INTRODUCTION

We often first hear about a natural disaster through a story of Noah and flood in the books of
Genesis. Disasters are sudden catastrophic events that disrupt pattern of life and in which
there is possible loss of life and poverty and addition to multiple injuries.

No community is immune to the emergencies caused by disasters. The disaster events result
in number of deaths, injuries amongst the community, widespread destruction of property,
economic loses etc and community requires immediate assistance to overcome its effects.

Both in man-made disasters and natural disasters the role of nurse shifts from direct care to
that of providing directions to and teaching and supervision of non personnel available to
tackle the disaster. She is reset to a doctor best equipped with knowledge and skill to estimate
the potential of such situations and ensure effective management.

‘DISASTER’ alphabetically means

D – Destructions

I – Incidents

S – Sufferings

A - Administrative, Financial Failures

S – Sentiments

T – Tragedies

E - Eruption of Communicable diseases

R - Research programme and its implementation

THE GLOBAL SCENARIO

Impact of natural disaster in the last 30 years.

Ø Death of 3 million people

Ø Economic loss increased due to disaster like flood
Ø In Indian scenario, 34million people affected per year and 5116 death per year

1
DEFINITION
DISASTER

A disaster can be defined as “any occurrence that causes damage, ecological disruption, loss
of human life or deterioration of health and health services on a scale sufficient to warrant an
extraordinary response from outside the affected community area”.

-WHO

Disaster can be defined as “the occurrence of a sudden or major misfortune which disrupts
the basic fabric and normal functioning of a society or community”.

-UN

DISASTER MANAGEMENT

Disaster management is the body of policy, administrative decisions and operational activities
required to prepare for, migrate, respond to, and repair the effects of natural or man-made
disasters.

-UN

DISASTER NURSING

Disaster nursing can be defined as “the adaptation of professional nursing skills in

recognizing and meeting the nursing, physical and emotional needs resulting from a disaster.
The overall goal of disaster nursing is to achieve the best possible level of health for the
people and the community involved in the disaster”.

FACTORS AFFECTING DISASTER

Disasters are affected by the following factors:

Poverty: Rich people are less affected by disaster as they get themselves immediately
secured. Normally poor people get much affected because they are insecure and don’t have
shelter or enough resources for protection.

Environmental deterioration: Many disaster happens due to deterioration in environment

and become more serious. Deforestation, removal of upper soil, over grazing all these factors
make disaster more serious.

Population explosion: There would be more harm in more population, through disaster. The
place where large number of people resides in number of buildings, then effect of disaster is
more.

2
Rapid urbanisation: People from villages or deprived places comes to cities in search of
financial opportunities and security. Due to intense and unorganised urbanisation, disaster
like landslide and floods use to happen. Because of intense and uncontrolled urbanisation,
families of low income group are obliged to live in slopes and banks of rivers which are not
safe.

Lack of vigilance and information: Lack of vigilance and information turn hazards into
disaster. Some people don’t know rescue measures to save themselves. Lack information,
education and communication leads them to be the victim of disaster.

Unsecured shelter: Wrong selection of land for houses or ignoring the possibility of
earthquake at the time of construction or ignoring the quality of soil, all these invites
disasters.

Apart from these reasons, disaster get affected by excessive exploration of natural
resources, environmental imbalance, global warming, climatic changes etc.

TYPE OF DISASTERS

Mainly there are two types of disasters.

 Natural disasters
Includes earth quake, floods, hurricanes, tsunami, cyclones, tidal waves, volcanic
eruptions, tornadoes, snow storms, drought, famine, deforestation
 Man made disasters
Includes nuclear accident, industrial accident, war fare

Disaster can be categorised into five. They are:-

Category 1- Water and Climate related disasters

a) Flood
b) Drought
c) Costal erosion
d) Thunder and Lightening
e) Cyclone and Storms etc.
Category 2 - Geologically related Disasters
a) Landslides and Mudflows
b) Earthquakes
c) Dam failures
d) Tsunami
e) Dam bursts etc.
Category 3 - Chemical Industrial and Nuclear related disasters
a) Leakage of hazardous materials at the time of their manufacture, processing and
transportation.
b) Disasters due to manufacture, storage, use and transportation of products, pesticides
etc and waster produced during the manufacturing process etc.
Category 4 - Biological related disasters
a) Epidemics

3
 b) Cattle epidemics
c) Food poisoning
d) Pest attacks etc.
Category 5- Man-made disasters
a) Forest fire
b) Urban fire
c) Village fire
d) Festival related disasters
e) Road, Rail and Air Accidents
f) Boat capsizing
g) Oil spill

TYPES OF MORBIDITY

On the whole, morbidity which results from a disaster situation can be classified into four
types:

 Injuries
 Emotional stress
 Epidemic of disease
 Increase in indigenous diseases

DISASTER MANAGEMENT

GOALS OF DISASTER MANAGEMENT

1. Reduce, or avoid losses from hazards

2. Assure prompt assistance to victims
3. Achieve rapid and effective recovery

PRINCIPLES OF DISASTER MANAGEMENT

Disaster management is a full time, continuous and ongoing process. In many cases it is not
predictable. The management of disaster is dependent upon the following principles.

• Prevent the occurrence of disaster whenever possible.

• Minimize the number of casualties if the disaster cannot be prevented.

• Prevent further casualties.

• Rescue the victims.

• Provide first aid to the injured

• Evacuate the injured to the medical facilities.

• Provide definitive medical care.

• Promote reconstruction.

4
FUNDAMENTAL ASPECTS OF DISASTER MANAGEMENT

There are three fundamental aspects of disaster management:

 Disaster response
 Disaster preparedness
 Disaster mitigation

DISASTER CYCLE

The disaster management cycle illustrates the ongoing process by which government,
businesses, and civil society plan for and reduce the impact of disasters, react during and
immediately following a disaster, and take steps to recover after a disaster has occurred.
Appropriate actions at all points in the disaster lead to greater preparedness, better warnings,
reduced vulnerability or the prevention of disaster during the next iteration of cycle. The
complete disaster management cycle includes the shaping of public policies and plans that
either modify the causes of disasters or mitigate their effects on people, property, and
infrastructure.

5
DISASTER IMPACT AND RESPONSE

Medical treatment for large number of casualties is likely to needed only after certain types
disaster. Most injuries are stained during the impact, and thus the greatest need for emergency
care occurs in the first few hours. The management mass casualties can be further divided
into search and rescue, first aid, triage and stabilization of victim’s hospital treatment and
redistribution of parents to other hospitals if necessary.

The first step in the disaster management programme is to assess the situation.

The situational analysis is done under the following steps:

 The impact which a hazard has had on a population

6
  The needs and priorities for immediate emergency measures to save and sustain the
lives of survivors
 The resources available
 The possibilities for facilitating

Long term recovery and development

Assessment is a crucial management task which contributes directly to effective decision

making, planning and control of the organised response. Assessment of needs and resources
is required in types of disasters, irrespective of the type or size of the disaster. Assessment is
required during all phases of a disaster from the start of emergency life saving through the
period of stabilisation and rehabilitation and into long term recovery, reconstruction and
return to normalcy.

Search, rescue and first aid

After a major disaster, the need for search, rescue and first aid is likely to be so great that
organized relief services will be able to meet only a small fraction of the demand. Most
immediate help comes from the uninjured survivors.

Field care

Most injured persons converge spontaneously to health facilities, using whatever transport is
available, regardless of the facilities and operating status. Providing proper care to casualties
such that the health service resources be redirected to this new priority. Bed availability and
surgical services should be maximised. Provisions should be made for food and shelter. A
centre should be established to respond to injuries from patient’s relatives and friends.
Priority should be given to victim’s identification and adequate mortuary space should be
provided.

Triage

When the quantity and severity of injuries overwhelm the operative capacity of health
facilities, a different approach to medical treatment must be adopted. The principle of “first
come, first treated”, is not followed in mass emergencies. Triage consists of rapidly
classifying, the injured on the basis of the severity of their injuries and the likelyhood of their
survival with prompt medical intervention. It must be adopted to locally available skills.
Higher priority is granted to victims whose immediate or long term prognosis can be
dramatically affected by simple intensive care. Moribund patients who require a great deal of
attention , with questionable benfit, have to the greatest number of injured in a disaster
situation.

Although different triage systems have been adopted and are still in use in some countries,
the most common classification uses the internationally accepted four colour code system.
Red indicates high priority treatment or transfer, yellow signals medium priority, green
indicates ambulatory patients and black for dead or moribund patients.

7
Triage should be carried out at the site of disaster, in order to determine transportation
priority, and admission to the hospital or treatment centre, where the patient’s needs and
priority of medical care will be reassessed. Ideally, local health workers should be taught the
principles of triage as part of disaster training.

Persons with minor or moderate injuries should be treated at their own homes to avoid social
dislocation and the added drain on resources of transporting them to central facilities. The
seriously injured should be transported to hospitals with specialised treatment facilities.

Tagging

All patients should be identified with tags stating their name, age, place of origin, triage
category, diagnosis, and initial treatment.

Identification of dead

Taking care of the dead is an essential part of the disaster management. A large number of
dead can also impede the efficiency of the rescue activities at the site of the disaster. Care of
dead includes:

 Removal of the dead from the disaster scene

 Shifting to the mortuary
 Identification
 Reception of bereaved relatives.

Proper respect for dead is of great importance.

The health hazards associated with cadavers are minimal if death results from trauma,
and corps are quite unlikely to cause outbreaks of disease such as typhoid fever, cholera or
plague. If human bodies contaminate streams, wells, or other water sources as in floods etc,
they may transmit gastroenteritis or food poisoning to survivors. The dead bodies represent a
delicate social problem.

Relief phase

This phase begins when assistance from outside starts to reach the disaster area. The type and
quantity of humanitarian relief supplies are usually determined by two main factors:

 The type of disaster, since distinct events have different effects on the population, and
 The type and quantity of supplies available locally.

