Tag Archive | "bag-valve-mask ventilations"

Direct Laryngoscopy Improves Choking Child’s Outcome

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From left: Jersey City (N.J.) Firefighter Pedro Reyes, Jersey City Medical Center EMT Dispatcher Jennifer Pedone, EMS Supervisor William Bayer and EMT Joseph Biggy, Fire Captain Albert Bauer, 5-year-old Priscilla Pereira, paramedics Brian Moriarty and James High, and firefighter Nelson Justino. Photo James Woods

Editor’s Note: Below are two pediatric choking cases. Read about each and then read JEMS Editor-in-Chief A.J. Heightman’s comments and suggestions on why they had different outcomes and how EMS providers can keep their pediatric airway skills sharp.

Grape Obstructs 5-Year-Old’s Airway
By Steven A. Cohen, BS, NREMT-P
JERSEY CITY, N.J. — At a backyard barbeque on July 10, 5-year-old Priscilla Pereira was buzzing around, singing songs and eating grapes when she began to choke. Priscilla’s mother, Ivelisse, saw her child turn purple and go limp. The mother told CBS news, “Honestly she was already gone. She was like gone…she was gone”.

A family friend, who is a nurse, was at the barbeque and tried to do the Heimlich maneuver to no avail. Another friend called 9-1-1 for assistance. The 9-1-1 call was received in the HUDCEN (Hudson County Emergency Network), Jersey City Medical Center’s EMS Dispatch Center. EMT Dispatcher Jennifer Pedone screened and prioritized the call while ensuring that the Heimlich Maneuver was being performed.

The first unit on the scene was a first responder engine from the Jersey City Fire Department, led by Capt. Albert Bauer; this first-in crew also found the child cyanotic and unresponsive. Using a bag-valve mask (BVM), firefighters Pedro Reyes and Nelson Justino were able to get a minimal amount of air into the small patient. It was just enough to keep her oxygenated and improve her color.

Shortly after the fire first responders arrived, a Jersey City Medical Center (JCMC) BLS unit manned by EMS Supervisor William Bayer and EMT Joseph Biggy arrived. They inserted an oral airway and continued BVM ventilations. They too were able to maintain the patient’s color and pulse.

JCMC’s ALS unit, staffed by paramedics Brian Moriarty and James High, then arrived on the scene. During direct laryngoscopy, paramedic Moriarty was able to visualize a grape lodged in Priscilla’s trachea and dislodged it with a pediatric Magill forceps. High was then able clear the grape from the airway with a finger sweep.

Paramedics Brian Moriarty and James High demonstrate how they removed a grape from a pediatric patient’s blocked airway.

Once the airway was cleared, and after a short round of BVM ventilations, Priscilla began to arouse and cry for her mother. This was the best sound that the paramedics said they had ever heard. In order to comfort Priscilla, the EMS crew gave her a teddy bear that’s kept on the ambulances for such occasions. She clutched it close to her throughout the short trip to JCMC. On arrival at the hospital, the child was given a thorough examination, mother and daughter were reunited, and Priscilla was discharged to the care and follow-up observation of her mother.

On Aug.10, 30 days after her choking incident, Priscilla got a chance to meet the team of rescuers that saved her life during a press conference at JCMC. The survivor showed no residual signs of the trauma she endured a month earlier, singing for the camera crews and high fiving her rescuers.
This is a story where all of the links of the chain of survival working as planned. There was early access with bystander intervention, rapid fire first response and intervention, solid BLS care and advanced care by a well-trained team of paramedics.

Related Link
Channel 2 WCBS News Story

Steven A. Cohen, BS, NREMT-P, is assistant director of EMS for the Jersey City (N.J.) Medical Center Department of Emergency Medical Services Office.

In many cases, a lodged foreign body such as a pushpin, can completely occlude a pediatric airway. Photo A.J. Heightman

Pushpin Obstructs 3-Year-Old’s Airway
OCEANSIDE, Calif. — A 3-year-old preschool student choked to death after swallowing a pushpin at the Montessori School of Oceanside, county officials said. Tyler Howell of Oceanside died Monday afternoon of asphyxiation due to airway obstruction, according to the San Diego County Medical Examiner’s Office.

His teacher told authorities that shortly before 1 p.m., the boy made a gasping sound, grabbed his neck and passed out, becoming unresponsive.

A bystander performed cardiopulmonary resuscitation while paramedics were summoned to the preschool at 3525 Cannon Road, the medical examiner’s Office reported. Paramedics took the boy to Tri-City Medical Center, where he died at 1:50 p.m.

Related Link
Fox 5 News Story

Editor A.J. Heightman comments: These two pediatric choking cases had completely opposite outcomes but a common genesis. Small children, particularly those under the age of five, have a habit of putting small objects in their mouth. In the Jersey City case, the fire first responders and EMT crew were both able to ventilate the 5-year-old child until the ALS crew arrived and used direct laryngoscopy and a pediatric Magill forceps to dislodged the grape which had “plugged” the airway like a rubber stopper in a sink.

A McGill forceps with a grape clasped in it simulates the obstacle that was removed from Priscilla’s blocked airway. Photo JEMS

In the Oceanside case, the object that caused the 3-year-old to choke to death was a pushpin, a common item in schools throughout the world. A pushpin is extremely dangerous if inhaled or ingested because it has a needle-like tip on one end that is a hazard in and of itself. If inhaled into the tiny airway of a young child, it can anchor itself in an unusual position, making it extremely difficult or impossible to dislodge. This is particularly true if it advances past the vocal cord region where it can no longer be visualized. In many cases, a lodged foreign body such as a push pin, can completely occlude the airway.

