# Obstructed Airway Question



## Mike97 (Apr 10, 2018)

Student here.  I’ve got a question on a patient with an obstructed airway that is unconscious.  

The books say if the patient goes unconscious to give chest compressions.  But, what if they are not pulseless?  Would you start compressions regardless as an attempt to clear the obstruction?


----------



## cprted (Apr 10, 2018)

Without a patent airway, the patient will become pulseless in fairly short order. An airway emergency tops pretty much everything else, thus chest compressions are indicated. In this situation, the compressions are about attempting to dislodge the obstruction, not CPR.

That being said, check to see if the obstruction dislodged when they became unresponsive.


----------



## MedicMcGoo (Apr 10, 2018)

Also according to the University of Arizona there is slim to no chance of injuring a patient when performing chest compressions on a beating heart. 

The real goal is to get that foreign body up and out of the airway or down and into the lung to get at least half of the lungs to ventilate.


----------



## michael150 (Apr 11, 2018)

When a patient goes unconscious from an airway obstruction the purpose is still remove the foreign body. Chest compressions are initiated for that reason, not yet for resuscitative measures. As other responses have mentioned though, an unconscious patient due to an airway obstruction is ominous and very shortly they will become pulseless if a patent airway is not established.


----------



## RocketMedic (Apr 11, 2018)

Depends on level and what/where the obstruction is. If you're an EMT, CPR, on the theory that compressions generate enough concussive force and pressure to dislodge an obstruction. If it's an oropharyngeal obstruction, remove it. 

If you're a paramedic, the world got big. Cut to air!


----------



## michael150 (Apr 11, 2018)

RocketMedic said:


> Depends on level and what/where the obstruction is. If you're an EMT, CPR, on the theory that compressions generate enough concussive force and pressure to dislodge an obstruction. If it's an oropharyngeal obstruction, remove it.
> 
> If you're a paramedic, the world got big. Cut to air!



I would be interested to see how many medics have actually done a surgical or needle cric in the field... Would we actually be prepared for it?


----------



## VentMonkey (Apr 11, 2018)

michael150 said:


> I would be interested to see how many medics have actually done a surgical or needle cric in the field... Would we actually be prepared for it?


Interestingly enough, I was listening to this past quarters Airway World webcast earlier. It’s pretty rare, however, current literature seems to advocate for surgical cric for apparent reasons. 

It was actually a pretty insightful webinar and focused on 3-4 prehospital related airway papers, but it was also quite lengthy.


----------



## Peak (Apr 11, 2018)

The difficulty with using compressions to force out a foreign body is that they would need to have relatively full lung volume when they became obstructed, otherwise there just isn't air to push out. We've had more than a few kids who started to breath in when a balloon popped and obstructed their airway without a significant amount of air in their lungs, in Japan we had an issue with kids sucking down these jello cup things that were just the right size to fit in and then obstruct the trachea. 

At a certain point the only options is direct visualization, trying to right mainstem whatever it is, or place a surgical airway. Surgical airways are a bloody mess, even when done right in a controlled setting, and are far from my preference. I have never had to actually perform one in the field, and we've never had to do one in the ED, but we have come close. Keep your skills up and start opening your cric kit to scare away the bad luck.


----------



## michael150 (Apr 11, 2018)

VentMonkey said:


> Interestingly enough, I was listening to this past quarters Airway World webcast earlier. It’s pretty rare, however, current literature seems to advocate for surgical cric for apparent reasons.
> 
> It was actually a pretty insightful webinar and focused on 3-4 prehospital related airway papers, but it was also quite lengthy.



I completely agree with the uses that it has in EMS and that we should all stay current on being confident in that skill. Is that webinar available for free somewhere? That would be great to listen to and read literature on it. As EMS evolves, I think it’s interesting to look at what data points to (i.e. should we ETT or just put in a supraglottic).


----------



## VentMonkey (Apr 11, 2018)

michael150 said:


> Is that webinar available for free somewhere?


http://www.airwayworld.com/webinars/


----------



## StCEMT (Apr 12, 2018)

michael150 said:


> I would be interested to see how many medics have actually done a surgical or needle cric in the field... Would we actually be prepared for it?


One medic here did one a year or so ago. I came close last winter and that pt eventually did get one. The level 1 that happened at does a handful each year from what I understand. Definitely rare as a whole, but they do pop up here from time to time.


----------



## michael150 (Apr 12, 2018)

StCEMT said:


> One medic here did one a year or so ago. I came close last winter and that pt eventually did get one. The level 1 that happened at does a handful each year from what I understand. Definitely rare as a whole, but they do pop up here from time to time.



May I ask where that is?


----------



## StCEMT (Apr 12, 2018)

michael150 said:


> May I ask where that is?


