dead. Severely hypothermic people have recovered after prolonged CPR. Hospital rewarming can save lives that appear hopeless.
• Stopping rewarming efforts. Continue CPR and gentle rewarming. There is a saying: "Nobody is dead until they are warm and dead."

Improvisation:

• No hot water bottles? Huddle closely with the person to share body heat (skin-to-skin contact is most effective). Wrap both of you in blankets.
• No blankets? Use available dry clothing, newspapers, cardboard, straw, or any insulating material. The goal is to prevent further heat loss.
• No warm drinks? Offer any available drink at room temperature. Water is fine; do not give alcohol.
• No warm room? Move to the most sheltered location available — a car, a windbreak, even a huddle of people sharing body heat.

Historical Note:

In early 1900s Britain, the dangers of rapid rewarming were not well understood. "Treatment" for hypothermia often included vigorous exercise, hot baths, and alcohol — all of which we now know are dangerous. The 1914 Field Service Pocket Book recommended "removing wet clothing and placing in warm conditions," which is correct, but gave no guidance on avoiding rapid rewarming. By the mid-20th century, the principle of gentle, gradual rewarming became understood. The key modern advance is recognizing that rapid skin rewarming causes afterdrop and cardiac arrest, and that very slow rewarming in a warm environment is essential. A great-grandparent in 1900 would have removed wet clothes and sought warmth, but would likely have applied a hot bath or vigorous massage — both of which would have increased the risk of death.

Safety:

• Gentle handling is essential. Avoid jostling or rough movement.
• Do not apply heat directly to the skin.
• Do not give alcohol or caffeine.
• Very slow rewarming takes hours, but it is the only safe approach.
• If consciousness is lost or breathing is very slow, call 999 immediately.
• In severe hypothermia, continue CPR during hospital transport, even if the person appears dead.

The Principle: The sequence of back blows and abdominal thrusts is designed to create sudden high pressure in the airway to dislodge the foreign object. Speed and persistence matter; do not give up until the airway is clear or help arrives.

What You Need to Know:

1. The response sequence for an adult: Encourage cough → 5 back blows → 5 abdominal thrusts → repeat the cycle until the object is dislodged or 999 arrives.

2. Coughing is the most effective first step. If the person can cough strongly, encourage them to cough as hard as possible. Do not interfere.

3. Back blows: Stand behind the person (or kneeling if they are seated or prone). Support their chest with one hand. Deliver 5 sharp, forceful blows to the back between the shoulder blades using the heel of your other hand. The goal is to dislodge the object with sudden impact.

4. Hand position for abdominal thrusts: Stand behind the person with your arms around their waist. Make a clenched fist and place it just above the navel (belly button) and well below the ribcage. Grasp your fist with your other hand. Pull sharply inward and upward (toward the person's head) up to 5 times. This creates a sudden pressure increase in the abdomen that can propel the object upward.

5. Check the mouth. After each cycle of back blows and thrusts, look in the mouth. If the object is visible and easily accessible, remove it. Do not fish blindly into the throat.

6. For children (1–8 years), the sequence is the same: Back blows, then abdominal thrusts. The difference is force — use less force than for adults.

7. For infants (under 1 year), do NOT use abdominal thrusts. Instead: 5 back blows (while supporting the head and jaw), then 5 sharp chest thrusts (using two fingers, in the same position as infant CPR compressions). Check the mouth. Repeat.

8. For unconscious choking: If the person becomes unconscious, open the airway and look for the object. If visible, remove it. Begin CPR (see Cardiac Arrest). Compressions may dislodge the object as a side effect.

9. When to call 999: If the object does not dislodge after 2–3 cycles of back blows and thrusts, call 999. Paramedics have equipment to remove airway objects. Do not stop trying while waiting for help.

10. Pregnant women and large individuals: Use the same abdominal thrust position (just above the navel), not the chest thrusts used for infants. Abdominal thrusts are safer than chest thrusts for these groups.