Both of these cases point out why EMS personnel need to stay current in their airway skills, carry adult and pediatric Magill forceps in their first-in airway bags and bring suction in with them on all airway calls.

In addition, crews need to understand, for their own emotional wellbeing, that there are often young children that get into impossible circumstances and can’t be resuscitated. It’s the nature of our work and a part of EMS that we all hate. But it’s critical that crews understand and accept the fact that, despite their best efforts, young patients are going to die.

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Airway Algorithms

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Airway Management AlgorithmIn my last EMS Airway Clinic article, “How to Make the Difficult Airway Less Difficult,” we looked at situations that can make airway management difficult; one of those situations was not having a strategy. Today, I’ll share with you the airway algorithm that has helped me over the years, and I want to give you some tips for building your own algorithm.

As professionals, we should know our protocols. We should be able to deliver quality patient care without looking up the details. I believe these ambitions, but folks, I’m just not one of those medics who remembers every nook and cranny of the protocol book. My worst example is the Glasgow Coma Scale. What a great tool to objectively record the conscious state of a patient. Let’s see, I know that if I’m dead for two weeks, I get a three, and I’m a 13 or a 14 when I get up in the morning. Otherwise, I’ve got to either look it up or use a memory aid, such as an algorithm.

An algorithm is “a step by step procedure for solving a problem.”(1) Medical algorithms help us deliver better patient care. They standardize treatment therapies, so we collectively deliver similar care in similar situations. They help us successfully navigate low-incidence, high-consequence incidents. They reduce medical errors. In EMS, we typically use two types of algorithms: flowcharts and checklists.

Flow charts guide us through a series of “if-then” situations that help us respond quickly and effectively in critical situations; if the patient is in ventricular fibrillation, then defibrillate them. A checklist is a memory aid to make sure we don’t forget something, especially in a situation that we don’t face regularly. A checklist for rapid sequence intubation (RSI) helps us remember to check patients for all contraindications.

I’ve found several characteristics that are commonly found in good emergency airway management algorithms. First and foremost, the algorithm must be based on your world—your patient population, distance to hospitals, available equipment and staff, as well as your own training, experience and confidence. It’s convenient to borrow an algorithm, but it won’t work if it doesn’t fit your operational environment. Using a hospital-based airway algorithm just doesn’t work in the parking lot of the Piggly Wiggly. A second feature of a good algorithm is comfort. If it’s awkward and unfamiliar, then you won’t use it well if at all. You make it comfortable by practicing and making adjustments. Finally, a good algorithm has to be systematic. It must logically and easily flow from one step to the next.

My Algorithm
I’ve used my current airway algorithm for about 15 years. Now, I didn’t just sit down at the kitchen table one morning and put it on paper. I started out using someone else’s algorithm, and then I gradually changed it to fit my needs. My algorithm will always be a work in progress. When I started, I didn’t consider video laryngoscopy or a bougie. Now, they both sit in a place of prominence.

Every patient receives oxygen at every possible moment. Do everything you can to wash out all of the nitrogen in the patient’s lungs and replace it with oxygen. A hyper-oxygenated patient will tolerate short periods of apnea better than a patient with low oxygenation.

Every EMS provider must be proficient at bag-valve-mask (BVM) ventilation. I think BVM ventilation is so important that it’s mentioned six times in my algorithm. I start with BVM to get a feel for compliance and how well the patient responds. Some folks do quite well with a little oxygen, an oral airway and gentle BVM ventilation. If my attempts at laryngoscopy or an alternative airway are unsuccessful, I reach right for the BVM.

Should we intubate?

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I’ve found that more than two attempts at laryngoscopy is usually a waste of a patient’s precious time because chances of success decrease with each attempt. I prepare to successfully place an endotracheal tube on my first attempt. I do everything to make my first attempt my best attempt. I have a second laryngoscopy attempt in the algorithm as an opportunity to make a course correction if I encounter an unanticipated condition, a technique or equipment failure, or I fail to prepare well enough.

I used to have supra-glottic airway placement as steps five and six in the algorithm until a colleague pointed out his success with nasal-tracheal intubation and digital intubation. Out of respect for Steve, I’ve changed these steps to use of an alternative airway. Similar to my experiences with multiple attempts at laryngoscopy, I’ve found that more than two attempts with an alternative airway become futile and detrimental to the patient. If you displace the tongue sufficiently and use adequate lubricant, first-pass success is likely. I’ve included a second attempt in the algorithm to give myself the opportunity to address an unexpected condition or a misstep in my preparation.

Step seven is our familiar friend, BVM ventilation and a quick ride to the hospital.

How long should you spend on each intubation attempt? Wow, that’s a loaded question. I wish I could give you a solid number backed up with a stack of studies, but I can’t. The time spent depends on the patient’s physiological condition, the level of difficulty you experience and your skill level. Many of us were taught to spend no more than 30seconds on an intubation attempt, and I think that’s a pretty safe number. From the moment you insert the blade into the patient’s mouth, it should take you about 10 seconds to locate the glottic structures, and then no more than another 10 seconds or so to place the tube, inflate the cuff and withdraw the stylette. The remaining 10 seconds are a pad for handling any surprises you might find.

I’d like to hear your thoughts on this. How much time do you think we should spend securing an airway?

Your Turn
Feel free to use this algorithm as template from which you build your own. A word of caution; an algorithm is one tool. It isn’t a replacement for sound clinical judgment. Please let me know how you fare in creating your own airway algorithm. In my next EMS Airway Clinic article, I’ll talk about some of the things you can do to improve your first pass success rate.

Be safe my friends.
Charlie

References
1. Merriam-Webster. www.m-m.com/dictionary/algorithm.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic.

For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police.

Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization.

Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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