Immediately following a disaster, the most critical health supplies are those needed for
treating casualties, and preventing the spread of communicable diseases. Following the initial
emergency phase needed supplies will include food, blankets, clothings, shelter, sanitary
engineering equipment and construction material. A rapid damage assessment must be carried
out in order to identify needs and resources. Disaster managers must be prepared to receive
large quantities of donations. There are four principal components in managing humanitarian
supplies:

8
 a. Acquisition of supplies
b. Transportation
c. Storage
d. Distribution

Epidemiologic surveillance and disease control

Disease can increase the transmission of communicable diseases through following

mechanisms:

1. Overcrowding and poor sanitation in temporary resettlements. This accounts in part,

for the reported increase in acute respiratory infections etc following the disasters.
2. Population displacement may lead to introduction of communicable diseases to which
either the migrant or indigenous populations are susceptible.
3. Disruption and the contamination of water supply, damage to sewage system and
power systems are common in natural disasters.
4. Disruption of routine control programmes as funds and personnel are usually diverted
to relief work.
5. Ecological changes may favour breeding of vectors and increase the vector population
density.
6. Displacement of domestic and wild animals, who carry with them zoonoses that can
be transmitted to humans as well as to other animals. Leptospirosis cases have been
reported following large floods (as in Orissa, India, after super cyclone in 1999).
Anthrax has been reported occasionally.
7. Provision of emergency food, water and shelter in disaster situation from different or
new source may itself be a source of infectious disease.

Outbreak of gastroenteritis, which is the most commonly reported disease in the post-
disaster period, is closely related to first three factors mentioned above. Increased
incidence of acute respiratory infections is also common in displaced population. Vector-
borne diseases will not appear immediately but may take several weeks to reach epidemic
levels.

Displacement of domesticated and wild animals increases the risk of transmission of

zoonoses. Veterinary services may be needed to evaluate such health risks. Dogs, cats and
other domestic animals may be reservoirs of infections such as leptospirosis, rickettsiosis
etc. Wild animals are reservoirs of infections which can be fatal to man such as
encephalitis, rabies, and infections still unknown in humans.

The principles of preventing and controlling communicable diseases after a disaster are to

a) Implement as soon as possible all public health measures, to reduce the risk of disease
transmission
b) Organize a reliable disease reporting system to identify outbreaks and to promptly
initiate control measures
c) Investigate all reports of disease outbreaks rapidly

9
Nutrition

A natural disaster may affect the nutritional status of the population by affecting one or more
components of food chain depending on the type, duration and extent of the disaster, as well
as the food and nutritional conditions existing in the area before the catastrophe. Infants,
children, pregnant women, nursing mothers and sick persons are more prone to nutritional
problems after prolonged draught or after certain types of disasters like hurricanes, floods,
land or mudslides, volcanic eruptions and sea surges involving damage to crops, to stock or
to food distribution systems.

The immediate steps for ensuring that the food relief programme will be effective include:

a) Assessing the food supplies after the disaster

b) Bridging the nutritional needs of the affected population
c) Calculating daily food rations and need for large population groups and
d) Monitoring the nutritional status of the affected population

Rehabilitation

The final phase in a disaster should lead to restoration of the pre disaster conditions.
Rehabilitation starts from the very first moment of a disaster. Too often, measures decided in
a hurry, tend to obstruct re-establishment of normal conditions of life. Provisions by external
agencies of sophisticated medical care for a temporary period has negative effects. On the
withdrawal of such care, the population is left with a few level of expectation which simply
cannot be fulfilled.

In first weeks after disaster, the pattern of health needs, will change rapidly, moving from
casualty treatment to more routine primary health care. Services should be recognised and
restructured. Priorities also will shift from health care towards environmental health
measures. Some of them are as follows:

Water supply

A survey of all public water supplies should be made. This includes distribution system and
water source. It is essential to determine physical integrity of system components, the
remaining capacities, and bacteriological and chemical quality of water supplied.

The main public safety aspect of water is microbial contamination. The first priority of
ensuring water quality in emergency situations is chlorination. It is the best way of
disinfecting water. It is advisable to increase residual chlorine level to about 0.2- 0.5 mg/litre.
Low water pressure increases the risk of infiltration of pollutants into water mains. Repaired
mains, reservoirs and other units require cleaning and disinfection.

Chemical contamination and toxicity are a second concern in water quality and potential
chemical contaminants have to be identified and analysed.

The existing and new water sources require the following protection measures;

10
 1. Restrict access to people and animals, if possible, erect a fence and appoint a guard.
2. Ensure adequate excreta disposal at a safe distance from water source.
3. Prohibit bathing, washing and animal husbandry, upstream of intake points of rivers
and streams
4. Upgrade wells to ensure that they are protected from contamination.
5. Estimate the maximum yield of wells and if necessary, ration the water supply.

In many emergency situations, water has to be trucked to disaster site or camps. All water
tankers should be inspected to determine fitness and should be cleaned and disinfected before
transporting water.

Food safety

Poor hygiene is the major cause of food borne diseases in disaster situations. Where feeding
programmes are used kitchen sanitation is of utmost importance. Personal hygiene should be
monitored in individuals involved in food preparation

Basic sanitation and personal hygiene

Many communicable diseases are spread through faecal contamination of drinking water and
food. Hence, every effort should be made to ensure the sanitary disposal of excreta.
Emergency latrines should be made available to the displaced, where toilet facilities have
been destroyed. Washing, cleaning and bathing facilities should be provided to the displaced
persons.

Vector control

Control programme for vector borne disease should be intensified in the emergency and
rehabilitation period, especially areas where such diseases are known to be endemic. Of
special concern are dengue fever, malaria, leptospirosis, rat-bite fever, typhus and plague.
Flood water provides ample breeding opportunities for mosquitoes.

A major disaster with high mortality leaves a substantial displaced population, among whom
are those requiring medical treatment and orphaned children. When it is not possible to locate
the relatives who can provide care, orphans may become the responsibility of health and
social agencies. Efforts should be made to reintegrate disaster survivors into the society, as
quickly as possible through institutional programmes coordinated by ministries of health and
family welfare, social welfare, education and NGOs.

DISASTER MITIGATION IN HEALTH SECTOR

Emergency prevention and mitigation involves measures designed either to prevent hazards
from causing emergency or to lessen the likely effects of emergencies. These measures
include flood mitigation works, appropriate land use planning, improved building codes, and
reduction or protection of vulnerable population and structures.

In most cases mitigation measures aims to reduce the vulnerability of the system. Medical
casualties can be drastically reduced by improving the structural quality of houses, schools

11
and other public and private buildings. Although mitigation in these sectors has clear health
implications, the direct responsibility of the health sector is limited to ensuring the safety of
health facilities and public health services, including water supply and sewage systems. When
water supplies are contaminated or interrupted, in addition to the social cost of such damage,
the cost of rehabilitation and reconstruction severely strains the economy. Mitigation
complements the disaster preparedness and disaster response activities. Mitigation activities
actually eliminate or reduce the probability of disaster occurrence, or reduce the effects of
unavoidable disasters. Mitigation measures include building codes, vulnerability analyses
updates, zoning and land use management, building use regulations and safety codes,
preventive health care and public education. Mitigation will depend on the incorporation of
appropriate measures in national and regional development planning. Its effectiveness will
also depend on the availability of information on hazards, emergency risks, and the
countermeasures to be taken, the mitigation phase, and indeed the whole disaster
management cycle, includes the shaping of public policies and plans that that either modify
the causes of disasters or mitigate their effects on people, property and infrastructure.

DISASTER PREPAREDNESS

The goal of emergency preparedness programs is to achieve a satisfactory level; of readiness

to respond to any emergency situation through programs that strengthen the technical and
managerial capacity of governments, organisations and communities. These measures can be
described as logistical readiness to deal with disasters and can be enhanced by having
response mechanisms and procedures, rehearsals, developing long term and short time
strategies, public education and building early warning systems. Preparedness can also take
the form of ensuring that strategic reserves of food, equipment, water, medicines and other
essential are maintained in cases of national or local catastrophes.

During the preparedness phase, governments, organisations and individuals develop plans to
save lives, minimise disaster damage and enhance disaster response operations. Preparedness
measures include preparedness plans, emergency exercise\ training; warning systems,
emergency communications systems; evacuations plans and training, resource inventories;
emergency personnel/contact lists; mutual aids agreements and public information/education.
As with mitigations efforts, preparedness actions depend on the incorporation of appropriate
measures in national and regional developments plans. In addition, their effectiveness
depends on the availability of information on hazards, emergency risks and the
countermeasures to be taken and on the degree to which government agencies, non-
governmental organisations and the general public are able to make use of this information.

PERSONAL PROTECTION EDUCATION IN DIFFERENT TYPES OF

EMERGENCIES

In addition to considering the rescuers, thought must be given to personal protection

measures in different types of emergencies. Making people aware of what is expected of
them in case of an emergency can make large difference to the organised management

12
efforts. By taking precaution, the individual assists the collective effort to reduce the efforts
of an emergency.

A number of measures must be observed by all persons in all types of emergency:

 Do not use the telephone, except to call for help, so as to leave telephone lines free for
the organization of response.
 Listen to the message broadcast by radio and the various media so as to be informed
of development.
 Carry out the official instructions given over the radio or by loudspeaker.
 Keep a family emergency kit ready.

In all the different types of emergency, it is better:

 To be prepared then to get hurt.

 To get information so as to get organised
 To wait rather than act too hastily.

Floods

What to do before hand

While town planning is a government responsibility, individuals should find out about risk in
the area where they live. For example, people who live in areas downstream from a dam
should know the special signals used when a dam threatens to break. Small floods can be
foreseen by watching the water level after heavy rains and regularly listening to the weather
forecast.

