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S.E.P. MANUAL CHAPTER 3
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Chapter: 3 Page: 1 Rev: 5 Date: 15 JUL 09
ETIHAD AIRWAYS UNITED ARAB EMIRATES
3.1. LIFE SAVING
PROCEDURES...................................................................
3
3.2. RESUSCITATION PLAN (ADULT)
............................................................ 4
3.3. RESUSCITATION PLAN (CHILD)
............................................................. 5
3.4. RESUSCITATION PLAN (INFANT)
........................................................... 6
3.5. UNCONSCIOUS CASUALTY (RECOVERY POSITION)
.......................... 7
3.6. CARDIAC ARREST
(C.P.R.)......................................................................
8 3.6.1. Alternative methods of
CPR......................................................................
10 3.6.2. C.P.R Technique
(Children)......................................................................
10 3.6.3. CPR Technique (Infants)
..........................................................................
11 3.6.4. Alternative Methods of Rescue
Breathing................................................. 11
3.7.
DEFIBRILLATION....................................................................................
12
3.8. GUIDELINES FOR
RESUSCITATION.....................................................
15
3.9.
CHOKING.................................................................................................
16 3.9.1. Management (Conscious
Adult)................................................................
16 3.9.2. Choking Management (Children)
.............................................................. 19
3.9.3. Choking Management
(Infants).................................................................
21
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3.1. LIFE SAVING PROCEDURES Oxygen is essential for life. The
airway should always be considered your first priority over
anything else when dealing with the casualty. If at anytime the
airway becomes blocked or closed, and/or there is no breathing, it
only takes minutes for the human body to become dangerously
compromised. Without Oxygen 3 - 5 minutes Irreversible brain damage
can occur 7 - 8 minutes Brain death may occur It is essential that
crew recognise when a casualty becomes unconscious and the airway
has become compromised.
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3.2. RESUSCITATION PLAN (ADULT)
Danger Check scene safety; look for hazards to yourself or
casualty (Chapt.2, p.3)
Response Gently shake casualtys shoulders and call to him to see
if he responds
Shout for Help 2nd crew AED 3rd crew Oxygen, pocket mask,
communicate
Treat for fainting Perform Secondary Survey
Remove hazards
Airway Head tilt, Clear if necessary, Chin lift
Breathing Assess Breathing
Recovery Position Chap 3-3.5
YES
YES
NO
NO
YES
NO or Abnormal
CPR 30 Compressions: 2 Breaths
Defibrillation Apply AED ASAP
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3.3. RESUSCITATION PLAN (CHILD)
Danger Check scene safety; look for hazards to yourself or
casualty (Chapt.2, p.3)
Response Gently shake casualtys shoulders and call to him to see
if he responds
Shout for Help 2nd crew AED 3rd crew Oxygen, pocket mask,
communicate
Treat for fainting Perform Secondary Survey
Remove hazards
Airway Head tilt, Clear if necessary, Chin lift
Breathing Assess Breathing
Recovery Position Chap 3-3.5
YES
YES
NO
NO
NO or ABNORMAL
YES
Defibrillation Apply AED ASAP
CPR 5 initial Breaths 30 Compressions: 2 Breaths
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3.4. RESUSCITATION PLAN (INFANT)
Danger Check scene safety; look for hazards to yourself or
casualty (Chapt 2, p.3 )
Response Gently tap/pinch infants arm/earlobe and call to him to
see if he responds
Shout for Help 2nd crew AED 3rd crew Oxygen, pocket mask,
communicate
Perform Secondary Survey (Parents to be asked questions)
Remove hazards
Airway Clear if necessary and open (chin lift)
Breathing Assess Breathing
Hold infant on its side Chap 3-3.5
YES
YES
NO
NO
YES
NO or ABNORMAL
CPR 5 initial Breaths 30 Compressions: 2 Breaths
Defibrillation Only on direction of MedLinks doctor or on board
doctor
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3.5. UNCONSCIOUS CASUALTY (RECOVERY POSITION) Unconsciousness -
prolonged state of collapse. Recognition
No response to crew members attempts to waken Breathing
present
Management 1. Recovery position. 2. Monitor Airway and breathing
continuously. 3. Contact MedLink. 4. Administer oxygen. 5. Keep
warm, cover with a blanket. 6. Give nothing by mouth. 7. Perform
Secondary Survey to identify any possible causes of Condition.
