Download Airway Obst Adult - Los Angeles County Fire Department

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
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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
 If unknown as to possible trauma, manage as trauma (determined
by environment and information obtained from bystanders).
** Consider spinal immobilization - if indicated
 If spinal immobilization is required, an additional rescuer is
needed to maintain in-line axial stabilization.
 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
Airway Emergency: Adult Airway Obstruction
© 2013, 2011, 2009, 2008, 2007, 2006, 2005, 2001
Page 1 of 5
Skill Component
Key Concepts
 Attempt to remove foreign body obstruction:
 DO NOT interfere if the patient has an effective cough.
 Mild obstruction - Encourage patient to 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.
 Severe obstruction - Perform abdominal thrusts
(Heimlich maneuver)
-
-
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 forceful
inward and upward thrusts - as many times as
needed
 Continue abdominal thrusts until obstruction is relieved or
the patient becomes unresponsive.
 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.
 Give each new thrust as a separate and distinct movement..
** If unresponsive – start sequence for airway
obstruction for unresponsive adult
 Patients who are responsive and not altered should be placed in
a position of comfort, unless spinal immobilization is indicated.
 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 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
 Assess breathing 5-10 seconds for:
 Apnea
 Abnormal breathing
 Gasping
 Assess breathing for at least 5 seconds and no more than 10
seconds.
 Agonal gasps are not breathing but may be present in the 1
several minutes after sudden cardiac arrest.
st
 Gasps may sound like a snort, snore, or groan.
rd
 If more than 2 rescuers, the 3 rescuer should open the airway
and start ventilations.
Airway Emergency: Adult Airway Obstruction
© 2013, 2011, 2009, 2008, 2007, 2006, 2005, 2001
Page 2 of 5
Skill Component
Key Concepts
 Palpate the pulse for at least 5 seconds and no more than
10 sec.
 Palpate carotid pulse 5-10 seconds - unless history of
chocking
 Palpate carotid pulse on same side as the rescuer. DO NOT
reach across the neck. An alternative to Palpating a carotid pulse
is to palpate a femoral pulse.
** NO need to check for pulse if chocking has been
established.
 Start compressions if unsure if patient has a pulse. Unnecessary
CPR is less harmful than if CPR is not performed when indicated.
 Start compressions (C-A-B sequence)
 Ratio cycle: 30 compressions to 2 ventilations
 Complete 5 sequences (2 minutes) of CPR
 Open airway:
 Medical
- head-tilt/chin-lift
 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.
 Trauma
- jaw-thrust
- neutral position (tragus of ear should be level with
top of shoulder)
 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.
 Look in mouth for foreign body:
 Attempt to remove foreign body obstruction - if
visualized
 Attempt 2 breaths with BVM or mouth-to-barrier-device
(1 second/breath)
Repositions head and attempt 2
ventilation is unsuccessful
nd
ventilation – if 1
st
**- If object is not visible – continue CPR, starting with
compressions
 Always look in mouth for foreign body prior to giving breaths
 In children, the most common cause of cardiac arrest is an
inadequate airway.
 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.
** Clear/suction airway - if indicated
 Continue CPR until foreign body obstruction is relieved
** Call for additional resources - If not called for
previously
 Reassess patient after obstruction is relieved

-
Check for:
Responsiveness to stimuli
Breathing
Pulse
 Patients not altered should be placed in a position of comfort.

** Provide rescue breathing - 10-12/minute
(every 5-6 seconds) - if indicated
Airway Emergency: Adult Airway Obstruction
 Always look in mouth for foreign body prior to giving breaths:
- Remove object - if visible
- Clear/suction airway - if indicated
 If a pulse is present and the patient is not breathing adequately,
start BVM ventilations.
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.
© 2013, 2011, 2009, 2008, 2007, 2006, 2005, 2001
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REASSESSMENT
(Ongoing Assessment)
Skill Component
Key Concepts
 Reassess a patient at least every 5 minutes or sooner
once the obstruction is relieved and the patient has
return of spontaneous respirations and circulation
(ROSC):
 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.
 Primary assessment
 Relevant portion of the secondary assessment
 Vital signs
 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
 Evaluating and comparing results assists in recognizing if the
patient is improving, responding to treatment or condition is
deteriorating.
**Manage patient condition as indicated.
§ 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:
 Reassessment of airway includes:
- chest rise and fall
- skin color
- airway patency
 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
Developed: 10/01
 Documentation must be on either the Los Angeles County EMS
Report or departmental Patient Care Record form.
Revised: 1/05, 6/06, 10/07, 9/08, 3/09, 10/11, 1/13
Airway Emergency: Adult Airway Obstruction
© 2013, 2011, 2009, 2008, 2007, 2006, 2005, 2001
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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:
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Gastric distention
Rib fractures
Sternal fractures
Separation of ribs from sternum
Laceration of liver or spleen
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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.
• Activate ALS response
• If responsive, perform abdominal thrusts
• Do NOT interfere with the victim’s own attempts to expel the
foreign body. Monitor his/her condition.
• If unresponsive, start chest compressions
• Activate ALS response if mild obstruction persists.
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.
Airway Emergency: Adult Airway Obstruction
© 2013, 2011, 2009, 2008, 2007, 2006, 2005, 2001
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