# Do you use an AED on a choking victim in cardiac arrest?



## Dan216 (May 8, 2013)

Someone goes into cardiac arrest from choking. Abdominal thrusts were performed but failed. You start CPR. Would you apply an AED in this situation? Or would you wait until the airway is clear? Because even if you do get the heart beating again it's not like you can get them breathing.

I'm probably overlooking something, and I'm a bit confused.

Thanks.


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## Handsome Robb (May 8, 2013)

Yes you use it.

No it won't work until you fix the hypoxia that causes the cardiac arrest.


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## Household6 (May 8, 2013)

Yes, you apply an AED.. The only difference is when you are doing your rescue breaths (30:2), you look in the airway to see if the object has become dislodged, and remove it IF YOU CAN SEE IT.

If your rescue breaths push the object into their right bronchus... Oh well.. At least their trachea is clear and you can get air in one lung.. 

One unobstructed lung > two obstructed lungs.. Right?


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## chaz90 (May 8, 2013)

Don't over think cardiac arrest. You don't ignore a shockable rhythm when you find it. Yes, treating the underlying cause is most important to a good outcome, but multiple things need to be managed at the same time.


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## the_negro_puppy (May 8, 2013)

From what I understand the patient will most likely present in PEA or Asystole. Still attach AED as hypoxia can cause VF / VT


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## Handsome Robb (May 8, 2013)

the_negro_puppy said:


> From what I understand the patient will most likely present in PEA or Asystole. Still attach AED as hypoxia can cause VF / VT



You are correct sir. Think about pedis...generally asystole or PEA and usually a respiratory etiology. 

VF/VT are generally secondary to a cardiogenic etiology whereas the patient in this scenario is a respiratory/hypoxia etiology. I've never had a choking but all except for one of my drowning victims was in a slow PEA or asystole. I don't know what the other one was, it was while I was a beach guard, picked him on the jet ski with my partner, started BLS on the rescue ski and continued on the beach, AED lit him up and he was breathing by the time the ambulance got to use.

If the choking is witnessed an EMS arrives in a timely fashion and is able to clear the airway these are the patients we can get "real" saves on. We know the cause and it is easily reversible, provided we can either clear the obstruction with BLS, direct laryngoscopy and magills or worst case scenario you have to get under it with a crich.


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## NYMedic828 (May 8, 2013)

Should the patient present in VF or VT, you still need to attempt to correct it...

Is it likely? No.


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## mycrofft (May 9, 2013)

Actually the OP question has some merit. But the protocol is to use the AED when it appears. The reason for this I suppose is that in the field you cannot know for sure the "arrest" was caused by an airway embarrassment, or if the subject lost airway patency secondarily to losing consciousness (and being rolled supine by rescuers). One way to tell: place an endotracheal or at least sub-laryngeal length airway of some type.

Yeah stopping compressions to use the AED is losing recirculatory time, but if they snap out of a sudden cardiac standstill situation they might regain airway control. Or your "airway blockage" might just be poor head tilt...stay tuned for next round of new standards.

Someone told me the "Oh well we shoved it into one bronchus" things was BS due to anatomy, can't remember who right now. Maybe Veneficus.


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## Hunter (May 9, 2013)

Household6 said:


> Yes, you apply an AED.. The only difference is when you are doing your rescue breaths (30:2), you look in the airway to see if the object has become dislodged, and remove it IF YOU CAN SEE IT.
> 
> If your rescue breaths push the object into their right bronchus... Oh well.. At least their trachea is clear and you can get air in one lung..
> 
> One unobstructed lung > two obstructed lungs.. Right?









I'm just gonna assume you weren't trolling.:unsure:

Considering that the main stem bronchi are smaller than the trachea, wouldn't an obstruction that is big enough to block the trachea also be too large to be pushed into either left or right bronchi? Just going with what i know from Anatomy, but correct me if i'm wrong. I also know the bronchi are more elastic, not sure if that would make a difference.


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## mycrofft (May 9, 2013)

*Yep I'm serious.*




You will find that _*most*_ airway embarrassments are not big enough to block the trachea, they are big enough to cause the epiglottis to slam shut (say a nice stiff granola crumb) or hang in the larynx. Hear of "dry land drowning"? Most of the time most of us can clear them. Sometimes not. And sometimes the wildass coughing they cause can trigger another mechanism like vagal syncope (with attendant falling to the ground, Nature's Heimlich Maneuver) cardiac arrhythmia or cerebral haemorrhage 

But yeah the trachea has a larger caliber than the bronchi. Thanks!


