Pressure Testing Procedure and Precautions required to be taken at work site


Hydro Testing: Test of strength and leak-resistance of a vessel, pipe, or other
hollow equipment by internal pressurization with a test liquid.

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Pneumatic Testing: Pressure testing of vessel, line by the use of air pressure

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General Philosophy
Pressure testing of equipment, system, and pipelines is carried out to prove the strength of
equipment designed to contain pressure or a fluid head or both. It may also be employed
to check equipment / piping for leaks or conditioning favorable stresses.

• Pressure may be applied hydrostatically, pneumatically or in combination.
• The adequacy of testing procedure is generally outlined with the following
− Basing the test pressure on the weakest member.
− Observing allowable stress in relation to:
􀂾 Minimum Metal Design Temperature.
􀂾 Joint Efficiency.
􀂾 Area Classification (Design Factor).
􀂾 Minimum specified yield strength value.
− Selection & treatment of testing medium.
− Temperature of the test medium & the ambient temperature.
− Installation of adequate pressure / vacuum relieving devices.
− Proper support of the equipment / system under test.
− Accuracy of pressure gauges and its proper calibration.
− Installing pressure gauges at the lowest location to account for fluid head and
monitoring during the test period.
− Installing pressure gauge at the highest location to meet the proof test pressure.
− Proper sizing of blinds & spades.
− Proper venting.
Correct pressure increase during test schedule.
− Mechanical Clearance of all works.
− Competent supervision.
− Pressure testing of relevant segment rather than entire system.
− The following documents are to be submitted prior to commencing any pressure
test and shall be available at the site during the test time
− Material Test Certificate including material identification
− The inspection report witnessed by company representative during manufacturing
& assembly.
− All NDT (Non – destructive Test) reports


The following precautions are to be taken during pressure testing:
• The material shall be procured from Company’s approved manufacturer’s list.
• Full technical detail in conformation to material specification shall be made available.
• The company can send its representative to witness all or part of inspection & testing
activity during manufacturing or assembly phase, as deemed essential to ensure the
equipment integrity and functional reliability.
• The fabrication work shall commence only after quality assurance of material and
• The test area shall be clear from any obstructions and cordoned off to prevent any
unauthorized intrusion. The test area is to be barricaded by visual warning/caution
tape from all the sides and warning signboard should be displayed near the testing site
in local as well as English language stating, “Pipe Line Under Pressure Keep Away”.
Post warnings signs shall also be given before 24 hours prior to the test. Signal man
should also be assigned to prevent unauthorized intrusion
• The cooling affect due to temperature reduction while depressurizing the system shall
be taken into account addressing the risk of brittle fracture.
• It is absolutely imperative that tank/vessel vents are open and clear when emptying
after test to avoid creation of a vacuum.
• Competent personnel are in attendance whilst tank, Vessel vents are closed during a
test since these would need to be opened in the event of a loss of liquid for any

Do not change (exceed/decrease) the duration of hydro-test without the permission
from QC Engineer.

 Pneumatic Testing

Pneumatic testing shall be considered only under following circumstances:
• Where strength has been satisfactorily proven by a prior hydrostatic test and it is
necessary to pressure test the same by pneumatic pressure.
• Where the equipment cannot be safely filled with liquid.
• Where trace liquids cannot be tolerated & their complete removal is considered
• The pressurization procedure as listed here under shall be taken into consideration:
− The equipment shall be gradually pressurized up to 50% of test pressure and
allowed to stabilize.
− Thereafter the pressure shall be increased in stages @ 1/10th of test pressure each
time along with stabilizing period in between.
− The test pressure shall be constantly monitored and controlled safely.
• A pressure relieving device has to be provided always.
General Test Procedure
The following precautions shall be kept in view during general test procedure:
• The pressure testing shall not be carried out with valves closed for the system.
• A Dead Weight Tester to cross check the pressure gauge reading shall be utilized
• The test pressure shall be monitored with a minimum of one gauge at the pressurizing
source and one each at extreme end, the highest & lowest point of the equipment /
system under test.
• The pressure-relieving device (PRV) [installed on the equipment / system under test]
shall be set at 110% or 50psi more, whichever is less.
• All pumps / compressors to be utilized for pressure testing shall be of suitable pressure
& capacity ratings.
• The pressure gauges shall have rating & range more than 1.5 to 2.0 times the test
• The Halides content of the testing medium shall not be more than 25ppm for the
testing of Stainless Steel equipment / system.

The test procedure and the package shall be approved by the Client prior to
commencing any pressure test.
• Testing against closed valves shall only be carried out when unavoidable. In any case,
this technique shall only be utilized for piping and not for equipment items.
• The seat rating of the valve shall not be exceeded. The un-pressurized side of the
valve shall be vented.
• A suitably calibrated gauge shall be used and there shall be no intervening valves
between the gauge and the equipment under test. The gauge shall not be used if there
is any doubt about its accuracy or functional condition. The gauge must be clearly
visible to the operator controlling the pressure.
• Condition of equipment shall be assessed by referring to previous maintenance or
status record as well as through physical inspection at site.
• When applying high pressure pneumatic testing, a thorough inspection shall be
performed immediately prior to the test and supplementary non-destructive testing will
often be advisable. The need for temporary restrain of bellows or other expansion
joints and spring supports should be assessed.
• Whenever possible, Manufacturers’ recommendations shall be consulted,
• Once the test pressure is attained and stabilized, all pumping connection and
accessories shall be disconnected after safe depressurizing.
• Spades should be avoided in relief lines, as failure to remove them after test would
render relief valves inoperative in future service.

