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Sdiver
11-14-2014, 17:33
Alright, let's get these scenarios back up and running ....


You respond on a respiratory emergency and find a patient unresponsive at a local restaurant. Bystanders are performing CPR.

They report to you that the patient started choking and attempts at the Heimlich were unsuccessful.

The patient has extremely labored, shallow, stridorous agonal respirations. He is cyanotic. There is a palpable carotid pulse. It is extremely difficult to ventilate the patient via BVM.

You grab a laryngoscope, visualize the cords, and see the following ...

What are your next steps in patient care and stabilization?


Other thoughts/considerations?

NurseTim
11-15-2014, 04:42
If you have a scope you likely have Mcgills as well. Latch on and remove. Failing that, continue to ventilate, you did say it was difficult, not impossible. Failing that, needle cric.

miclo18d
11-15-2014, 11:09
^^^ this plus O2.

Trapper John
11-15-2014, 16:29
Do I have a cricothyrotomy kit? If not I improvise. Use the oropharyngeal airway to support the opening and pass O2 through a cannula. Transport to the hospital for extraction of the foreign body or surgical repair of the trachea as the case may be.

Stephens
11-16-2014, 14:10
I just want to say that some of you exhibit better clinical reasoning than more than a few Nurse Anesthetists, Anesthesiologists, PAs and ICU docs I've seen attempt airway rescue.

I won't say what I would do as it has already been posted (twice). :)

ETA: Also, remember, at this point you have a free hand to feel the anterior neck and possibly improve your view while also assessing.

Sdiver
11-16-2014, 16:04
I'm still wondering about level of training.

Current level of training is what YOU are currently at ... EMT Basic, Advanced, Paramedic, RN, PA, MD, etc ....

Take the scenario for what it's worth.

"YOU respond on a respiratory emergency and find a patient unresponsive at a local restaurant." ... meaning that you are on a first response vehicle, with the appropriate ALS stocked bag(s).

The fact that YOU "grab a laryngoscope, visualize the cords ..." tells that this is an advanced airway procedure, so this would RO Basics and Advanced EMTs.

Don't READ into the post or the picture too much. This scenario is very much seen and any subsequent Tx is within the scope of first-responders (Paramedics and above).

Yes, knowing what the Pt. was eating is good to know, but looking at the picture and given that there is some, although minimal, air movement, it very well could be an undercooked piece of elbow macaroni.

Not only did I post this for training purposes, but in a situation like this, there are inevitably two camps as for initial treatment.

.... and GO.

MR2
11-16-2014, 17:58
Does he have a nice watch? Is there any unattended lobster or filet mignon?

Sdiver
11-16-2014, 18:09
Does he have a nice watch? Is there any unattended lobster or filet mignon?

Tsk, tsk, tsk ... He's only MOSTLY dead, he's NOT all dead.

Trapper John
11-16-2014, 18:51
Does he have a nice watch? Is there any unattended lobster or filet mignon?

You funny Petason! :D

Brush Okie
11-16-2014, 18:51
What does his date look like? Is she hot?

RichL025
11-16-2014, 21:20
Knife, please....

ie - he is already cyanotic and cannot ventilate with a BVM. He needs a surgical airway.

PedOncoDoc
11-17-2014, 06:45
Knife, please....

ie - he is already cyanotic and cannot ventilate with a BVM. He needs a surgical airway.

I agree with RichL. I'm surprised there aren't more secretions with that obstruction - it's likely also obstructing the esophagus with how rigid it appears.

CSB
11-17-2014, 12:01
Looks like half of a fortune cookie lodged in there.
Agree I'd grab it ASAP, before it softens up and drops into the trachea / lungs.

Koldsteel
12-06-2014, 21:26
Im coming to this conversation late. But as a CRNA and an old street medic, I would remove the obstruction with the Magils and admin O2. Ive had this exact scenario once before.

NurseTim
12-07-2014, 10:49
I'd attempt to remove it via suction. Should that work, I'd go for my second attempt at combitube insertion.

Why would you intubate after removal? Possible airway edema secondary to trauma?

Koldsteel
12-15-2014, 21:58
Why would you intubate after removal? Possible airway edema secondary to trauma?

Airway edema is surely possible and if the obstruction is complete, negative pressure pulmonary edema is possible. If the patient is tolerating my laryngoscope then he will tolerate the ETT. I can always extubate later.

Damocles
07-07-2015, 09:42
Based on my current level of training (EMT-B): Obtain an initial oxygen saturation level and closely monitor O2 sat throughout treatment and transport. Administer 15 lpm O2 via BVM, rapid transport. Depending on ETA to more advanced emergent care, request ALS intercept en route.

If we're a significant distance from an ER, I would guess we're looking at an emergency cric. This is beyond my scope of practice, thus the request for ALS intercept. That being said, if I'm driving an ALS unit with a medic in the back, he/she's probably already performed the procedure and we're running lights and sirens with liberal application of diesel.

Edit: Sorry guys, just realized the age of this thread. Didn't mean to resurrect it. Hope these scenarios continue, fun times.

Red Flag 1
07-07-2015, 15:56
Im coming to this conversation late. But as a CRNA and an old street medic, I would remove the obstruction with the Magils and admin O2. Ive had this exact scenario once before.

I agree with ^^^^. Looks like a Tortaline, or something that would be worn on a finger. Have suction at hand, and remove the object with Magills, or Bayonet forceps. Cords are open, so intubate in the usual fashion, inflate the ETT cuff, check for breath sounds, etc. Perhaps something systemic to reduce tissue swelling that is sure to present later on.

If you can't remove the obstruction, secure an airway with Cricothyrotomy. Ventilate via cric, and transport. Resist the temptation to remove the object, leave that to the ER/ENT docs at the end of the ride.

doctom54
07-07-2015, 16:51
If Magills available then 1 attempt to remove. If successful then attempt to ventilate.
If unsuccessful removing then Cric

Mean Bone
07-24-2015, 14:57
First some observations:

1 - Not a typical laryngoscope view. Looks more like what one would see with a bronchoscope in the OR. And . . . it's upside down.

2 - Is this a pediatric AW? The narrowest part of a child's AW is below the cords, just like the picture. If that is indeed macaroni, look at its size in relation to the glottic opening. The opening is not much bigger than the macaroni.

Well, just some observations. Now to the scenario of the adult.

- Unresponsive, but struggling to breath
- Cyanotic
- Foreign body visible with laryngoscope

My initial reaction would be grab the McGills and promptly remove . . . if possible! If it is well cooked it may come out in pieces, or just get pushed further down. I would not spend a lot of time with the forceps if unsuccessful. This tissue is very friable. The scenario could easily turn into cyanotic, unresponsive patient with FB obscured by blood.

No luck with the forceps? Intubate, push the obstruction into the right main stem and ventilate one lung. Bring an alive patient to the ED and let the ENT doc bronch the patient in the OR.

Cric? You're trying to open an AW right at the FB. It may very well be that once the AW is surgically opened you could push the FB cephalid and open an AW below. Then, again . . . maybe not. It's a small opening and hard to visualize. If you're successful you'll look like a hero.

Tough call . . .