Obstructed Airway Question

Gurby

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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

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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

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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

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No one should suffocate without a hole in their throats
 

Rommel

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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

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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

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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

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

DesertMedic66

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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

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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

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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

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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

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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

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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/conatls.doc
 
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