Look, listen, and feel for breathing (Figure 1). Put your ear close to the victim’s mouth and nose, and try to detect if he is moving air into and out of his lungs. Watch for chest wall motion. Determine if a victim is breathing by listening and feeling for air movement around the mouth and nose and observing the chest for unassisted rise and fall. In cold weather, look for a vapor cloud or feel for warm air moving across your hand. If the victim is not breathing well (or at all), you must manage the airway (see page 22) and begin to breathe for him (see page 28), taking care to maintain the position of the neck if there is any chance of a cervical spine injury (see page 37). Observe the number of breaths per minute; normal is 12 to 18 per minute for adults, 18 to 25 per minute for small children, and 25 to 50 per minute for infants.

Feel for a pulse. Current American Heart Association guidelines advise laypersons to begin chest compressions without going through a pulse check on victims who are not breathing and who do not show any sign of life. Basic life support may also be initiated by checking for a pulse. Place the tips of your index and middle fingers (not your thumb, which can generate a “false” pulse—your own!) gently on the radial artery in the wrist (see Figure 16, C, page 33). If you cannot detect a pulse there (particularly if your fingers are cold), move your fingers quickly to the brachial artery (this is particularly useful for infants) at the midpoint of the inside of the upper arm (see Figure 16, E, page 33), the femoral artery in the groin (see Figure 16, B, page 33), or the carotid artery in the neck (see Figure 16, A, page 33). If no pulse is detected in any of these locations (and the victim is not breathing or verbalizing), begin chest compressions (see page 32). Observe the pulse rate; normal is 55 to 90 per minute for adults, 80 to 110 per minute for small children, and 100 to 130 per minute for infants. The pulse rate is faster with excitement or fear and slower in trained athletes. A rapid and weak (“thready”) pulse is a sign of impending shock (see page 60), usually due to excessive bleeding, dehydration, or heart problems. An irregular pulse may indicate an abnormal heart rhythm.

Locate brisk bleeding. Quickly survey the victim to locate any obvious sources of brisk bleeding. Quickly apply firm pressure to these areas (see page 54).

If an injury may be extensive, examine the whole victim. Particularly dangerous situations include falls; blows to the head, neck, chest, or abdomen; altered mental status; difficulty breathing or shortness of breath; and injuries to children. In these cases, or whenever the diagnosis is not readily apparent, evaluate the victim from head to toe. Weather and appropriate modesty permitting, be sure to undress the victim sufficiently to perform a proper examination. Look around the neck or on the wrist(s) for a medical alert (such as MedicAlert) tag, and in a wallet, helmet, or pack for an information card.

4. Examine the head—but try not to move it. Feel the entire scalp for raised areas or cuts. Look into the ears for drainage (clear [spinal] fluid, blood, or pus). If there is blood, capture some on a white absorbent cloth or gauze pad. If the blood forms a ring, with a faded or yellow area toward the center, this may indicate the presence of spinal fluid. Feel the nose for obvious malalignment or instability. Look up into the nostrils. If you have a flashlight, shine it into the eyes to see if the pupils constrict and are equal in size. If you don’t have a flashlight, cover the eyes and then uncover them to see if the pupils constrict. Pinpoint (constricted) pupils may be a sign of brain injury or drug overdose. Unequal pupils may represent a direct injury to an eye or a brain injury. Nonreactive and bilaterally dilated pupils may represent a severe brain injury. Ask the victim to follow your fingers with his eyes; if this cannot be done, if the eyes do not move together, or if he reports blurred or double vision, there may be a problem. If the eyes are spontaneously jerking or wandering, this may also indicate abnormality. If the victim has contact lenses, he may require assistance with their removal (see page 183).

Figure 1 Look, listen, and feel for air movement.

Have the victim open and close his mouth to see if the teeth fit properly. Check the teeth for absence, looseness, or breaks, and the tongue for cuts. Ask the victim if he can swallow. Ask him to say “Ah” and see if you can get a glimpse of the back of his throat. Smell for any unusual odor on his breath. If dentures are loose, remove them. Smell the victim’s breath to detect any abnormal odor (e.g., alcohol or “fruity” breath associated with severe diabetes).

Send for help early. As soon as you have determined that a situation will require extrication, rescue, or advanced life support, initiate your prearranged plan for communication and transportation. Don’t assume that someone will call for help; you must assign this task to a specific individual.