Test Fluid

• Consideration shall be given to the possibility that supports may not have been
designed for the weight of test liquid.
• Before filling equipment with liquid, the arrangement should be checked to ensure that
all air can be vented. In addition to aiding leak detection, this also serves to minimize
the energy stored and the potential hazard.
• To avoid undue stresses from temperature gradients, test fluid and equipment should
be allowed to reach the same temperature before pressurization.
• Flammable gas shall never be used for pressure or leak testing purposes.
• The use of flammable liquids shall be avoided if possible. The flash points shall exceed
by an ample margin of the maximum surface temperature of the equipment under test

and in any case must be not less than 50° C. The boiling point must be well in excess
of test temperature.
• Consideration shall be given to corrosive and other potentially detrimental effects on
materials of construction.
• When testing to high pressures pneumatically, an inert gas must be used if there is
any possibility of a flammable material being present. This is to avoid the possibility of
internal compression-ignition.

Competent Supervision

It is important that competent personnel supervise all stages of testing. In addition, it will
often be necessary for tests to be witnessed to satisfy contractual requirements or
• Pre-work tools must be done prior to the test.
• Supervisor should assign competent persons to check for the leaks.
• Leak inspection should be done only when the pressure is held.
• All workers responsible for the work must attend the training session on pressure
testing conducted by the site safety personnel.
• Good communication must be maintained during the pressure test.
• Do not leave the pressurized hose or pump unattended when the hydro-test is going

Different Mechanical machinery Hazards at Workplace

Mechanical machinery Hazards
Most machinery has the potential to cause injury to people,and machinery accidents figure prominently in official accident statistics. These injuries may range in severity from a minor cut or bruise, through various degrees of wounding and disabling mutilation, to crushing, decapitation
or other fatal injury. It is not solely powered machinery that is hazardous, for many manually-operated machines

(e.g. hand-operated guillotines and fly presses) can still cause injury if not properly safeguarded.
Machinery movement basically consists of rotary, sliding or reciprocating action, or a combination of these. 

These movements may cause injury by entanglement, friction or abrasion, cutting, shearing, stabbing or puncture, impact,crushing, or by drawing a person into a position where one
or more of these types of injury can occur. The hazards of machinery are set out in ISO 12100 Part 1: 2003, which covers the classification of machinery hazards and how harm may occur. 

The following mechanical hazards follow this standard (Figure  shows a number of these hazards). A person may be injured at machinery as a result of: ää a crushing hazard through being trapped between a moving part of a machine and a fixed structure, such as a wall or any material in a machine;
 Shearing hazard which shears part of the body, typically a hand or fingers, between moving and fixed parts of the machine, or between two or more moving parts; 
 cutting or severing hazard through contact with a cutting edge, such as a band saw or rotating cutting disc; 
An Entanglement hazard with the machinery which grips loose clothing, hair or working material, such as
emery paper, around revolving exposed parts of the machinery. The smaller the diameter of the revolving part, the easier it is to get a wrap or entanglement;
 drawing-in or trapping hazard such as between in-running gear wheels or rollers or between belts and pulley drives; 
 An Impact hazard when a moving part directly strikes a person, such as with the accidental movement of a robot’s working arm when maintenance is taking place; ää a stabbing or puncture hazard through ejection of
particles from a machine or a sharp operating component like a needle on a sewing machine;
contact with a friction or abrasion hazard, for example, on grinding wheels or sanding machines;

 High-pressure fluid injection (ejection hazard)for example, from a hydraulic system leak.
In practice, injury may involve several of these at once, for example, contact, followed by entanglement of clothing, followed by trapping. 

Emergency Eyewash, ANSI Shower Standard in Safety

“ANSI Emergency Eyewash, Shower Standard Revised" – "Are You In Compliance?”