The Simple Process:

For an adult with complete choking (unable to cough or speak):

1. Encourage cough if possible. If the person can cough, let them cough as hard as they can.

2. If no effective cough, deliver 5 back blows:

   • Stand behind the person.
   • Support their chest with one hand.
   • Deliver 5 sharp, hard blows to the back between the shoulder blades with the heel of your other hand.

3. If the object does not dislodge, deliver 5 abdominal thrusts:

   • Stand behind the person.
   • Make a clenched fist and place it just above the navel, well below the ribcage.
   • Grasp your fist with your other hand.
   • Pull sharply inward and upward, repeating 5 times.

4. Check the mouth. Look in the mouth. If the object is visible and easy to remove, do so.

5. Repeat the cycle: Back blows → abdominal thrusts → check mouth. Repeat until the object is dislodged.

6. If after 2–3 cycles the object is still not dislodged, call 999. Continue back blows and thrusts while waiting for help.

7. If the person becomes unconscious: Open the airway, look for the object and remove if visible. Begin CPR immediately (see Cardiac Arrest).

For a child (1–8 years):

The sequence is identical: back blows → abdominal thrusts → check mouth → repeat. Use less force than for adults.

For an infant (under 1 year):

1. Back blows: Support the infant's head and jaw with one hand, lean them forward. Deliver 5 back blows between the shoulder blades with the heel of your other hand.

2. Chest thrusts: Turn the infant onto their back (supporting the head). Using 2 fingers, deliver 5 sharp thrusts to the centre of the chest, just below the nipple line.

3. Check the mouth. Remove any visible object.

4. Repeat back blows and chest thrusts if needed. Call 999 if the object does not dislodge.

Common Mistakes:

• Not delivering forceful enough blows or thrusts. Gentle pats will not dislodge the object. Blow hard; thrust hard.
• Assuming the person will cough it up. Encourage cough first, but do not wait indefinitely. Move to back blows quickly if coughing is not effective.
• Incorrect hand position for abdominal thrusts. Placing the fist too low (over the navel itself) or too high (over the ribcage) reduces effectiveness and can cause injury. Place it just above the navel.
• Fishing blindly into the throat. You may push the object deeper or cause gagging and further blockage. Only remove objects you can see clearly.
• Giving up too soon. Persist. It may take several cycles to dislodge the object.
• Using abdominal thrusts on infants. Infants have fragile abdomens. Use chest thrusts instead.
• Not calling 999. If the object does not dislodge after a few minutes, call for help. Paramedics have specialized equipment.

Improvisation:

• Back blows: No special equipment needed. Use the heel of your hand.
• Abdominal thrusts: Your hands and arms are the only tool needed.
• Cough encouragement: Speak calmly and reassure the person to cough as hard as possible.

Historical Note:

In early 1900s Britain, choking management was not standardized and often ineffective. The Heimlich maneuver (abdominal thrusts) was not described until 1974. Older British first aid manuals recommended upside-down inversion (hanging the person upside down or having them bend over sharply), which sometimes worked but was awkward and risky. The Field Service Pocket Book (1914) did not systematically address choking. The key modern advance is understanding that back blows combined with abdominal thrusts (or chest thrusts for infants) are more effective and can be reliably taught. A great-grandparent in 1900 might have inverted an adult or given vigorous back thumps, but would not have understood the systematic back-blow-and-thrust sequence used today.

Safety:

• Do not attempt abdominal thrusts on infants under 1 year; use chest thrusts instead.
• Do not delay calling 999 if the object does not dislodge quickly.
• If the person becomes unconscious, open their airway and begin CPR immediately.
• Be prepared to clear the mouth and airway as the object comes loose (it may be sudden).

The Principle: Immobilize the injured area to prevent further damage, swelling, and pain. Assessment distinguishes fractures from sprains (not always possible without X-rays, so treat any serious injury as a potential fracture). Do not attempt to straighten a fractured bone.

What You Need to Know:

1. RICE principle for assessment and early treatment:

   • Rest: Avoid movement and further injury.
   • Ice: Cold reduces swelling and pain. Apply for 10–15 minutes, several times a day (not directly on skin; wrap ice in a cloth).
   • Compression: Elastic bandage or wrap to reduce swelling. Not so tight that it cuts off circulation.
   • Elevation: Raise the injured limb above the level of the heart to reduce swelling.