Forecasting of floods or tidal waves is very difficult, but hurricanes and cyclones often occur
at the same time of the year, when particular vigilance must be exercised. They are often
announced several hours or days before they arrive.

During a flood

 Turn off the electricity to reduce the risk of electrocution

 Protect people and property
 As soon as the flood begins, take any vulnerable people to an upper floor.
 Whenever possible, move personal belonging upstairs or go to raised shelter
provided for use in floods.
 Beware of water contamination – if the taste, colour, or smell of the water is
suspicious, it is vital to use some means of purification. Evacuate danger zones
ordered by the local authorities, it is essential to comply strictly with the
evacuation advice given. Authorities will recommend that families take with the
emergency supplies they have prepared.

After a flood

13
When the flood is over, it is important that people do not return home until told to do so by
the local authorities, who will have ensured that buildings have not been undermined by
water. From then on it is essential to;

 Wait until the water is declared safe before drinking any that is untreated.
 Clean the room that has been flooded.
 Sterilize or wash with boiling water all dishes and kitchen utensils.
 Get rid of any food that has been in or near the water, including canned foods, any
food kept in refrigerators and freezers.
 Get rid of consumables.

Storms, Hurricanes And Tornadoes

What to do beforehand

 Choose a shelter in advance, before the emergency occurs – a basement, or may be

suitable.
 Take measures against flooding.
 Prepare a family emergency kit.

During an emergency

 Listen to the information and advice provided by the authorities.

 Do not go out in a car or boat once the storm has been announced.
 If possible, tie down any object liable to be blown away by the wind.
 In a thunderstorm keep away from doors, windows, and electrical conductors, unplug
electrical appliances and television aerials. Do not use any electrical appliances or the
telephone.
 Anyone who is outside should:
 Look for shelter in a building (never under a tree)
 If out in a boat, get back to the shore
 Keep away from fences and electric cables
 Kneel down rather than standing

After an emergency

 Follow the instructions given by the authorities

 Give first aid to injured
 Make sure that the water is safe to drink and check the contents of the refrigerators
and freezers
 Check the exterior of dwelling and call for assistance if there is a risk of falling
objects.

Earthquakes

What to do beforehand

14
  Build in accordance with urban planning regulations for risk areas.
 Ensure that all electrical and gas appliances in houses, together with all pipes
connected to them, are firmly fixed.
 Avoid storing heavy objects and material in a high position.
 Hold family evacuation drills and ensure that the whole family knows what to do in
case of an earthquake.
 Prepare a family emergency kit.

During an earthquake

 Keep calm, do no panic

 People who are indoors should stay there but move to the central part of the building.
 Keep away from the stairs that might collapse suddenly.
 Anyone in a vehicle should park it, keeping away from bridges and buildings.

After an earthquake

 Obey the authority’s instructions

 Do not go back into damaged buildings since tremors may start again at any moment.
 Give first aid to the inured and alert the emergency services in case of fire, burst pipes
etc.
 Do not go simply to look at the stricken areas: this will hamper rescue works.
 Keep emergency packages and a radio near at hand.

Clouds of toxic fumes

What to do beforehand

 People in a risk area should:

- find out about evacuation plans and facilities;
- familiarize themselves with the alarm signals used in case of emergency;
- equip doors and windows with the tightest possible fastenings;
- prepare family emergency kits.

During an emergency
- Do not use the telephone; leave lines free for rescue services.
- Listen to the messages given by radio and other media.
- Carry out the instructions transmitted by radio or loudspeaker.
- Close doors and windows.
- Stop up air intakes.
- Seal any cracks or gaps around windows and doors with adhesive tape.
- Organize a reserve of water (by filling wash basins, baths, etc.).

15
 - Turn off ventilators and air conditioners.

After an emergency
- Comply with the authorities' instructions and do not go out until there is no longer any
risk.
- Carry out necessary decontamination measures.

DISASTER MANAGEMENT IN INDIA

According to government of India, Ministry of Home Affairs Disaster
Management division the STANDARD OPERATING PROCEDURE describes five
phases. They are:
i. Early Warning Phase
ii. Response Phase
iii. Relief Phase
iv. Restoration

PREPAREDNESS PHASE

This phase will include taking all necessary measures for planning, capacity building and
other preparedness so as to be in a state of readiness to respond, in the event of a natural
disaster. This Stage will also include development of Search & Rescue Teams, mobilization
of resources and taking measures in terms of equipping, providing training, conducting mock
drills/exercises etc.

INSTITUTIONAL MECHANISM
In our federal system of governance, in the aftermath of a disaster, the primary
responsibility for undertaking the rescue, relief and rehabilitation measures rests with the
concerned State Governments. The role of the Central Government is supportive, in terms
of physical and financial resources and complementary in sectors such as transport, early
warning systems, etc.
The Disaster Management Act 2005, lays down a three tier" institutional structure for
disaster management at the national, state and district levels in the form of
NDMA, SDMA and DDMA. National Policy on Disaster Management (NPDM) has further
specified the roles and responsibilities of various organizations for disaster response.

16
NATIONAL LEVEL
National Crisis Management Committee (NCMC)
At the National Level, the Command, Control and Coordination of the disaster
response will be overseen by the National Crisis J\1anagementCommittee (NCJ\1C) under
the Cabinet Secretary. NCMC will issue guidelines from time to time as required for effective
response to natural disasters.
All Ministries/Departments/Agencies at the national level shall comply with the
instructions of NCMC. The NPDM prescribes that NCM C shall deal with 'major disasters
that have serious or national ramifications.

Ministry of Home Affairs (MHA)

The Ministry of Home Affairs is the nodal agency at the National level for
coordination of response and relief in the awake of natural disasters (except drought, pest
attack & hailstorm). MBA will provide financial and logistic support to the State
Governments, keeping view, their resources, the severity of the natural disaster and the
capacity of the State Governments to respond in a pat1icular situation.

National Executive Committee (NEC)

Disaster Management Act stipulates that the NEC under the Union Home Secretary will
'coordinate response in the event of any threatening disaster situation or disaster’. NEC may
give directions to the concerned Ministries/Departments of the Govt. of India, the State
Governments and the State Authorities regarding measures to be taken by them in response to
any specific threatening disaster situation or disaster.

Other Central Ministries/Departments

The other concerned Central Ministries/Departments/Organisations will render Emergency
Support Functions (ESF) wherever Central intervention and support are needed by the State
Governments.

STATE LEVEL
State Executive Committee (SEC)
It will be the primary responsibility of the State Government to respond to natural
disasters and provide relief to the affected people Disaster Management Act stipulates that

17
the SEC under the State Chief Secretary shall 'coordinate response in the event of any
threatening disaster situation or disaster'. SEC shall give directions to any Department of the
State Government or any other authority or body in the State regarding actions to be taken in
response to any disaster.
Department of Relief/ Disaster Management shall be the nodal department for
disaster management and Secretary of the Department/Relief Commissioner shall implement
the decisions of the SEC pertaining to State level Response to natural disasters. State
Governments will provide emergency support in their relevant domains at the State/District
levels.

DISTRICT LEVEL
District Disaster Management Authority (DDMA)
Disaster Management Act stipulates that the DDMA under the chair of the Collector
or District Magistrate or Deputy Commissioner, as the case may be and the co-chair of the
elected Representative of the local authority shall 'coordinate response to any threatening
disaster situation or disaster'. The Collector/District Magistrate/Deputy Commissioner, as the
head of administration at the district, shall be the focal point in the command and control for
disaster response at the district level, in accordance with the policies/guidelines/instructions
from the national and state levels. Depending on the nature of disaster and response he will
be the Incident Commander himself or delegate the responsibility to some other officer. All
the Departments/Agencies of the Central and State Governments in the District/City involved
in response and relief will work in accordance with the directions of the Incident
Commander.
The lower administrative units of Districts viz; Subdivisions under the
administrative control of a Sub-divisional Magistrate/Officer and Blocks and
Tehsils under the administrative control of the Block Development
Officers/Tehsildars will coordinate the functioning of the various departments in
their respective jurisdiction.
The Incident Command Teams at Subdivision and Block levels under SDO/SDM or
BDO/Tehsildar as the case be will be responsible for all response and relief works.

18
Mechanism for International Assistance
As a stated policy of the Government of India no appeals shall be made seeking foreign
aid for disaster response. However if the foreign national governments voluntarily offer
assistance as a goodwill gesture in solidarity of the disaster victims, the Ministry of Home
Affairs will coordinate with the Ministry of External Affairs for obtaining and channelizing
such assistance..
All national and international non-government agencies while rendering emergency
support functions on the ground will function under the' overall command of the State
Government through the Incident Commander.

HOSPITAL PREPAREDNESS
Hospital preparedness is crucial to any disaster response system. Each hospital need to
have an emergency preparedness plan to deal with mass casualty incidents and the hospital
administration/doctor trained for this emergency.

EARLY WARNING PHASE

This phase will include all necessary measures to provide timely, qualitative and
quantitative warnings to the disaster managers to enable them to take preemptive measures
for preventing loss of life and reducing loss/damage to the property. On· the occurrence of a
natural disaster or imminent threat thereof, all the concerned Agencies will be
informed/notified for initiating immediate necessary follow up action.

RESPONSE PHASE
This phase will include all necessary measures to provide immediate succor to the
affected people by undertaking search, rescue and evacuation measures.

RELIEF PHASE
This phase will include all necessary measures to provide immediate relief and
succor to the affected people in terms of their essential needs of food, drinking water,
health &hygiene, clothing, shelter.

19
RESTORATION STAGE
This phase will include all necessary measures to stabilize the situation and restore the
utilities.

HOSPITAL DISASTER PLAN

The hospital is an integral part of the society and it a has great role to play in the
disaster management; Every hospital small or big, public or private has to prepare a disaster plan.

