Basic airway management
Basic airway management are a set of medical procedures preformed in order to prevent airway obstruction and thus ensuring an open pathway between a patient’s lungs and the outside world.
This is accomplished by clearing or preventing obstructions of airways, often referred to as choking, cause by the tongue, the airways them self, foreign bodies or materials from the body it self, such as blood or aspiration.
Contrary to advance airway management; minimal-invasive techniques does not rely on the use of medical equipment and can be performed without or with little training.
Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.
Treatment
Choking can be treated with a number of different procedures, with both basic techniques available for first aiders and more advanced techniques available for health professionals. In the United States, members of the public commonly assume that abdominal thrusts (or Heimlich maneuver) is the correct procedure for choking, due to widespread promotion of this technique in the past, including recommendations from the American Heart Association and the American Red Cross. People elsewhere also often assume this, due in part to widespread use of this technique in movies.[1]
Most modern protocols, including those of the American Heart Association and the American Red Cross, recommend several stages, designed to apply increasingly more pressure. The Red Cross changed their recommendation in 2006, ending their promotion of abdominal thrusts as the primary treatment for choking.[2]
The key stages in most modern protocols include:
Encouraging the victim to cough
This stage was introduced in many protocols as it was found that many people were too quick to undertake potentially dangerous interventions, such as abdominal thrusts, for items which could have been dislodged without intervention. Also, if the choking is caused by an irritating substance rather than an obstructing one, and if conscious, the patient should be allowed to drink water on their own to try to clear the throat. Since the airway is already closed, there is very little danger of water entering the lungs. Coughing is normal after most of the irritant has cleared, and at this point the patient will probably refuse any additional water for a short time.
Back blows
The majority of protocols now advocate the use of hard blows with the heel of the hand on the upper back of the victim. The number to be used varies by training organization, but is usually between five and twenty. For example, the Mayo Clinic recommends five blows between the shoulder blades.[3]
The back slap is designed to use percussion to create pressure behind the blockage, assisting the patient in dislodging the article. In some cases the physical vibration of the action may also be enough to cause movement of the article sufficient to allow clearance of the airway.
Almost all protocols give back slaps as a technique to be used before potentially damaging interventions such as abdominal thrusts.[4][5] Henry Heimlich, noted for promulgating abdominal thrusts, claimed that back slaps were proven to cause death by lodging foreign objects into the windpipe.[6] The 1982 Yale study by Day, DuBois, and Crelin that "persuaded the American Heart Association to stop recommending back blows for dealing with choking...was partially funded by Heimlich's own foundation."[7] According to Roger White MD of the Mayo Clinic and American Heart Association (AHA), "There was never any science here. Heimlich overpowered science all along the way with his slick tactics and intimidation, and everyone, including us at the AHA, caved in."[8]
Abdominal thrusts
Abdominal thrusts, also known as the Heimlich maneuver (after Henry Heimlich), can dislodge foreign bodies from the airway. (Heimlich has objected to the name "abdominal thrusts" on the grounds that the vagueness of the term "abdomen" could cause the rescuer to exert force at the wrong site.[9])
Performing abdominal thrusts involves a rescuer standing behind a patient and using his or her hands to exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on any object lodged in the trachea, hopefully expelling it. This amounts to an artificial cough. For example, WebMD recommends the rescuer placing his or her fist just above the person's bellybutton and grasping with other hand. To assist a larger person, more force may be needed.[10] The Mayo Clinic recommends the same placement of fist and hand and upward thrusts as if you are trying to lift the person. In addition, keep trying and alternate between five back blows, five abdominal thrusts, five back blows, and so on.[3]
Due to the forceful nature of the procedure, even when done correctly, it can injure the person on whom it is performed. Bruising to the abdomen is highly likely and more serious injuries can occur, including fracture of the xiphoid process or ribs.[11]
In some areas, such as Australia, authorities believe that there is not enough scientific evidence to support the use of abdominal thrusts and their use is not recommended in first aid. Instead, chest thrusts are recommended.[12]
Self treatment with abdominal thrusts
A person may also perform abdominal thrusts on himself by using a fixed object such as a railing or the back of a chair to apply pressure where a rescuer's hands would normally do so. As with other forms of the procedure, it is possible that internal injuries may result.
Chest thrusts
A modified version of the technique is sometimes taught for use with pregnant and/or obese patients. The rescuer places their hand in the center of the chest to compress, rather than in the abdomen. Due to the fact that the Heimlich maneuver can inflict numerous injuries, the government of Australia recommends chest compressions for all individuals, irrespective of size, instead of the Heimlich maneuver. These compressions are performed by applying pressure to the lower portion of the sternum in a manner which is quicker than the chest compressions done in CPR.[13] A study by the Norwegian Department of Research and Education in Acute Medicine demonstrated that chest compressions are more effective than the Heimlich maneuver.[14]
Finger sweeping
The American Medical Association advocates sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions, once the choking victim becomes unconscious.[15]
Some protocols advocate the use of the rescuer's finger to 'sweep' foreign objects away once they have reached the mouth.[citation needed] However, many modern protocols recommend against the use of the finger sweep since, if the patient is conscious, they will be able to remove the foreign object themselves, or if they are unconscious, the rescuer should simply place them in the recovery position as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea due to gravity. There is also a risk of causing further damage (for instance inducing vomiting) by using a finger sweep technique.