2. Fracture vs. sprain (clinical signs):

   • Fracture indicators: Severe deformity (bone visibly out of place), crepitus (a grinding or cracking sensation when the area is gently touched), inability to bear weight or move the limb, severe pain that does not ease with position changes, loss of sensation or power below the injury, open fracture (bone breaking the skin).
   • Sprain indicators: Localized swelling, moderate pain, some ability to move or bear weight, no deformity.
   • Gray area: Many fractures and sprains have similar signs. If in doubt, treat as a fracture.

3. Immobilization is the core treatment. Splint the injured limb in the position you find it. Do not attempt to realign or straighten a fractured bone.

4. Improvised splinting materials: Rolled magazines, rolled newspaper, sticks, cardboard, pillows, blankets. Secure with belts, cloth strips, scarves, or ties — anything that holds the splint in place without cutting off circulation.

5. Improvised arm sling: Use a large triangular piece of fabric (a scarf, shawl, or a cloth triangle cut from a sheet). Drape it over the shoulder with the injured arm resting in the fold, and tie the ends around the neck and side. This supports the arm and reduces movement.

6. Fracture locations requiring emergency care: Open fractures (bone has pierced the skin), suspected spinal injury (neck or back pain after a fall or trauma), hip or pelvic fractures (pain when bearing weight, inability to move the leg), compound fractures with severe bleeding, loss of pulse below the fracture (suggests vascular damage).

7. Assess circulation below the fracture. Check for pulse, colour, warmth, and sensation in the fingers or toes below the injury. If circulation is compromised, seek urgent hospital care.

8. Compartment syndrome (late sign): Progressive pain disproportionate to the injury, pain on passive stretching of the injured muscles, numbness, or coolness can develop hours after a fracture. This is a surgical emergency.

The Simple Process:

For a suspected fracture (limb):

1. Stop the activity. Avoid any further movement or weight-bearing.

2. Assess the limb for deformity, inability to move, loss of sensation, or severe pain.

3. Immobilize in the position found. Do not attempt to straighten. Splint the injured limb using whatever rigid material is available (magazine, stick, rolled newspaper, pillow).

4. Secure the splint with belts, cloth strips, or ties. Ensure the splint covers the joint above and below the fracture.

5. Apply ice (wrapped in cloth, not directly on skin) for 10–15 minutes to reduce swelling.

6. Elevate the limb if possible.

7. Monitor circulation below the fracture. Check for pulse, colour, warmth, and sensation in the fingers/toes. If circulation is lost, seek urgent care.

8. Assess pain. Give paracetamol or ibuprofen if conscious and able to swallow.

9. Seek hospital assessment if:

   • The deformity is severe
   • The person cannot move or bear weight
   • The injury is to the hip, pelvis, or spine
   • There is an open fracture
   • Circulation is compromised
   • Any doubt

For an arm fracture:

1. Splint the arm in position (use a sling or rest it across the body).
2. Immobilize with a support or bandage.
3. Apply ice wrapped in cloth.
4. Elevate in a sling.
5. Seek hospital assessment.

For a leg fracture:

1. Do not move the leg unless in immediate danger (e.g., fire).
2. Splint the leg in position using rolled magazines, pillows, or sticks as supports.
3. Apply ice wrapped in cloth.
4. Elevate the leg on pillows.
5. Call 999 for transport if the injury is significant (hip, thigh, severe deformity).

Common Mistakes:

• Attempting to straighten the fracture. This causes severe pain and can damage blood vessels and nerves. Splint in the position found.
• Ignoring signs of circulation loss. Numbness, coldness, or loss of pulse below the fracture is a surgical emergency. Seek urgent hospital care.
• Applying ice directly to skin. This can cause ice burn. Always wrap ice in cloth.
• Splinting too tightly. This cuts off circulation. The splint should be snug but not tourniquet-tight.
• Delaying assessment. Fractures can be hidden (e.g., stress fractures of ribs or vertebrae), and late assessment increases infection risk or compartment syndrome risk.
• Not immobilizing the joints above and below. A splint that only covers the fracture site allows movement and pain. Immobilize generously.

