Foreign Body Obstruction

It is important to recognize and be able to assist someone with an airway obstruction from a foreign body. The National Safety Council reported that approximately 2900 deaths from foreign body airway obstruction occurred in 1993.1 An individual in distress from a compromised airway is likely to use the universal sign for an airway obstruction, which is for the individual to grab his or her neck with both hands. Foreign bodies can cause partial or complete obstruction. With a partial airway obstruction, air exchange may be adequate or inadequate. If the victim is able to speak, cough, and exchange air, then he or she should be encouraged to continue spontaneous efforts. Assistance, such as activation of the local emergency medical services system, should be obtained. No interference should be made with the patient's attempts to cough or expel the foreign body. If air exchange becomes inadequate, indicated by increased difficulty breathing, weak and ineffective cough, worsening inspiratory stridor, or cyanosis, direct medical intervention should occur. Inadequate air exchange from either a severe partial or a complete airway obstruction should be managed the same. In an unconscious person, airway obstruction may be noted through inadequate airflow and poor chest rise on efforts to ventilate.

OBSTRUCTION-RELIEVING MANEUVERS Maneuvers used to relieve foreign body obstructions include the Heimlich maneuver (subdiaphragmatic abdominal thrusts), chest thrusts, and the finger sweep. As a single method, back blows are no longer recommended to relieve obstructions in adults. In a conscious individual, the Heimlich maneuver is the recommended maneuver in most adults for relieving airway obstruction from a solid object. It is not useful for liquids. In an unconscious individual suspected of having an aspirated foreign body, the recommended first step is the finger sweep. Otherwise, in an unconscious patient the recommended sequence is the Heimlich maneuver up to five times, open mouth and perform a finger sweep, and then attempt to ventilate. This sequence may be repeated as long as needed until the patient recovers or additional assistance arrives.

Heimlich Maneuver (Fig 8-5) Described by Dr. Heimlich in 1975, this maneuver creates an artificial cough through elevating the diaphragm and forcing air from the lungs.2 It may be repeated multiple times; each individual thrust should be performed with the intent to relieve the obstruction. It can be performed with the victim standing, sitting, or lying down, or it can be self-administered. To perform with the patient standing or sitting, the rescuer stands behind the patient and places the thumb side of a fist against the victim's abdomen midline just above the navel and well below the xiphoid process. Grasping the fist with the other hand, the rescuer presses the fist into the victim's abdomen with a quick upward thrust. This is repeated until the item is dislodged or the patient becomes unconscious. For an unconscious patient, the individual is placed supine on a firm surface with the rescuer sitting astride the victim's thighs ( Fig..,. ... 8-6). The heel of a hand is positioned midline just above the patient's umbilicus, and the second hand is placed directly on top of the first. The rescuer then delivers quick upward thrusts. To self-administer thrusts, the individual can either use his or her own fist to delivery the thrusts or lean against a firm object, such as a porch rail or back of a chair. Potential complications of the Heimlich maneuver include injury or rupture of abdominal or thoracic viscera or regurgitation of stomach contents.

FIG. 8-5. Standing Heimlich maneuver administered to conscious victim of foreign body airway obstruction.

FIG. 8-6. Prone Heimlich maneuver administered to unconscious victim of foreign body airway obstruction.

Chest Thrusts This maneuver is used primarily if someone is morbidly obese or in the late stages of pregnancy and the rescuer cannot reach around the patient's abdomen to perform abdominal thrusts (Fig, 8-7). To perform chest thrusts with the patient standing or sitting, the rescuer stands behind the patient and places the thumb side of a fist against the victim's sternum, avoiding the costal margins and the xiphoid process. Grasping the fist with the other hand, the rescuer presses the fist into the victim's chest with a quick backward thrust. This is repeated until the item is dislodged or the patient becomes unconscious. For an unconscious patient, the individual is placed supine on a firm surface with the rescuer kneeling close to the victim's side. The hands are placed in the same position as for chest compression, i.e., the lower sternum, and quick thrusts are delivered.

FIG. 8-7. Standing chest-thrust maneuver administered to conscious victim of foreign body airway obstruction.

Finger Sweep This maneuver is used only in unconscious patients ( Fig 8-8). Using the thumb and fingers of one hand, the rescuer grasps both the tongue and the mandible and lifts. This may partially relieve the obstruction by lifting the tongue away from the back of the throat. With the other hand, the rescuer then inserts his or her index finger into the back of the throat and uses a hooking action in an attempt to dislodge the foreign body to move it into the mouth for manual removal. Care must be used so as to not push the foreign object deeper into the throat.

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