# Choking pt becomes unconscious...inserting an airway?



## Mya (Oct 3, 2017)

I recently took a BLS CPR class to renew my cert and the instructor told us that after some time if the patient has no chest rise and fall and the object is still there, that ALS will insert an advanced airway and just push the object into the lungs.

1. If there's no ALS (I'm an EMT) do we just insert and OPA in this case?

2. How long do we wait until inserting an airway?


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## luke_31 (Oct 3, 2017)

First off if they are choking don't place an OPA in the airway, it won't move the object into the lungs and allow air to go in.  All you will do is block the airway even more, as the object will now have no way to come up as you are doing CPR to try and dislodge it.  I'd say I would almost never insert an advanced airway to shove a object further in the lungs, it would make it that much harder for a doctor to get out, plus lead to more complications for the patient.  Maybe the instructor was referring to Magil forceps, which can grab a object in the airway if the ALS provider can visualize it with the laryngoscope.


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## EpiEMS (Oct 3, 2017)

luke_31 said:


> Maybe the instructor was referring to Magil forceps, which can grab a object in the airway if the ALS provider can visualize it with the laryngoscope.



I thought it was not uncommon to use the ETT to force an object into the right mainstem bronchus then intubate the left *if all other measures fail*.


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## VFlutter (Oct 3, 2017)

EpiEMS said:


> I thought it was not uncommon to use the ETT to force an object into the right mainstem bronchus then intubate the left *if all other measures fail*.



Correct. If patient has FBO that can not be retrieved with Magils the intubate and attempt the push the object distally and ventilate. Happens in pediatrics occasionally.


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## DesertMedic66 (Oct 3, 2017)

If you can’t remove the object what is going to be the better option? Not ventilate the patient because of the obstruction so the patient is not getting any oxygen or to either push the object to one side or even push the tube through the object so you can ventilate the patient?


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## luke_31 (Oct 3, 2017)

It's been a while since school and couldn't remember learning that part, but it's not a bad last ditch effort. Not something I'd want to ever have to do but at least it's now in my bag of tricks if it needs to be done.


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## PassionMedic (Oct 4, 2017)

If your patient has gone into respiratory arrest, I would treat by protocol (OPA/NPA) until ALS arrived/you arrive at the hospital. I would NOT wait to insert an airway if your pt isn't breathing. If the obstruction didn't dislodge with Any interventions before unresponsiveness, I doubt it will dislodge on its own, and preventing the tongue from further obstructing the airway and providing supplemental oxygenation/ respirations are the most effective thing an EMT can do for that pt.    


Sent from my iPhone using Tapatalk


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## SpecialK (Oct 4, 2017)

AFAIK most services' in Australasia have moved laryngoscopy for airway obstruction down to base level; honestly it's not hard to do, and the disposable laryngascopes are pretty cheap.  It's literally just literally having to look in the larynx for e.g. a big piece of sandwich and hook it out with a pair of forces.  For the want of maybe $50 can literally be the difference between life and death.

I can't see a reason not to do it so you blokes might want to follow suit.


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## Akulahawk (Oct 4, 2017)

At the BLS level, you just keep attempting the BLS maneuvers to clear that airway until ALS shows up. ALS will then attempt to remove the obstruction and if that is not possible, you go to your next best option. That may be doing a needle cric or a surgical cric or if neither is immediately available to you, attempt to shove the obstruction into a mainstem and ventilate the other lung. I would rather have a living patient that needs reasonably immediate surgery to remove the object than a patent that's dead because I wanted to prevent the patient getting an infection or having to undergo emergency surgery. 

Hopefully the laryngoscope and Macgill foreceps are sufficient!


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## Specialized (Oct 6, 2017)

If your pt was choking and is now unconscious, yeah as everyone said above follow your local protocol and use BLS adjuncts. Insert your OPA and use high flow O2 via NRB or BVM and provide chest compressions if pt is pulseless and apneic. Hook up to AED and get a shock on board.  

For some reason, the use of an NPA crossed my mind but that wouldn't make any sense in this situation..


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## SpecialK (Oct 7, 2017)

Why piss-arse around with an OPA or bag and mask ventilation? How is the insufflatory volume supposed to get past the obstruction in the larynx?

As for CPR, yes, CPR is the go-to for an unconscious person; why? because good, hard CPR will decrease the thoracic volume and raise PA above PB which is exactly what we want to happen so whatever ERV or FRC this guy has can be used to dislodge the obstruction.

Of course, a much better idea is to just get the disposable laryngoscope and forceps for everybody like has been done in Australasia.


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## Carlos Danger (Oct 7, 2017)

Specialized said:


> For some reason, the use of an NPA crossed my mind but that wouldn't make any sense in this situation..



Actually, an NPA makes good sense. It won't relieve the obstruction, but no matter what you need to maintain a patent upper airway. An NPA makes that easier, and is probably a better idea than an OPA because once ALS arrives the first thing they are going to do is laryngoscopy, which would require removal of the OPA anyway. 



SpecialK said:


> Why piss-arse around with an OPA or bag and mask ventilation? How is the insufflatory volume supposed to get past the obstruction in the larynx?
> 
> As for CPR, yes, CPR is the go-to for an unconscious person; why? because good, hard CPR will decrease the thoracic volume and raise PA above PB which is exactly what we want to happen so whatever ERV or FRC this guy has can be used to dislodge the obstruction.
> 
> Of course, a much better idea is to just get the disposable laryngoscope and forceps for everybody like has been done in Australasia.



How often are you successful in using Magills to relieve a complete airway obstruction that has progressed to unconsciousness? My guess is not very. That's because in adults, any obstruction that can't be dislodged with coughing and abdominal compressions is probably subglottic, which means it can't be reached with Magill forceps. Almost any obstruction at the level of the glottis can be dislodged non-invasively, which is why these are (thankfully) such rare events.