Improvisation:

• Splints: Rolled magazines, newspaper, cardboard, sticks, rolled blankets, or pillows. Anything rigid enough to prevent movement.
• Securing material: Belts, cloth strips, scarves, towels, or fabric torn from clothing. Tie snugly but not so tight that circulation is cut off.
• Arm sling: A scarf, shawl, or large cloth folded into a triangle. Drape over the shoulder, rest the arm in the fold, tie the ends.
• Ice: Snow, cold water, or even a bag of frozen vegetables. Wrap in cloth before applying.
• Elevation: Pillows, bags, or rolled clothing.

Historical Note:

By the early 1900s, the principle of immobilization was well established in British military first aid. The 1914 Field Service Pocket Book recommended "fixation of the fracture" to prevent movement and pain. The RICE principle (or variants) was understood conceptually — rest, cold, elevation — though the formal "RICE" acronym was not standardized until the 1970s. Early practice sometimes involved splinting with bark, wood, cloth, and straw, which is conceptually the same as modern improvisation. However, the understanding that bones should not be realigned by non-professionals came gradually; older texts sometimes recommended "pulling the limb straight," which we now know can cause injury. A great-grandparent in 1900 would have understood immobilization and rest, but might have attempted gentle realignment, which modern first aid avoids.

Safety:

• Do not attempt to realign the bone.
• Immobilize in the position found.
• Check circulation below the fracture regularly.
• Ice reduces swelling and pain but should not be applied directly to skin.
• Seek hospital assessment for any fracture involving major joints or limbs.
• If an open fracture is present (bone has broken through the skin), call 999 immediately and do not move the person unless in danger.

The Principle: Anaphylaxis is a rapid, potentially fatal allergic reaction. The only effective treatment is intramuscular adrenaline, given immediately. Time is critical — delays of even a few minutes can be fatal.

What You Need to Know:

1. Anaphylaxis symptoms (rapid onset, minutes):

   • Swelling of the lips, mouth, tongue, or throat (angioedema).
   • Difficulty breathing, wheezing, or stridor (high-pitched breathing sound).
   • Rash, flushing, or itching.
   • Dizziness, confusion, or loss of consciousness.
   • Abdominal pain, nausea, or vomiting.
   • Rapid or weak pulse.
   • Collapse.

2. Anaphylaxis is not the same as a mild allergic reaction. A mild reaction (localized itching, minor swelling) does not require adrenaline. Anaphylaxis involves breathing difficulty, significant swelling, or collapse, and always requires adrenaline.

3. The adrenaline auto-injector (EpiPen, Emerade, Jext) is the emergency treatment. It delivers intramuscular adrenaline to the mid-thigh. It is the only reliable treatment for anaphylaxis.

4. How to use an auto-injector:

   • Remove the auto-injector from its carrier tube.
   • Remove the safety cap (varies by brand; usually a blue or orange cap is removed first, then a red cap).
   • Place the orange or black tip (the needle end) against the outer mid-thigh, over clothing is fine.
   • Push down firmly until you hear a click. This injects the adrenaline.
   • Hold in place for 3–10 seconds (check the specific injector; EpiPen recommends 10 seconds, others may differ).
   • Remove and massage the injection site for 10 seconds.

5. One auto-injector is often not enough. A second dose can be given 5–15 minutes after the first if there is no improvement or if symptoms return.

6. After giving adrenaline, position the person appropriately:

   • If breathing difficulty: sit upright.
   • If faint or dizzy (without breathing difficulty): lie down with legs raised.

7. Always call 999, even after using an auto-injector. The person needs hospital observation because anaphylaxis can return or worsen hours after the first injection. This is called biphasic anaphylaxis.

