5.1 Primary Assessment (DRABC), CPR and Basic Life Support

5.1 Primary Assessment (DRABC), CPR and Basic Life Support

In the private security sector of the Emirate of Abu Dhabi, licensed security officers are frequently the very first trained personnel to arrive at the scene of an on-site medical emergency. Whether stationed at a commercial high-rise on Al Maryah Island, an industrial warehouse complex in Musaffah, an educational facility in Khalifa City, or a busy retail mall, security officers carry an indispensable responsibility to safeguard human life. Regulated by the Private Security Business Department (PSBD) under the UAE Ministry of Interior (MOI) and trained according to National Source Security Institute (NSI) standards, guards must master the core competencies of basic life support (BLS), rapid primary assessment, cardiopulmonary resuscitation (CPR), and Automated External Defibrillator (AED) operation.

---

The Security Guard as First Responder: Mandate and Legal Duty

A security officer is not an emergency physician or a certified paramedic. However, first aid is part of the NSI Basic Security Guard course, and post orders normally make the guard the first responder within the assigned site, with a duty of care to the people there. The primary purpose of workplace first aid encompasses four foundational objectives:

1. Preserve Life: Take immediate, priority actions to keep the casualty alive.
2. Prevent Deterioration: Intervene to stop conditions from worsening (e.g., stopping massive bleeding, maintaining an open airway, preventing shock).
3. Promote Recovery: Provide comfort, alleviate pain, reassure the casualty, and protect them from environmental hazards.
4. Secure Professional Medical Aid: Rapidly summon professional emergency medical services and provide a structured operational handover.

[Emergency Event Occurs]
          │
          ▼
[Preserve Life] ──► [Prevent Deterioration] ──► [Promote Recovery] ──► [Professional Handover]

Operational Scope and Legal Boundaries

Security guards must operate strictly within their NSI training certification. Officers must never attempt invasive medical procedures, never prescribe or administer oral medications (including aspirin or painkillers), and never declare a casualty deceased. Once first aid is initiated, the guard must remain with the casualty until relieved by qualified emergency medical personnel or until the scene becomes physically unsafe. Abandoning an injured casualty after initiating care constitutes gross professional negligence under UAE civil and criminal statutes.

Casualty Consent: Expressed vs. Implied

Before touching or treating any casualty, the security guard must consider the legal principle of consent:

• Expressed Consent: Must be obtained from every conscious, mentally competent adult. The guard must introduce themselves, state their training, and ask permission before touching the person: "Good morning, my name is Officer Tariq. I am a licensed security officer trained in first aid. May I assist you?"
• Implied Consent: In first aid practice, if a casualty is unconscious, unresponsive, delirious or in life-threatening confusion, consent to life-saving emergency help is implied, because the person would be expected to agree. The guard must proceed with immediate assessment and basic life support without hesitation.

Emergency Dispatch Liaison in Abu Dhabi

Rapid communication with the correct emergency authority is essential. In the UAE, specialized emergency telephone lines operate 24 hours a day:

• 998 — Ambulance: The primary emergency number for all acute medical crises, sudden collapses, trauma, cardiac arrests, and occupational health emergencies.
• 999 — Abu Dhabi Police: Dispatched for road traffic accidents, violent crimes, public order breaches, or scene security control.
• 997 — UAE Civil Defence: Contacted for building fires, hazardous material leaks, structural collapses, and trapped persons.

When contacting the ambulance service (998), the security officer must provide structured, accurate information:

• Exact facility name, community, street, building tower, floor, and room/gate number.
• Nature of the medical emergency (e.g., collapse, severe bleeding, suspected heart attack).
• Number of casualties, approximate ages, and observed sex.
• State of consciousness and breathing status.
• Known physical or environmental hazards at the scene (e.g., live electrical wires, toxic gas, chemical spills).
• Designated gate or entrance where a secondary guard will meet and guide the ambulance crew directly to the casualty.

---

The DRABC Primary Survey: Systematic Assessment

The DRABC Primary Survey is the internationally recognized operational methodology for rapidly identifying and managing immediate, life-threatening conditions. Every step must be executed in exact sequential order; skipping a step or jumping ahead jeopardizes both the casualty and the rescuer.

