3.4 — Choking, Severe Bleeding and Burns

Three situations where a bystander's hands are the treatment, and where the correct action is simple and immediate.

Choking

Tell the difference first

Mild: they can cough, speak, or breathe.

Do not intervene. **Encourage them to cough. A person who can cough is moving air and their own cough is far more effective than anything you can do.

Severe: they cannot speak, cannot cough effectively, cannot breathe. Often clutching the throat, going red then blue, silent.

Silence is the danger sign. A choking person who is making noise is doing better than one who is not.

What to do — adult or child over one

**Ask: are you choking? If they cannot answer, act.

Five back blows. **Lean them forward, well over. **Heel of your hand, firm and sharp, between the shoulder blades. Check after each one.

Five abdominal thrusts. **Stand behind, arms around the waist. **Fist just above the navel, other hand over it. **Pull sharply inwards and upwards. Check after each one.

Alternate five and five until it clears or they become unresponsive.

If they become unresponsive: lower them to the floor, call emergency services, and start CPR (3.2). The chest compressions themselves generate pressure that can dislodge an obstruction.

And anybody who has had abdominal thrusts should be checked by a doctor afterwards, because internal injury is possible.

Infants under one

Different, and gentler.

Face down along your forearm, head lower than the body, supporting the jaw. Five back blows between the shoulder blades with the heel of your hand.

Turn them over, face up along your other forearm. Five chest thrusts — two fingers on the breastbone, just below the nipple line, sharper and deeper than compressions.

No abdominal thrusts for infants.

Alternate, checking the mouth between rounds and removing anything you can clearly see. Never sweep a finger blindly — you can push it further in.

If you are alone and choking

Call emergency services even if you cannot speak — an open line to the emergency number will be treated as a possible emergency and located where that capability exists.

And self-administer abdominal thrusts: your own fist above the navel and a hard inward-upward pull, or thrust yourself sharply against the back of a chair.

Severe bleeding

The most controllable life-threatening emergency there is, and pressure is almost the whole treatment.

The sequence

Press. Hard, directly on the wound, with whatever you have — a cloth, a shirt, your gloved hand.

Press harder than feels reasonable. Insufficient pressure is the commonest failure.

Keep pressing. Do not lift to check. Every check disturbs a clot that is forming.

Add on top. If blood comes through, do not remove the first dressing — put another on top and keep pressing.

Raise the limb above the level of the heart if you can do so without causing more injury.

Lay them down. A person losing blood may faint, and falling adds injury.

And call — 112 or 108.

If something is embedded

Do not remove it. It may be the only thing stopping worse bleeding.

Press around it, on either side, and build up padding around it so it is not pushed further in.

Tourniquets

For catastrophic limb bleeding that pressure will not control — a severed or partly severed limb, or an arterial bleed that is not stopping.

Modern guidance has moved back towards tourniquets for these specific situations, because the evidence from trauma care is that they save lives and the historical fear of losing the limb was overstated.

**How: apply it high on the limb, above the wound, over clothing if necessary. **Tighten until the bleeding stops — it will hurt considerably and that is expected. Note the time of application and tell the ambulance crew.

And do not loosen it once applied.

Improvised tourniquets are much less effective than proper ones and are worth attempting if there is no alternative — a wide band and a rigid rod to twist it, never a thin cord.

Shock

Watch for: pale, cold, clammy skin, fast weak pulse, rapid shallow breathing, confusion, thirst.

Lay them flat, raise the legs if there is no leg injury, keep them warm, and do not give anything to drink.

Burns

The immediate action, and it matters more than anything else

Cool the burn with cool running water for twenty minutes.

Twenty minutes is longer than everybody thinks and it is the number.

And it is effective for up to about three hours after the burn — so if you did not do it immediately, still do it.

Cool running water only. Not ice, not iced water — ice damages tissue and can worsen the injury.

Remove jewellery and clothing near the burn while cooling, unless it is stuck to the skin, in which case leave it.

Then cover loosely with cling film laid on — not wrapped tightly around a limb — or a clean non-fluffy cloth.

Keep the person warm while cooling the burn, because cooling a large area can drop body temperature, particularly in children.

What not to put on a burn

Ice. Butter. Oil. Toothpaste. Turmeric or other pastes. Ointments. Cotton wool.

None of them help, several cause harm, and all of them make the wound harder for a doctor to assess.

And do not burst blisters.

When it needs a hospital

Any burn that is: larger than the person's palm; on the face, hands, feet, genitals or across a joint; deep — white, brown, black, or leathery, or painless in the middle, because painless means the nerves are gone; caused by chemicals or electricity; or in a child or an older person.

And any burn where the person has inhaled smoke or hot gases (6.1), **because airway swelling can develop over hours.

Chemical burns

Brush off any dry powder first, then flush with large amounts of running water for a prolonged period — longer than for a thermal burn.

Protect yourself while doing it.

Electrical burns

Do not touch the person until the power is off (6.2).

And electrical injury needs a hospital regardless of how small the visible burn is, because the damage runs along the path of the current internally and the entry and exit wounds tell you very little.

What to do with this page

Choking: a silent person is the emergency. Five back blows, five abdominal thrusts, alternate. No abdominal thrusts on infants.

Bleeding: press hard, do not lift to check, add on top, and press for longer than feels reasonable.

Embedded object stays in. Press around it.

Burns: twenty minutes of cool running water, and it works up to three hours later. Nothing else on it.

And a painless burn is a serious burn. That inversion is the one people get wrong.

Next: 3.5 — seizures, fainting, diabetic emergencies and anaphylaxis, all of which look alarming and are usually manageable.