Prevention
Prevention techniques focuses on preventing the tongue from falling back and obstructing the airways, such as head-tilt chin-lift and jaw-thrust maneuvers, while use of the recovery position mainly prevents aspiration of things like stomach content or blood. If head-tilt chin-lift and jaw-thrust maneuvers are performed with any objects in the airways it may dislodge them further down the airways and thereby cause more blockage and harder removal.
Head-tilt chin-lift
The head-tilt chin-lift is the primary maneuver used in any patient in whom cervical spine injury is not a concern. The simplest way of ensuring an open airway in an unconscious patient is to use a head tilt chin lift technique, thereby lifting the tongue from the back of the throat. This is taught on most first aid courses as the standard way of clearing an airway.
Jaw-thrust maneuver
The jaw-thrust maneuver is an effective airway technique, particularly in the patient in whom cervical spine injury is a concern. The jaw thrust is a technique used on patients with a suspected spinal injury and is used on a supine patient. The practitioner uses their index and middle fingers to physically push the posterior (back) aspects of the mandible upwards while their thumbs push down on the chin to open the mouth. When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding (blocking) the entrance to the trachea, helping to ensure a patent (secure) airway.
The International Liaison Committee on Resuscitation no longer advocates use of the jaw thrust by lay rescuers,[16][failed verification] even for spinal-injured victims, although health care professionals still maintain the technique for specific applications. Instead, lay rescuers are advised to use the same head-tilt for all victims.
Recovery position
The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters prone position of the body, in to which an unconscious but breathing casualty can be placed. Use of the recovery position prevents aspiration.
Cervical spine immobilization
Most airway maneuvers are associated with some movement of the cervical spine.[17][18] Even though collars for holding the head in-line can cause problems maintaining an airway and maintaining a blood pressure,[19] it is unrecommended to remove the collar without adequate personnel to manually hold the head in place.[20]
References
- ^ "Girl, 7, saves mom's life with move she remembered from Mrs Doubtfire movie". Daily Mail. London. November 18, 2013.
- ^ "The American Red Cross Unveils Innovative New First Aid and CPR/AED Training Programs". American National Red Cross. April 4, 2006. Archived from the original on April 29, 2006.
- ^ a b Foreign object inhaled: First aid, Mayo Clinic staff, Nov. 1, 2011.
- ^ Guildner CW, Williams D, Subitch T (September 1976). "Airway obstructed by foreign material: the Heimlich maneuver". JACEP. 5 (9): 675–7. doi:10.1016/S0361-1124(76)80099-8. PMID 1018395.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Langhelle A, Sunde K, Wik L, Steen PA (April 2000). "Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction". Resuscitation. 44 (2): 105–8. doi:10.1016/S0300-9572(00)00161-1. PMID 10767497.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ "Heimlich, on the maneuver". New York Times. 2009-02-06. Retrieved 2009-02-07.
- ^ "Lifejackets on Ice (August 2005)" (PDF). University of Pittsburgh Medical School. Retrieved 2009-05-24.
- ^ Pamela Mills-Senn. "A New Maneuver (August 2005)". Cincinnati Magazine. Retrieved 2013-12-22.
- ^ John R. Fletemeyer, Sports Aid Intl Inc, Samuel James Freas (1998). Drowning: new perspectives on intervention and prevention. Informa Health Care. ISBN 978-1-57444-223-6.
{{cite book}}: CS1 maint: multiple names: authors list (link) - ^ Heimlich Maneuver for Adults and Children Older Than 1 Year - Topic Overview, WebMD, April 28, 2010.
- ^ Broomfield, James (2007-01-01). "Heimlich maneuver on self". Discovery Channel. Retrieved 2007-06-15.
- ^ "Australian(and New Zealand) Resuscitation Council Guideline 4 AIRWAY". Australian Resuscitation Council (2010). Retrieved 2014-02-09.
- ^ [1], Australian Resuscitation Council FAQ, August 14, 2012.
- ^ [2], Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. , April 2000.
- ^ American Medical Association (2009-05-05). American Medical Association Handbook of First Aid and Emergency Care. Random House. ISBN 978-1-4000-0712-7.
- ^ Part 2: Adult Basic Life Support - 112 (22 Supplement): III-5 - Circulation
- ^ Donaldson WF, Heil BV, Donaldson VP, Silvaggio VJ (1997). "The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study". Spine (Phila Pa 1976). 22 (11): 1215–8. doi:10.1097/00007632-199706010-00008. PMID 9201858.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F (2000). "Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers". Anesth Analg. 91 (5): 1274–8. doi:10.1213/00000539-200011000-00041. PMID 11049921.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Kolb JC, Summers RL, Galli RL (1999). "Cervical collar-induced changes in intracranial pressure". Am J Emerg Med. 17 (2): 135–7. doi:10.1016/S0735-6757(99)90044-X. PMID 10102310.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Mobbs RJ, Stoodley MA, Fuller J (2002). "Effect of cervical hard collar on intracranial pressure after head injury". ANZ J Surg. 72 (6): 389–91. doi:10.1046/j.1445-2197.2002.02462.x. PMID 12121154.
{{cite journal}}: CS1 maint: multiple names: authors list (link)