[D] DANGER        ──► Verify scene is completely safe for rescuer, bystanders, and casualty
      │
[R] RESPONSE      ──► Check level of consciousness using the AVPU scale and shoulder tap
      │
[A] AIRWAY        ──► Open airway via Head-Tilt, Chin-Lift (or Jaw-Thrust if trauma suspected)
      │
[B] BREATHING     ──► Look, Listen, and Feel for normal breathing for NO MORE than 10 seconds
      │
[C] CIRCULATION   ──► Check for catastrophic external haemorrhage and initiate CPR if pulseless

1. Danger (Assess the Scene)

Personal safety is the absolute prerequisite of all security and rescue operations. A guard who becomes a casualty cannot save anyone and doubles the burden on responding emergency services. Before entering a scene, look up, down, and 360 degrees around for active hazards:

• Live electrical wires or exposed busbars
• Toxic fumes, refrigerants, or sewer gases (e.g., hydrogen sulfide in confined spaces)
• Moving forklifts, delivery trucks, or vehicular traffic
• Falling construction debris or unstable shelving
• Active fires, dense smoke, or chemical pools
• Hostile, aggressive, or armed individuals

If the scene is unsafe, the guard must maintain a safe perimeter, prevent bystanders from entering, contact emergency services immediately, and attempt to eliminate the hazard from a safe distance (e.g., switching off an emergency electrical isolation breaker) before approaching.

2. Response (Check Consciousness)

Determine whether the casualty is conscious or unresponsive using the AVPU Scale:

• A (Alert): The casualty is fully awake, responsive, speaks coherently, and follows movement with their eyes.
• V (Voice): The casualty is drowsy or semi-conscious, opening eyes or responding only when spoken to loudly.
• P (Pain): The casualty does not respond to voice, but responds to physical sensory stimulation (such as a gentle squeeze of the trapezius muscle or pressure on the nailbed).
• U (Unresponsive): The casualty shows zero reaction to verbal or physical stimuli. This indicates a critical medical emergency.

Action: Approach the casualty from their field of vision. Kneel beside their upper torso, place hands gently on both shoulders, tap firmly, and ask in a clear, loud voice into both ears: "Hello, can you hear me? Open your eyes! I am a security officer, can you hear me?" Never shake a casualty vigorously, as this can sever an injured cervical spinal cord.

3. Airway (Ensure an Open Air Passage)

An obstructed airway will cause irreversible brain hypoxia within 4 to 6 minutes. In an unresponsive casualty lying on their back, the muscular tone of the tongue relaxes, allowing the base of the tongue to slide backward against the posterior pharyngeal wall, completely blocking the trachea.

• Head-Tilt, Chin-Lift Technique (Medical / Non-Trauma Cases): Place one hand firmly on the casualty's forehead and push gently downward to tilt the head back. Simultaneously, place the tips of two fingers from your other hand under the bony point of the casualty's chin and lift the chin upward. This maneuver pulls the tongue forward away from the back of the throat.
• Jaw-Thrust Technique (Suspected Cervical Spinal Trauma): If the casualty has suffered a fall from height, a blunt blow to the head, or a motor vehicle collision, tilting the neck could paralyze or kill them. The guard must perform a jaw-thrust without extending the neck: place index and middle fingers behind the angles of the lower jawbone (mandible) on both sides and lift the jaw upward and forward with gentle pressure.
• Inspect the Mouth: Look inside the mouth. If loose foreign objects, vomit, or broken dentures are clearly visible, sweep them out carefully with a gloved, hooked finger. Never insert fingers blindly into the throat, as this can push an unseen obstruction deeper into the larynx.

4. Breathing (Look, Listen, and Feel)

While maintaining the open airway position, position your ear and cheek directly above the casualty's mouth and nose, while directing your eyes toward their chest and abdomen:

• Look: Observe whether the chest and abdomen rise and fall symmetrically.
• Listen: Listen closely for normal exhalation breath sounds.
• Feel: Feel for warm exhaled air against your cheek.

Conduct this assessment for no more than 10 seconds.

