10 airway obst-adult

EMS SKILL

AIRWAY EMERGENCY: AIRWAY OBSTRUCTION ADULT

PERFORMANCE OBJECTIVES Demonstrate competency in recognizing and managing a foreign body airway obstruction in an adult who is choking

CONDITION Recognize and manage an airway obstruction in an adult who is found choking. Necessary equipment will be adjacent to the manikin or brought to the field setting.

EQUIPMENT Adult CPR manikin, adult bag-valve-mask or barrier device, O2 connecting tubing, oxygen source with flow regulator, goggles, various masks, gown, gloves, timing device.

PERFORMANCE CRITERIA Items designated by a diamond ( ) must be performed successfully to demonstrate skill competency. Items identified by double asterisks (**) indicate actions that are required, if indicated. Items identified by (§) should be practiced. Ventilations and compressions must be performed at the minimum rate required.

PREPARATION

Skill Component

Key Concepts

Take body substance isolation precautions

Mandatory (minimal) personal protective equipment – gloves Assess scene safety/scene size-up

** Consider spinal immobilization - if indicated

If unknown as to possible trauma, manage as trauma (determined by environment and information obtained from bystanders).

Evaluate need for additional BSI precautions

Situational - goggles, mask, gown Approach the patient and introduce yourself to the

patient/caregivers

RESPONSIVE ADULT

PROCEDURE

Skill Component

Key Concepts

Establish that the person is choking:

** Call for additional resources – if needed

Mild Obstruction: - adequate air exchange - coughing - gagging - wheezing

Severe Obstruction: - poor or no air exchange - increased respiratory distress - weak, ineffective cough or no cough - high-pitched noise while inhaling (stridor) or no noise - unable to speak - clutching the neck (universal sign of choking) - cyanosis - decreasing level of consciousness

Attempt to remove foreign body obstruction:

Mild obstruction - Encourage patient to cough

Severe obstruction - Perform abdominal thrusts (Heimlich maneuver)

Continued

DO NOT interfere if the patient has an effective cough.

If the patient is sitting or standing, place the patient in a position that allows for balance and supports the patient when performing abdominal thrusts.

Continued

Airway Emergency: Adult Airway Obstruction © 2001, 2005, 2006, 2007, 2008, 2009

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Skill Component

Key Concepts

- Stand or kneel behind the victim and place thumb side of fist between the patient’s xiphoid and

umbilicus - Grasp fist with other hand and give quick inward

and upward thrusts - as many times as needed

If the patient is found supine, straddle the patient and perform abdominal thrusts.

Deliver as many abdominal thrusts as needed until the object is expelled, the patient starts to breathe or becomes unresponsive.

Continue abdominal thrusts until obstruction is relieved or the patient becomes unresponsive.

** If unresponsive – start sequence for airway obstruction for unresponsive adult.

Manage ventilations after removal of obstruction:

If breathing is restored and adequate: - medical - place in recovery position if patient is altered

or unresponsive - trauma - initiate spinal immobilization – if indicated

If breathing is absent or inadequate: - perform rescue breathing of 10-12 per minute (1 breath every 5-6 seconds) with BVM or barrier

device

Patients who are responsive and not altered should be placed in a position of comfort, unless spinal immobilization is indicated.

Patients who are altered or unresponsive should be placed in the recovery position to reduce the chance of the airway being occluded by the tongue and the aspiration of mucus or vomitus.

Some signs of inadequate breathing are: respiratory distress, fast/slow respirations, cyanosis, poor perfusion, and altered LOC.

Supplemental oxygen should always be used after spontaneous breathing has resumed.

Use only enough force when providing positive pressure ventilation to allow for adequate chest rise. Over-inflation results in gastric distention and decreases tidal volume by elevating the diaphragm.

Use of a BVM by a single rescuer can result in an inadequate seal on the face and may not be as effective as a barrier device.

If the airway is open and it is difficult to compress the bag and/or air leaks around the seal, an airway obstruction may still be present.

UNRESPONSIVE ADULT

PROCEDURE

(Patients who were previously responsive may have the obstruction relieved when muscles relax)

Skill Component

Key Concepts

Establish unresponsiveness

** Call for additional resources – if needed

Open airway: Medical

- head-tilt/chin-lift

Trauma- jaw-thrust - neutral position (tragus of ear should be level with

top of shoulder)

** Clear/suction airway - if indicated

The tongue is the most common cause of airway obstruction due to decreased muscle tone.

