Help! Choking! Nothing is working!

[Mountain Res-Q]

As I understood it, if the pt goes unconscious, a finger sweep is recommended, as the loss of consciousness may relax the muscles of the pharynx, thus releasing the object. If nothing is seen or felt, then proceed to give 2 rescue breaths

The last time I saw fingure sweeps in protocol was about 7 yers ago, about the same time a good friend of mine, Willaim Rogers, went on medical leave... we call him Two-Fingured-Willy now! ^_^

 

[Jeremy89]

We don't do blind finger sweeps anymore...haven't for several years. If you see the object, then you can attempt to remove it...otherwise keep your fingers out of their mouth.

er....uh, yeah, I knew that....


See what happens when you don't use your prehospital skills??

 

[LAS46]

er....uh, yeah, I knew that....


See what happens when you don't use your prehospital skills??

Don't worry about it Jeremy, We all forget things every now and then.

 

[marineman]

Mt Jerry, what system do you work in that has you inserting a combitube before attempting to give 2 breaths? Has your medical director even had boy scout first aid training?

 

[Mountain Res-Q]

Mt Jerry, what system do you work in that has you inserting a combitube before attempting to give 2 breaths? Has your medical director even had boy scout first aid training?

Maybe someone is reading the cookbook backwards.

 

[SES4]

Woah!

Woah. Blow foreign object INTO the lungs?!?!

Can we say ASPIRATION?!?! Yikes. Seriously, it is quite disturbing to me that the instructor would tell you to do this.

 

[JPINFV]

Aspiration or asphyxia. Pick one and only one.

 

[Mountain Res-Q]

Aspiration or asphyxia. Pick one and only one.

I'll take "I don't want to die, and will deal with the apiration" for $200 Alex. ^_^ What part of "as a last resort" "when all else fails" is in question?

 

[SES4]

Just saying LOL

LMAO. Just saying.... Aspiration here "we" come!

Hypoxia is NOT my preference either!

 

[boingo]

Well, one of the options will definately kill you....choose the other one.

 

[mycrofft]

Like daedalus said.

Maybe the instructor was a little graphic, but if you follow the routine, that will follow if you try to ventilate forcefully enough.
Just don't waste time *****footing around with mousebreaths.
Just as a bolus can be dislodged by CPR compressions if it has truly sealed the airway (no one way valve function).

makes you wish you could adminsiter an oxygenated fluid.

Oh, PS: if it's 100% occluded when they call for help, there's a good likelihood you will not get there in time to save them anyway.

 

[Aidey]

I was taught that in the absence of the ability to crich the patient, inserting a ET tube and forcing the obstruction into the right mainstem and then pulling the ET out enough to ventilate the left lung was an acceptable procedure. Yes you are causing them to aspirate, but as has been said, the alternative is letting them die.

 

[AJ Hidell]

The main problem here is that the instructor is either ignorant of basic respiratory anatomy, or else he failed to use the proper terminology to make a cogent point. Consequently, people are arguing a moot point. But even so, he was on the right track.

Anything big enough to block the trachea is not going to get blown into the lungs. The respiratory tract gets smaller as it descends, not bigger. The farthest an object that sie will make it is the mainstem bronchus. Anything small enough to go farther wouldn't have obstructed the trachea in the first place. It won't cause aspiration pneumonia in the bronchus. And it is easily retrieved by bronchoscopy. But only if they live to make it to the hospital. And in order for that to happen, you have to first get it out of the trachea. Blowing it down is an acceptable way of doing that when conventional methods fail.

I also like JPs analogy of rocking a stuck car back and forth until it breaks free. Whether it breaks free north or south, it is still free, and your have established an airway.

 

[mycrofft]

Many good points.

We need to remember also that most airway embarassments include or are nearly 100% epiglottal. If a tiny irritant like dust or an errant sip of water can slam it shut, what about a pea-sized...well, PEA!. Or a half-cup of Granny's mashed potatos! The airway clearance protocols are aimed at this vast-majority factor.

What about fluids like vomitus, blood, mucus, water?

 

[MtJerry]

Mt Jerry, what system do you work in that has you inserting a combitube before attempting to give 2 breaths? Has your medical director even had boy scout first aid training?

You are jumping to conclusions that were not referred to. I was referring to obtaining a patent airway before using a BVM and nothing more.

In a choking patient, I understand that this may not be possible.

After reading some of the recent posts, i guess I could see the value of asperation vs. death, however, we should be emphasising the need to get the object out if possible. I think AJ Hidell makes a good point:

Anything big enough to block the trachea is not going to get blown into the lungs. The respiratory tract gets smaller as it descends, not bigger. The farthest an object that sie will make it is the mainstem bronchus. Anything small enough to go farther wouldn't have obstructed the trachea in the first place.

But I think the original poster was talking about what he was taught by a CPR instructor. If this were a course for the general public, he is teaching them to do something that could cause them to be sued. There is NO REFERENCE to this procedure in the materials of the American Red Cross nor the American Heart Association. If the layperson were to do as he instructed, they would be outside of the protection of the Good Samaritan Laws.