           Maintain Airway (Head-Tilt / Chin-Lift)
                             │
              ┌──────────────┴──────────────┐
              ▼                             ▼
[Breathing Normally]                [Absent or Agonal Breathing]
       │                                   │
       ▼                                   ▼
Place in Recovery Position          Initiate Immediate CPR (30:2)
Monitor vitals continuously         Deploy AED without delay

Critical Warning on Agonal Gasps: Casualties in the first minutes of cardiac arrest frequently present with irregular, slow, noisy, labored, or snoring gasps known as agonal breathing. Agonal gasps are not normal breathing; they are involuntary brainstem reflexes indicating clinical death. If the casualty is not breathing normally, treat them immediately as being in cardiac arrest.

5. Circulation (Check Signs of Life and Catastrophic Bleeding)

Scan the casualty's body rapidly from head to toe for catastrophic external hemorrhage. If severe, spurting arterial bleeding is discovered, it must be arrested immediately with direct manual pressure or a tourniquet. In an unresponsive casualty with absent or abnormal breathing, the guard must assume absent circulation and immediately initiate chest compressions without wasting time searching for a weak peripheral pulse.

---

Cardiopulmonary Resuscitation (CPR) in Adults

Cardiopulmonary Resuscitation (CPR) is an emergency lifesaving procedure combining artificial chest compressions with ventilations to maintain a continuous flow of oxygenated blood to the brain, heart, and vital organs during cardiac arrest. Effective CPR extends the window of clinical viability, preventing irreversible biological brain death while an AED or advanced medical team is en route.

              ADULT CPR SPECIFICATION MATRIX (NSI / ILCOR STANDARDS)
┌────────────────────────────┬────────────────────────────────────────────────────────┐
│ Operational Parameter      │ Certified Mandatory Standard                           │
├────────────────────────────┼────────────────────────────────────────────────────────┤
│ Compression-Ventilation    │ 30 chest compressions to 2 rescue breaths (30:2)       │
│ Compression Rate           │ 100 to 120 compressions per minute (e.g. "Stayin' Alive")│
│ Compression Depth          │ 5 to 6 cm (2 to 2.4 inches) in adult casualties        │
│ Chest Wall Recoil          │ Complete, unrestricted recoil between each compression │
│ Hand Placement             │ Center of the chest on the lower half of the sternum   │
│ Rescuer Body Position      │ Knees shoulder-width apart; locked elbows; vertical shoulders │
│ Breath Interruption Limit  │ Less than 10 seconds total to deliver 2 rescue breaths │
└────────────────────────────┴────────────────────────────────────────────────────────┘

The Mechanics of Effective Chest Compressions

1. Casualty Surface: Ensure the casualty is lying flat on their back (supine) on a firm, hard surface (such as a tiled lobby floor or pavement). Performing CPR on a soft surface (like a couch or spring mattress) absorbs downward force and renders compressions ineffective.
2. Hand Position: Place the heel of one hand directly in the center of the casualty's chest, on the lower half of the breastbone (sternum). Place the heel of your other hand directly on top of the first hand, interlocking your fingers. Ensure your fingers do not rest against the ribs, as localized pressure on rib margins can cause fractures.
3. Postural Alignment: Kneel close beside the casualty's chest. Lock your elbows completely straight. Position your shoulders vertically directly above your hands so that the thrust comes from your upper body weight and core hips, not from your arm muscles.
4. Depth and Recoil: Press straight down firmly to a depth of 5 to 6 cm (2 to 2.4 inches). After each compression, release all downward pressure completely, allowing the chest wall to recoil fully. Full recoil allows the heart chambers to refill with venous blood; leaning continuously on the chest drastically reduces cardiac output.
5. Rate and Rhythm: Compress at a steady cadence of 100 to 120 compressions per minute. Count aloud: "1, 2, 3, ... 29, 30."

Delivering Rescue Breaths

After 30 compressions, immediately deliver 2 rescue breaths:

• Ensure the head is tilted back and the chin is lifted.
• Pinch the casualty's nostrils closed using the thumb and index finger of the hand resting on the forehead.
• If a pocket mask or one-way resuscitation face shield is available in the post first aid kit, seat it firmly over the casualty's mouth and nose.
• Take a normal breath, seal your lips completely around the mask or mouth, and blow steadily for 1 second while watching the casualty's chest.
• Observe the chest rise. Break the mouth seal, allow the chest to fall completely as air escapes passively, and deliver a second 1-second breath.
• Deliver the two breaths within under 10 seconds, then immediately return hands to the lower sternum for the next 30 compressions.

