Emergency Situations: Foreign Body Obstruction

High Acuity and Emergency Situations

• Foreign body obstruction is a life-threatening clinical emergency.
• Obstructions can be partial or complete, caused by foreign objects (e.g., food, toys).
• Respiratory distress, sudden coughing, and agitation are common symptoms.
• Improper chewing of large food pieces, alcohol intake, loose dentures, and childhood behaviors (e.g., running while eating) can contribute to obstruction.
• Obstructions are categorized into anatomical (tongue dropping back) and mechanical (foreign objects lodged in the pharynx).
• Mild obstruction is characterized by responsive victims with effective coughing, often with wheezing.
• Severe obstruction is where victims have ineffective coughs, high-pitched inhaling noises, increased respiratory difficulty, possible cyanosis, and inability to speak, breathe, or cough. Movement of air is absent.
• A choking algorithm, based on the Resuscitation Council's guidelines, provides quick guidance.
• Assessment of the severity and the appropriate procedure for infants (<1 year) and children (>1 year) is crucial.
• Prevention advice includes cutting food into small pieces, keeping small objects out of reach for children, and always supervising young children while eating.
• A mild obstruction, with effective coughing, does not require external maneuvers, but close observation is needed.

Foreign Body Airway Obstruction

• Foreign body airway obstruction involves a blockage of the breathing tubes to the lungs.
• The blockage is caused by a foreign body, such as food, beads, or toys.
• The onset of respiratory distress often involves coughing.
• Agitation can be a key symptom at initial stages of obstruction.
• This situation is a clinical emergency that could be life-threatening.
• Nurses need to confidently assess the severity of the airway obstruction, intervene to relieve the obstruction, and know when to call emergency assistance.

Causes of Obstruction

• Improper chewing of large food pieces
• Excessive alcohol intake
• Loose dentures
• Children running/playing while eating
• Unattended children at the “hand-to-mouth” stage

2 Types of Obstruction

• Anatomical obstruction: The tongue blocks the throat. Other causes include acute asthma, croup, diphtheria, swelling and whooping cough.
• Mechanical obstruction: Foreign objects in the pharynx or airways, or fluids accumulating in the back of the throat.

Classification of Obstruction

• Mild obstruction: The victim is responsive and can cough forcefully. Wheezing commonly occurs between coughs.
• Severe obstruction: The victim shows a weak, ineffective cough, high-pitched inhaling sounds, increases respiratory difficulty, and possible cyanosis. The victim cannot speak, breathe or cough and may clutch their neck with their hands. Air movement is absent.

Prevention of Choking in Infants and Children

• Always cut food into small pieces.
• Keep small objects, like small toys, out of reach.
• Always supervise infants and young children while eating.

Mild Airway Obstruction (Effective Cough)

• Coughing generates high and sustained airway pressures, potentially expelling the foreign body.
• Encourage the child or patient to cough.
• Patients with an effective cough are able to cry or respond verbally to questions.
• No external maneuvers (e.g., back blows) are needed but continuous observation until improvement is needed.

Severe Airway Obstruction (Ineffective Cough)

• Infants (<1 year):
  • Call for help immediately.
  • Deliver up to 5 back blows (slaps). Place the infant prone, head downward, supporting the head and neck.
  • Stabilize the head by placing one hand on the angle of the jaw and the other hand on the opposite side of the jaw.
  • Deliver 5 sharp back slaps between the shoulder blades.
• Check for improvement after each maneuver.
• Children (>1 year): Similar procedure, but the child can typically be guided to a leaning forward position.

If Back Blows Fail

• If the object doesn't dislodge, and the infant is still conscious, deliver up to 5 chest thrusts.
• Turn the infant supine, head in a downward position.
• Locate the xiphisternum
• Deliver 5 sharp chest thrusts at a slower rate.
• Check for improvement after each maneuver.
• Alternate back blows and chest thrusts if necessary.

Management of the Unconscious Infant or Child

• Carefully support to a flat surface.
• Call for help.
• Open the infant or child's mouth and check for visual obstruction. If present, attempt removal with a single finger sweep.
• Open the airway, perform 5 ventilations, and reposition head if chest does not rise.
• If unresponsive, begin CPR: 30 compressions, 2 ventilations, check the mouth, and remove any present object before repeating these steps.

Aftercare

• Medical advice is critical even after successful treatment and/or removal of the foreign body.
• Complications may arise from the initial incident as well as interventions (e.g,. chest/abdominal thrust).
• Evaluation by the appropriate health professional is important.
• Patients requiring these interventions should be examined for potential injuries.
• Nurses have the professional responsibility to implement these steps according to approved protocols and local policies.

Treatment of FBAO in Adults

• If a Foreign Body Airway Obstruction (FBAO) is suspected in an adult, start by assessing the severity using a choking algorithm.
• Always ask the patient if they are choking. This will help distinguish mild from severe airway obstruction.

Severity of Airway Obstruction

• Mild obstruction: Patient can talk and has an effective cough.
• Severe obstruction: Patient responds to "yes" by nodding, but cannot speak or cough effectively.

Mild Airway Obstruction (Effective Cough)

• Coughing generates high pressures needed to expel a foreign body.
• Encouraging patients to cough is a key step.
• Patients with mild airway obstruction should be continuously monitored for any signs of worsening. Aggressive treatment is not immediately needed.

Severe Airway Obstruction (Ineffective Cough)

• Call for help immediately, encourage coughing.
• Support the patient's chest using one hand.
• Lean the patient slightly forward.
• Use the heel of your hand to deliver up to five back blows between the scapulae.
• Check for improvement after each blow.
• If required use, abdominal thrusts if the patient is still conscious and back blows continue if necessary.