Richmond, Virginia. Busy city with outside counties coming in to the level 1. We also did a transfer for a botched croc from a small community hospital to the level 1, so I know of at least 3 within the last year here, not all done by EMS.


----------



## CityEMT212 (Jun 19, 2018)

Mike97 said:


> Student here.  I’ve got a question on a patient with an obstructed airway that is unconscious.
> 
> The books say if the patient goes unconscious to give chest compressions.  But, what if they are not pulseless?  Would you start compressions regardless as an attempt to clear the obstruction?



Hi Mike,

We just talked about this in my EMT-B class yesterday since it was a CPR Course. My answer to you would be yes, still do compressions. The compressions would clear the airway and possible remove the obstruction. Also we discussed the order for an Unconsciouss patient is the A,B,C format, but if a patient "appears dead" (which was hotly debated in the class yesterday, then the format would then be C,A,B.

Hope I (somewhat) helped.

~ Estrella


----------



## phideux (Sep 2, 2018)

michael150 said:


> I would be interested to see how many medics have actually done a surgical or needle cric in the field... Would we actually be prepared for it?


Last week we had a cardiac arrest due to anaphylaxis. We get on-scene and this guy is so swollen that his eyes are bugging out and his tongue is about 3" out of his mouth. Very weak bradycardic pulse. We hit him with his Epi pen, plus another .5mg and started CPR. Drilled him and started with the normal ACLS stuff. No compliance with bagging, 2 other medics tried tubing him but couldn't get a blade and tube in his mouth. Got him in the ambulance and we break out the CricKit. We got it done, It was a bloody mess, which helped a little, we followed the bubbles in with the tube. It worked, the doc said it was a bold move, but it was too little, too late. It is actually not a hard procedure to do, 2 cuts, grab the Trachea with the hook, stick in the tube, inflate and go.


----------



## SpecialK (Sep 2, 2018)

I'd say because it's a pragmatic way to get some quasi-abdominal thrusts in.  

However, rather than bugger around with muppetry, it would be much more effective to just use a disposable laryngoscope and forceps to remove the obstruction.  There have been several cases where this has been used successfully and I believe it's now common to all services in Australasia.


----------



## VFlutter (Sep 2, 2018)

phideux said:


> the doc said it was a bold move, but it was too little, too late. It is actually not a hard procedure to do, 2 cuts, grab the Trachea with the hook, stick in the tube, inflate and go.



I am not sure I would consider it a "bold move" since it was clearly indicated. Most say that the biggest mistake when doing a surgical airway is waiting too long. The decision to cut is the hardest part but really shouldn't be. If they need it, do it.


----------



## RocketMedic (Sep 2, 2018)

Airway sucks and can't plausibly see? Cut to air!


----------



## StCEMT (Sep 2, 2018)

That bad of an airway, cric would probably get done before epi. No warm fuzzies there either way.


----------



## Bill (Oct 1, 2018)

Just be sure you know the landmarks to locate the cricothyroid membrane. In males usually easy because of the prominence of the thyroid cartilage. In most cases, however, you can palpate the location.


----------



## Gurby (Oct 1, 2018)

I got to do one on a cadaver and it was surprisingly easy.  I feel like as long as you stay midline you probably can't really screw it up too badly.  If you hit the thyroid cartilage just move down a bit and keep trying.


----------



## CANMAN (Oct 7, 2018)

I have been fortunate, or I guess unfortunate enough to have 2 surgical airways under my belt. One medical scenario and one trauma, performed with a different technique each time with the second one being dictated by my medical director's (at the time) preferred method. Honestly, there is some blood, but it's not a blood bath as some make it out to be. As long as you stay midline and away from the vascular structures that run parallel to midline you're all good. An open surgical airway is a procedure that is done all by feel, or at least should be, so blood obscuring your visualization shouldn't be a worrying factor. As stated here the biggest difficulty is just mentally committing to the procedure itself. Once executed it's an easy day, you have likely just saved a life, and the minor bleeding is easily controlled with 4x4's cut into trach sponges with scissors. Hold them in place as you hold the tube for the duration of the transport. 

Given a known airway obstruction in the unconscious patient, that I can't visualize using DL and remove with Magill forceps or dislodge with CPR, I'm absolutely resorting to a surgical airway as a last ditch otherwise the patient is priority 4.


----------



## medichopeful (Oct 7, 2018)

CANMAN said:


> Given a known airway obstruction in the unconscious patient, that I can't visualize using DL and remove with Magill forceps or dislodge with CPR, I'm absolutely resorting to a surgical airway as a last ditch otherwise the patient is priority 4.



^This.  Our protocol is 1 attempt at intubation -> 1 attempt with Magills -> surgical crich.