 

[VentMedic]

I was taught that in the absence of the ability to crich the patient, inserting a ET tube and forcing the obstruction into the right mainstem and then pulling the ET out enough to ventilate the left lung was an acceptable procedure. Yes you are causing them to aspirate, but as has been said, the alternative is letting them die.

To aspirate is to get something below the cords. If you are using an ETT, I would hope you also have forceps to grap anything above the cords. If the object is below the cords, then the patient has already aspirated the object. You are merely trying to dislodge or move the object to a sight that allows you to ventilate.

BTW, this is also why a cuff on a trach or an ETT does not prevent aspiration. If the vomit or whatever makes it to the cuff, it is below the cords and in the lungs. Having the tube just makes it easier to suction out.

 

[zappa26]

What about fluids like vomitus, blood, mucus, water?

Suction, no?

 

[marineman]

You are jumping to conclusions that were not referred to. I was referring to obtaining a patent airway before using a BVM and nothing more.

In a choking patient, I understand that this may not be possible.

After reading some of the recent posts, i guess I could see the value of asperation vs. death, however, we should be emphasising the need to get the object out if possible. I think AJ Hidell makes a good point:



But I think the original poster was talking about what he was taught by a CPR instructor. If this were a course for the general public, he is teaching them to do something that could cause them to be sued. There is NO REFERENCE to this procedure in the materials of the American Red Cross nor the American Heart Association. If the layperson were to do as he instructed, they would be outside of the protection of the Good Samaritan Laws.

How do you know it's patent if you don't test with a BVM?

Not sure what conclusion I jumped to, you quoted a post outlining appropriate ABC assessment, emphasized the section about giving 2 breaths with a BVM and said you would insert a combitube first.

 

[BossyCow]

I'm amazed at how many taught layperson CPR and FBAO with Red Cross and AHA are coming up with this type of misunderstanding. The rescue breath attempts are not attempts to dislodge the item with your breath or the BVM. These are not pressure washers or air compressors. It is an attempt to determine if there is any air getting around the object.

If the object is dislodged with a rescue breath, the object should have been able to be dislodged by either the abd thrusts or chest compressions. The current standard for breathing is not a gale force wind but a breath. This is the type of education we get from CPR instructors trained in how to present a video, not on how to perform CPR.

 

[cshaw84]

Hello everyone. I ran across this page while reviewing BLS protocols before my clerkships and I'd like to share a few comments to help defray misconceptions.

Do not attempt to blow an object into a patient's lungs
Short version: You are unlikely to progress a tracheal obstruction fully into a bronchus. By doing so, you make it less likely that you will be able to expel the obstruction by abdominal thrusts.

- Anatomy and Physiology -
From a physiologic standpoint, the idea of pushing an obstruction from the trachea into a bronchus is sound in a 100% blocked situation with an unconscious patient. 50% lung capacity is definitely better than no gas exchange at all. Ultimately, the further down the bronchial tree you can advance the obstruction, the more gas exchange can occur.

If the patient is conscious, you obviously want to encourage coughing, use abdominal thrusts, and give supplemental oxygen if indicated. Do not administer artificial ventilation.

AJ Hidell brings up an excellent point that the bronchial tree becomes narrower as you go further down. This is certainly true. In fact, it's also likely that you'd get the obstruction stuck at the bifurcation. On a side note, one should also remember that the tracheal rings and the larger bronchial rings are made of cartilage, which is somewhat flexible. Furthermore, more terminal bronchi do not have cartilaginous rings. This isn't to say that you can jam anything down the tubes by simple pressure, but it is possible that a malleable obstruction (ei. food) could be forced down further.

If an obstruction were to be advanced into a main stem bronchus or lesser bronchi, it is statistically more likely to go into the right main stem bronchus and then the right lower lobe for anatomical reasons. The possible sequelae of an aspirated object within the lungs are obviously minor in comparison to death. The most common serious outcome would be a bacterial pneumonia, which can ultimately be treated with antibiotics. The most fatal possibility would be respiratory distress syndrome (RDS), but that is fairly uncommon and, again, is minor in comparison to death.

- Main Point -
Now, in terms of EMS, I would suggest AGAINST[/U] such a procedure on the largely grounds of lawsuit and malpractice. There are also limited chances of being able to progress the obstruction and it could possible limit other advanced therapies. My recommendation will be to follow your service's protocols. Now, if you "accidently" blow too hard on a rescue breath, it may or may not be beneficial to the patient, but there is also serious risk of detriment to the patient's condition. Another danger is the progression of a pre-cricoid or cricoid obstruction further down the esophagus, which could eliminate the possible benefit of a field cricothyrotomy.

Moral of the story: It may make sense, but don't do it.

I welcome any comments or questions.
(I was in a hurry, please excuse any typos)

C.S.
Former EMT
3rd year medical student (allopathic)