8. Knowing who is at risk: Ask family members about allergies and where auto-injectors are kept. In schools or workplaces, know the locations of auto-injectors for staff and students with known allergies. Some settings have spare auto-injectors for people who may be at risk but don't have one.

9. Common triggers: Peanuts, tree nuts, shellfish, milk, eggs, sesame, latex, insect stings (wasps, bees), medications (especially antibiotics), and contrast dye used in medical imaging.

10. Auto-injectors are safe to use even if a reaction is not anaphylaxis. If there is doubt, use the auto-injector. The risks of delaying are far greater than the risks of giving adrenaline for a mild reaction.

The Simple Process:

1. Recognize anaphylaxis: Rapid onset of breathing difficulty, throat swelling, significant rash, dizziness, or collapse within minutes of exposure to an allergen.

2. Call 999 immediately. State "anaphylaxis" to prioritize the call.

3. Get the auto-injector (from the person, from a nearby location, or from emergency equipment in your workplace/school).

4. Inject immediately:

   • Remove the safety caps.
   • Place the needle tip against the outer mid-thigh.
   • Push down firmly.
   • Hold for 3–10 seconds (follow the specific injector instructions).
   • Remove and massage the site for 10 seconds.

5. Position the person:

   • If breathing difficulty: sit them upright.
   • If dizzy or faint: lie them down with legs elevated.

6. Monitor and reassure. Stay with the person until help arrives.

7. If symptoms have not improved after 5–15 minutes, give a second auto-injector (if available) using the same process.

8. Inform paramedics about the auto-injector use (state the time and dose).

9. Expect hospital observation. Even after successful adrenaline treatment, the person may have a second reaction (biphasic anaphylaxis) hours later and needs observation.

Common Mistakes:

• Delaying use of the auto-injector. Anaphylaxis can be fatal within minutes. Inject immediately if there is any doubt. The risk of under-treating far outweighs the risk of over-treating.
• Removing the auto-injector too early. Hold it in place for the full time (usually 3–10 seconds).
• Injecting into the wrong site. The outer mid-thigh is the standard; injecting into the buttock or other sites is less effective.
• Not calling 999. Even after adrenaline, professional hospital observation is essential.
• Failing to give a second dose if needed. If symptoms worsen or do not improve after 5–15 minutes, give a second auto-injector.
• Not knowing where auto-injectors are kept. In homes with allergic members, auto-injectors should be in multiple known locations.
• Panic. Remain calm and reassure the person. Adrenaline has been given; help is on the way.

Improvisation:

• No auto-injector available? Call 999 immediately. Paramedics carry adrenaline. Do not delay the call hoping to find an auto-injector.
• Auto-injector expired? Use it anyway. Expired adrenaline is still better than no adrenaline in anaphylaxis.
• Unsure if it is anaphylaxis? Inject. The risks of withholding adrenaline are far greater than the risks of giving it unnecessarily.

Historical Note:

Anaphylaxis was first formally described in the late 1800s; adrenaline was isolated and synthesized in 1901. However, adrenaline injection for anaphylaxis did not become standard practice until the 1940s–1950s. The auto-injector was invented in the 1970s and became widely available in the 1980s–1990s. In early 1900s Britain, anaphylaxis was a medical mystery — people would suddenly collapse and die after an insect sting or after eating certain foods, with no clear mechanism or treatment. Death from anaphylaxis was common because no effective intervention existed. A great-grandparent in 1900 would have had no understanding of anaphylaxis or any effective treatment; they would have attempted stimulation, warmth, and prayer, all of which were useless. The modern auto-injector has transformed anaphylaxis from almost certainly fatal to highly survivable.

Safety:

• Use the auto-injector immediately if anaphylaxis is suspected. Do not wait.
• Always call 999, even after successful adrenaline injection.
• Position the person appropriately (upright if breathing difficulty, legs elevated if dizzy).
• Be prepared to give a second dose 5–15 minutes after the first if symptoms do not improve.
• Do not be afraid to use the auto-injector. Adrenaline is safe in anaphylaxis; the risks are in not using it.
• Keep auto-injectors in known, accessible locations. Check expiry dates regularly.