The disasters in the hospital perspective can be grouped into two categories:

1. Internal Hospital disaster like fire, building collapse, terrorism, etc.

2.External disasters like; earthquakes, floods, etc.
Objectives of the Hospital Disaster Plan
1. Preparedness of staff, optimizing of resources and mobilization of the logistics and supplies
within short notice.
2. To make community aware about the hospital disaster plan and benefits of plan. Training and
motivation of the staff.
3. To carry out mock drills.
4. Documentation of the plan and making the hospital staff aware about the various steps of plan.

Designing of Hospital Disaster Plan

Disaster management committee; The hospital disaster management committee is the decision
making body for formulation of the policy and plan for disaster management.
The committee is constituted with the following members;
a. Director of the Hospital .
b. HOD of Accidents and Emergency Services
c. All heads of the department
d. Nursing Superintendent

e. Hospital administrator

f. Representatives of the staff.

Functions of the disaster management committee:

The functions of the committee can be enumerated as;

20
a. To prepare a hospital disaster plan for the hospital.

b. To prepare departmental plan in support of the hospital plan.

c. Assign duties to the staff.

d. Establishment of criteria for emergency care

e. To conduct, supervise and evaluate the training programs.

f. To supervise the mock drills.

g. Updating of plans as need arises.

h. Organise community awareness programs, through mass media.

i. Assist in Information Education Communication (lEC) programs in respect of the disaster

preparedness, prevention and management.

Role and functions:

The effective implementation of the program will depend upon the clarity of the plan, role and
functions of the different members and staff. These are being enumerated as follows.
a. Disaster coordinator: The coordinators' role will be:
i. Organising
ii. Communicating
iii. Assigning duties
iv. Deployment of staff
v. Taking key decisions
..
b. Administrator: The responsibilities of the administrator will be; to execute the authority
through the departmental heads.

c. Departmental heads: Development of departmental plans.

d. Nursing superintendent: Deployment of nursing staff.

21
 e. Medical staff: Specific role of rendering medical care both pre hospital land hospital care.
f. Nursing staff: Nursing care and support critical care.

Important departments: The important departments of the hospital have to play a key role in the disaster
management;
a. Accident and Emergency department
b. Operating department
c. Critical care units
d. Radiology departments
e. Laboratory
f. Blood bank

Support areas: Logistics and prompt supply of drugs, linen, surgical items, fluids are required in
the hospital and due care has to be taken to incorporate the role and function of the following units:
a. Laundry
b. CSSD
c. Dietary department
d. Housekeeping services
e. Medical records
f. Public Relation
g. Communications
h. Transportation
i. Mortuary
j. Medic-social worker
k. Engineering department
l. Security and safety services
m. Media relations

Organising Disaster Facilities

1. Triage: This is very important part for successful implementation of the disaster management
program in the hospital. This is located in the; emergency services, where triage team
consisting of physician, surgeon, nursing personnel, handle the incoming patients.
Rapid assessment of the injury and extent of severity of the casualty is done by doctors/ nurses
and assign the casualty to an appropriate treatment area based upon the medical/nursing

22
 needs of the patients. To identify different categories of casualty, colour coding is preferred.
2. Primary treatment area: The treatment areas are divided into: ..
a. Immediate care
b. Urgent care
c. Non-urgent care
3. Secondary treatment areas: It will include· all wards, critical care units, operating and
diagnostic units. The casualties requiring treatment will be taken from primary treatment
area to ICU, OT or Wards.
4. Inpatient evacuation holding area: To open one or two wards to receive all the admitted
victims of a disaster is essential. Additional beds are made available in other wards or
sometimes creating temporary wards in nearby schools or buildings can also be considered
if the intake is much.
5. Additional facilities: In addition to the existing facilities of the hospital some additional
facilities are also created:
a. Control room
b. Information Public Relation counter
c. Relative's waiting area
d. Media room
e. Volunteers reception

DISASTERS IN INDIA
With a wide range of topographic and climatic conditions, India is the highly
disaster-prone country in Asia-Pacific region with an average of 8 major natural calamities a
year. While floods, cyclones, draughts, earthquakes and epidemics are frequent from time to
time, major accidents happen in railways, mines and factories causing extensive damage to
human life and property.
Northern mountain regions, including the foot hills are prone to snow-storms,
land slides and earthquakes. The eastern coastal areas are prone to severe floods and cyclones
(Andhra Pradesh, West Bengal, Orissa, etc.). Bihar, Assam and Uttar Pradesh get major
floods almost every year. Western desert areas are prone to draughts. There is hardly a year
when some or the other part of the country does not face the spectre of drought, floods or
cyclone. Orissa had super cyclone on 29th October 1999, when thousands lost their lives and
many more became homeless. Gujarat had a severe earthquake in which about 16480 people
died and lacs became homeless. More recently, Tsunami killed more than 200,000 persons in

23
India in Dec. 2004 and major earthquake in Jammu & Kashmir (7.4 RS) left 2100 dead and
30,000 injured. India also saw world's worst man-made disaster in 1984, when methyl
isocyanate gas leaked at Union Carbide Pesticide Plant in Bhopal killing about 3000 people.
People are still suffering from variety of diseases, as an after effect of this tragedy.
In the federal structure of India, the state governments are responsible for
the execution of relief work in wake of natural disasters. Government of India plays a
supportive role, in terms of supplementation of final resources to the states. An administrative
system has been developed to combat and minimize the adverse impact of the natural
disasters. At the centre, the Ministry of Agriculture is the nodal ministry for coordination of
all activities during a natural disaster. Since health is an important part of disaster
management, in the DGHS under the ministry of Health and Family Welfare there is a special
wing called the Emergency Medical Relief Wing which coordinates all activities related to
health.
In a vast country like India, it is not practicable for the government machinery
alone, to undertake disaster reduction programmes without involvement of NGOs. Public
education and community involvement plays a vital role here. As part of the International
Decade for Natural Disaster Reduction activities, every year, the second Wednesday of
October has been designated as World Disaster Reduction Day.
Indian Meteorological Department (IMD) plays a key role in forwarning the
disaster. It has five centres in Kolkata, Bhubaneshwar, Vishakhapatnam, Chennai and
Mumbai for detection and tracing of cyclone storms. Satellite imagery facilities and cyclone
warning radars are provided to various Cyclone Warning Centres. In addition, it has 31
special observation posts set up along east coast of India. For all ships out at sea, warnings
are issued six times a day. Insat Disaster Warning System (DWS) receivers have been
installed primarily in the coastal areas of Tamil Nadu and Andhra Pradesh. This has proved
very reliable for.n of communication system. The Snow and Avalanche Study Establishment
(SASE) in Manali has been issuing warning to people about avalanches 24 to 48 hours in
advance.

RESEARCH STUDIES

1. Perceptions of knowledge of disaster management among military and civilian

nurses in Saudi Arabia.

24
Al Thobaity A, Plummer V, Innes K, Copnell B
Abstract
BACKGROUND:
It is generally accepted that nurses have insufficient knowledge about disaster preparedness
due to a lack of acceptance of core competencies and the absence of disaster preparedness
in nursing curricula.1 This study explored nurses' knowledge and sources of knowledge, and
skills as they relate to disaster management in Saudi Arabia, where more than 4660 people
have died, 32,000 people have been affected, and US$4.65 billion in damage has been caused
by disaster since 1980.2 METHODS: A quantitative, non-experimental, descriptive research
design.
RESULTS:
Nurses in Saudi Arabia have moderate knowledge concerning disaster preparedness.
However, nurses in military hospitals possess more knowledge than those who work in
government hospitals. The majority of nurses gained their knowledge and skills
from disaster drills.
CONCLUSIONS:
Nurses need more education in all areas of disaster management, most importantly in their
roles during response to disasters. Nurses perceive themselves as not well-prepared but they
are willing to improve their skills in disaster preparedness if educational opportunities are
provided.

2) Design and development of compact monitoring system for disaster remote health
centres.
Santhi S1, Sadasivam GS.
Abstract
PURPOSE:
To enhance speedy communication between the patient and the doctor through newly
proposed routing protocol at the mobile node.
MATERIALS AND METHODS:
The proposed model is applied for a telemedicine application
during disaster recovery management. In this paper, Energy Efficient Link Stability Routing
Protocol (EELSRP) has been developed by simulation and real time. This framework is
designed for the immediate healing of affected persons in remote areas, especially at the time
of the disaster where there is no hospital proximity. In case ofdisasters, there might be an
outbreak of infectious diseases. In such cases, the patient's medical record is also transferred
by the field operator fromdisaster place to the hospital to facilitate the identification of
the disease-causing agent and to prescribe the necessary medication. The heterogeneous
networking framework provides reliable, energy efficientand speedy communication between
the patient and the doctor using the proposed routing protocol at the mobile node.
RESULTS:
The performance of the simulation and real time versions of the Energy Efficient Link
Stability Routing Protocol (EELSRP) protocol has been analyzed. Experimental results prove
the efficiency of the real-time version of EESLRP protocol.
CONCLUSION:
The packet delivery ratio and throughput of the real time version of EELSRP protocol is
increased by 3% and 10%, respectively, when compared to the simulated version of EELSRP.

25
The end-to-end delay and energy consumption are reduced by 10% and 2% in the real time
version of EELSRP.

3) Post-tsunami relocation of fisher settlements in South Asia: evidence from the

Coromandel Coast, India.
Bavinck M1, de Klerk L, van der Plaat F, Ravesteijn J, Angel D, Arendsen H, van Dijk T, de
Hoog I, van Koolwijk A, Tuijtel S, Zuurendonk B.
Abstract
The tsunami that struck the coasts of India on 26 December 2004 resulted in the large-scale
destruction of fisher habitations. The post-tsunami rehabilitation effort in Tamil Nadu was
directed towards relocating fisher settlements in the interior. This paper discusses the
outcomes of a study on the social effects of relocation in a sample of nine communities along
the Coromandel Coast. It concludes that, although the participation of fishing communities in
house design and in allocation procedures has been limited, many fisher households are
satisfied with the quality of the facilities. The distance of the new settlements to the shore,
however, is regarded as an impediment to engaging in the fishing profession, and many
fishers are actually moving back to their old locations. This raises questions as to the
direction of coastal zone policy in India, as well as to the weight accorded to safety (and other
coastal development interests) vis-à-vis the livelihood needs of fishers.