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## Specialized (Oct 7, 2017)

Remi said:


> Actually, an NPA makes good sense. It won't relieve the obstruction, but no matter what you need to maintain a patent upper airway. An NPA makes that easier, and is probably a better idea than an OPA because once ALS arrives the first thing they are going to do is laryngoscopy, which would require removal of the OPA anyway.



Oh okay gotcha. However, would this pt still be getting adequate ventilation's if you were bagging them with 21%/100% oxygen? I have this feeling that the foreign object in the airway would be causing some resistance and hinder tidal volume while using a bvm?


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## Carlos Danger (Oct 7, 2017)

Specialized said:


> Oh okay gotcha. However, would this pt still be getting adequate ventilation's if you were bagging them with 21%/100% oxygen? I have this feeling that the foreign object in the airway would be causing some resistance and hinder tidal volume while using a bvm?


If it is truly a complete obstruction, then no, they won't be getting any gas exchange at all. But you still want to keep the upper airway open in case the obstruction becomes incomplete.


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## RocketMedic (Oct 10, 2017)

The 'definitive fix' here in obstructions that don't move is to cut to air.


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## NPO (Oct 23, 2017)

In the extreme patient with a FBO that cannot be retrieved, and is in fact pushed past the corina to allow for ventilation, what is the definitive care for the patient? I presume there aren't kids walking around with dimes in their lungs or a piece of turkey, mayo and provolone on wheat bouncing around. Is the FBO surgically removed?


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## DesertMedic66 (Oct 23, 2017)

NPO said:


> In the extreme patient with a FBO that cannot be retrieved, and is in fact pushed past the corina to allow for ventilation, what is the definitive care for the patient? I presume there aren't kids walking around with dimes in their lungs or a piece of turkey, mayo and provolone on wheat bouncing around. Is the FBI surgically removed?


I don’t know if it’s physically possible to remove the FBI...

From what I have seen they are either surgically removed or they will go in with a bronchoscope to attempt to remove it non-surgically


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## SpecialK (Oct 23, 2017)

A timely opportunity to say I learnt the other day a couple of personnel recently hooked a giant obstruction out a bloke's airway using the disposable laryngoscope and forceps introduced about 10 months ago.  Had this not been introduced to all personnel, they would not have had access to and would have had to wait for backup.  This previously happened about 3-5 times a year and resulted in several preventable deaths.  I can categorically say this will save several lives a year.

So, perhaps those services who do not have this should think again?


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## Mya (Oct 23, 2017)

Worked with an experienced medic yesterday and she said she'll try a few times to get it out but will NOT waste time and immediately force the object in when intubating. She's done it before. So...yup!


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## SpecialK (Oct 24, 2017)

That's it mate, have a good old squiz and if it's not obviously removable try to shove it down a main bronchi with an ETT and if you can't ventilate the other for gawd sake don't arse around just do a bloody cricothyroidotomy.  Somebody once said I had big balls for being a little bit keen to cut somebodies neck, but I reckon that's right bollocks, If somebody is that munted, you're just taking the absolute piss trying to bugger around oh maybe we can ventilate with a bag and mask oops no we can't let's keep fossicking around trying to hook it out oops no that didn't work, um, oops look the patient is cabbage patch material honestly.


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## Tigger (Oct 24, 2017)

SpecialK said:


> AFAIK most services' in Australasia have moved laryngoscopy for airway obstruction down to base level; honestly it's not hard to do, and the disposable laryngascopes are pretty cheap.  It's literally just literally having to look in the larynx for e.g. a big piece of sandwich and hook it out with a pair of forces.  For the want of maybe $50 can literally be the difference between life and death.
> 
> I can't see a reason not to do it so you blokes might want to follow suit.


I have an immense amount of respect for NZ EMS, but didn't you once say that the services would not be willing to spend money on CPAP, which is cheaper per unit than that? CPAP is much more likely to be used than direct laryngoscopy. Our base level EMT education does not even cover supraglotic airways (I realize that many programs do however) so sadly I don't think will be coming to most EMT's scope anytime soon.


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## SpecialK (Oct 25, 2017)

Tigger said:


> I have an immense amount of respect for NZ EMS, but didn't you once say that the services would not be willing to spend money on CPAP, which is cheaper per unit than that? CPAP is much more likely to be used than direct laryngoscopy.



No, I sad it's a case of _*not having *_the money to spend on some form of CPAP considering the cost of replacement consumables and oxygen.

A $50 disposable set of laryngoscope and forceps which statistically, per ambulance, will take five to seven years to be used (if my math is correct - about five per year nationally) is much different than the cost of replacing expandables and the oxygen they will consume when you consider 500,000 patients a year.

Hopefully this will change in the next couple of years.


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## Tigger (Oct 26, 2017)

SpecialK said:


> No, I sad it's a case of _*not having *_the money to spend on some form of CPAP considering the cost of replacement consumables and oxygen.
> 
> A $50 disposable set of laryngoscope and forceps which statistically, per ambulance, will take five to seven years to be used (if my math is correct - about five per year nationally) is much different than the cost of replacing expandables and the oxygen they will consume when you consider 500,000 patients a year.
> 
> Hopefully this will change in the next couple of years.


I should hope, every remotely modern EMS system should have CPAP widely available.


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## SpecialK (Oct 27, 2017)

Tigger said:


> I should hope, every remotely modern EMS system should have CPAP widely available.



Me too ... but the Crown could honestly care less it seems.  They recently ponied up a couple million for full crewing, but eh, with Emergency Medical Assistants who are barely allowed to do anything without direct supervision.


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