The immediate management of an unconscious person involves addressing the fundamental need for oxygen, as brain damage can begin within minutes of deprivation. When a person loses consciousness, muscles relax, causing the tongue and other soft tissues in the throat to fall backward against the posterior wall of the pharynx. This mechanical collapse creates a life-threatening obstruction, preventing air from reaching the lungs. A rapid intervention to clear this blockage is the most time-sensitive initial step in any resuscitation effort.
The Standard Approach: Head-Tilt, Chin-Lift
The Head-Tilt, Chin-Lift (HTCL) maneuver is the universally accepted standard technique for opening the airway of an unconscious person when a spinal injury is not a concern. This method is highly effective because it directly counteracts the mechanical problem of the tongue obstructing the throat. By repositioning the head, the maneuver lifts the tongue away from the back of the pharynx, creating a clear pathway for air.
The procedure begins with the rescuer kneeling beside the person’s head. One hand is placed gently on the person’s forehead to control movement. The rescuer then uses the fingertips of the other hand to lift the bony part of the chin upward. This motion should be gentle yet firm, avoiding pressure on the soft tissue under the chin, which could inadvertently worsen the obstruction.
The simultaneous action of tilting the head backward and lifting the chin forward achieves the necessary extension of the neck, aligning the oral and pharyngeal axes for unobstructed airflow. Once the airway is open, the rescuer can check for breathing by looking for chest movement, listening for breath sounds, and feeling for air movement. For an adult, the head is tilted past neutral, while infants require a neutral position to prevent airway collapse.
The Trauma Alternative: Jaw-Thrust Maneuver
When the mechanism of injury suggests potential damage to the neck or spine, such as in cases involving a car accident, a significant fall, or blunt force trauma, the standard HTCL maneuver is avoided. Tilting the head backward could cause movement in an unstable cervical spine, potentially leading to further neurological damage. In these scenarios, the Jaw-Thrust maneuver is the required alternative for opening the airway.
The Jaw-Thrust maneuver is designed to achieve the same result—moving the tongue away from the throat—but without extending the neck. The rescuer positions themselves at the top of the person’s head and places their fingers under the angles of the lower jaw, near the ears. The jaw is then gently but firmly lifted and pushed forward and upward with the fingers.
This action thrusts the mandible forward, which pulls the attached tongue base away from the back of the airway. The thumbs can be used to stabilize the head or gently push the chin down to open the mouth slightly. This technique is more physically demanding and difficult for a single rescuer to maintain over time, but it preserves the neutral alignment of the cervical spine.
Deciding Which Maneuver to Use
The determination of the “best means” to open the airway hinges entirely on the assessment of the mechanism of injury. If the person’s collapse is non-traumatic, such as from a medical event like a heart attack, stroke, or overdose, the Head-Tilt, Chin-Lift is the superior choice. It is faster, easier to perform correctly, and more reliably opens the airway for lay rescuers.
If there is any suspicion of trauma, the Jaw-Thrust maneuver should be attempted first to protect the spinal cord. Identifying a suspected spinal injury requires a high index of suspicion based on the circumstances, such as a fall from a height or a high-velocity impact. However, securing an open airway is always the primary priority, taking precedence over any potential injury, including an unconfirmed spinal injury.
If the Jaw-Thrust is ineffective or the rescuer is unable to perform it correctly, an immediate shift back to the Head-Tilt, Chin-Lift is required. A person cannot survive without oxygen; while spinal protection is important, the need for air is immediate and absolute. Securing a patent airway, even with minimal head movement, is necessary to prevent death or severe brain injury.