Foreign Body Airway Obstruction (Choking)

Respiratory emergencies, whether caused by a foreign body airway obstruction or as a result of illness or injury to any part of the respiratory system, are extremely distressful for the patient.

CAUSES OF OBSTRUCTIONS

• Tongue ‑ unconsciousness results in base of the tongue falling back obstructing the airway.
• Foreign Objects ‑ food, toys, dentures.
• Tissue Damage ‑ burns, swelling.
• Illness.

SIGNS AND SYMPTOMS

Partial Blockage

• Not a full expansion of the chest wall
• Sounds during exhaling (whistling)
• Cyanosis

Total Blockage

• No chest movement
• No audible sounds
• Unconsciousness
• Cyanosis

Other Signs

• The person desperately grabs at their neck
• The person cannot speak or cry out
• The person's face turns blue from lack of oxygen

Conscious Choking Adult and Child

ALGORITHM FOR CHOKING – CONSCIOUS PATIENT

Stand behind the victim, encircle his waist with your arms, place the thumb side of your fist above the navel but below the rib cage — with the other hand over it — give a sharp upward thrust. If the stuck object doesn’t pop out, repeat the manoeuvre until it does

ABDOMINAL THRUST

• Stand behind patient and wrap your arms around his / her waist. A two-finger width above the navel is the thrust site. Ball your fist, placing flat side on the thrust site.  Place your other hand on top of fist.
• Perform quick inward and upward thrust.

Abdominal thrusts are only used on conscious adult or child victims with severe airway obstructions. Before attempting abdominal thrusts, ask the victim "Are you choking?" If the victim can reply verbally, you should not interfere, but encourage the victim to cough.

If the victim's airway obstruction is severe, then perform abdominal thrusts:

•         The rescuer stands behind and to the side of the victim and wraps their arms around the victim's sides, underneath the victim's arms

•         One hand is made into a fist and placed, thumb side in, flat against the victim's upper abdomen, below the ribs but above the navel

•         The other hand grabs the fist and directs it in a series of upward thrusts until the object obstructing the airway is expelled

•         The thrusts should not compress or restrict the ribcage in any way.

•         If you're not able to compress the victim's diaphragm due to their size or pregnancy, then perform the thrusts at the chest.

CHEST THRUSTS

• Chest thrusts are used on pregnant or obese patients.
• Apply compression to breastbone.

If you know the patient is choking

• The victim is on the floor, already unconscious from oxygen deprivation.

Roll the person on his back, face up, kneel astride his hips, place the heel of one hand between the navel and rib cage, put the other hand over it and press quickly with an upward thrust. Repeat the manoeuvre until the “plug” is expelled.

• You are alone and choking.

Use your own fist and the other hand for the inward-upward jab, or press your abdomen quickly and forcefully into a rounded corner of a table or sink, or the back of a chair. Almost any blunt object that provides pressure under the breastbone will cause the lungs to expel an obstruction.

•  The victim is an infant under one year of age.

For infants, a severe obstruction may be accompanied by a high-pitched, crow-like sound which is not present in adults or children.  This is due to the incomplete formation of the infant's airway.

While the standard Heimlich manoeuvre can be used on older children, special care is necessary in dealing with babies. Place the child face up on your lap or on a firm surface, or sit him on your lap facing away from you.

Make a “pad” out of the index and middle fingers of both your hands and position it just under the rib cage. Then, with a quick but gentle motion, apply the important inward-upward thrust.

Rescue Breathing

Rescue breathing is the process where a first aider breathes air into a patient. When we inhale, we breathe approximately 21 % oxygen from the atmosphere. Normally we use about 5 % of that oxygen in respiration. When we exhale, 16 % (the unused portion of oxygen) leaves through our airway. This unused portion can be used for rescue breathing on a patient who is unable to breathe on their own.

The brain can go without O₂ for approximately 4 ‑ 6 minutes before any permanent damage is done.

Rescue Breathing:

• Open and maintain the airway as described in the previous sections.
• Place the one-way valve or mask into or onto the patients mouth.
• The fingers that are used to open the airway and hold the forehead must be placed under the plastic or hold the mask into place.
• Pinch nose closed with thumb and index finger of hand on victim’s forehead.
• Inhale normally.
• The first aider then places his/her mouth OVER the one-way valve, and forms an airtight seal.
• Provide 2 rescue breath(s) to patient lasting 1 second.
• Watch the chest rise as you give breath.
• Let the chest deflate after you give breath.

Face Shields or Mask Use (Barriers)

First Aiders should always utilise a barrier to protect themselves while performing rescue breathing. The barrier allows a first aider to supply the needed air and protect themselves from any body fluids. Barriers should have a one-way valve to protect from breathing the patient’s exhaled air.