Recovery position Before placing into the recovery position,
attempt to determine the cause of the illness or injury and take
necessary precautions if a spinal injury is suspected. Reasons For
Placing The Casualty Into The Recovery Position
a. To keep the airway open and prevent the tongue from blocking
he airway b. To allow fluid to drain from the mouth, reducing the
risk of the casualty inhaling
stomach contents. c. To keep the head, neck and back in a
straight line (correct anatomical
alignment) Before turning a casualty, remove their eye glasses,
if worn.
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Technique (Recovery Position) 1. Kneeling beside the casualty,
open the airway by tilting the head and lifting the chin.
Straighten the legs. Place the arm nearest you at right-angles
to the body, elbow bent and with the palm of the hand facing
upwards.
2. Bring the arm furthest from you across the chest, and hold
the back of the hand
against the casualty's nearer cheek. 3. With your other hand,
grasp the leg furthest from you and pull the knee up, so that
the foot is flat on the floor. 4. Keeping the hand pressed
against the cheek, pull at the knee to roll the casualty
towards you and onto the side. 5. Tilt the head back to make
sure the airway remains open. Adjust the hand under the
cheek, if necessary, so that the head stays in a tilted
position. 6. Adjust the upper leg, if necessary, so that both the
hip and the knee are bent at right
angles. Note: Check casualtys breathing every one minute for 10
seconds.
If the casualty has to be kept in the recovery position for more
than 30 minutes, he should be turned to the opposite side, every 30
minutes.
Recovery Position - Children Use the same technique as for the
adult. Recovery Position - Infants Hold the baby on their side,
supporting the babys head and neck, tilting the baby slightly head
downwards to prevent inhalation of vomit and stop the tongue
blocking the airway.
3.6. CARDIAC ARREST (C.P.R.) Sudden stoppage of the heartbeat
and cardiac function, resulting in the loss of effective
circulation. Recognition
Sudden collapse No response No breathing Skin bluish, grey in
colour Possible complaining of chest pain prior to collapse
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Causes
Massive heart attack Abnormal heart rhythm e.g. ventricular
fibrillation Complication of serious medical condition e.g.
shock
Management CPR (Cardio-Pulmonary Resuscitation) &
Defibrillation Technique (CPR) 1. Position the casualty on their
back on a flat, hard surface; kneel by the side of the
casualty 2. Place the heel of one hand in the centre of the
casualtys chest 3. Place the heel of your other hand on top of the
first one, interlock the fingers of your
hands and ensure that pressure is not applied over the casualtys
ribs
4. Lean over the casualty, with your shoulders directly above
their chest 5. Keeping your arms straight and locked, compress the
chest 1/3-1/2 of the casualtys
chest diameter (approximately 4-5 cm) Release the pressure
without removing your hands Give 30 regular, smooth compressions at
a rate of 100 compressions / minute Count out loud to keep time and
rhythm
6. Give two effective rescue breaths
Pinch the soft part of the nose closed using the index finger
and thumb of the hand on the forehead
Allow the mouth to open but maintain a chin lift Take a normal
breath and place your lips around the mouth making sure you
have a good seal
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Blow steadily into the mouth while watching for the chest to
rise, taking
approximately 1 second as in normal breathing (this will ensure
an effective rescue breath is given)
Maintaining head tilt and chin lift, take your mouth away from
the casualtys mouth and watch for the chest to fall as air passes
out
Take another breath and blow into the victims mouth once more to
achieve a total of 2 effective breaths
7. Continue cycle of 30 chest compressions and two rescue
breaths
(Do not attempt more than 2 breaths each time before returning
to chest compressions)
8. As soon as the AED arrives, turn on machine, place pads on
the casualtys chest,
and follow machine prompts
Adult CPR Ratio - 30 Compressions : 2 Rescue breaths
CPR should continue while the AED is being set up and the pads
are placed on the casualtys chest.