The Occupational Safety and Health Administration (OSHA) has a general requirement specifying where and when emergency eyewash and shower equipment must be available, but it does not specify operating or installation requirements.
That’s where the ANSI/ISEA standard comes in. While it doesn’t have the full force of an OSHA regulation, the standard helps employers meet OSHA requirements.
“Safety showers and eyewashes are your first line of defense should there be an accident,” said Casey Hayes, director of operations for Haws Integrated, a firm that designs, builds and manages custom-engineered industrial water safety systems. “We’ve seen OSHA stepping up enforcement of the standard in the last couple of years and issuing more citations,” he said.
What Is ANSI/ISEA Z358.1-2014?
The standard covers plumbed and self-contained emergency showers and emergency eyewash equipment, eye/face wash equipment, combination units, personal wash units and hand-held drench hoses. These systems are typically found in manufacturing facilities, construction sites, laboratories, medical offices and other workplaces.
The standard specifies minimum performance criteria for flow rates, temperature and drenching patterns for a user to adequately rinse off a contaminant in an emergency situation. It also provides maintenance directives to ensure that the equipment is in proper working condition.
One of the most significant requirements of the standard deals with the location of the equipment, Hayes said, and “It’s probably the most difficult part for employers to comply with.” The equipment must be accessible to workers within 10 seconds—a vague requirement, according to Hayes—but the standard’s appendix references 55 feet, he pointed out.
The wash or shower must be located on the same level as the hazard. “You can’t have somebody working on a stairwell and have to go up or down a flight to get to the shower. The equipment needs to be installed on the same level where the accident could happen,” he said.
The wash station must also be free of obstructions. “Someone needing to get to the shower or eyewash could be in a panic—their eyes could be blinded by chemicals—so employers must ensure that the shower is accessible and free of obstructions,” he said.
All equipment must be identified with highly visible signage, must be well-lit, and needs to be able to go from “off” to “on” in one second or less.
“The volume of water that is required for a 15-minute flow is not always considered,” Hayes said. The standard requires the victim to endure a flushing flow for a minimum of 15 minutes. With water pressure from the drench shower 10 times the amount of a typical residential shower, “that is a significant amount of water, and you need to deal with it on the floor and from a capacity standpoint,” he said.
The comfort of the person using the wash also needs to be considered. “It is not a pleasant experience to put your eyes in the path of water. The controlled flow of flushing fluid must be at a velocity low enough to be noninjurious to the user,” Hayes said.
The standard stipulates minimum flow rates of:
  • 0.4 gallons per minute for eyewashes.
  • 3 gallons per minute for eye/face washes. A good eye/face wash will have separate dedicated flows of water for your eyes and face, Hayes said.
  • 20 gallons per minute for showers. That’s 300 gallons of water required for the 15-minute wash.
Washes must deliver tepid water defined as between 60 degrees and 100 degrees Fahrenheit.
Studies have shown that tepid water increases the chances that a victim can tolerate the required 15-minute wash. Tepid water also encourages the removal of contaminated clothing, which acts as a barrier to the flushing fluid.
“We’re also seeing employers putting showers in enclosed areas or in curtained areas, to promote the removal of clothing and alleviate workers’ privacy concerns,” Hayes said.
2014 Revisions to the Standard
There weren’t that many changes to the 2009 standard, but a few highlights include the following:
  • A requirement was included that emergency showers be designed, manufactured and installed in such a way that, once activated, they can be operated without the use of hands.
  • The way the height of eyewashes and eye/face washes are measured changed from the floor to the wash basin to from the floor to the water flow. The height should still be between 33 inches and 53 inches. “Something to consider when inspecting washes is to ensure that, even though your wash fits within these limits, it’s still realistically usable,” Hayes said.
  • A single step up into an enclosure where the wash is accessed is not considered an obstruction. This had not been addressed previously.
The 2014 version further clarifies that fluid flow location and pattern delivery for emergency eyewashes and eye/face washes is the critical aspect in designing and installing these devices, rather than the positioning of nozzles. Additionally, illustrations have been updated to reflect contemporary design configurations.
Best Practices
Hayes recommended a few best practices that go above and beyond the standard and that he has seen used at companies with strong safety cultures:
  • Locate washes and showers in areas with adequate space for emergency responders to fulfill their duties. “If the equipment is in a tight space, you’re preventing responders from helping victims,” he said. Enclosures can be built to allow multiple people to be inside.
  • Monitor and evaluate all accessible components of washes and showers on a frequent and routine basis to manage potential problems.
  • Use eye/face washes in lieu of simply eyewashes. “It’s highly unlikely that a chemical splash will only land on your eye surface. This is common sense, so put in the right equipment,” he said.
  • Check that the washes meet the proper gauge height. The standard’s weekly activation requirement is mainly to ensure that water is available and to clear sediment buildup. “While a quick activation might seem sufficient, it’s not an accurate representation of functionality for the required 15-minute flush,” Hayes said. “If water is there but doesn’t rise up to the proper gauge height, you are compliant, but that equipment may fail you in the event that it’s needed.”

Complete Procedure for First Aid Complete Training

 What is First Aid?
First aid is the initial care of the injured or sick. It is the care administered by a concerned person as soon as possible after an accident or illness. It is the prompt care and attention that sometimes means the difference between life and death, or between a full or partial recovery.

First aid has limitations- not everybody is a doctor- but it is an essential and vital part of the total medical concept.FIRST AID SAVES LIVES! …. ask any ambulance offer or doctor who works in the emergency medical field.

Immediate action:

It is important that any action taken by the first aid provider is done as quickly as possible. Quick action is necessary to preserve the life and truth. A casualty who is not breathing effectively, or is bleeding copiously, requires immediate intervention, and if quick effective first aid is provided, then the casualty’s chances of recovery are improved immeasurably. It should be remembered though that any action undertaken is to be deliberate and panic by the first aid provider and bystanders will not be beneficial to the casualty. Try to remain calm and think your actions through.

 How do I get help?

To get expert medical assistance, call the Police ambulance on “999”. If your company has a medical clinic on site, it is better to call the clinic staff and let them decide whether it is necessary to call an outside ambulance.

If you are attending a casualty, get a bystander to telephone for help- if you are on your own, then you may have to leave the casualty momentarily to make a call. It’s common sense, the decision is yours!

Medic alert

Some individuals suffer from certain medical conditions that may cause them to present with serious signs and symptoms at any time. As a form of assistance and notification, these people may wear a form of medical identification, usually a special bracelet, or less commonly, a necklace. These devices are commonly referred to as ‘ Medical Alert’ bracelets, but are also known as ‘Vital of Life’ and ‘SOS Talisman’. They are stamped with the person’s identity, the relevant medical condition, and other details which may include allergies, drugs required, or specialized medical contact. Medical conditions that may be notified vary from specific heart diseases, to diabetes, epilepsy, asthma etc.

The function of the circulation system is to distribute blood to all parts of the body, so the that oxygen and nutrients it carries can be delivered to the cells. When the system fails, and insufficient oxygen reaches the cells, the medical condition known as “shock” will develop.
Since the brain and heart need a permanent supply of fresh oxygen, they will first be affected by shock. Other vital organs, like the liver, spleen, kidneys and pancreas can be without oxygen for a longer time (15 to 60 minutes) before their function will decrease: The skin, muscles and bone can be without oxygen for up to 4 hours before permanent damage or death will occur. If shock is not rapidly treated the vital organs will fail, leading to unconsciousness, coma and death. The condition of shock is increased if pain is present.
Ø  What causes shock?
ü  First, shock can develop when the heart fails to pump effectively, resulting in a drop in circulating blood pressure. The most common cause of this type of shock is a heart attack.
ü  Secondly, shock can develop when the volume of fluid circulating around the body is reduced. External and internal bleeding, or loss, of other body fluids because of diarrhoea, vomiting, sweating or bums, are the most common reasons. The body responds by withdrawing the blood supply from the surface and extremities to the core of the body. The main symptoms and sips of shock is related to this re-distribution of blood
1.         A rapid, weak pulse,
2.         Pale tissue color (tissue color refers to the inside the mouth and under the eyelids)
3.         Reduced peripheral circulation — if the fingernail original color immediately;
4.         Sweating and a cold, clammy skin;
5.         Weakness and confusion;
6.         Nausea and vomiting;
7.         Fast, shallow breathing;
8.         Fear and anxiety;
9.         Decreased level of consciousness;
10.       Heart and brain failure, causing death.