Compressions

The purpose of doing chest compressions is to effectively squeeze the heart inside the victim's chest, causing blood to flow. This allows the normal gaseous exchange between the lungs, bloodstream and  tissues to occur. Compressions are now usually performed before any rescue breaths due to the fact that when normal breathing and circulation stop, there is still a good amount of residual oxygen left in the bloodstream (as it has no way to exchange out of the body).

 Technique

The aim is always to compress in the center of the chest, regardless of the victim. This means that compressions are performed on the sternum or breastbone of the victim, approximately in line with the nipples on males and children.

For adults (>8) - place the palm of one hand in the centre of the chest, approximately between the nipple line (on adult males - for females, you may need to approximate the ideal position of this line due to variations in breast size and shape). Bring your other hand to rest on top of the first hand, and interlock your fingers. Bring your shoulders directly above your hands, keeping your arms straight. You should then push down firmly, depressing the chest to about one third (1/3) of its depth.

For children (1-8) - place the palm of one hand in the centre of the chest, approximately between the nipple line. Bring your shoulder directly above your hand, with your arm straight, and perform compressions to one third (1/3) the depth of the chest with one arm

only.

• For infants (<1yr) - Use your forefinger and middle finger only. Place your forefinger on the centre of the child's chest between the nipples, with your middle finger immediately below it on the chest, and push downwards using the strength in your arm, compressing the chest about one third (1/3) of it's depth. 

Give 30 compressions in a row, and then two (2) rescue breaths.

Then restart your next cycle of compressions

 

Making compressions effective

You MUST allow the ribs to come all the way back out after each compression, followed by a brief pause. This allows the heart's chambers to refill. Spacing compressions too close together will lead to them being ineffective.

You are aiming for a rate of 100 compressions per minute, which includes the time to give rescue breaths. In practice, you should get just over 2 cycles of 30 compressions in along with breaths per minute.

Almost everyone compresses the chest too fast - Experience shows that even well trained first aiders tend to compress the heart too fast. The rate you are aiming for is only a little over one per second. The best equipped first aid kits should include a Metronome with an audible 'beep' to match your speed to. Many public access defibrillators have these included in their pack. If one is not available, count the number of compressions with the word 'and' between them. When you press down on the chest, say the number, when the chest rises say 'and'. this way, you will be saying 'one-and-two-and-three...'

Keep your arms straight - A lot of television and films show actors 'performing CPR' bending their elbows. This is not correct - you should always keep your arms straight, with your elbows locked and directly above your hands.

It often helps to count out loud - You need to try and get 30 compressions per cycle, and it helps to count this out loud or under your breath. Performing compressions is tiring, and you may not be able to count out loud for the duration, but ensure you keep counting.

If you lose count, don't stop, just estimate - It is important to carry on once you've started, so if you lose count, don't panic, and simply estimate when 30 compressions is over, and do 2 breaths, then start over counting again.

You are likely to break ribs - When performed correctly, especially on older people, compressions are more likely than not to break ribs or the sternum itself. You should carry on regardless of this occurring. It is a sign that you are performing good, strong compressions. Oftentimes the cracking sound you will hear is just the cartilage of the ribs and sternum breaking, and not the bones themselves. If bystanders are concerned about injury to the victim, you may want to remind them of the life over limb principle and assure them that it is normal to hear these sounds.

Deadly Bleeding

 

CPR without enough blood is useless, so a check for deadly bleeding should be included in your primary survey whenever possible.

 If your victim is breathing, then you should continue your primary assessment with a check for deadly bleeding.

If your victim isn't breathing, then you'll be doing CPR; a bystander or second trained first aider may be able to perform this check while you continue resuscitation.

Assessment

With gloved hands check the victim's entire body for bleeding, starting with the head. Run your hands as far under the victim as possible on either sides, checking your gloves often. If your hands are bloody, then you've found bleeding. Make sure you check the head carefully; if you find an injury on the head or neck, it may indicate a spinal injury, in which case, the spine should be immobilized. As well, hair conceals blood surprisingly well - make sure you check the scalp thoroughly.

 Remember that about 80% of life-threatening bleeding can be controlled adequately using direct pressure alone and the application of a tourniquet may result in the loss of the limb.

Treatment

 The key element in treating severe bleeding is the application of firm, direct pressure to the wound, using sterile gauze or other dressing. The wound may be elevated above the heart to reduce blood pressure, though this should not be done if there is a risk of disturbing fractures, or if it causes much pain to the victim.

 Consider using pressure points to control major bleeding: press down on an artery that is between the heart and the wound to keep blood from flowing to the wound. Tourniquets may also be useful in controlling massive bleeding; this is not a standard procedure and should only be used as a last resort when the victim will die without it.