Hands-Only (Compression-Only) CPR: If a security guard lacks a personal resuscitation face shield, is not trained in rescue breathing, or is unwilling to perform mouth-to-mouth on an unknown casualty, the guard must perform continuous, uninterrupted chest compressions at 100 to 120 per minute. Hands-only CPR maintains vital coronary perfusion pressure and is far superior to doing nothing.

Mandatory Criteria to Discontinue CPR

A security officer must never arbitrarily stop CPR. Once started, compressions must continue until one of the following five conditions is met:

1. The casualty shows definite signs of life (wakes up, moves purposefully, coughs, or resumes normal, continuous breathing).
2. An Automated External Defibrillator (AED) arrives, is powered on, and instructs rescuers to stand clear for rhythm analysis.
3. Certified emergency medical personnel (ambulance paramedics) arrive on scene and explicitly take over physical custody of the casualty.
4. The rescuer is completely physically exhausted and physically unable to continue, and no relief rescuer is available.
5. The immediate environment becomes acutely unsafe, posing a direct threat to the rescuer's life.

---

Automated External Defibrillator (AED) Deployment and Safety

An Automated External Defibrillator (AED) is a portable, computerized medical device that automatically analyzes a casualty's cardiac rhythm and, if appropriate, delivers a controlled electrical shock (defibrillation). Defibrillation temporarily stuns an irregularly quivering heart, allowing the heart's natural pacemaker (the sinoatrial node) to re-establish an organized, pumping rhythm.

             AED CLINICAL OPERATIONAL PATHWAY
                            │
              ┌─────────────┴─────────────┐
              ▼                           ▼
     [Shockable Rhythms]         [Non-Shockable Rhythms]
     • Ventricular Fibrillation  • Asystole ("Flatline")
     • Pulseless Vent. Tach.     • Pulseless Electrical Activity
              │                           │
              ▼                           ▼
        [DELIVER SHOCK]             [NO SHOCK ADVISED]
              │                           │
              └─────────────┬─────────────┘
                            │
                            ▼
     Immediately Resume CPR (30:2) for 2 Minutes

The Step-by-Step AED Protocol

1. Power On Immediately: As soon as the AED arrives at the scene, open the lid or press the green "Power" button immediately. Modern AEDs provide clear, synthesized spoken voice prompts and flashing visual diagrams that guide the rescuer through every single step.
2. Expose and Prep the Chest: Quickly strip off the casualty's shirt, jacket, and undergarments. The chest must be bare and dry.
   • Moisture: If the casualty has been submerged in water or is sweating profusely, wipe the chest dry with a towel or gauze from the AED kit before applying pads.
   • Chest Hair: If heavy chest hair prevents the adhesive pads from sticking firmly to the skin, use the razor included in the AED preparation pack to shave the specific pad contact zones rapidly. If no razor is available, press the first pair of pads down firmly and rip them off quickly to remove hair, then apply a second fresh pair.
   • Medical Patches: If a transdermal medication patch (such as nitroglycerin) is present on the upper chest, remove it using a gloved hand and wipe the skin clean before attaching the pad.
   • Implanted Devices: If an implanted pacemaker or defibrillator is present (visible as a hard lump beneath the skin with a surgical scar under the clavicle), never place a pad directly over the device; position it clear of the lump (European Resuscitation Council guidance suggests about 8 cm away) or use an alternative pad position such as front-and-back.
3. Attach Adhesive Electrode Pads: Remove the protective plastic backing and adhere the pads firmly to the casualty's bare skin:
   • Upper Right Pad: Placed on the casualty's upper right anterior chest, directly below the collarbone (clavicle) and to the right of the sternum.
   • Lower Left Pad: Placed on the casualty's lower left lateral chest wall (mid-axillary line), slightly below and to the side of the left nipple and armpit.
4. Rhythm Analysis ("Stand Clear!"): The AED will announce: "Analyzing heart rhythm. Do not touch the patient."
   • The guard must immediately raise both hands in the air, look up and down the casualty's body, and shout loudly in an authoritative command voice: "STAND CLEAR!" Ensure nobody is touching the casualty, the casualty's clothing, or conducting CPR, as mechanical motion interferes with computerized rhythm analysis.
5. Delivering the Shock:
   • If the AED detects Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT), it will state: "Shock advised. Charging."
   • Once charged, the shock button will flash. The guard must perform a final visual sweep, shout loudly: "STAND CLEAR! SHOCKING IN THREE, TWO, ONE!" and firmly depress the flashing button (fully automatic models will count down and deliver the shock autonomously).
6. Immediate Post-Shock Action: The moment the shock has been delivered (or immediately if the AED announces "No shock advised"), the guard must not check for a pulse or pause to evaluate the casualty. Immediately resume CPR, starting with 30 firm chest compressions, followed by 2 rescue breaths. Continue CPR for 2 full minutes (approximately 5 cycles of 30:2) until the AED prompts you to pause for another rhythm analysis.