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## Handsome Robb (May 9, 2013)

I've been told over and over again that attempting to right mainstem the obstruction as a last ditch attempt is an option. I still don't understand it.

One, at that point I'm going to be cutting rather than ****ing around trying to jam the obstruction further into someone's airway.

Two, if the obstruction was above the crichothyroid membrane and now you force is down in line or below it but not into the right mainstem you've signed that patient's death warrant. 

Three, unless you plan on leaving the stylet in place and risking potentially catastrophic airway trauma (but I will agree the argument can be made that "at this point does it matter?") a bougie or ETT doesn't seem stiff enough to me to force anything anywhere. The bougie will just curl up and the ETT would just collapse on itself, in my opinion. With that said, rescue breaths "forcing" the obstruction down aren't an option either, to move that obstruction you're going to need a lot of pressure. If there were nowhere else for that pressure to go then MAYBE, but unfortunately our patients have these pesky little things called an esophagus and a stomach for all that pressure to wander its way into rather than moving the obstruction down the airway any further. 

Four, and this is a consideration in urban systems and one of the few times I'd advocate just picking them up and driving fast, how far from a hospital and an MD with a glidescope, bronchoscope, tracheostomy kits and all their other toys?

We had a choking recently that was literally 45 seconds, routine, from the level two trauma center. They tried once, were unsuccessful and picked up and boogied to the ER. They were able to relieve the obstruction and obtain ROSC but unfortunately the patient suffered a massive anoxic brain injury. You'd have to be really close but it's worth a thought, especially if you take a look with a laryngoscope and you recognize there's nothing you can do.


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## Household6 (May 9, 2013)

Robb said:


> I've been told over and over again that attempting to right mainstem the obstruction as a last ditch attempt is an option. I still don't understand it.
> 
> One, at that point I'm going to be cutting rather than ****ing around trying to jam the obstruction further into someone's airway.



Last resort, that's what I was taught, I hope it never happens.

I'm guessing crics aren't in the OPs scope?? They're not in mine (....yet)


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## Hunter (May 9, 2013)

Household6 said:


> Last resort, that's what I was taught, I hope it never happens.
> 
> I'm guessing crics aren't in the OPs scope?? They're not in mine (....yet)



I don't think I would try that until after the patient coded... it just seems like the risk vs benefit doesn't plan out. Aspiration pneumonia aside making a 95% obstruction into 100% with out hope for a cric even at the hospital seems like making  smaller problem into a bugger one. Plus if I'm working bls and I have a patient with a severely obstructed air way I'm gonna call for ALS. Sooner rather than later.


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## emtblaze (May 22, 2013)

Yeah, you would perform CPR as you usually would. Although you would put more emphasis on the rescue breaths and checking the airway for the object as mycroftt said because the cardiac arrest was caused by hypoxia. And the main cause of Vfib is hypoxia to the heart muscle.

It appears that you're confused as to why we would shock them, instead of trying to get the airway clear. We shock them because they're in Vfib and we have to stop it and get the heart beating normally again, along with trying to airway clear.


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## Carlos Danger (May 22, 2013)

Robb said:


> I've been told over and over again that attempting to right mainstem the obstruction as a last ditch attempt is an option. I still don't understand it.
> 
> One, at that point I'm going to be cutting rather than ****ing around trying to jam the obstruction further into someone's airway.
> 
> Two, if the obstruction was above the crichothyroid membrane and now you force is down in line or below it but not into the right mainstem you've signed that patient's death warrant.



If the obstruction is at the level of the glottis, which the vast majority are, it will probably be dislodged with BLS maneuvers, or it will be visible upon laryngoscopy and easily removed with magills.

If the obstruction is below the glottis, then it's probably below the level where you do your cric, so a cric will do nothing for you. This is especially likely in a ped.

Attempting to intubate past / through the obstruction, and hopefully either get around it or push it into a mainstem, is a crappy option but it's pretty much all you have at that point.


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## NomadicMedic (May 22, 2013)

Luckily, I've only had one full FBAO, and I was able to remove it with Magills, but in the back of my mind I was thinking if I wasn't able to grab it, I was going to try to push it down with a bougie.


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