First Aid for Conscious Patients

• Minimise head and neck movements; control bleeding with direct pressure and dressings.
• Avoid disturbing any blood clots and reassure the patient.

First Aid for Unconscious Patients

• Do not move the person unless an immediate danger is present.
• Protect injured persons from any dangers at the scene.
• Monitor their airway and breathing until the arrival of help/ambulance.
• If breathing or pulse stops, initiate cardiopulmonary resuscitation (CPR).

Treatment of Concussion

• Concussion is a mild traumatic brain injury (TBI) after head trauma assessed by a doctor
• Symptoms may persist up to 3 weeks.
• Seek medical attention if persistent vomiting, loss of coordination, or worsening headaches occur.

Facial Trauma

• Facial trauma includes injuries to the mouth, face, and jaw.
• Common causes include assaults, vehicle accidents, industrial injuries, sports injuries, and falls.
• Facial fractures can affect eating, speaking, breathing, hearing, sight and overall function.

Facial Fracture Causes

• High-impact accidents
• Sports injuries
• Workplace accidents
• Falls
• Interpersonal trauma

Facial Fracture Symptoms

• Pain, bruising, swelling, or tenderness.
• Bleeding, purplish skin patches (ecchymosis).
• Discoloration under the eyes (black eyes).
• Blockage of nostrils; crooked or indented nose bridges.
• Nosebleeds
• Vision changes
• Weakness/difficulty with jaw, swallowing or chewing or speaking

Orbital Fracture Symptoms

• Blurred, decreased, or double vision (diplopia)
• Difficulty moving eyes
• Swollen forehead or cheeks
• Flatness of cheeks
• Sunken or bulging eyeballs
• Facial numbness near the injury.
• Blood or discoloration in the white (sclera) part of the eye.

Upper and Lower Jaw Fracture Symptoms

• Difficulty with chewing, eating, or speaking.
• Loose, broken, or missing teeth.
• Teeth not fitting together properly.
• Cheek pain when opening the mouth.

Determining Priorities of Care

• Maintain airway, breathing, and circulation (ABCs).
• Provide supplemental oxygen if indicated.
• Establish intravenous access for crystalloid fluid or blood products.
• Obtain and set up necessary equipment and supplies.
• Prepare for any medical interventions or treatments.
• Administer any necessary medications or therapies.

Protocol for Airway Management in Maxillofacial Trauma

• Anticipate airway obstruction.
• Clear the airway (chin lift, jaw thrust).
• Confirm that the oral and nasal apertures are clear.
• Perform bag-valve-mask ventilation, ideally via a two-person technique.
• Proceed with intubation if necessary.
• Consider surgical airway if intubation is unsuccessful..

Spinal Cord Injury (SCI)

• SCI is damage to any part of the spinal cord or nerves in the spinal canal.
• Common causes are motor vehicle accidents, acts of violence, and sporting injuries.
• The mechanism of injury influences the injury type and severity (complete or incomplete).
• Classification is based on the level and extent of neurological deficit (e.g., tetraplegia or paraplegia).

SCI Physical Findings

• Physical findings vary based on the level of injury, degree of spinal shock, and phase of recovery.
• The classifications are generally categorized by levels.
• Different levels result in different functional deficits. (Examples provided in the text)

Signs and Symptoms of SCI

• Unusual body positioning
• Skin feeling clammy or cool
• Inability to move limbs
• Flaccid paralysis below the injured level
• Loss of spinal reflexes below the injured level
• Loss of sensation (pain, touch, temperature, proprioception)
• Loss of sweating below the injured level
• Loss of sphincter tone (bowel and bladder dysfunction)

Diagnostic Tests for SCI

• X-rays
• CT scans
• MRIs
• Myelography

Toddlers and Head Injuries

• A fall from a child's own height does not usually cause serious head injury.
• Head injury severity is not related to the size of the bump.
• Minor head injuries can usually be treated with medication and parental reassurance.
• Medical attention needs to be sought immediately if the child shows unusual drowsiness, vomiting or appears unconscious after a fall.

Initial Care - Immobilization

• Immobilise the entire spine of any patient suspected of or known to have SCI, using a hard collar.
• Turn patients only using a log roll with adequate personnel.
• Using an airway pad for children under eight years old will promote neutral cervical spine position.
• Within 6 hours, the hard collar should be changed to a two-piece collar.

Airway with Cervical Spine Protection

• Early and safe airway management is crucial for favourable long-term patient outcomes.
• Look for signs of airway obstruction (accessory muscle use, paradoxical respiration).
• Listen for upper airway sounds (diminished or noisy).
• Spinal patients are at risk of passive regurgitation.
• High cervical injuries put patients at risk of impaired gag and cough reflex.

Attempt Simple Airway Manoeuvres if Required

• Open the airway via a chin-lift or jaw-thrust.
• Suction the airway if excessive secretions are present.
• Use an oropharyngeal (OPA) or nasopharyngeal (NPA) airway if required.

Secure the Airway if Necessary

• Treat airway obstruction as a medical emergency.
• Consider early intubation with signs of decreased level of consciousness or an unprotected airway.

Intubation/Manual In-Line Cervical Stabilization

• Skilled and teamwork are vital during intubation and maintaining spinal precautions.
• Maneuvers that mobilize the cervical spine (e.g., neck tilt) should not be used.
• Only use chin lift and jaw thrust movements.
• Manual in-line cervical stabilisation must be maintained while changing collars.
• A second assistant should deliver cricoid pressure.

Assess the Chest

• