Life-threatening emergencies: cardiac arrest, choking, bleeding

1Cardiac arrest: cardiopulmonary resuscitation

A casualty who is unresponsive and not breathing normally is in cardiac arrest. Every minute without chest compressions sharply reduces their chances of survival.

• Casualty on their back, on a firm surface. Hands one on top of the other in the centre of the chest.
• Compressions 5 to 6 cm deep in adults, at a rate of 100 to 120 per minute, letting the chest rise fully.
• If you are trained and willing: 30 compressions then 2 rescue breaths. Otherwise, continuous compression-only CPR is already very useful.
• Continue until help arrives, normal breathing returns or you are exhausted; swap every two minutes if there are several of you.

Child: one or two hands, about one third of the depth of the chest. Infant: two fingers, about 4 cm. In children, arrest is often caused by breathing problems: rescue breaths are important if you are trained.

2The defibrillator and the recovery position

An automated external defibrillator (AED) analyses the heart rhythm and delivers a shock if needed. Switch it on and follow the voice prompts; attach the pads to the bare, dry chest; nobody touches the casualty during analysis and shock; resume compressions as soon as the device tells you to. Find out in advance whether your office, the airport or the nearby hospital has one.

A casualty who is unresponsive but breathing normally is placed in the recovery position: on their side, head tilted back, mouth pointing down so that vomit can drain. Check their breathing regularly: if it stops, roll them onto their back and start resuscitation.

3Choking: clearing the airway

A foreign body (food, small object) can block the airway.

• Mild obstruction: the person coughs, speaks, breathes. Encourage them to cough and do nothing else.
• Severe obstruction: they cannot speak, cough effectively or breathe, and often clutch their throat. Give 5 back blows between the shoulder blades with the person leaning forward; if unsuccessful, give 5 abdominal thrusts (fist just above the navel, pull inwards and upwards). Alternate 5 and 5.
• Infant: 5 back blows, face down along your forearm with the head lower, then 5 chest thrusts with two fingers. No abdominal thrusts.
• If the casualty becomes unresponsive: call for help and start resuscitation.

4Severe bleeding and shock

Catastrophic bleeding can kill within minutes. Gloves if possible, then firm direct pressure on the wound, with your hand or a thick dressing; do not release it to look. Add more dressings on top if blood soaks through.

If direct pressure is not enough or not possible on a limb (amputation, several casualties, inaccessible wound), apply a tourniquet: 5 to 7 cm above the wound, never over a joint, tightened until the bleeding stops. Write down the time it was applied and never loosen it yourself. An improvised tourniquet (wide strip of cloth and a stick) is less effective than a commercial one: field vehicles should carry one.

Shock (pale, cold, clammy skin, rapid pulse, agitation then drowsiness) often follows bleeding: lay the casualty down, cover them, reassure them, give nothing to eat or drink and monitor them until evacuation.

5The chain of survival and high-quality CPR: what really makes the difference

Resuscitation, choking relief and bleeding control cannot be learned by reading. This online course prepares for and complements certified hands-on training, with manikin practice and assessment by an instructor; it does not replace it. Guidelines change: check that your training follows the current version of the IFRC and European Resuscitation Council guidelines, or the equivalent national protocol.

International guidelines describe the management of cardiac arrest as a chain of survival: early recognition and call for help, early cardiopulmonary resuscitation (CPR) by bystanders, early defibrillation, advanced life support, and then post-resuscitation care. In humanitarian settings, the last two links are often absent or far away. This does not make CPR pointless, but it changes its role: the bystander and the defibrillator carry almost all of the chance of survival, and teams need to be told this honestly.

Recognising cardiac arrest without hesitation

The ERC and IFRC guidelines use two simple criteria for a first aider: the casualty is unresponsive and is not breathing normally. Checking for a pulse is not taught to first aiders for this decision. Two pitfalls are common:

• Agonal gasps: slow, deep or noisy agonal breaths, present in the first minutes in many casualties. They must be interpreted as an absence of normal breathing.
• Seizure-like movements at the moment of arrest: a brief seizure-like episode may accompany the arrest. Once it is over, check breathing; if it is not normal, start CPR.

Where an emergency service can be reached, the guidelines stress calling early, with the phone on speaker, so that the dispatcher can guide the bystander. In a setting without an emergency service, the equivalent is immediately alerting the medical focal point or the referral facility, and sending someone to fetch the defibrillator if there is one.

The determinants of effective CPR

The guidelines accept that untrained bystanders, or trained ones who are unwilling or unable to give rescue breaths, perform continuous compression-only CPR. For trained people, the sequence of 30 compressions and 2 rescue breaths remains the standard in adults. A pocket mask with a one-way valve protects the rescuer and should be included in every kit.

Children and infants

In children, cardiac arrest is most often the consequence of respiratory failure (drowning, choking, severe respiratory infection, severe dehydration). This is why the ERC paediatric guidelines provide that people trained in paediatric life support start with 5 initial rescue breaths, then alternate compressions and breaths at the ratio taught in their paediatric training. The guidelines specify that a bystander trained only in adult CPR should apply what he or she knows rather than do nothing: imperfect CPR is far better than no CPR at all.

• Depth: at least one third of the depth of the chest (about 4 cm in an infant, about 5 cm in a child).
• Technique: two fingers or two encircling thumbs in an infant; one or two hands in a child, depending on size.
• Rate: 100 to 120 per minute, as in adults.

When not to start, when to stop

A first aider does not start CPR when there are obvious signs of death that occurred some time ago or injuries clearly incompatible with life, or when the scene is dangerous. He or she stops when a professional takes over, when the casualty shows signs of life (movement, eye opening, normal breathing), when exhausted, or when the scene becomes dangerous. In isolated settings, the question arises of how long it is reasonable to continue CPR without a defibrillator or backup; the decision rests on medical advice, obtained remotely if possible, and on the organisation's protocol. The first aider must not carry this decision alone.

6Team resuscitation and defibrillation: roles, timing and special circumstances

When several people are present, the quality of CPR depends more on organisation than on individual technique. Humanitarian teams, often gathered in an office, at a distribution site or in a base camp, can practise a simple allocation of roles.

Allocation of roles

Using the automated external defibrillator: detailed sequence

1. As soon as the device arrives, switch it on and follow the voice prompts. Compressions continue in the meantime.
2. Bare the chest. Dry it quickly if wet; quickly shave or remove hair if the device contains a razor and the pads do not stick; remove any visible medication patch where a pad needs to go.
3. Attach the pads as shown in the diagram: generally one below the right collarbone and the other on the left side of the chest, below the armpit. Avoid placing them directly over an implanted device visible under the skin (pacemaker).
4. During analysis, nobody touches the casualty. The team leader clearly calls everyone to stand clear.
5. If a shock is advised, check that nobody is touching the casualty, then press the button (or let the device deliver it if it is fully automatic). Resume compressions immediately, without waiting or checking breathing.
6. If no shock is advised, resume compressions immediately. The absence of a shock does not mean the casualty is improving.
7. Continue following the device's prompts; it re-analyses at regular intervals. Do not remove the pads, even if the casualty resumes normal breathing.

For a child, use paediatric pads or the paediatric mode if the device has one; failing that, the guidelines accept the use of adult pads, placed so that they do not touch each other (for example one on the front and one on the back).

Special circumstances

• Drowning: the arrest is respiratory in origin. The guidelines provide that a trained rescuer starts with 5 rescue breaths before compressions. Do not enter the water without water rescue training: reach, throw, don't go.
• Advanced pregnancy: CPR is performed in the same way. Specialist guidelines provide that, when a second rescuer is available and the uterus is visibly enlarged, it should be manually displaced to the left to improve blood return to the heart.
• Trauma: traumatic cardiac arrest has specific causes (haemorrhage, airway obstruction). The first aider first controls catastrophic bleeding, then performs CPR.
• Opioid poisoning: in programmes that authorise it, trained first aiders may administer naloxone. This does not replace either the alert or CPR.
• Electrical injury: cut off the power before any contact.
• Epidemic of a respiratory-transmitted disease: guidance published during the COVID-19 pandemic advised bystanders to favour compression-only CPR and to cover the casualty's mouth and nose with a cloth. Follow the guidance in force at the time of the epidemic.

Warning signs that precede cardiac arrest

Some cardiac arrests are preceded by signs that allow earlier action.

• Chest pain suggestive of a heart attack: pain or tightness in the centre of the chest, possibly radiating to the arm, jaw or back, with sweating, nausea, shortness of breath. Have the person rest in the position they find most comfortable, raise the alarm immediately, and, if the organisation's protocol and training allow it and there is no known allergy or contraindication, have a conscious adult chew aspirin, as permitted by the European first aid guidelines. Get the defibrillator ready.
• Stroke: facial asymmetry, weakness in one arm, speech disturbance, of sudden onset. The FAST tool (Face, Arm, Speech, Time) or an equivalent scale helps to recognise it. Note the time the signs began, raise the alarm, give nothing by mouth.

7Choking and bleeding: detailed techniques and points of vigilance

Foreign body airway obstruction

The principle of the guidelines is to recognise the severity, then apply a simple sequence, repeated as needed.

• After each blow or thrust, check whether the obstruction has cleared: there is no need to complete all five.
• Do not perform blind finger sweeps of the mouth; remove only an object that is clearly visible and reachable.
• For a woman in advanced pregnancy or a person whose abdomen cannot be encircled, many programmes teach chest thrusts instead of abdominal thrusts: follow the protocol of your training.
• Anyone who has received abdominal thrusts must be examined by a health professional, because of the risk of internal injury.

Bleeding: the hierarchy of interventions

The 2020 IFRC guidelines and the 2021 ERC guidelines converge on a clear hierarchy:

1. Direct manual pressure, firm and continuous, on the wound, with gloves if possible, through a dressing or clean cloth. This is the first action for the vast majority of bleeds.
2. Haemostatic dressing (a dressing impregnated with an agent that promotes clotting), when the first aider is trained and the equipment is available, particularly for wounds where a tourniquet cannot be applied.
3. Tourniquet for life-threatening bleeding from a limb, when pressure is insufficient or not feasible. A commercial tourniquet is preferable; an improvised tourniquet is recommended only as a last resort, by a first aider trained to make one, because it often fails.

Recent guidelines no longer include limb elevation or proximal pressure on a "pressure point" as bleeding control measures, for lack of evidence of effectiveness.

The tourniquet: technique and pitfalls

• Place it on the limb, above the wound (between the wound and the heart), a few centimetres from it, never over a joint. If the wound is difficult to locate, many combat trauma protocols teach placing it high on the limb.
• Tighten until the bleeding stops. An insufficiently tightened tourniquet can increase bleeding by blocking venous return without blocking arterial inflow.
• If bleeding continues despite a correctly tightened tourniquet, a second tourniquet may be applied just above the first, in line with the training received.
• Application is painful: warn the casualty, and do not loosen it to relieve the pain.
• Record the time of application visibly (on the tourniquet, on the skin, on the form). Do not cover the tourniquet with clothing or blankets that would hide it from the medical team.
• Only a medical team decides whether to loosen it or convert to another method.

Junctional wounds and wound packing

In junctional areas (groin, armpit, base of the neck), a limb tourniquet is impossible. The trained first aider packs the wound with gauze or a haemostatic dressing, pressing it firmly into the depth of the wound, then applies firm and prolonged pressure. This skill is taught in trauma training courses; it is covered again on day 4.

Shock: monitoring and preventing deterioration

Shock is a failure of the circulation. The first aider cannot treat it, but can prevent it from getting worse: stop the bleeding, lay the casualty down, protect from the cold (insulating blanket underneath and on top), reassure, give nothing to drink or eat, monitor and arrange evacuation. The European guidelines allow the legs of a casualty in shock without trauma to be raised for a limited time; in trauma, the casualty is left flat. Signs to report: pallor, cold sweats, fast and weak pulse, rapid breathing, thirst, agitation followed by drowsiness.

The order is not up for debate: catastrophic bleeding is treated before anything else. A casualty bleeding heavily from the thigh can die within minutes; neither the alert nor the full assessment should delay pressure or the tourniquet, which can be handed to a guided bystander if the first aider has to raise the alarm.

8Worked example: cardiac arrest on the premises of a field office

Fictitious context: the office of the organisation "Solidarité Vallée Verte" in Kalo, 22 employees, located 15 minutes from the regional hospital, which has an emergency department and an ambulance. The office has a defibrillator, bought the previous year following a security audit and kept at reception. Four employees are certified in first aid. The medical plan was exercised three months earlier.

Minute-by-minute timeline

Why this outcome was possible

• Time from collapse to compressions: 30 seconds, thanks to immediate recognition of agonal gasps.
• Time to first shock: about 2 minutes, because the device was less than a minute's run away and everyone knew where it was.
• Instructions given by name: "Karim, call" is more effective than "somebody call".
• Limited interruptions: pads attached during compressions, immediate resumption after the shock.
• Record-keeping: the timekeeper noted the times, allowing a complete handover.

The same situation at an isolated base

If the same casualty collapses at a base four hours from the nearest hospital, without a defibrillator, the chances of survival are much lower. High-quality CPR must nevertheless be started immediately, the alarm raised and medical advice sought. This gap illustrates two management decisions: purchasing defibrillators for bases with large numbers of staff or staff exposed to cardiovascular risk, and taking medical history into account during pre-deployment medical checks, while respecting confidentiality.

A second short case: bleeding at a distribution point

During a distribution, a crowd surge knocks a man onto a sheet of corrugated iron. Deep wound on the inner thigh, heavy and continuous bleeding. The first aider immediately applies pressure with both hands over a thick dressing, putting his full weight on it, then asks for the tourniquet from the kit. Pressure is not enough: blood soaks through quickly. He applies the commercial tourniquet to the thigh above the wound, tightens it until the bleeding stops, writes the time with a marker on the tourniquet and on the form, lays the casualty down, covers him, and has the on-site health partner alerted, who arranges transfer to the hospital with an operating theatre. The distribution is suspended while control of the crowd is regained.

9Tools: kit contents, CPR card and equipment checks

The contents below are indicative. They must be validated by the organisation's medical adviser, adapted to the risks of the context and to the training level of staff, and compliant with national regulations. No medication should be added to a kit without a corresponding protocol and training.

Vehicle kit and office kit

Monthly check sheet

CPR reminder card (to be laminated)

1. Is the scene safe?
2. Unresponsive? Shout for help.
3. Open the airway, check breathing (no more than 10 seconds).
4. No normal breathing: have someone call for help (on speaker) and fetch the defibrillator, naming the people you send.
5. Compressions: centre of the chest, 5 to 6 cm, 100 to 120 per minute, full recoil.
6. If trained: 30 compressions, 2 rescue breaths. Otherwise: continuous compression-only CPR.
7. Defibrillator: switch on, follow the prompts, nobody touches during analysis and shock, resume immediately.
8. Change rescuers every two minutes; record the times.

Resuscitation record form

10Common mistakes, contextual variations and what assessors expect

Common mistakes and how to avoid them

• Hesitating to start for fear of doing it wrong or causing harm. Ribs may fracture during effective CPR; this is no reason to stop. A casualty in cardiac arrest cannot be made worse by CPR: without it, he or she will die.
• Compressions too shallow, especially after the first minute. Regular changeovers and monitoring by the team leader are the remedy.
• Stopping compressions to check breathing or pulse regularly: only the defibrillator or obvious signs of life justify stopping.
• Delaying the shock to finish a cycle or to check: follow the device.
• Defibrillator unusable: flat battery, expired pads, device locked in an office. Monthly checks and a location accessible at all times.
• Tourniquet too loose, badly placed, or loosened by the first aider "to relieve the casualty"; tourniquet hidden under a blanket with no time recorded.
• Releasing direct pressure to see whether the bleeding has stopped: maintain pressure without releasing it.
• Giving fluids by mouth to a casualty in shock or who will need surgery.
• Blind finger sweeps of the mouth in choking.

Contextual variations

Sudden-onset crisis: large numbers of casualties, few defibrillators, priority given to bleeding control and airway management. Traumatic cardiac arrest in a mass casualty situation falls under triage (day 4): resources are directed to the casualties who can be saved.

Protracted crisis: skills erode. The education guidelines stress frequent, short refreshers; a practical manikin session of a few tens of minutes several times a year maintains skills better than a long course that is rarely repeated.

Camps and distribution sites: plan for a visible first aid post, a dedicated first aider who does not take part in the distribution, and an evacuation route to the site clinic. Train community volunteers.

Urban settings: public-access defibrillators may exist; identify them and include them in the plan.

Insecurity: CPR on a casualty in an area exposed to gunfire is not feasible; the priority is to take cover, then control bleeding. First aid training for conflict zones, such as that of the ICRC, clearly distinguishes what can be done under threat from what can only be done in a safe area.

Partners with limited capacity: budget for training manikins, training tourniquets, kits and refresher courses. A commercial tourniquet costs little compared with a life; its absence from an exposed vehicle is hard to justify during a post-incident investigation.

What assessors look for

• Percentage of field staff certified and up to date, by base and by partner.
• Commercial tourniquets in exposed vehicles and defibrillators in offices and bases where justified.
• CPR exercises carried out and timed.
• Incident reports describing the actions taken, the time frames and the lessons learned.
• Consistency of training with current guidelines (IFRC 2020, ERC 2021 or national protocol).

11Interview questions and key references

1. "How do you recognise cardiac arrest, and what do you do in the first minute?"

A good answer cites the two criteria (unresponsive, not breathing normally), the pitfall of agonal gasps, early alerting and sending a named person to fetch the defibrillator, followed by the immediate start of high-quality compressions. It mentions the option of compression-only CPR and the 30:2 sequence for trained people.

2. "Why install a defibrillator at a base, and how do you make sure it will be used?"

The candidate explains that early defibrillation is the single most decisive factor for survival in certain cardiac arrests, then talks about an accessible location known to everyone, staff training, regular checks of the device, pads and battery, and exercises.

3. "A colleague is bleeding heavily from the leg after an accident. Describe what you do."

The candidate begins with safety and gloves if possible, then firm direct pressure, a tourniquet if pressure is insufficient or not possible, the time recorded, the tourniquet left visible and not loosened, prevention of hypothermia, alerting and evacuation to a surgical facility. He or she mentions that elevation and pressure points have been abandoned.

4. "A child chokes during an activity in a child-friendly space. What must the team be able to do?"

The candidate distinguishes an effective cough from severe obstruction, describes alternating back blows and abdominal thrusts in a child over one year, and back blows and chest thrusts in an infant, what to do if the child loses consciousness, and the need for medical review after abdominal thrusts. He or she adds team training and the presence of a trained person at every activity.

5. "How do you maintain CPR skills in a team with high turnover?"

The candidate cites short, frequent refreshers, manikin practice, timed exercises, tracking of certifications, training built into the induction of new arrivals, and the distribution of reminder cards.

Key references

• International First Aid, Resuscitation and Education Guidelines (2020): IFRC.
• European Resuscitation Council Guidelines (2021): chapters on adult basic life support, paediatric life support, special circumstances and first aid.
• ILCOR annual scientific consensus statements on resuscitation and first aid.
• First Aid in Armed Conflicts and Other Situations of Violence: ICRC.
• Basic Emergency Care: approach to the acutely ill and injured: WHO and ICRC.
• The Sphere Handbook (2018), health standards on trauma care and emergencies.

Reminder: this online course does not replace certified hands-on training. CPR, choking relief and tourniquet application require supervised practical training and regular refreshers.