4) Strategic planning and designing of a hospital disaster manual in a tertiary care,

teaching, research and referral institute in India.
Talati S1, Bhatia P2, Kumar A3, Gupta AK1, Ojha CD1
Abstract
BACKGROUND:
As per the "Disaster Management Act, 2005" of India, it is mandatory for government
hospitals in India to prepare a disaster plan. This study aimed to prepare a disaster manual of
a 1 900 bed tertiary care hospital, in consultation and involvement of all concerned
stakeholders.
METHODS:
A committee of members from hospital administration, clinical, diagnostic and supportive
departments worked on an initial document prepared according to the Act and gave their
inputs to frame a final disaster manual.
RESULTS:
The prepared departmental standard operating procedures involved 116 people (doctors and
paramedical staff), and were then synchronized, in 12 committee meetings, to produce the
final hospital disaster manual.
CONCLUSIONS:
The present disaster manual is one of the few comprehensive plans prepared by the
stakeholders of a government hospital inIndia, who themselves form a part of
the disaster response team. It also helped in co-ordinated conduction of mock drills.

5) Multiple shocks, coping and welfare consequences: natural disasters and health
shocks in the Indian Sundarbans.

26
Mazumdar S1, Mazumdar PG2, Kanjilal B3, Singh PK1.
Author information
Abstract
BACKGROUND:
Based on a household survey in Indian Sundarbans hit by tropical cyclone Aila in May 2009,
this study tests for evidence and argues that health and climatic shocks are essentially linked
forming a continuum and with exposure to a marginal one, coping mechanisms and welfare
outcomes triggered in the response is significantly affected.
DATA & METHODS:
The data for this study is based on a cross-sectional household survey carried out during June
2010. The survey was aimed to assess the impact of cyclone Aila on households and
consequent coping mechanisms in three of the worst-affected blocks (a sub-district
administrative unit), viz. Hingalganj, Gosaba and Patharpratima. The survey covered 809
individuals from 179 households, cross cutting age and gender. A separate module on health-
seeking behaviour serves as the information source of health shocks defined as illness
episodes (ambulatory or hospitalized) experienced by household members.
KEY FINDINGS:
Finding reveals that over half of the households (54%) consider that Aila has dealt a high,
damaging impact on their household assets. Result further shows deterioration of health
status in the period following the incidence of Aila. Finding suggests having suffered
multiple shocks increases the number of adverse welfare outcomes by 55%. Whereas,
suffering either from the climatic shock (33%) or the health shock (25%) alone increases such
risks by a much lesser extent. The multiple-shock households face a significantly higher
degree of difficulty to finance expenses arising out of health shocks, as opposed to their
counterparts facing only the health shock. Further, these households are more likely to
finance the expenses through informal loans and credit from acquaintances or moneylenders.
CONCLUSION:
This paper presented empirical evidence on how natural and health shocks mutually reinforce
their resultant impact, making coping increasingly difficult and present significant risks of
welfare loss, having short as well as long-run development manifestations.

CONCLUSION
Disasters are of different types which can happen anytime, anywhere, in the world
causing tremendous after effects such as loss of human life, economical imbalances, food
scarcity, epidemics, forced relocation of population etc. Disasters usually affect the
developing countries comparing with the developed countries. While deserting the matter
we could come to the conclusion that the adverse effects of natural disasters can be
minimized by proper preventive measures alert technologies at high risk areas, proper
mobilization of resources, and decreased corruption in the field and also the mock
training programmes in the community.

27
 BIBLIOGRAPHY

 Tener Goodwin Veenema, “Disaster Nursing and Emergency Preparedness for

Chemical, Biological, and Radiological Terrorism and Other Hazards, 1st edition,
Springer publishers, Page No. 3-168.
 Park K;PREVENTIVE AND SOCIAL MEDICINE;2005;18th edition; Jabalpur;
Banarsidas Bhanot publishers; pp 600-605.
 Swarankar . Community Health Nursinf, 3rd edition, N.R.Brother’s publication, page
no: 870-885.

 http://www.ncbi.nlm.nih.gov/pubmed/25170846

 http://www.ncbi.nlm.nih.gov/pubmed/25657125
 http://www.ncbi.nlm.nih.gov/pubmed/25215145

Appendix A Cardiopulmonary Resuscitation and Basic Life

Suppport
The steps of basic life support (BLS) consist of a series of actions and skills performed by
the rescuer(s) based on assessment findings. The first action performed by the rescuer upon
finding an adult victim is to assess for responsiveness. This is accomplished by tapping or
gently shaking the victim's shoulder and asking, “Are you all right?” If the victim does not
respond and the rescuer is alone, the rescuer should activate emergency medical services
(EMS), get an automatic external defibrillator (AED) (if available), return to the victim,
and begin cardiopulmonary resuscitation (CPR) and defibrillation if necessary.1

The American Heart Association includes training in the use of AEDs with instruction of
health care personnel and laypersons in BLS. Survival from cardiac arrest is the highest
when immediate CPR is provided and defibrillation occurs within 3 to 5 minutes.1 AEDs
now can be found in many out-of-hospital, public settings (Fig. A-1).
FIG. A-1 Automatic external defibrillator (AED) located in
an airport.

28
Airway
The next step in BLS is to assess the victim's airway to confirm the absence of breathing
and to establish a patent airway. Fig. A-2 demonstrates opening the airway and
performing mouth-to-mouth ventilation. An adult's airway is opened by hyperextending
the head. The head tilt–chin lift maneuver is used and involves tilting the head back with
one hand and lifting the chin forward with the fingers of the other hand. If the victim is
gasping occasionally or not breathing, the rescuer attempts to ventilate the victim with
mouth-to-barrier (recommended) or mouth-to-mouth resuscitation.1

29
FIG. A-2 The head tilt–chin lift maneuver is used to open
the victim's airway to give mouth-to-mouth resuscitation. A,
Rescuer places one hand on the victim's forehead and
applies firm, backward pressure with the palm to tilt the
head back. The chin is lifted and brought forward with the
fingers of the other hand. B, Rescuer pinches the victim's
nostrils, seals mouth over victim's mouth, and delivers a
regular breath. Rescuer should observe for a rise in the
victim's chest (arrow).

30
31
TABLE A-1 Management of Foreign Body Airway
Obstruction (FBAO)
Conscious Adult Victim

Assess Victim for Severe Airway Obstruction

Signs of severe airway obstruction:

• Universal choking sign (victim clutches neck with hands)

• Inability to speak

Ask the victim, “Are you choking?”

• Silent cough

• High-pitched sound or no sound while inhaling

• Increased difficulty breathing

• Cyanosis

If the victim displays any of the above signs, severe or complete airway
obstruction may be present and the rescuer must take action.

Heimlich Maneuver (Abdominal Thrusts) with Standing/Sitting Victim

(Fig. A-3)

1. Stand behind victim and wrap arms around waist.

2. Make fist with one hand.

3. Place thumb side of fist against victim's abdomen. Position fist

midline, slightly above umbilicus and well below xiphoid process.

4. Grasp fist with other hand.

5. Press fist into victim's abdomen using quick upward thrusts. Each
thrust should be a separate, distinct movement. Note: If victim is in the late
stages of pregnancy or obese, chest thrusts should be used. Position hands (as
described) over lower portion of the sternum and apply quick backward
thrusts.

6. Repeat thrusts until object is expelled or victim becomes unresponsive.

Unconscious Adult Victim

Assessment

If rescuer sees victim collapse and knows that FBAO is the cause:

32
 1. Activate the EMS system by calling 911.

2. Be sure victim is supine.

3. Perform tongue-jaw lift; look to see if a foreign body is visible and, if

seen, remove it (Fig. A-4).

4. Open airway and attempt to ventilate:

• Give two rescue breaths.

• If breaths are unsuccessful in making victim's chest rise:

a. Reposition victim's head.

b. Reopen airway.

c. Reattempt to ventilate.

5. If efforts to ventilate are still unsuccessful, begin CPR (see Tables A-2
and A-3).

Source: 2005 American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life
Support, Circulation 112:IV-19, 2005.
FIG. A-3 Heimlich maneuver administered to a conscious
(standing) victim of foreign body airway obstruction.

33
Breathing
Ventilations are given with the victim's nostrils pinched and the rescuer's mouth placed
around the victim's mouth to make a tight seal. Face mask or bag-mask devices can also
be used. Two breaths are given by the rescuer (1 second per breath). The volume of air of
each ventilation should be equal to a regular breath and enough to produce a visible rise
in the victim's chest.1 When the victim has a tracheostomy, ventilation should be given
through the stoma.
FIG. A-4 With the victim's head up, the rescuer grasps
both the tongue and the lower jaw between the thumb and
34
 fingers and lifts (tongue-jaw lift). This action draws the
tongue from the back of the throat and away from the
foreign body. The rescuer looks to see if any foreign body is
visible and, if seen, removes it.

If airflow is obstructed, the rescuer should reposition the head and repeat the attempt to
ventilate. If the victim cannot be ventilated after repositioning the head, the rescuer
should proceed with CPR. When providing rescue breaths, the rescuer should look for
any foreign objects in the victim's mouth and remove them if visible (Table A-1).

In those rare instances when airway obstruction is not relieved, additional procedures are
necessary. These include transtracheal catheter ventilation and cricothyroidotomy, which
should only be attempted by health care professionals experienced in these procedures.1

Cardiac Compressions
Cardiac arrest is characterized by the absence of a pulse in the large arteries of an
unconscious victim who is not breathing. Health care providers are instructed to perform
a pulse check in victims that are unresponsive and not breathing. Lay rescuers are not

35
taught this skill. Instead they are instructed to begin chest compressions immediately after
delivering two rescue breaths.