3.6.1. Alternative methods of CPR CPR in pregnancy If a woman in
the later stages of pregnancy requires CPR:-
Position her on her back Place pillows under her right buttock
to tilt the pelvis to the left
CPR in confined spaces In confined spaces, over the head CPR may
be considered. For example, if you are unable to move the casualty
from between seats.
3.6.2. C.P.R Technique (Children) 1. Give 5 initial rescue
breaths before starting chest compressions 2. Continue with 30:2
ratio (same as per adult technique) One or two hand technique may
be used in order to depress the chest by approximately 1/2 to 1/3
of its depth
Child CPR Ratio - 30 Compressions : 2 Rescue breaths
Attach the AED as soon as it arrives on the scene, using the
paediatric pads in the appropriate locations.
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3.6.3. CPR Technique (Infants) 1. Lay the infant on his back on
a firm, flat surface. 2. Hold the infants head with one hand. 3.
Seal the nose and mouth of the infant with your mouth. 4. Give 5
initial rescue breaths. 5. Draw an imaginary line between the
infants nipples. 6. One finger space below this line, place index
and middle fingers, on chest.
7. Compress the chest, 1/3 -1/2 of the infants chest diameter 8.
Release the pressure without removing your fingers from the infants
chest 9. Give 30 regular, smooth compressions, at a rate of 100
compressions per minute,
without removing your fingers from the chest throughout the
compressions 10. Give two effective breaths 11. Continue cycles of
30 compressions and two breaths
Infant CPR Ratio - 30 Compressions : 2 Rescue breaths
The AED is only to be used on an infant if directed by MedLink
to do so or in the absence of contact with MedLink, a Doctor of
Medicine
travelling as a passenger onboard recommends its use.
3.6.4. Alternative Methods of Rescue Breathing Mouth To Nose
Breathing If the casualty has a mouth or jaw injury, it may not be
possible to seal their mouth, so rescue breathing must be performed
via the nose.
Seal your mouth over the casualtys nose and blow in as per
normal technique Hold the casualtys mouth closed After each breath,
remove your mouth and hand to allow air out of the casualtys
lungs Mouth To Stoma Breathing If a casualty has had an
operation to remove his voice box or open the windpipe, he will
breathe through a hole (stoma) in his neck. If he were to stop
breathing, rescue breathing must be performed via the stoma.
Hold the casualtys nose and mouth closed with one hand. Seal
your mouth over the stoma to make an airtight seal. Deliver breaths
into the stoma. After giving each breath, lift your mouth away to
allow air to escape from the
casualtys lungs.
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3.7. DEFIBRILLATION The AED should only be attached to the
casualtys chest when there is unresponsiveness and absence of
normal breathing.
Paediatric pads should be used on children from 1-8 years old
(less than 25 kg), however do not delay defibrillation to determine
exact age/weight. The defibrillator should only be used on infants
if directed by MedLink or on board medical professional to do
so.
Technique For Use Of The Defibrillator (CPR in progress) 1.
Clear the area around the casualty. 2. Press the On/Off button to
turn the Heartstart FR2+ on. 3. Ensure that the casualtys chest is
exposed and prepared for pad placement (dry,
free of excess hair, medication patches, jewellery and
undergarments are removed). 4. Follow the instructions provided by
the FR2+ voice and screen prompts. 5. Apply pads to patients bare
chest; plug in connector
i. Open defibrillator pads package ii. Remove pads from
protective backing one at a time (to reduce risk of pads
sticking to each other) 6. Place each pad on the casualtys bare
chest.
i. One pad just below the right collarbone ii. Second pad over
the casualtys ribs in line with the armpit, below the left
breast
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7. Plug in pads connector to the FR2+ by inserting firmly into
the connector socket (top
left of AED where flashing light is seen). 8. FR2+ - Analyzing
heart rhythm, do not touch the patient
As soon as the defibrillator detects that pads are connected
properly, it automatically begins analyzing the casualtys heart
rhythm. Do not touch the casualty during rhythm analysis and ensure
no other crew members are touching casualty at this time AED
Operator must shout Stop CPR - Stand clear
Note: If the casualtys heart is not in a shockable rhythm, the
FR2+ will prompt No
shock advised, Check for signs of circulation, if needed begin
CPR, and the AED operator should direct person administering CPR to
check breathing and continue CPR as required.
