Rescue breaths should be delivered slowly to avoid inflation of the stomach, which might lead to regurgitation of any stomach contents and possible pulmonary aspiration (Lawes & Baskett 1987).

Mouth-to-mouth breathing

• Ensure the airway is open (head tilt/chin lift).

• Ensuring the casualty is on their back, give two slow rescue breaths.

• The nose should be occluded by pinching the nostrils between the index finger and thumb of the hand you have on the casualty's forehead.

• The mouth must be open whilst a head tilt/chin lift is maintained.

• You should take a deep breath and place your mouth over the casualty's, ensuring a good seal.

• Exhale slowly, over two seconds.

• You need to observe the chest rise and fall, which gives a measure of the effectiveness of rescue breathing.

• A further deep breath should be taken and a second breath delivered.

• If rescue breathing is not effective, try repositioning the head tilt/chin lift and check for obstructions in the casualty's mouth.

• You can make up to five attempts to deliver two effective breaths.

• If you are unable to secure effective breathing, then proceed to assess for signs of circulation.

• Exhalation can be aided through opening the casualty's mouth at the appropriate time.

Use of mouth barriers/airway adjuncts

Rescuers may have access to barrier devices, such as faceshields or airway adjuncts. The use of faceshields is recommended, especially when attempting resuscitation in unfamiliar environments, away from home (AHA & ILCOR 2000). The dearth of research reviewing the effectiveness of faceshields results in a lack of evidence to support their use by healthcare professionals, for whom the use of masks is recommended when available (Simmons et al. 1995).

Use of a mouth mask

• The mask should be placed on the casualty's face, following the manufacturer's instructions.

• The seal of the mask on the face should be ensured by placing your thumbs and fingers around the lower portion of the mask and jaw (as in Chapter 7).

• Slow breaths are delivered through the mask non-return valve.

• Chest movements should be observed. Assess for signs of circulation

If the rescuer is a lay person they should assess the casualty for signs of circulation and not be expected to undertake a carotid or femoral pulse check, though the healthcare professional should undertake this procedure as well.

• Look, listen and feel for any signs of life, such as breathing, coughing and movement.

• Assess the carotid pulse, if trained to do so.

• Maintain the head tilt with one hand on the casualty's forehead throughout the assessment.

• Using the index finger and middle finger of your free hand, trace down the trachea of the casualty and slide across to palpate the pulse between the trachea and sternocleidomas-toid muscle, at the side of the neck.

• Apply gentle pressure over the carotid pulse for up to ten seconds.

If circulation is present

• Continue your rescue breathing.

• Recheck for signs of circulation every minute.

• If breathing recommences, place the casualty in the recovery position (see page 82).

If circulation is not present

• You should commence chest compressions.

• Locate the lower margin of the casualty's ribs with your index and middle fingers.

• Trace along the lower rib to the xiphoid, where the two ribs join the sternum.

• Place your two fingers on the sternum and bring the heel of your other hand down the sternum to touch your index finger.

• Take your other hand and place the heel on top of the hand already in position.

• Interlock the fingers of both hands to avoid compression of the ribs.

• You should ensure your own safe positioning, with knees apart, shoulders above the point of compression and elbows straight.

• Compressions must be delivered with an even movement, between 4 and 5 cm in depth.

• Release the chest, allowing it to rise, whilst maintaining hand contact and positioning over the point of compression.

• Repeat chest compressions at the rate of 100 compressions per minute.

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