The carotid artery is used to determine the absence of a pulse. After an airway has been
established and two ventilations have been delivered, the rescuer checks the pulse of the
carotid artery. While maintaining the head-tilt position with one hand on the forehead, the
rescuer locates the victim's trachea with two or three fingers of the other hand. The
rescuer then slides these fingers into the groove between the trachea and the muscles of
the side of the neck where the carotid pulse can be felt. The technique is more easily
performed on the side nearest the rescuer. If a pulse is palpated, the rescuer should
provide rescue breaths at a rate of 10 to 12 breaths/minute and recheck the pulse every 2
minutes. If no pulse is palpated within 10 seconds, chest compressions should be
initiated.1

The proper technique for administering chest compressions is shown in Fig. A-5. Chest
compression technique consists of serial, rhythmic applications of pressure on the lower
half of the sternum. The victim must be in the supine position when the compressions are
performed. The victim must be lying on a flat, hard surface, such as a CPR board
(specially designed for use in CPR), a headboard from a unit bed, or, if necessary, the
floor. The rescuer should be positioned close to the side of the victim's chest.

The guidelines for proper compression technique are presented in Tables A-2 and A-3
and Fig. A-5. Rescue breathing and chest compressions are combined for an effective
resuscitation effort of the victim of cardiopulmonary arrest. The compression-ventilation
ratio for one- or two-person CPR is 30 compressions to 2 ventilations (see Tables A-2 and
A-3). If the patient is intubated and the airway is secure, compressions should not be
paused for ventilations.1

It is preferable to have two persons performing CPR (see Table A-3). One person,
positioned at the victim's side, performs chest compressions while the other rescuer,
positioned at the victim's head, maintains an open airway and performs ventilations. In
order to maintain the quality and rate of compressions, rescuers should change roles
approximately every 2 minutes.1
FIG. A-5 Cardiopulmonary resuscitation (CPR). A,
Position of the hands during application of cardiac
compressions. B, When pressure is applied, the lower
portion of the sternum is displaced posteriorly with the palm
of the hand. C, To apply maximum downward pressure, the
rescuer leans forward so that both arms are at right angles
to the patient's sternum and the elbows are locked.

36
Interruptions in CPR should be limited. When the AED or advanced cardiac life support
(ACLS) team arrives, the victim's rhythm should be assessed. If the victim has a
shockable rhythm (i.e., ventricular tachycardia or ventricular fibrillation), one shock
should be delivered followed by five cycles of CPR before checking the rhythm. If the
rhythm is not a shockable rhythm, CPR should be resumed and the rhythm rechecked
every five cycles. CPR should continue between rhythm checks and shocks, and until the
ACLS team arrives or the victim shows signs of movement.1

ACLS involves the use of detailed medical algorithms for the provision of lifesaving
cardiac care in settings ranging from the pre-hospital environment to the hospital setting.
Nurses are often required to obtain ACLS certification in addition to BLS depending on
their area of practice.

TABLE A-2 Adult One-Rescuer Cardiopulmonary

Resuscitation (CPR)
Assess

Determine unresponsiveness:

Tap or gently shake shoulder.

37
Shout, “Are you all right?”

Activate Emergency Medical Services (EMS) System*

Activate EMS system by calling 911 and get the AED (if available) (outside of
hospital).

Call a code and ask for the AED or crash cart (in the hospital).

Airway

Position the victim:

• Turn on back (if necessary) using logroll technique.

• Open the airway using proper technique:

a. Head tilt–chin lift maneuver (see Fig. A-2)

b. Jaw-thrust maneuver (if cervical spine injury is suspected); if unable to

open airway using jaw-thrust maneuver, use head tilt–chin lift maneuver.

Breathing

1. Assess for cessation of breathing:

• LOOK for chest rising and falling.

• LISTEN for air escaping during exhalation.

• FEEL for flow of air.

2. If victim is breathing adequately:

• Continue to protect airway.

• Place victim in recovery position.

3. If victim is unresponsive and gasping occasionally or not breathing:

• Provide two regular breaths each over 1 second.

a. Observe chest rise.

b. Allow for complete exhalation between breaths.

• If unable to give two effective breaths:

a. Reposition victim to try to open airway.

b. Look for foreign body and, if seen, remove.

c. Reattempt to ventilate.

38
 • If ventilation is still unsuccessful, assess circulation.†

• If adequate spontaneous breathing is restored and signs of circulation

are present:

a. Maintain open airway.

b. Place victim in recovery position.

Circulation

Lay Rescuer

Begin chest compressions after delivering two initial breaths.

Health Care Professional

1. Assess for signs of circulation after delivery of the two initial breaths.

2. Feel for carotid pulse (10 seconds).

3. If victim has signs of circulation but is not breathing adequately,

continue rescue breathing (1 breath/5 to 6 seconds) and recheck circulation
every 2 minutes.

4. If there are no signs of circulation, begin chest compressions.

Compression/Ventilation

Compression-Ventilation Cycle

Compression-ventilation ratio is 30:2.

Begin Compressions

1. Get into position for compressions at victim's side (by shoulders).

2. Locate landmark notch (hands in the center of chest, right between the
nipples, and two fingers above the xiphoid-sternal notch).

3. Position hands, arms, and shoulders.

• Elbows are locked and arms are straight.

• Rescuer's shoulders positioned directly over hands.

4. Begin compressions:

• Compressions should depress victim's sternum approximately ½ to 2

inches.

• Allow chest to rebound to normal position after each compression.

39
 • Perform compressions hard and fast at the rate of 100 per minute.

• Maintain correct position at all times.

Provide Ventilation

1. Open airway using proper technique.

2. Deliver two slow regular breaths (1 second each) at the end of a cycle
of 30 compressions.

3. Return hands to chest.

4. Find proper landmark and hand position.

5. Restart compressions.

Defibrillation

If witnessed arrest, use AED as soon as possible.

If unwitnessed arrest, deliver five cycles of CPR before using AED.

If rhythm is shockable, deliver one shock, then resume CPR for five cycles
before rechecking rhythm.

If the rhythm is not shockable, resume CPR and recheck rhythm every five
cycles.

Continuation of CPR

• CPR should be continued between rhythm checks and shocks, and until
ACLS providers arrive or the victim shows signs of movement.

• Do not interrupt CPR except in special circumstances.

Source: 2005 American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life
Support, Circulation 112:IV-19, 2005.

ACLS, Advanced cardiac life support; AED, automatic external defibrillator.

* Rescuers should phone 911 for unresponsive adults before beginning CPR,
except in the case of drowning or a likely asphyxiation.
† Lay rescuers are no longer taught a pulse check.

TABLE A-3 Adult Two-Rescuer Cardiopulmonary

Resuscitation (CPR)
Assess/Activate Emergency Medical Services (EMS) System*

One Rescuer

40
Determine unresponsiveness:

Tap or gently shake shoulder.

Shout, “Are you OK?”

Other Rescuer

Activate EMS system by calling 911 and get the AED (if available) (outside of
hospital).

Call a code and ask for the AED or crash cart (in hospital).

Airway

Position the victim:

• Turn on back (if necessary) using logroll technique.

• Open the airway using proper technique:

a. Head tilt–chin lift maneuver (see Fig. A-2).

b. Jaw-thrust maneuver (if cervical spine injury is suspected); if unable to

open airway using the jaw-thrust maneuver, use the head tilt–chin lift
maneuver.

Breathing

1. Assess for cessation of breathing:

• LOOK for chest rising and falling.

• LISTEN for air escaping during exhalation.

• FEEL for flow of air.

2. If victim is breathing adequately:

• Continue to protect airway.

• Place victim in recovery position.

3. If victim is unresponsive and gasping occasionally or not breathing:

• Provide two regular breaths each over 1 second.

a. Observe chest rise.

b. Allow for complete exhalation between breaths.

• If unable to give two effective breaths:

41
 a. Reposition victim to try to open airway.

b. Look for foreign body and, if seen, remove.

c. Reattempt to ventilate.

• If ventilation is still unsuccessful, assess circulation.†

• If adequate spontaneous breathing is restored and signs of circulation

are present:

a. Maintain open airway.

b. Place victim in recovery position.

Circulation

Lay Rescuers

Begin chest compressions after delivering two initial breaths.

Health Care Professionals

1. Assess for signs of circulation after delivery of the two initial breaths.

2. Feel for carotid pulse (10 seconds).

3. If victim has signs of circulation but is not breathing adequately,

continue rescue breathing (1 breath/5 to 6 seconds) and recheck circulation
every 2 minutes.

4. If there are no signs of circulation, say “No pulse” and prepare for
chest compressions.

Compression/Ventilation

Compression-Ventilation Cycle

Compression-ventilation ratio is 30:2.

One Rescuer/Compressor

1. Get into position for compressions at victim's side (by shoulders).

2. Locate landmark notch (hands in the center of chest, right between the
nipples, and two fingers above the xiphoid-sternal notch).

3. Position hands, arms, and shoulders:

• Elbows are locked and arms are straight.

• Rescuer's shoulders positioned directly over hands.

42
 4. Begin compressions:

• Compressions should depress victim's sternum approximately ½ to 2

inches.

• Allow chest to rebound to normal position after each compression.

• Perform compressions hard and fast at the rate of 100 per minute.

• Maintain correct position at all times.

Other Rescuer/Ventilator

1. Get into position at victim's head.

2. Maintain an open airway.

3. Deliver two slow regular breaths (1 second each) at the end of a cycle
of 30 compressions.

4. Ensure that chest is rising with each ventilation.

5. Monitor carotid pulse during compressions to verify effectiveness.

Switching

Rescuers should change compressor and ventilator roles every 2 minutes to

avoid compressor fatigue.

