Medical Scenario V

[Sdiver]

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?

[Mean Bone]

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 . . .

[NurseTim]

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]

^^^ this plus O2.

[Trapper John]

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]

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]

Originally Posted by DocIllinois

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.