9. If the casualtys heart is in a shockable rhythm, the FR2+
will state Shock advised,
charging 10. AED Operator must shout - All clear, defibrillating
and visually reconfirm that no
one is touching the casualty or pads. 11. FR2+ prompt - Press
the orange button now.
Press flashing button to deliver shock to casualty. 12. After
the first shock has been delivered, the AED will re-analyse the
casualtys
cardiac rhythm. FR2+ prompt - Analyzing heart rhythm, do not
touch the patient AED Operator - Stand clear.
13. If a shockable rhythm is detected, the AED will charge again
and prompt to deliver a
further shock. Continue following the FR2+ prompts. If required,
the FR2+ will run through a cycle of 3 shocks, then prompt to
perform CPR if required for one minute.
Note: The FR2+ continues to analyse when charging for a shock if
it detects a
rhythm change and a shock is no longer appropriate, the FR2+
will cancel the charge.
Adult Pad Placement
Paediatric pad placement
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14. After one minute of CPR, the voice prompt will say:
Analyzing heart rhythm, do not touch the patient. If a shockable
rhythm is again detected the AED will run through additional shocks
if required (in cycles of three), followed by one minute of
CPR.
REMEMBER TO ALWAYS FOLLOW THE INSTRUCTIONS GIVEN TO YOU BY THE
AED
This sequence should continue until:
Medical assistance (either MedLink or an on board medical
volunteer) advises you to cease.
The aircraft diverts and medical staff on ground takes over
physically from you. There is no diversion, no medical advice is
available and you have been
attempting resuscitation for 30 minutes for an adult, 60 minutes
for a child/infant. The casualty shows signs of life.
Precautions
Do not touch or move the casualty while the AED is analysing or
delivering a shock.
Never place the AED pads directly on top of medication pads such
as nitro glycerine. Patches should always be removed and the skin
wiped dry prior to placing the pads.
If the casualty has a pacemaker or internal defibrillator with
battery pack (visible as a lump under the skin about 2 inches (5 cm
long), place the defibrillator pads at least one inch (2.5cm) away
from the implanted medical device.
Do not use the AED within 2 metres of electronic equipment e.g.
video compartment (VCC) should be suspended by the Cabin Manager if
within 2 metres of resuscitation site.
The AED should be operated in an area large enough to prevent
the casualty touching anything e.g. in the galley, not aircraft
aisle
Keep the area as dry as possible. Move oxygen bottles, face
masks away from the casualty when the AED prompts
a shock. Ensure all people assisting are clear of the casualty
prior to defibrillation by
shouting Stand clear. Confirm no-one is touching the casualty
when about to deliver a shock by then shouting All clear -
defibrillating
After Use
Check the status indicator is Flashing Black Hourglass. If the
indicator is showing a red flashing cross (X) with a chirping sound
carry out
a BIT. If it continues document and report to Engineering on
return to AUH for replacement battery.
Complete relevant documentation. Check that additional equipment
is replenished and ready to use. Place any other soiled equipment
(and used pads if removed by medical
personnel) into a plastic bag and arrange for disposal.
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Reseal the AED with a BLUE seal (RED seal if the machine is
unserviceable and therefore potentially faulty).
Documentation The following documentation should be completed as
soon as possible:- 1. Medical Incident Report 2. AED form 3. Death
on board form (as appropriate) 4. MedLink Patch check list form 5.