Rescuers should exchange positions simultaneously with minimal delay:

• Ventilator moves to chest.

• Compressor moves to head.

Defibrillation

If witnessed arrest, use AED as soon as possible.

If unwitnessed arrest, deliver five cycles of CPR before using AED.

If rhythm is shockable, deliver one shock, then resume CPR for five cycles
before rechecking rhythm.

If the rhythm is not shockable, resume CPR and recheck rhythm every five
cycles.

Continuation of CPR

• CPR should be continued between rhythm checks and shocks, and until
ACLS providers arrive or the victim shows signs of movement.

• Do not interrupt CPR except in special circumstances.

43
 Source: 2005 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life
Support, Circulation 112:IV-19, 2005.

SEMINAR ON CARDIO PULMONARY RESUSCITATION

INTRODUCTION

Rapid intervention is the key to success and is critical in saving life. CPR
is a vital link in the chain of survival that supports the victim until more advanced
help is available. All health care professionals should be skilled in CPR because by the
heart may occur at any time /in any setting.

BASIC LIFE SUPPORT

This involves the external support of circulation and ventilation for a patient
with cardiac / respiratory arrest through CPR. Artificial respiration (mouth-to-mouth,
mouth-to-mask, mouth-to-nose, mouth- to-stoma) and external chest compressions
substitute for spontaneous breathing and circulation.

DEFINITION

Cardiopulmonary resuscitation is the process of artificially supporting a

patient’s breathing and heart beat when respirations and pulse have ceased.

OR

CPR is the process of externally supporting the circulation and respiration of a

person of who has a cardiac arrest.

OR

CPR is an emergency procedure which is performed in an effort to manually

preserve intact brain function until further measures are taken to restore spontaneous
blood circulation and breathing in a person in cardiac arrest.

INDICATIONS

CPR is indicated in those who are unresponsive with no breathing or abnormal

breathing or who is only breathing in occasional agonal gasps.

If a person still has a pulse, but is not breathing (respiratory arrest), artificial
respirations may be more appropriate, but due to the difficulty people have in
accurately assessing the presence or absence of a pulse

44
 CPR involves chest compressions at least 5 cm deep and at a rate of at least 100
per minute in an effort to create artificial circulation by manually pumping blood
through the heart. In addition, the rescuer may provide breaths by either exhaling into
the subject's mouth or utilizing a device that pushes air into the subject's lungs. This
process of externally providing ventilation is termed artificial respiration. Current
recommendations place emphasis on high-quality chest compressions over artificial
respiration.

PURPOSE

The main purpose of CPR is not to "start" the heart, but rather to circulate
oxygenated blood, and keep the brain alive until advanced care (especially
defibrillation) can be initiated.

OBJECTIVES

 Delay tissue death

 Extend the brief window of opportunity for a successful resuscitation without
permanent brain damage.
 Induce a heart rhythm which may be shockable.

CPR is generally continued until the subject regain return of spontaneous

circulation (ROSC) or is declared dead.

HISTORY

In the 19th century, Doctor H. R. Silvester described a method (The Silvester

Method) of artificial respiration in which the patient is laid on their back, and their
arms are raised above their head to aid inhalation and then pressed against their chest
to aid exhalation. The procedure is repeated sixteen times per minute. This was
practiced in the early 20th century.

A second technique, called the Holger Neilson technique, in the United States
in 1911, described a form of artificial respiration where the person was laid on their
front, with their head to the side, resting on the palms of both hands. Upward pressure
applied at the patient’s elbows raised the upper body while pressure on their back
forced air into the lungs, essentially the Silvester Method with the patient flipped over.
This form is seen well into the 1950s, and was often used, for comedic effect, in
theatrical cartoons of the time. This method would continued till 1979. The technique
was later banned from first-aid manuals in the U.K.

In the middle of the 20th century the wider medical community started to
recognize and promote artificial respiration combined with chest compressions as a
key part of resuscitation following cardiac arrest. The combination was practiced
during 1962 Jude and Knickerbocker, along with William Kouwenhoven and Joseph
S. Redding discovered the method of external chest compressions, whereas Safar had
worked with Redding and James Elam to prove the effectiveness of artificial
45
respiration. It was at Johns Hopkins University where the technique of CPR was
developed. The first effort at testing the technique was performed on a dog by
Redding, Safar and JW Perason. Soon afterward, the technique was used to save the
life of a child. Their combined findings were presented at annual Maryland Medical
Society meeting on September 16, 1960 in Ocean City, and gained rapid and
widespread acceptance. Peter Safar wrote the book ABC of resuscitation in 1957.

Artificial respiration was combined with chest compressions based on the

assumption that active ventilation is necessary to keep circulating blood oxygenated,
and the combination was accepted without comparing its effectiveness with chest
compressions alone. However, research over the past decade has shown that
assumption to be in error, resulting in the AHA's acknowledgment of the effectiveness
of chest compressions alone.

PRINCIPLES

PRINCIPLE 1: DEFINE THE TEAM LEADER

A single person must command the resuscitation team, should attempt to

determine the cause of the arrest, confirm the appropriateness of resuscitation, and
establish treatment priorities. The leader should also monitor the ECG, order
medications, and direct the actions of the team members but must avoid distraction
from the command role.

PRINCIPLE 2: ESTABLISH EFFECTIVE ARTIFICIAL CIRCULATION

Blood flow during closed-chest CPR occur by 2 complementary

mechanisms.

 Cardiac Compressions
 Thoracic Pumping

Cardiac Compressions:

This generate positive intracardiac pressures simulating cardiac muscle

contraction and a positive intra arterial pressure relative to extra thoracic structures
with the heart valves establishing forward flow. Retrograde venous flow is prevented
by jugular venous valves and functional compression of the inferior venecava at the
diaphragmatic hiatus.

Thoracic pumping:

On relaxation of chest compression, falling intrathoracic pressure

promotes blood flow into the right heart chamber and pulmonary arteries, filling
these structures for next compression.

46
 Ideally performed closed-chest compression provides only one third of
the usual output of the beating heart. Thus WHEN CPR performed more than 10-15
min, hypoperfusion predictably results in tissue acidosis. If performed improperly,
CPR is not only ineffective but potentially injurious.

Maximal blood flow occurs when approximately 60% of the cycle is in

the compression phase with a compression rate near 100beats/min. During CPR, it is
difficult to determine whether blood flow is adequate because each organ derives
optimal flow at different pressures.

PRINCIPLE 3: ESTABLISH EFECTIVE OXYGENATION AND VENTILATION

Establishing an airway and oxygenating the patient is essential if the

primary problem was respiratory in origin.Ventilation can be accomplished with
mouth-to-airway or bag-mask ventilation.

When the airway is patent, the chest should rise smoothly with each
ventilation. Though cricoid pressure (Sellick maneuver) help seal the esophagus,
gastric distension and vomiting still occur if inflation pressures are excessive,
barotrauma can also occur with this and can impede the venous return.

To avoid this breaths should be delivered slowly, avoiding excessive

inflation pressures and allowing complete lung deflation between breaths.

During CPR, ventilation should attempt to restore PH to near normal

levels and provide adequate oxygenation. The corner stone of pH correction is
adequate ventilation during effective circulation-not NaHCO3 administation. CO2 in
mixed venous blood returned to the lung during CPR freely diffuses into the airway
for elimination, reductions in pulmonary blood flow limit the capacity for CO2
excretion. Thus hypercapnea is produced at the tissue level during ongoing CPR.

PRINCIPLE 4: ESTABLISH A ROUTE FOR MEDICATION ADMINISTRATION

Access to the circulation must be established rapidly during CPR.

Femoral access is easier to establish without interrupting CPR but less desirable than
a jugular or subclavian route because of the high risk of infection.

Intraosseous access is prefered in children and adults who donot have IV access.IO
administered drugs reach heart in <30s.

Intratracheal route can be used to produce therapeutic drug levels rapidly during
resuscitation.

PRINCIPLE 5: CREATE AN EFFECTIVE CARDIAC RHYTHM

47
 The availibility of AEDs has changed defibrillation from an often
delayed procedure performed by an expert in a hospital to one rapidly accomplished
by a novice in a public location. The basic steps include:

 Power on the AED

 Attach the pads and connect the cables using the illustration provided.
 Wait for the device to analyze the rhythm and charge
 Make sure all the people are clear of the patient
 Discharge the device if instructed

VT/VF resistant to cardioversion after several minutes of effective CPR

predicts a poor outcome.

PRINCIPLE 6: EVACUATE THE PATIENT TO THE ICU AS SOON AS

PRACTICAL

When cardiac arrests occur outside an ICU, facilities, equipment, and

personnel for resuscitation are less than ideal. Electrical access and suction
capabilities are commonly limited and specialized equipment, especially for airway
management, is not always available. The most important limitation of performing
CPR outside the ICU is many of the personnel available to help have little experience
performing real resuscitations. So do the absolute minimum required to establish
ventilation and a rhythm that produces a pulse then transport the patient to the ICU.

PRINCIPLE 7: RE-EVALUATE AND STABILIZE

After arriving in the ICU with a perfusing rhythm with adequate

oxygenation and ventilation, it is important to rethink the cause of arrest, take
measures to prevent recurrence, and to search for resuscitation complications.

Eg: The tubes and catheters often sub-optimally positioned or inserted with less sterile
technique should be checked.

PRINCIPLE 8: PRESERVE THE BRAIN

For an optimal cognitive recovery a reasonable perfusion pressure,

hemoglobin concentration and saturation should be maintained. The use of mild
therapeutic hypothermia has shown benefits for out-of-hospital VF arrest patients. The
patient shouldn’t have active bleeding/significant bradycardia since hypothermia may
exacerbate both. Therapeutic hypothermia can be achieved only through deep sedation
and therapeutic paralysis to prevent the heat generating shivering. Invasive and
external methods have been tried, the target is a core temperature of 32-34 degree
celsius for 12-24h, with subsequent slow rewarming over 6-8h.