1.    Call for help
2.    Treat any cause of shock (if there is bleeding, stop it, if there is a fracture, stabilize and  
       immobilize it, if the is no breathing, give ventilation, if the heart stopped, do CPR.)
3.    If the casualty is conscious, lay him down on his back,
4.    If the casualty is unconscious, turn him on his side — take care of his spinal column.
5.    Elevate the legs and arms — if a fracture is present, first immobilize the fracture before
       elevating the limb. If the patient has a brain injury, stroke, asthma or a heart attack,
       don’t   elevate the legs or arms.
6.    Give oxygen
7.    Loosen tight clothing to allow the patient to breathe easier.
8.    Maintain normal body temperature- do not overheat the patient- ideal ambient temperature
        is 22-24 degree Celsius.
9.     Talk constantly with the patient, re-assure him and try to calm him.
10.   Check and record breathing, pulse and level of consciousness.
11.   DO NOT allow the patient to eat, drink, smoke or move unnecessary

12.   DO NOT leave the patient unattended.


Oxygen is essential to support life. The process of breathing enables air which contains oxygen to enter the lungs, where the oxygen are transferred to the blood, and then circulated through the body. The action of breathing, and the process of gas exchange in the lungs are commonly described as respiration, and the organs, tissues and structures that enable us to breathe is called the RESPIRATORY SYSTEM.

The respiratory system supply oxygen to the individual cells and removes the waste product, carbon dioxide. Oxygen is obtained from the air, which is a mixture of oxygen, nitrogen and other gasses.
   Mechanics of breathing
We have three sets of muscles which enable us to breathe. There are two sets of intercostals (between the ribs) muscles, and the diaphragm, which is below the lungs and above the abdomen.

There are two phases of breathing:
1. Inhalation —when air is drawn into the lungs.
2. Exhalation — the expulsion of air from the lungs.

During inhalation,one set of intercostals muscles and the diaphragm contract to enlarge the chest cavity. Because the chest cavity becomes bigger, negative pressures are formed inside the chest, and air from outside the body enters the lungs to equalize the pressure, thus air enters the lungs.
During exhalation,one set of intercostals muscles contract, the other set relaxes, the diaphragm relaxes, the chest cavity becomes smaller, a higher pressure is created inside the lungs, and the air exits the lungs to the outside.
Breathing is controlled by the respiration center, situated in the medulla oblongata of the brain. When the oxygen level in the blood decrease (and the carbon dioxide level increases), the brain sends impulses through the nerves to the respiration muscles, stimulating them to work faster. This results in an increase of respiration speed, resulting in more oxygen being present in the lungs and more oxygen present in the blood. The respiratory muscles works involuntarily, but can be controlled to some extend.

Respiration rates
The average rate of breathing for an adult is between 12 and 20 times per minute. Children and infants breathe faster. The breathing rate, or respiration rate may differ vastly, depending on age, level of fitness, activity level, outside air pressure, temperature and the psychological state of the person.
Respiratory disorders
Asphyxia is the medical term for suffocation, when there is no oxygen being taken up iri the blood. Reasons for asphyxia include:
ü S mothering
ü  Obstruction of the air passages by means of a foreign object, strangulation, aspiration, airway swelling or any other reason which prevents oxygen from being absorbed into the blood.
ü  Chest or lung trauma such as external pressure and pneumothorax injuries.
ü  Paralysis of the respiratory muscles, due to spinal or brain injury, electrocution, poison, drugs or a medical disease such as Gillian Beret.
                 ü  Lack of oxygen, where the air doesn't contain enough oxygen to sustain life, as can be found in the presence of certain gasses, chemical fumes, smoke and high altitude.
ü  Lung disease or illness, such as emphysemia, oedema, pneumonia and asthma.

Hypoxia is the medical term for a condition where gas exchange takes place, but the amount of oxygen absorbed into the blood is not enough to sustain life. In this case the cells of the vital organs (brain arid heart) starts dying within three to four minutes
• All the causes for asphyxia can be the reasons for hypoxia, the only difference is that in hypoxia, some gas exchange will still take place.

Signs and symptoms of hypoxia
• Rapid, shallow, distressed breathing
• Decreased level of consciousness,
• Cyanosis and skin! tissue color changes
• All the signs and symptoms of shock

If hypoxia and asphyxia is not quickly reversed, respiratory and heart functions will stop.
SCABCSis the prime consideration for everyone involved in the care and treatment of casualties. Experienced first aid providers, ambulance crews, nurses and medical specialists, are all-aware of the importance of Safety, Communication, Airway, Breathing, Circulation and Stop profuse bleeding.

  • To yourself: don’t put yourself in danger!
  • To the casualty: remove the danger from the casualty, or the casualty from the danger!
  • If it is not safe to touch or treat the patient, then don’t!
Part of safety includes protecting yourself against infectious diseases.