Cabin Maintenance Log 6. Aircraft Maintenance Log (Flight Deck) See
Chapter 6-6.5 for detailed information about the Heartstart FR2+
Automated External Defibrillator machine Debriefing of Crew
following Resuscitation The Cabin Manager should contact NOC
following an incident involving resuscitation. NOC will contact
Cabin Crew Management who will arrange for a crew debriefing of the
incident, for the purposes of crew support and an opportunity for
crew to express any concerns. A representative from Management,
Training and the Critical Incident Stress Management team will be
involved in this debriefing on return to AUH.
3.8. GUIDELINES FOR RESUSCITATION Diversion In the case where a
diversion is possible, crew will not stop resuscitating until the
aircraft comes to a stop and medical personnel take over on the
ground. In case of diversion, one crew member should stay out of
their jump seat and continue resuscitating even after the command
comes for crew to take their seats for landing. No Diversion
Possible In a situation where:-
No diversion is possible, MedLink cannot be contacted, and/or No
Medical Volunteer available on board
Recommended guidelines for Resuscitation attempt time limits are
- 30 minutes (Adult); 60 minutes (Child/infant) A decision will
then be made in conjunction with the Captain and Cabin Manager to
cease resuscitation.
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If CPR and defibrillation have been continuing for this time
without any signs of life, resuscitation has been unsuccessful.
3.9. CHOKING Partial or total obstruction of the airway by food,
fluid or foreign objects. Recognition
Clutching the throat Coughing, wheezing, gagging Difficulty
speaking or swallowing Making violent attempts to breathe Face,
neck, lips, ears, fingernails turning blue Making a whistling or
crowing noise Collapsing or becoming unconscious
Causes
Eating or drinking too quickly Swallowing small bones Not
chewing food sufficiently Tablets or capsules Talking or laughing
at the same time as eating/drinking
3.9.1. Management (Conscious Adult) 1. Reassure casualty and
confirm that they are choking 2. Encourage casualty to cough and do
nothing else If the casualty is unable to dislodge object through
coughing :-
a. Administer up to 5 Back Blows b. Check to see if each back
blow has relieved the obstruction c. If back blows do not dislodge
obstruction, administer up to 5 Abdominal
Thrusts d. Give 5 more back blows, if necessary e. Keep
alternating between back blows and abdominal thrusts until the
obstruction is removed f. If casualty collapses, revert to
management for unconscious choking casualty
(over page) Use chest thrusts instead of abdominal thrusts for
obviously pregnant women or obese casualties.
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Back Blows
Stand to the side and slightly behind the casualty Support his
chest with one hand and lean him well forwards, so that when
the
object is dislodged, it comes out the mouth rather than going
further down the airway
Give up to 5 sharp blows to the back between the shoulder
blades, with the heel of your other hand
Abdominal Thrusts
Stand behind the casualty, bend the casualty well forward Place
both arms around the upper part of the abdomen just below the rib
cage
(area between the navel and the bottom of the breast bone)
Clench your fist and grasp it with your other hand Pull sharply
inwards and upwards Repeat up to 5 times
Note: Abdominal thrusts can cause internal injuries; therefore a
casualty that had
abdominal thrusts administered to them should be examined for
injury by a doctor as soon as possible afterwards.