ADULT BASIC LIFE SERVICE SEQUENCE

48
  DETERMINE PATIENT RESPONSIVENESS AND DETECT FOR
BREATHING

This is done by gently shaking or tapping the patient and shouting “Are
you ok?” This action is enough to awaken the patient who has just fallen
asleep.

 How to do?

- Kneel beside the victim

- Put both your hands over the victim's shoulders

- Shake gently and shout into the victim's ear, "Are you okay?" or "Can
you hear me?"

- Victim must respond immediately (i.e within 3 - 5 seconds)

- Watch for rising and falling of chest

DECISION TO BE TAKEN - Is the victim responsive, breathing? YES or NO

 ACTIVATE EMERGENCY

If the patient doesn’t respond, nurse require to yell for other staff or dial the
emergency hospital line or call for help by telling someone next to you, to
get medical help immediately

 What to tell the operator?

- Your name and what work you do

49
 - Type of medical emergency

- Location or address of the victim

- Call back number

Eg. Medical Emergency Call Center - " Hello? This is 108 emergency service.
How can I help you?"

"Hello? My name is Danny and I am a college student. I have a man here who
has collapsed in front of me. I think he is having a heart attack. Please send an
ambulance quickly. I'm in 3rd floor, ABCD mall, EFGH street. Next to the
Chinese Hotel. My mobile number is 1234567890. I starting CPR on him now.
Okay?"

Convince the person next to you to get help:

"You!!! Go to the security desk or reception and call an ambulance. They will
have a phone directory. Tell them the proper address. Page for a doctor if
available. Quickly! Go!! Go!! Go!!"

REMEMBER - Do not ever (Ever!) miss this step. Always call for help first.

- Success of resuscitation depends on how quickly the victim can

recieve advanced medical care.

- For an normal person, performing CPR is like running uphill. A single

rescuer can perform CPR only for a few minutes (5-10) before getting

50
 exhausted. CPR must be continous without interruptions. You need
more people to help you.

- Advanced high quality resuscitation is done by trained paramedics or

doctors, using oxygen, injectable drugs, electric shocks, interpreting
cardiac rhythms, etc. So either a well equiped ambulance with a
paramedic must reach the victim or the victim must reach a hospital.

 ASSESS THE PULSE

Assess the patient for circulation.

Feel for presence of a carotid pulse in the neck

 Where to feel for the carotid artery?

- Use your index & middle fingers to find the hard prominence in the front
upper part of the neck. This is commonly known as Adam's Apple. Also known
in medical terminology as Thyroid Cartilage.

- Slide your fingers to one side away from the center for about 1-2 inches. The
carotid artery is present in the groove.

Do this only for upto 10 seconds.

DECISION TO BE TAKEN - Does the victim have a pulse? YES or NO

 START EXTERNAL CHEST COMPRESSIONS

This is performed when the nurse detects no signs of circulation. Chest

compressions are performed by placing the heel of one hand at the center of
the chest between the nipples. The nurse should be able to see the patient’s
chest while performing compressions. To be effective, compressions should

51
 depress the sternum 1.5-2 inches on an adult. The emphasis is on push hard,
push fast to ensure enough oxygen delivery to the cells.

If other health care providers present, pulse checks can be performed by

palpating the femoral/carotid pulse to determine the effectiveness of
compressions.

The nurse should be positioned on the patient’s side on his /her knees.
Compressions should be performed at a rate of 100/min. Each set of 30
compressions should take approximately 18 seconds or less. After the first
30 compressions, patient should receive 2 ventilations at a rate of 10-12
breaths/ min in adults and 12-20 breaths/min in child. The cycle of 2 breaths
and 30 compressions should continue without any interruptions for >10s.

Begin chest compressions and breaths at 30:2 ratio

Feel for the depression just below the edge of the breastbone

Place your left palm, two fingers width above this depression

Place your other hand on the first hand and

interlock your fingers.

Now you hands will be in the center of a

line connecting the nipples.

Compressions should be delivered on the

breastbone, not over the soft depression.

Begin chest compressions at speed of 100 per minute, pressing down about 1.5 to 2
inches.

Keep your elbows straight, locked and in-line with the victim's chest, so that you use
your upper body weight for chest compression.

52
Give 30 continuous chest compressions within 18 seconds.

 START RESCUE BREATHING

In the absence of detectable breathing,start rescue breathing by

pinching the patient’s nose and placing his or her mouth over a barrier
device (facemask/face sheild) around the patient’s mouth and blowing. If a
face mask is used, ensure a tight seal around the patient’s mouth and nose.
Two slow breaths are given by the rescuer (2sec/breath). The volume of air
of each ventilation is 700-1000ml that can be determined by noting a rise of
1-2 inches in the victim’s chest. Smaller volumes (400-600ml) should be
attempted during mouth-to-barrier and bag-mask ventilations. When the
victim has a tracheostomy, ventilation should be given through the stoma. If
airflow is obstructed, the rescuer should reposition the head and repeat the
attempt to provide ventilation. An ambu-bag can be used to deliver air in a
hospital setting.

How to give mouth-to-mouth breaths?

- Perform head tilt –chin lift

- Kneel next to the victim's head

- Put one hand over forehead and with the other hand, hold under
the chin

- Take a deep breath

- Bend down and place your mouth over the victim's mouth.

- Press on the sides of the victim's nose with your fingers to seal the
nostrils.

53
 - Seal your lips with the victim's lips

- Deliver or blow your breath into the victim's lungs over 2 seconds.

- When the first breath is delivered, just turn your head and look at the
victim's chest. You will see the chest fall as the victim exhales passively
after your 'rescue breath'.

Repeat this one more time.

If you see the chest fall, then you have delivered a breath correctly.

If you dont see any chest rise or fall, then perform the head tilt - chin lift
again, close the nostrils tightly, seal your lips properly with the victim's
lips and give a deep breath again.

If the victim can’t be ventilated after repositioning the head, the rescuer should
proceed with certain maneuvers to remove foreign bodies that obstruct the
airway.

MANAGEMENT OF FBAO (Foreign Body Airway Obstruction)

 Conscious Adult Victim

Assess the victim for airway obstruction.

Signs Of Airway Obstruction

 Universal choking sign (Victim clutches neck with thumb

and index finger).
 Inability to speak (Ask the victim “Are you choking?”).
 Weak ineffective cough.
 High pitched sound /no sound while inhaling.
 Increased difficulty breathing.
 Cyanosis.

54
 If the victim can cough forcefully / speak, the rescuer need not
interfere. The rescuer should stay with the victim, monitor his condition,
if partial obstruction persists, activate EMS.

If the victim displays any of the above, severe/ complete

airway obstruction may be present and the rescuer should take action.

Hemilich Maneuver with standing / sitting victim

 Stand behind victim and wrap arms around waist.

 Make fist with one hand.
 Place thumb side of fist against victim’s abdomen. Position fist
midline, slightly above umbilicus and well below the xiphoid
process.
 Grasp fist with other hand.
 Press fist into victim’s abdomen using quick upward thrusts.
Each thrust should be a separate, distinct movement.
 Repeat thrusts until object is expelled / victim becomes
unresponsive.

 Unconscious Adult Victim

Assessment: If rescuer sees victim collapse and knows that FBAO is

the cause then;

 Activate the EMS system by calling 911.

 Be sure victim is supine.
 Perform tongue-jaw lift, then a finger sweep to remove the
object.
 Open airway and attempt to ventilate.
 Give 2 rescue breaths.
 If breaths unsuccessful in making victim’s chest rise:

o Reposition victim’s head.

o Reopen airway.
o Reattempt to ventilate.

If efforts to ventilate are still unsuccessful, prepare to perform Heimilich

Maneuver.

Heimilich Maneuver with Unresponsive Victim

 Place victim supine.

 Kneel straddling victim’s thighs.
 Place heel of one hand against victim’s abdomen. Position first midline,
slightly above umbilicus and well below xiphoid.
 Place the other hand directly over the first hand.

55
  Press both hands into victim’s abdomen using quick upward thrusts.
 Each thrust should be a separate distinct movement.
 After 5 abdominal thrusts open victim’s airway using tongue-jaw lift.
 Perform finger sweep to remove the object.
 Continue repeating this until airway is cleaned.
 If obstruction removed assess the breathing.
 If victim not breathing: provide rescue breaths , assess for signs of
circulation (breathing, coughing, movement ,pulse ).
 If no signs of circulation present, begin chest compressions.

CPR IN CHILDREN

Perform 5 cycles of 30 chest compressions followed by 2 breaths, then use an

AED to evaluate the heart rhythm if available. If an AED is not available, and the
child is still not breathing normally, coughing, or moving, continue cycles of 30
compressions to 2 Sudden cardiac arrest is less common in children than it is in adults.
It usually happens when there is a lack of oxygen caused by a breathing problem such
as choking, near-drowning, or respiratory infections. Because oxygen often corrects
the problem in a child, when an unresponsive, non-breathing child is found, CPR is
performed for 1 minute before activating the EMS system. This may reverse the lack
of oxygen and revive the child.

In order to use an AED on a child from one year of age through eight years of age a
special pediatric cable is used to reduce the amount of energy provided by the
electrical shock.

Doing CPR on children aged one year to eight years is similar to doing CPR on adults.
However, there are some minor differences. Most are due to the child's smaller size.

 When compressing the chest, the heel of only 1 hand is used instead of 2
hands, and the chest is pressed down about ½ of its depth.

 breaths until help arrives.

CPR IN INFANTS

An infant is defined as a child younger than one year of age. Because an infant is
smaller than a child, the CPR technique for infants contains further changes.

 Even smaller breaths are given-enough to just get the chest to rise. Only 2
fingers are used to compress the chest down about 1 inch.

 Otherwise, the CPR sequence is the same as for the child

56
57