---

The Recovery Position

If an unresponsive casualty is assessed during the primary survey and found to be breathing normally with an intact circulatory pulse, and there is no suspicion of cervical spinal, pelvic, or major skeletal trauma, the casualty must be placed immediately into the recovery position.

                  PHYSIOLOGICAL BENEFITS OF RECOVERY POSITION
┌───────────────────────────────────┬───────────────────────────────────────────┐
│ Mechanical Mechanism              │ Direct Life-Preserving Result             │
├───────────────────────────────────┼───────────────────────────────────────────┤
│ Head tilted back, mouth downward  │ Saliva, blood, and vomit drain freely via │
│                                   │ gravity, preventing pulmonary aspiration  │
├───────────────────────────────────┼───────────────────────────────────────────┤
│ Tongue pulled forward             │ Prevents flaccid tongue from falling back │
│                                   │ and occluding the posterior pharynx       │
├───────────────────────────────────┼───────────────────────────────────────────┤
│ Bent knee and locked elbow tripod │ Stabilizes the body firmly, preventing    │
│                                   │ accidental rolling onto stomach or back   │
└───────────────────────────────────┴───────────────────────────────────────────┘

Step-by-Step Recovery Position Execution

1. Kneel beside the casualty. Ensure both of their legs are straight and aligned with their torso. Remove bulky items (such as heavy keyrings, pens, or radios) from their pockets, and remove their eyeglasses if present.
2. Take the casualty's arm that is nearest to you, extend it straight out at a right angle (90 degrees) to their body, with the elbow bent and the palm facing upward.
3. Bring their far arm across their chest. Place the back of their far hand firmly against their near cheek, and hold it in place with your hand.
4. With your other hand, grasp the casualty's far leg just above the knee and pull the knee upward until the foot rests flat on the floor.
5. Keeping the casualty's hand pressed tightly against their cheek to protect the head, pull firmly on the bent far leg toward you, rolling the casualty smoothly onto their side facing you.
6. Adjust the upper leg so that both the hip and knee are bent at right angles (90 degrees), forming a stable supporting tripod that prevents the body from rolling forward.
7. Gently tilt the casualty's head backward to ensure the airway remains widely open. Adjust their hand under the cheek so that the mouth faces slightly downward toward the floor, allowing fluids to drain freely.
8. Continuous Surveillance: Never walk away from a casualty in the recovery position. Kneel beside them, observing chest movement and monitoring pulse and facial skin color every minute until the ambulance service (998) arrives. If breathing deteriorates or stops, immediately roll the casualty flat onto their back and begin CPR.

---

Practical UAE Operational Scenario

The Incident

Officer Tariq is on static duty at the ground-floor concierge desk of a 40-story commercial office tower in the Abu Dhabi Global Market (ADGM) free zone on Al Maryah Island. At 10:15, a 54-year-old financial executive walking across the marble lobby suddenly clutches his chest, collapses forward onto the floor, and becomes completely unresponsive.