INFECTIOUS DISEASES are those diseases that cause infections to the human body, and in some cases are transmitted by contact or by cross-infection. Infection may be due to bacteria, viruses, parasites or fungi. The usual methods of communication are:
ü  Direct contact(contact with an infected person)
ü  Indirect contact(through feces, air conditioning etc)
ü  Through  a Host(insects, worms)
Many deadly infectious diseases have been eradicated in the world, but several, such as poliomyelitis (a virus), are again on the increase. Many are preventable by immunization. Some, such as the Human Immunodeficiency Virus (HF’!), have no cure or medical prevention. Examples of infectious diseases are:
Parasitic Infections: Malaria, tapeworm, hookworm, itch mites, public and body lice.
Fungal Infections: Ringworm. tinea (Athlete’s Foot).
Bacterial Infections: Throat infections, whooping cough, diphtheria, rheumatic fever, tuberculosis strains, cholera, staphylococcus infection, and some forms of meningitis.
Viral Infections: Measles, mumps, rubella, hepatitis, influenza, chicken pox, HIV/AIDS, common cold, Ebola fever, Congofever, bronchitis and SARS. There is no effective treatment for any virus, no medicine can kill a virus, only the body’s immune system can neutralize a virus.
The human body has natural defenses against infection, and remains immune to certain types: Immunity is usually achieved by previous exposure to a particular infection, with resultant chemical antibodies being produced. The blood contains leukocytes (white blood cells), which assist in the production of antibodies. The leukocytes and antibodies combat any infection, which invades the body. Unfortunately, the body’s natural defenses work slowly and cannot cope adequately with some infections. It is at this stage that the body requires help in the form of medically prescribed antibiotics or similar drugs.

General Precautions
1)      Avoid direct contact with infection.
2)      Avoid transmitting infection.
3)      Care of the susceptible, for example: the ill, the elderly, the very young.
4)      Care in nutrition and preparation of food.
5)      Maintenance of personal hygiene.
6)      Maintenance of sanitary standards.
There is no definitive first aid treatment for infectious diseases. However, the first aid provider should be familiar with the signs and symptoms of the common diseases, and provide advice to the infected person to seek appropriate medical attention.
You have to protect yourself against infectious diseases which you can get from the patient. In order to protect yourself, you have to wear the following PPE’s before touching or treating any patient:
    1. Medical gloves,
    2. Medical face mask,
    3. Eye protection
    4. A barrier device such as a mask or bag-valve-mask ventilation device (Ambubag) if   
        you need to do ventilation — mouth-to mouth ventilation is not advised without
        proper protection!
 Ø  Shake and shout (medical patient) or tap and talk (trauma patient).
 Ø  Is the casualty alert?
 Ø  Is the casualty drowsy or confused?
 Ø  Is the casualtyunconscious, but reacting?
 Ø  Is the casualty unconscious with no reaction?

Level of consciousness refer to the level of brain function detectable. Prior to continuing the examination of the patient, we need to determine the level of consciousness. The level of consciousness can be divided into hundreds of small steps, each step referring to a different level of brain function. In basic first aid, we are primarily concerned with the following levels of consciousness:   
Alert and responsive                  Responds to verbal or physical stimuli, knows who, where
                                                 and what.
Disorientated and confused        May respond to verbal and physical stimuli but does not 
                                                 know who, where or what.
Stuporous but arousable            Responds to verbal and/or physical stimuli momentarily.
Unconscious                             Responds only to physical stimuli, will respond to painful
Comatose                                 Breathing and heartbeat present, does not respond to verbal
                                                stimuli, respond to painful stimuli.
Clinically dead                          Breathing and/or heart function may be present no detectable
                                                brain function present
Biological dead                        No body or brain functions present

Unresponsiveness/ Unconsciousness:

Before you touch any patient, you should ensure that you have Latex (or similar) gloves on both hands, to protect you against any disease the patient may have.
To determine if a patient is unresponsive, you should talk to the patient, and gently shake the shoulders of the patient. Care should be taken if the patient has had, or could have sustained trauma, since the shaking of a trauma patient’s shoulders could cause paralysis in a patient with a cervical spine injury. Trauma patients should not be shaken, and in this case “touch and talk” is safer that “shout and shake”
Remember that the unresponsive patient you may encounter could be unresponsive due to an anxiety attack, hypoglycemic coma or even because the patient took his prescribed sleeping tablet. In this case the patient may not respond to talking, shouting or shaking, same as the deaf patient will not respond to talking. In order to be sure that the patient is unresponsive, some pain stimuli can be applied, such as depressing the post-clavicular fossa.
If the patient is unresponsive, you should determine if the patient is breathing. In order to determine patient respiration, you must ensure that the airway is open, and the only way to be sure that the airway is open, is to open it manually. Before opening the airway, the patient should be positioned supine (lying flat on his / her back).
If the patient is suspected to have received any trauma (injury, falling down, etc.), the patient must be treated as if though he has spinal injuries. You cannot simply turn the patient. You should roll the patient as a unit, keeping the spinal column intact and aligned.

Once the patient is supine, you should position yourself at the victims’ side. In a supine unconscious patient, the most common cause for airway obstruction is the tongue, falling back against the back of the throat. Since the tongue is attached to the lower jaw, moving the lower jaw away from the back of the throat will move the tongue away from the back of the throat and open the airway.
 You should use the head tilt-chin lift method   of opening the airway by following these steps:
Ø  Place one hand on the forehead of the patient and apply firm backward pressure to tilt the head back
Ø  Place the fingers of the other hand under the bony part of the lower jaw.
Ø  Lift the chin forward and support the jaw, helping to tilt the head backwards.
      ØThe mouth should not be closed when lifting the chin.

Figure: Head tilt-chin lift. Note that the finger
Lifting the chin are not exerting pressure
On the soft tissues under the chin

In trauma patients, you should use the Jaw- thrust man-oeuvre to open the airway. Jaw-thrust is achieved by following these steps
Ø  Kneel at the top of the patient’s head, resting your

Elbows on the same surface that the patient is
lying on.
Ø  Reach forward and gently place one hand on each
side of the patient’s lower jaw, at the angles of
the mandible (lower jaw).
Ø  Stabilize the patient’s head with your forearms.
Ø  Using your index fingers, push the angles of the
mandible forward while tilting the head backward 
Ø  You may need to retract the patient’s lower lip 
     with you thumb to keep the mouth open.   Figure: Jaw thrust. The thumbs can be used to
                                                                   open the mouth, but it is not always necessary   
This technique is effective in opening the airway, but is fatiguing and technically difficult. If jaw alone is unsuccessful, the head should be tilted backward very slightly.
The first objective after opening the airway is to determine of the patient is breathing or not. In order to determine if the patient is breathing, you should:
1. LOOK at the patient’s chest and stomach and observe 
Figure: Look for breathing
if there are any raising and falling movements present.
2.  LOOK at the general appearance of the
patient and for signs of oxygen shortage.
If no air is exhaled, and no chest or stomach movement
can be detected, the patient is in respiratory arrest. The
evaluation procedure should take between 3 and 5 seconds