The tongue and epiglottis may obstruct the entrance of the trachea due to inspiratory efforts creating negative pressure in the airway.

Move the patient no more than necessary to maintain an open airway. A second rescuer is needed to maintain in-line axial stabilization if spinal immobilization is required.

If the patient is found in a prone position with suspected trauma, the patient should be turned using the log-roll method to avoid flexion or twisting of the neck and back.

Assess for adequate breathing 5-10 seconds: Look Listen Feel

Look at chest for adequate tidal volume and rate. Check breathing for at least 5 seconds and no more than

10 seconds.


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Skill Component

Key Concepts Manage ventilations:

If breathing is adequate: - medical - place in recovery position – if altered or

unresponsive - trauma - maintain spinal immobilization - if indicated

If breathing is absent or inadequate:

- attempt 2 breaths with BVM or barrier device – (1 second/breath)

** If 1st breath is unsuccessful, reposition the head, attempt 2nd ventilation and initiate obstructed airway procedures.

Patients who are altered or unresponsive should be placed in the recovery position to reduce the chance of the airway being occluded by the tongue and aspiration of mucus or vomitus.

DO NOT hyperventilate. Hyperventilation reduces the success of survival due to:

- cerebral vasoconstriction resulting in decreased cerebral perfusion

- increase in intrathoracic pressure and decrease in venous return to the heart resulting in decreased cardiac output.

Rescuers have a tendency to ventilate too rapidly.

Ventilate using only enough force to cause the chest to rise. Over-inflation causes gastric distention decreasing tidal volume by elevating the diaphragm.

Using a BVM by a single rescuer can result in an inadequate seal on the face, and may not be as effective as a barrier device.

Remove dentures only if they cannot be kept in place. Dentures maintain facial form for a good seal.

Look in mouth for foreign body: If object is visible – remove foreign body If object is not visible – begin CPR, starting with

compressions

** Clear/suction airway - if indicated

DO NOT perform a blind finger sweep, this may force object further down the trachea. Perform finger sweep only if object is visible.

To remove foreign body: - Insert the index finger inside the cheek and into the throat to the

base of the tongue. - Use a hook like motion to grasp the foreign body and maneuver

it into the mouth so it can be removed. Perform chest compressions - if indicated:

Center of chest (lower half of sternum ) between the nipples

Heel of one hand on the sternum and other hand on top of the 1st

Depth: 1½ - 2 inches

Rate: approximately 100/minute

Ratio cycle: 30 compressions to 2 ventilations

** Always look in mouth for foreign body prior to giving breaths:

- Remove object - if visible - Clear/suction airway - if indicated

** DO NOT compress on or near the xiphoid process.

** Compressions must be deep, hard, fast, and allow for full chest recoil

Chest compressions must be performed on a hard surface, place a board under the patient or move the patient to the floor.

Compression landmark: Place the heel of 1 hand on the center of chest (lower half of sternum) between the nipples.

Compression method: push hard and fast - place the heel of one hand on top of the 1st hand

- fingers may be extended or interlaced, but must be kept off chest

- shoulders directly over hands

- arms straight and elbows locked - delivers force of compression straight down in order to be more effective

- allow chest to recoil (return to normal position) after down stroke to allow blood to flow into the chest and heart (50% of time for down stroke and 50% for chest relaxation)

Compressions need to be hard and fast to be effective. Compression rate: 100/minute (speed of compressions) delivers

fewer than 100/minute due to interruption of providing ventilations. The actual number is determined by the accuracy and consistency of the compression cycle (30 compressions should be delivered within 23 seconds). Five (5) cycles of 30:2 should take approximately 2 minutes.

Continue compressions until foreign body obstruction is relieved

** Call for additional resources - If not called for previously

Always look in mouth for foreign body prior to giving breaths: - Remove object - if visible - Clear/suction airway - if indicated

Reassess patient after obstruction is relieved

Check for: - Responsiveness to stimuli - Breathing - Pulse

** Provide rescue breathing - 10-12/minute (every 5-6 seconds) - if indicated

If a pulse is present and the patient is not breathing adequately, start BVM ventilations.

Patients not altered should be placed in a position of comfort.

Patients who are altered should be placed in the recovery position to reduce the chance of the airway being occluded by the tongue, and aspiration of mucus or vomit.


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REASSESSMENT

(Ongoing Assessment)

Skill Component

Key Concepts

Reassess a patient at least every 5 minutes once the obstruction is relieved once the patient has return of spontaneous respirations and circulation (ROSC):

Primary assessment Relevant portion of the secondary assessment Vital signs

This is a priority patient and must be re-evaluated at least every 5 minutes or sooner, if any treatment is initiated, medication

administered, or condition changes.

