Management of Upper Airway Obstruction

INITIAL STABILIZATION

1. Airway

     - have a difficult airway tray at hand

• Complete Obstruction

            In the emergency Department setting manual man oeuvres (GE Heimlich man oeuvre) to relieve obstruction are not indicated as more definitive measures exist.

            Initially, use basic airway opening measures and attempt ventilation via bag valve mask attached to oxygen

            Then attempt indirect clouds cape and removal of obstructing agent with a Ma gill's forceps or suction

            If unable to remove the obstruction mechanically GE when due to swelling, proceed to emergency surgical airway IE trans tracheal jet insulation or hypothyroidism

            Then proceed as per "Specific Treatment" below.

• Partial Obstruction

            Encourage self posturing GE in epiglottis the patient will prefer to sit upright and lean forwards

            Unless there is an obviously visible foreign body and the patient is cooperative DO NOT perform any airway clearing man oeuvres, such as the Heimlich man oeuvre. This may convert a partial obstruction into a complete one.

• Potential Obstruction

            No immediate intervention is required

Then, for partial obstruction or potential obstruction :

2. Breathing

• Measure respiratory rate. If inadequate, assist ventilation with bag valve mask attached to oxygen.
• Measure SA O2. If < 95% and not requiring ventilation, administer high flow oxygen by mask.

3. Circulation

In partial obstruction great care must be taken to avoid agitating the patient and precipitating a complete obstruction GE measuring the PB or inserting a annular in a child with epiglottis may cause agitation and precipitate a complete airway obstruction.

4. Disability

Record a G CS and pupil response. Consider incubation (if this has not already occurred), if G CS is 8 or less to protect the airway.

5. Monitor

ECG, SA O2, PB (if this will not agitate the patient)

6. Summon

- a senior doctor with airway skills.

DIRECTED HISTORY AND EXAMINATION

Ask About :

Event

• precipitating factors, likelihood of foreign body aspiration

Symptoms

• of possible precipitants GE epiglottis, croup

Past History

• drug allergies
• medications
• medical problems

Look For :

• stride, hypnosis
• signs suggestive of particular clinical syndromes GE epiglottis, croup, angina-o oedema

Measure :

• reassess SA O2, respiratory rate, level of consciousness

Tests

• in the airway control phase there is no test of any use and tests may delay definitive management and worsen the condition.

SPECIFIC TREATMENT

     If partial obstruction, potential obstruction or complete obstruction with temporary surgical airway in place :

1. Notify anesthetist / NET surgeon or local equivalents

2. Notify the operating heater

3. When all resources are assembled transfer to the operating heaters accompanied by skilled staff, oxygen, suction, bag valve mask system, difficult incubation tray and surgical airway setup.

DISPOSITION

     Depends on the cause, but in most cases would require admission to an Intensive Care Unit after definitive treatment in the operating heater.
Airway must be stabilize before any inter-hospital transfer is attempted

IMPORTANT POINTS

1. Heimlich man oeuvre is generally not indicated in the Emergency Department setting.

2. If partial airway obstruction is present then intervention in the Emergency Department should be minimal and the patient should be transferred to the operating theater accompanied by appropriate staff and equipment.

3. Do not attempt to remove penetrating foreign bodies of the neck in the Emergency Department.