If the patient is breathing after the airway is opened, the patient should be placed in the recovery position
Figure: Recovery position
A trauma patient should not be moved without special precautions. Your actions will be determined by the nature of the breathing, the history of the patient and your own level of training and expertise.
Ventilation must be given if the patient is not breathing. Whichever device you use, you should initially give two slow ventilation, each ventilation lasting two seconds. The 2-second time period for ventilation is necessary in order to deliver slow inspiratory breaths. Exhalation is a passive phenomenon and occurs primarily during chest compression if CPR is being performed. If a pulse is present but spontaneous respiration is absent, ventilation should be given at a rate of 10 to 12 per minute.

By giving the ventilation with a slow inspiratory flow rate and avoiding trapping of air in the lungs between ventilation, the possibility of exceeding the esophageal opening pressure will be less. It should result in less stomach distension and aspiration (inhaling of stomach contents). Care must be taken not to ventilate with excessive volume, since the excessive air can only go to the stomach. Ventilate only until the chest start to rise.

Although mouth-to-mouth ventilation is effective, it must be avoided because of the dangers of cross-infection. It can however be given to somebody which you know have no infectious disease, like your own small child. In all other patients, a barrier-device, such as face shields, must be used to ventilate. Face shields only protect you against direct contact, which makes face shields almost impractical.


Pulse check
Determine the absence of pulse by feeling for the carotid artery for up to 10 seconds. Locate the windpipe while maintaining the head-tilt position. Slide the fingers into the groove between the windpipe and the muscles at the side of the neck in order to locate the carotid artery. You must feel for the pulse on your side of the patient, since feeling pulse on the opposite side causes pressure on the throat and could aggravate swelling or partially obstructed airway. It is important to be sure that there is no pulse before starting with chest compression since performing chest compression on an adult who has a pulse may result in serious complications.

Figure: Check for carotid pulse. 
If a pulse is present, but breathing is
still absent, continue with artificial
Ventilation at a rate of 10-12/ minute 
If no pulse is present, you have confirmed a definite cardiac arrest. If help has not been summoned, you should call now for help

The chest compression technique consists of serial, rhythmic applications of pressure over the lower half of the sternum. These compression provide circulation -as a result of a generalized increase in internal chest pressure or direct compression of the heart.
The patient must be in a horizontal, supine position during chest compression. Even with properly performed compression, blood flow to the brain is reduced.

Figure: Place the head of the hand on the lower
half of the sternum
The hand position is important. The heel of the hand must be on the lower half of the sternum or breastbone. The hand should touch the imaginary line between the nipples of a child or male patient.
                                                                                The hand should not exert pressure directly on the ribs, or on the xiphoid process. A hand position which is too low can lead to liver damage.

Proper hand position is on the lower half of the sternum. It does not matter which method you use to establish the lower half of the sternum, however, the long axis of the heel of the hand is located on the lower half of the long axis of the sternum.

  1. Your elbows should be locked into position, your arms straightened and your shoulders directly above the patient’s sternum.

  1. To achieve the most pressure with the least effort, lean forward until your shoulders are directly over your outstretched hands (lean forward until the body reaches natural imbalance — a point at which there would be a sensation of falling forward if the hands and arms were not providing support). The weight of your shoulders, chest and back creates the necessary pressure that makes compressions easier on the arms and shoulders. Natural body weight falling forward provides the   force to depress the sternum.

  1. The sternum should be depressed approximately 1V to 2 inches (3.8 to 5.1cm) for the normal-sized adult. The depth of compressions may change according to the size of the chest of the patient; a large, barrel-shaped chest rriay need deeper compressions — as much as one half of the depth of the chest. The only way to know that your compressions are deep enough is to have somebody feel for palpable carotid pulse. If your compressions create palpable carotid pulse, the compression depth is sufficient.

  1. Release pressure on the chest between compressions to allow blood to flow into the chest and
            heart. The chest must be allowed to return to its normal position.
  1. The duration of the compression should be equal to the duration of pressure release: in other
words, the time you spend to press down on the chest should be same as the time you spend to
“come up” from the chest.
  1. There should be no pause between compressions in a cycle, don’t pause on top.

  1. Do not lift the hands from the chest, you will loose correct hand position.

8.Bouncing compressions, jerky movements, improper  hand  position and leaning on the chest can decrease the effectiveness of the compressions and can cause injuries.
9. The chest compression rate should be minimum 80 to 100 per minute.
During cardiac arrest, properly performed chest Compressions can produce systolic arterial blood pressure peaks of 60 to 80mm Hg, but diastolic pressure is low.

Figure: Correct compression position.
Note that the elbows are locked ,the heel
Of the lower hand is on the sternum, and the
Shoulders are directly above the hand and the                             

Cardiac output resulting from chest compressions is likely to  be only 17% — 25% of normal cardiac output.
Cough CPR

Self-induced CPR is possible. Its use is limited to clinical situations in which the patient has a cardiac monitor, the arrest was recognized before loss of consciousness (usually within I( 15 seconds from the cardiac arrest), and the patient can cough forcefully. The increase intrathoracic pressure will generate blood flow to the brain to maintain consciousness for prolonged period.

Sequence for Adult One-person CPR

1. Determine unresponsiveness.
a. Tap or gently shake the shoulders and shout
b. Consider giving painful stimuli.
c. Call for help locally, inform the help of the situation you have.