Evaluate response to treatment

The patient must be re-evaluated at least every 5 minutes if any treatment was initiated or medication administered.

Evaluate results of reassessment and compare to baseline condition and vital signs

**Manage patient condition as indicated.

Evaluating and comparing results assists in recognizing if the patient is improving, responding to treatment or condition is deteriorating.

§ Explain the care being delivered and transport destination to the patient/caregiver

Communication is important when dealing with the patient, family or caregiver. This is a very critical and frightening time for all involved and providing information helps in decreasing the stress they are experiencing.

PATIENT REPORT AND DOCUMENTATION

Skill Component

Key Concepts

§ Give patient report to equal or higher level of care personnel

Report should consist of all pertinent information regarding the assessment findings, treatment rendered and patient response to care provided.

§ Verbalize/Document:

Cause of obstruction - identify foreign body Observed or reported signs of obstruction: - skin signs - absent or inadequate respirations

Response to obstruction maneuver Reassessment of airway Additional treatment provided

Reassessment of airway includes: - chest rise and fall - skin color - airway patency

Documentation must be on either the Los Angeles County EMS Report or departmental Patient Care Record form.

Developed: 10/01 Revised: 1/05, 6/06, 10/07, 9/08, 3/09

AIRWAY EMERGENCY: AIRWAY OBSTRUCTION ADULT

Supplemental Information INDICATIONS:

Patients who show signs of mild or severe airway obstruction

CONTRAINDICATIONS:

None when above condition applies.

COMPLICATIONS: Gastric distention Rib fractures Sternal fractures Separation of ribs from sternum Laceration of liver or spleen

Pneumothorax Hemothorax Lung and heart contusion Fat emboli

Recognizing Choking in the Responsive Adult

Mild Airway Obstruction Signs

Severe Airway Obstruction Signs

• Adequate air exchange • Responsive and able to cough forcefully • May wheeze between coughs

• Poor or no air exchange • Increased respiratory distress • Weak, ineffective cough or no cough • Stridor (high-pitched noise while inhaling) or no noise • Unable to speak • Possible cyanosis

• Clutching the neck (universal sign of choking) • Decreasing level of consciousness

Rescuer Actions

Mild Airway Obstruction

Severe Airway Obstruction

• Encourage victim to continue coughing and attempt to breathe as long as there is adequate air exchange.

• Do NOT interfere with the victim’s own attempts to expel the foreign body. Monitor his/her condition.

• Activate ALS response if mild obstruction persists.

• Activate ALS response

• If responsive, perform abdominal thrusts

• If unresponsive, start chest compressions

• Activate ALS NOTES: • In responsive patients who are pregnant or obese, perform chest compressions instead of abdominal thrusts.

• The tongue is the most common cause of airway obstruction due to decreased muscle tone. Intrinsic causes of an obstruction include infection and swollen air passages. Extrinsic causes include foreign body, facial injuries, vomitus, etc.

• The tongue and epiglottis may obstruct the entrance of the trachea due to inspiratory efforts creating negative pressure in the airway.

• A second rescuer is needed to maintain in-line axial stabilization if spinal immobilization is required.

• If the patient is in a prone position with suspected trauma, the patient should be turned using log-roll method to avoid flexion or twisting of the neck or back.

• Patients who are not altered or unresponsive should be placed in a position of comfort, unless spinal immobilization is indicated.

• Patients who are altered or unresponsive should be placed in the recovery position to reduce the chance of the airway being occluded by the tongue and the aspiration of mucus or vomitus.

• Remove dentures only if they cannot be kept in place. Fitted dentures maintain form for a good seal.

• If obstruction is relieved, there may be a potential that not all foreign body fragments are completely removed.

• Any patient who received abdominal thrusts must be evaluated medically to ensure there are no complications, injuries or retained foreign body fragments.

• DO NOT hyperventilate. Hyperventilation reduces the success of survival due to cerebral vasoconstriction resulting in decreased cerebral perfusion. In addition, hyperventilation increases intrathoracic pressure and decreases venous return to the heart resulting in diminished cardiac output. Rescuers have a tendency to ventilate too rapidly.

• Priority patients are patients who have abnormal vital signs, signs/symptoms of poor perfusion, or if there is a suspicion that the patient’s condition may deteriorate.


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10 airway obst-adult

Health & Medicine