10:15 Collapse in Lobby ──► Officer Tariq verifies scene safety (dry marble, no hazards)
           │
           ▼
Checks AVPU & Shoulder Tap ─► Completely unresponsive ('U'); no verbal or motor reaction
           │
           ▼
Radio Broadcast to SOC ─────► "Code Blue at Main Concierge. Call 998 immediately.
                              Officer Rashid dispatch lobby AED. Officer Saeed meet medics at Gate 1."
           │
           ▼
Airway & Breathing Check ───► Head-tilt, chin-lift; 2 irregular snoring gasps in 8 sec (Agonal!)
           │
           ▼
Immediate High-Quality CPR ─► 30 compressions, 5.5 cm depth, 110 cpm on lower sternum
           │
           ▼
Officer Rashid Arrives ────► Deploys AED, attaches pads (upper right, lower left)
           │
           ▼
"STAND CLEAR!" ─────────────► Shock advised; Tariq shouts "Stand Clear!", delivers shock
           │
           ▼
Post-Shock CPR (30:2) ──────► Immediate compressions resumed; the ambulance crew arrives at 10:22

Applied Actions

1. Danger & Response: Tariq conducts an instantaneous 360-degree scene sweep. The polished floor is dry, with no electrical cables or falling hazards. He approaches, kneels beside the casualty, taps both shoulders firmly, and shouts: "Sir, can you hear me? Open your eyes!" The casualty is completely limp and unresponsive.
2. Emergency Escalation: Tariq activates his two-way radio to the building Security Operations Center (SOC): "Control, this is Officer Tariq at the Main Lobby. We have an adult male collapse, unresponsive. Call an ambulance on 998 immediately for priority dispatch to Tower 2. Dispatch Officer Rashid to my location with the wall-mounted AED and trauma bag, and instruct Officer Saeed at Gate 1 to hold the emergency elevator and escort paramedics."
3. Airway & Breathing Assessment: Tariq executes the head-tilt, chin-lift technique, looking inside the mouth for foreign objects. He places his ear over the mouth and watches the chest for 8 seconds. The casualty produces two harsh, snoring, irregular gasps. Recognizing these as agonal gasps and not normal breathing, Tariq treats the casualty as an active cardiac arrest.
4. Chest Compressions: Tariq locks his elbows, positions his shoulders directly over the center of the casualty's lower breastbone, and delivers 30 high-quality compressions at a depth of 5.5 cm and a rate of 110 beats per minute, allowing complete chest recoil.
5. AED Deployment & Defibrillation: Officer Rashid arrives with the AED. Rashid turns the unit on, tears open the executive's dress shirt, dries perspiration with a clean cloth, and applies the self-adhesive pads to the upper right chest and lower left ribcage. The AED announces: "Analyzing heart rhythm. Do not touch the patient." Tariq raises his hands and commands: "Stand clear!" The AED states: "Shock advised. Charging." Tariq visually verifies that neither he nor Rashid is touching the casualty, announces "Shocking in three, two, one!" and depresses the flashing orange shock button.
6. Post-Shock Protocol & Handover: Immediately following shock discharge, Tariq resumes chest compressions without pausing. Rashid delivers two breaths via pocket mask every 30 compressions. At 10:22, ambulance paramedics enter the lobby via the cleared Gate 1 route. Tariq provides an exact verbal handover: "54-year-old male, witnessed collapse at 10:15, agonal breathing noted, CPR initiated immediately, one shock delivered via AED at 10:19, currently completing cycle 4 of CPR." The paramedics take over and confirm the restoration of a viable spontaneous sinus rhythm. Tariq's disciplined adherence to the DRABC and CPR protocols saved the executive's life.

---

Section Summary Review Checklist for the PSBD Exam

• First Aid Objectives: Preserve life, prevent condition deterioration, promote recovery, secure professional emergency services.
• Emergency Contact: Ambulance emergency medical dispatch is 998; Abu Dhabi Police is 999; UAE Civil Defence is 997.
• Consent: Expressed consent for conscious adults; implied consent applies to unconscious casualties.
• DRABC Sequence: Danger (scene safety first), Response (AVPU scale), Airway (Head-tilt/chin-lift or jaw-thrust), Breathing (look, listen, feel max 10s), Circulation (massive bleed / CPR).
• Agonal Breathing: Irregular, noisy gasping is a sign of cardiac arrest, not normal breathing; begin CPR immediately.
• CPR Metrics: Adult ratio is 30:2; compression depth is 5 to 6 cm; compression rate is 100 to 120 compressions/minute; allow full chest recoil.
• AED Operation: Turn on immediately, apply pads (upper right chest, lower left ribs), shout "Stand clear!" during analysis and shock, resume compressions immediately post-shock.
• Recovery Position: For unconscious casualties breathing normally with no spinal trauma; maintains patent airway and prevents aspiration of vomit.