2. Open the airway
a. Position the patient.
b. Open the airway by head tilt-chin lift manoeuvre or jaw-thrust.

3. Assess breathing
a. Look, listen and feel for breathing for up to 10 seconds.
b. If the patient is unresponsive but obviously breathing and if there is no trauma, place the
    patient in the recovery position and maintain an open airway.
c. If the adult patient is unresponsive and not breathing, ventilate twice using a barrier device.
d. If unable to ventilate twice, reposition the head and attempt to ventilate again.
e. If ventilation is still unsuccessful, perform the foreign body airway obstruction sequence.
f If ventilation is successful, continue to next step — determine pulse.

4. Determine pulselessness
a. Palpate carotid pulse for up to 10 seconds.
b. If pulse is present and patient is still unresponsive, continue ventilation at 10 to 12 per
c. If pulse is absent, begin chest compressions:
·         Position yourself properly
·         Determine correct landmark for hand position
·          Perform 15 compressions at a rate of 80 to 100 compressions per minute.
·          Open the airway and give two slow ventilations. (2 seconds per ventilation)
·          Re-determine proper hand position and begin 15 more compressions at a rate of 80 to 100   per minute.
·         Perform at least four complete cycles of 15 compressions and 2 ventilations, but no longer than about one minute.

5. Reassess patient.
a. Re-evaluation should be performed after the first minute of CPR, and thereafter every few
    minutes. Re-evaluations should last no longer than 5 seconds.
b. After four cycles or about one minute of compressions and ventilations, re-evaluate the   
c. Check for return of carotid pulse (3 to 5 seconds)
d. If pulse still absent, continue with compressions and ventilations.
e. If pulse is present, check breathing;
ü  If breathing is present, closely monitor breathing and pulse, and treat accordingly
ü   If breathing is absent, continue ventilations at 10 to 12 per minute
f. Continue treatment accordingly until you have handed the patient over to a higher qualified professional and then follow instructions.

Two-person Adult CPR

When another person is available to assist you with CPR, the second person can perform the chest compressions when the first person becomes fatigued. This change should be done with as little interruption as possible.

When the second person becomes available, the pulse and breathing of the patient should be re-assessed before CPR is resumed. For example: the first person completes a cycle of 15 compressions and 2 ventilations. The second person can give the two ventilations. CPR is then stopped (if CPR has been performed for more than one minute) and the pulse is checked.

If pulse is still absent, the second person resumes chest compressions at a rate of 80 to 100 per minute, and at a ratio of 15 compressions : 2 ventilations and does not precede the chest compressions with ventilations. No need for a formal “change” exists, only two rules for the change needs to be followed:
1. As little interruption as possible must be made during the change, and;
2. The change should be made after a pulse check.


Blood consists of red cells (erythrocytes), which convey oxygen throughout the body; white cells (leukocytes), which fight introduced infection; platelets (thrombocytes), which assist in the clotting process; and plasma, the fluid portion of blood. There are between six and seven liters of blood in the average adult body.

Blood is moved around the body und pressure by the cardiovascular system - the heart and blood vessels. Without an adequate blood volume and pressure, the human body soon collapses. Bleeding, or hemorrhage, poses a threat by causing both the volume and the pressure bf the blood within the body to decrease through blood loss.

Types of Bleeding
The types of bleeding and characteristics are:-
Ø  Artery:  Bleeding from an artery is characterized by the spurting motion.This is in time with the heart beat because arteries come directly from the heart and are under greatest pressure.
Ø  Capillary: Bleeding shows by oozing out from the skin. This is because it is under a lot less pressure.

Ø  Venous: Bleeding from the venous Gushes out and is characterized by being dark red colour, because the blood has given up oxygen and is on the way back to the heart to  be re-pumped to the lungs. Venous bleeding can be severe, especially from varicose vein.

The body’s initial reaction to bleeding
The body reacts 3 ways to control bleeding:
• Blood clots.
• Ends of vessels contract.
• Blood pressure falls.
Platelets congregate at the site of the wound.
Fibrin threads start to form a plug, controlling bleeding 
                                  The compact clot seals the wound while the skin is repaired.
Control of bleeding

Ø  Remove or cut clothing to expose the wound Watch out for sharp objects, such as glass, that might injure you.
Ø  Apply direct pressure over the wound with your fingers or palm, preferably using a sterile dressing or gauze. Don’t use cotton wool.

Direct Pressure
Leaving any original pad in place, apply a
sterile dressing. Bandage it in place firmly,
but not a tightly as to impede the circulation.
If bleeding strikes through the dressing,
Bandage another firmly over the top


Raise and support an injured limb above the level of the casualty’s heart. Handle limbs very gently if the injury involves a fracture. When a patient is suffering from a wound and a fracture of a limb, you will have to stabilize the fracture before you elevate the limb

ü  It may help to lay the casualty down. This will reduce blood flow to the site of injury and minimize shock.
ü  If there is a protruding foreign body, build up pads on either side of the object until they are high
             enough to bandage over the object without pressing on it.
ü   Secure and support the injured part as for a broken bone.
ü   Contact advanced help and if necessary, take the patient to the advanced help (clinic, doctor,
             ambulance and hospital).
ü   Treat the casualty for shock.
ü   Check the dressing and the circulation beyond the bandage.
Indirect Pressure

Sometimes direct pressure is still not enough to stem the blood flow. (This is usually in the leg where there has been damage to the main artery in the upper leg-thin). On these occasions you may have to consider indirect pressure. Indirect pressure may be applied to a pressure point where a main artery runs close to a bone. Pressure at these points will cut off the blood supply to the limb. It must not be applied for longer than 10 minutes.


Radial and ulnar

  Pressure points:
  These are specific places in the arms and legs where this pressure
   can be applied. These points are just underneath the muscle in the
   upper arm and in the groin to cut off supply to the leg. Investigate
   on yourself to find the correct place.
 Press hard against the bone in the upper arm and your hand should       
 feel cold, numb and strange. This is because the blood supply has been cut off.