----------



## RocketMedic (Oct 8, 2018)

No one should suffocate without a hole in their throats


----------



## Rommel (Oct 12, 2018)

SpecialK said:


> I'd say because it's a pragmatic way to get some quasi-abdominal thrusts in.
> 
> However, rather than bugger around with muppetry, it would be much more effective to just use a disposable laryngoscope and forceps to remove the obstruction.  There have been several cases where this has been used successfully and I believe it's now common to all services in Australasia.



Yes, Australia (and I believe NZ) uses back blows and or chest thrusts to dislodge. If pt is unconscious a laryngoscope and forceps are used to remove obstruction. Given the relative size of the glottis it is assumed that a body small enough to be sucked through will likely be small enough to be blown down the 4" of trachea to allow access to at least one side of the lung or allow air to flow by the obstruction lodged within the trachea. You run into problems if these assumptions are incorrect or clumsy use of forceps forces the body (or part of it) through the glottis and into the upper trachea making it very difficult (or impossible) to get a purchase on. The BVM allows a degree of high pressure to move the body in worst case scenario but is not without obvious secondary risks to airway via barotrauma and aspiration of stomach contents post possible aggressive ventilation. 

I think maybe cric has a place if vocal cords are unable to be visualised and therefore no sight of the obstructive body was possible. What I don't like about the Australian protocol is that there is a risk that the body, which may otherwise be removed with dextorous use of forceps, may be shifted through the vocal cords if one resorts to the BVM too quickly. But that is the world we live and work in. Thankfully I have not had to make this decision... yet. 

Airway world was informative, thanks guys!


----------



## ZootownMedic (Nov 16, 2018)

I’ve been a paramedic 7 years and did my first one last year. 17 year old kid hit by a drunk driver and was sitting upright in the car trapped. Unconscious, unresponsive, agonal respirations, blood pooling in his airway. I tried to ice axe him to intubate him but couldn’t control the head and was half in the car half out. Ended up cric’ing him on the side of the road and doing bilateral needle decompressions. By the time we got him extricated he was a full arrest and we ended up calling him. Sad case.


----------



## Bill (Nov 16, 2018)

Wow! That's a tough case, especially since you also have to assume a c-spine injury in play as well. Can't use a hard c-collar if you also have to do a cricothyrotomy. Somehow you have to still stabilize the head during the whole process. Sometimes you are faced with a no-win situation but you did the best you could! Agree challenging and sad case.


----------



## Tigger (Nov 17, 2018)

I think concerns for c-spine precautions are a bit misplaced in the setting of a surgical airway attempt.


----------



## DesertMedic66 (Nov 17, 2018)

Bill said:


> Wow! That's a tough case, especially since you also have to assume a c-spine injury in play as well. Can't use a hard c-collar if you also have to do a cricothyrotomy. Somehow you have to still stabilize the head during the whole process. Sometimes you are faced with a no-win situation but you did the best you could! Agree challenging and sad case.


Pop the collar off and say “hey bro, hold his head still for me”


----------



## VFlutter (Nov 17, 2018)

KED and strap the head down? I rarely ever pop a C-collar when I intubate unless I have difficulty getting a view. Usually not as issue.


----------



## Bill (Nov 17, 2018)

You always have to assume the worse until proven otherwise. If you don't take measures to protect the c-spine in a trauma patient, even when attempting to obtain an airway, you run the risk of having a breathing patient who is now a paraplegic. Attorneys would be gnawing at the bit for that case. You do the best you can under the circumstances.


----------



## VFlutter (Nov 17, 2018)

We are a very litigious society but are there any actual cases of this. Most SCI happen at the time of injury, few are the result of negligence after the fact. Pretty easy to defend when lack of airway clearly leads to death vs possible contribution to disability from lack of c-spine precautions which have little evidence to support in the first place.


----------



## Tigger (Nov 17, 2018)

Bill said:


> You always have to assume the worse until proven otherwise. If you don't take measures to protect the c-spine in a trauma patient, even when attempting to obtain an airway, you run the risk of having a breathing patient who is now a paraplegic. Attorneys would be gnawing at the bit for that case. You do the best you can under the circumstances.


The spine is not made of glass. There is little if any evidence to suggest that the forces placed on the c-spine by manual movement can worsen an injury. There is a reason we don't do standing take downs and whatnot anymore. Airway takes precedence. If you can stabilize the spine at the same time, but that is not always possible, nor expected.

Also saying that attorneys will be "gnawing at the bit" is a bit histrionic. Have case law to support that statement?


----------



## Bill (Nov 18, 2018)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660300/


----------



## Bill (Nov 18, 2018)

All of us want to do what's in a patient's best interest. Control / maintenance of airway and c-spine precautions in the high risk patient ae not mutually exclusive but sort of go hand-in-hand. Certainly can be extremely challenging but we give it our best shot. Attached is a link to a helpful ATLS Teaching Guide (hope it works):www.disaster.org.tw/er119dropbox/lectures/*atls*_ettc/con*atls*.doc


----------

