Airway Management Basics

The CPR class didn't teach you this. Not every unconscious person needs chest compressions—but every unconscious person needs airway management. Here's what the 10 seconds after collapse actually look like.

This scenario plays out more often than most people expect in the backcountry. Not every emergency is cardiac arrest. Not every unconscious person needs CPR. But every unconscious person needs airway management—and the difference between doing it right and doing it wrong can be the difference between life and death.

In our companion Stop the Bleed post, we covered the "C" in ABC. This post moves upstream to the "A"—because if the airway isn't open, nothing else matters. Chest compressions, oxygen, dressings—all of it is downstream of a functioning airway.

The first skill is recognition. Bystanders frequently mistake agonal breathing—gasping, irregular, snorting breaths—for normal breathing. This mistake is catastrophic. Agonal breathing occurs in 40–60% of cardiac arrest cases and is a sign the brain is dying, not recovering. Someone standing over an agonal-breathing patient thinking "he's breathing, he'll be fine" is watching the window close.

Here's how to tell the difference at a glance:

When you find someone unconscious, you have 10 seconds to make three critical assessments. Here's the flowchart that should be burned into your memory:

The decision tree is straightforward, but each branch has critical details that determine success or failure. The rest of this post is those details.

If the patient is unconscious but breathing normally, the recovery position is your answer. It keeps the airway open by using gravity, allows fluids (vomit, blood, saliva) to drain out of the mouth instead of into the lungs, and prevents the tongue from falling back and blocking the throat. Research shows using the recovery position significantly reduces hospital admission rates for these patients.

The technique looks simple, but doing it wrong can make things worse. Here's the field-tested version:

Critical Details Most People Miss

• The extended arm (Step 1) acts as a brake—without it, the patient can roll too far onto their face and lose airway access
• The crossed arm (Step 2) must stay in place during the roll—it stabilizes the head and cushions the cheek
• Pull the knee, don't push—it's a lever, not a shove
• After positioning, always tilt the head back slightly and check the mouth for obstructions

If you need to give rescue breaths—either during CPR or for a patient who's not breathing adequately—you must open the airway first. The tongue is the most common culprit in unconscious patients. When muscles relax, the tongue falls back and blocks the throat.

There are two basic maneuvers, and which one you use depends on one question: Is there a possible spinal injury?

The jaw thrust is harder to do correctly under stress and much harder to maintain. Studies show it produces comparable tidal volumes to head tilt–chin lift when done correctly, but it requires practice. This is exactly the technique to rehearse before you need it in a real emergency.

The American Heart Association's Hands-Only CPR campaign has saved countless lives by removing the barrier of mouth-to-mouth contact. But it's not always the right choice. The scenario determines the technique.

In the wilderness, drowning and environmental exposure are common. That means rescue breaths are often necessary—which is precisely why every serious kit needs a CPR face shield. Without one, most bystanders won't attempt the breaths. Studies show people are 70% less likely to perform CPR without a barrier device. The face shield removes the hesitation.

Compression Basics

• Rate: 100–120 compressions per minute (the tempo of "Stayin' Alive")
• Depth: 2–2.4 inches for adults; about ⅓ the depth of the chest for children
• Hand position: Center of the chest, on the lower half of the sternum
• Full recoil: Let the chest come all the way up between compressions. Incomplete recoil reduces effectiveness
• Minimize interruptions: Any pause >10 seconds reduces survival. Keep going

The Wilderness Reality: Complications You Can't Avoid

Classroom scenarios are clean. Wilderness emergencies are not. Three complications you should expect:

Vomiting. Unconscious patients vomit. It's not a question of if, but when. If a patient in recovery position vomits, roll them further onto their side, clear the mouth with your gloved fingers, and reposition. Don't wait for them to finish—act immediately. Airway blockage from vomit is one of the top preventable causes of death in unconscious patients.

Cold. Hypothermia complicates everything. Cold patients have slower metabolisms and can survive longer without perfusion—but they're also harder to assess. Check for breathing for a full 10 seconds. Cold slows respiratory rate to the point where you may miss it if you rush.

Uneven ground. The recovery position assumes flat ground. On a slope, position the patient so fluids drain downhill. On rocky terrain, use clothing or a pack to support the head and prevent it from hanging at an awkward angle that closes the airway.

Being alone. Someone needs to manage the airway. Someone else needs to call for help. If you're alone, the math is brutal—you can't do both simultaneously. In the wilderness, this is where a satellite communicator becomes as essential as the CPR face shield. Set it, then focus on the patient.