External bleeding is usually associated with wounds, those injuries that are caused by cutting, perforating or tearing the skin. Serious wounds involve damage to blood vessels. As arteries carry oxygenated blood from the heart, damage to a vessel is characterized by bright red blood which spurts’ with each heartbeat. Damage to veins appears as a darker red flow. Capillary damage is associated with wounds close to the skin and is of a bright red ‘ooze’ from below the surface.
Types of wounds

Incision is the type of wound made by ‘slicing’

            with a sharp knife or object.

             Treatment of incisions and lacerations:

ü  Quickly check the wound for foreign bodies.
ü  Immediately apply pressure to stop any bleeding.
ü  Apply non-adherent pad or dressing.

Apply a firm roller bandage.

ü  Rest and elevate injured limb if injuries permit

Laceration is a deep wound with associated
loss of tissue- the type of wound barbed
wire or direct force from a blunt object( such
            as a fist or boxing glove) would cause

Penetration wounds are found when a foreign
body enters the body and stay inside the body, or are
removed afterwards. It may be caused to anything

from a corkscrew to a bullet.

  Treatment for penetration wounds and penetrating

ü  Inspect the wound- do not remove any
            penetrating object
ü  Stabilize the penetrating object to
            prevent movement
ü  Apply pressure to stop any bleeding.
ü  Apply non-adherent pad or dressing.
ü  Apply a firm roller bandage.
ü  Rest and elevate injured limb if injuries
 üTransport to clinic or hospital urgently
Amputation is the loss of a digit or limb by trauma
Treatment for an amputation
·         Apply immediate pressure to stop any bleeding.
·         Apply a large pad or dressing to the wound .
·         Treat patient for shock.
·         Rest and elevate injured limb if possible.
·         Collect amputated part-keep moist with wet gauze, do not wash or clean
·         Seal the amputated part in plastic bag or wrap in similar waterproof material.
·         Place in cold water- do not allow the part to come in direct contact with ice.
·         Remember- if the initial  dressing doesn't stop the bleeding, put another over the top-don’t remove a dressing once it is in place!

·         Ensure the amputated part travels to hospital with the casualty.

Abrasion is a wound where the

 skin layers have been scarped off.

  Treatment for an abrasion wound:
·         Inspect the wound for foreign bodies.
·          Swab with an antiseptic solution like 10% Povidone Iodine USP.
·          Cover with a light, dry dressing if necessary.

Avulsion is a  wound where a section of skin and underlying tissue have been partially removed,
Resulting in a “flap”

Treatment for an avulsion wound:

§  If “ flap” is open, attempt to put it in it’s

   normal place without causing further injuries.
§  Rest of treatment is the same as for any open wound,
             the only complicating factor is that the wound is general
             large in surface area, which may increase the amount of
             blood loss.
  §Cover with bandage, apply pressure, elevate etcetera

Internal bleeding is classified as either visible, in that the results of the bleeding can be seen, or concealed, where no direct evidence of bleeding is obvious. Internal Heeding is always to be considered as a very serious matter, and urgent medical aid is a necessity.

In most instances, obtaining an adequate history of the incident or illness will give the first aid provider the necessary clue as to whether internal bleeding may be present. Remember that current signs and symptoms, or the lack of them do not necessarily indicate the casualty’s condition. Certain critical signs and symptoms may not appear until well after the incident due to the stealth of the bleed.

·         Very often there is no visible wound on the outside and no visible bleeding around the site of the  
              internal bleeding

·       Internal bleeding is often due to impact of a blunt object to the body. This impact can cause    organs such   as the liver and spleen to burst open, or rupture. Since organs have a very good blood supply, a ruptured organ can bleed profusely, threatening the life of the patient due to blood loss. In many cases, a ruptured liver can cause sufficient blood loss that the patient can die in as little as 20 to 30 minutes.

·      If internal bleeding occurs inside the trunk of the body, it is impossible to control, except   through surgery. Internal bleeding in a limb can be controlled by the use of indirect pressure.

·     Sometimes you will find no signs of internal bleeding, no swelling, bruising, external wound and so forth, but the patient is unconscious and in severe shock. If the patient has a history of trauma, the most common cause will be internal bleeding.

Visible internal bleeding
Visible internal bleeding is referred to this way because the results are visible:

ü  Bleeding in the lungs - frothy, bright red blood coughed up by the casualty.
ü   Bleeding in the stomach - dark coffee grounds”, or red blood in vomit.
ü   Bowel, or intestinal bleeding - dark, loose, foul smelling stools.
ü   Anal or vaginal bleeding - usually red blood, mixed with mucous.

Concealed internal bleeding
En these cases, the first aid provider is heavily reliant on history, signs and symptoms.
Judgment and experience play a part, but it may come down to a first aid provider’s “gut
feeling”. If you are unsure, assume the worst and treat for internal bleeding.

Signs and symptoms
ü  Lowering level of consciousness
ü  Pale, cool, clammy skin
ü  Weakness, dizziness or fainting
ü  Thirst
ü   Rapid, weak, irregular pulse
ü   Rapid, shallow breathing shortness of breath
ü   Swelling or bruising at the injured site
ü   ‘Guarding’ of the abdomen, with fetal position if lying down
ü   Pain or discomfort
ü  Nausea and/or vomiting
ü  The more symptoms you observe, the more extensive and serious the bleeding.

Care and treatment
·         SAFE and ABC
·          Activate local emergency procedures
·          Position the conscious casualty supine, with legs and arms elevated (care R of fractures immobilize them first)
·          Position the unconscious patient lateral, taking care of his spinal column and fractures — if any
·          Control any bleeding
·          Reassurance
·          Urgent medical aid
·          Give nothing by mouth
·          Treat any injuries
·          Take note that if the patient swallows blood, he may vomit
·          Monitor and record level of consciousness, breathing and pulse rates.

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