Chest Thrusts
Stand behind the casualty and put both arms around the chest
Clench your fist in between the nipples and grasp it with your
other hand Pull sharply inwards Give up to 5 chest thrusts
If casualty becomes unconscious:- 1. Support the casualty
carefully to the ground, Shout for help, and apply the AED as
soon as possible 2. Commence 30 chest compressions 3. Check the
airway, for any obvious object. If an object is seen, make an
attempt to
remove it with a single finger sweep 4. Open airway and attempt
2 rescue breaths 5. Continue with cycles of 30 chest compressions,
followed by a mouth check and two
rescue breaths (as per procedure Chapter 3-3.6) See Flowchart
over page - Collapsed Choking Adult
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Unconscious Choking Adult
30 Chest Compressions
Check mouth for object/Open
Airway
30 Chest Compressions
2 Rescue Breaths
Check mouth for object/Open
Airway
Continue cycles as per CPR procedure
(chap 3-3.6),
If object visible, try single finger
sweep to remove
If object visible, try single finger
sweep to remove
Note Apply and operate the AED as soon as possible
Keep Checking Airway before attempting the
Rescue Breaths
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3.9.2. Choking Management (Children) 1. Reassure casualty and
confirm that they are choking. 2. Encourage casualty to cough. If
unable to dislodge object through coughing:-
a. Hold the child in a face down position and try to position
the head lower than the body
b. Perform up to five back blows c. If unable to dislodge the
obstruction, perform up to five abdominal thrusts d. Repeat the
cycle until the object is clear or the child becomes
unconscious
If child becomes unconscious:- 1. Support the casualty carefully
to the ground, Shout for help, and apply the AED as
soon as possible 2. Check the mouth for any obvious object. If
an object is seen, make an attempt to
remove it with a single finger sweep 3. Open the airway and
attempt 5 Rescue breaths 4. If there is no response (moving,
coughing, spontaneous breathing) proceed with 30
chest compressions as per CPR procedure, Chapter 3-3.6.2 5.
Check the mouth for any obvious object. If an object is seen, make
an attempt to
remove it with a single finger sweep 6. Open the airway and
attempt 2 rescue breaths 7. Continue with cycles of 30 chest
compressions, followed by a mouth check and two
rescue breaths (as per CPR procedure, Chapter 3-3.6.2) See Flow
Chart over page Unconscious Choking Child
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Unconscious Choking Child or Infant
Check mouth for object/Open
Airway
If object visible, try single finger
sweep to remove
30 Chest Compressions
5 Initial Rescue Breaths
Check mouth for object/Open
Airway
Continue cycles as per CPR procedure
(chap 3-3.6.2/3.6.3)
If object visible, try single finger
sweep to remove
Note Children: Apply and operate the AED as soon as possible
Infant: AED only on direction of MedLinks doctor or onboard
doctor
Keep Checking Airway before attempting the
Rescue Breaths
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3.9.3. Choking Management (Infants) 1. Lay infant face down
across your lap or down your forearm 2. Support infants head by
placing thumb of one hand at the angle of the lower jaw and
1-2 fingers from the same hand at the same point on the other
side of the jaw 3. Position infants head, lower than its body 4.
Deliver up to 5 sharp back blows with the heel of hand in the
middle of the back
between the shoulder blades If these do not dislodge the
obstruction;
5. Turn infant into a face up/head down position (place free arm
along infants back and with the same hand, cup the back of its
head)
6. Support infant down your arm, which is placed down (or
across) your thigh 7. Identify the same landmark used for Chest
compressions on an infant 8. Deliver 5 Chest thrusts with 2 fingers
9. Repeat the cycle until the object is clear or the infant becomes
unconscious If the choking infant becomes unconscious:- Follow the
same procedure as for child (Chapter 3-3.9.2) The AED to be used on
an infant if directed by MedLink to do so or in the absence of
contact with MedLink, a Doctor of Medicine travelling as a
passenger onboard recommends its use
END OF CHAPTER
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INTENTIONALLY LEFT BLANK
3.1. LIFE SAVING PROCEDURES3.2. RESUSCITATION PLAN (ADULT)3.3.
RESUSCITATION PLAN (CHILD)3.4. RESUSCITATION PLAN (INFANT)3.5.
UNCONSCIOUS CASUALTY (RECOVERY POSITION)3.6. CARDIAC ARREST
(C.P.R.)3.6.1. Alternative methods of CPR3.6.2. C.P.R Technique
(Children)3.6.3. CPR Technique (Infants)3.6.4. Alternative Methods
of Rescue Breathing
3.7. DEFIBRILLATION3.8. GUIDELINES FOR RESUSCITATION 3.9.
CHOKING3.9.1. Management (Conscious Adult)3.9.2. Choking Management
(Children)3.9.3. Choking Management (Infants)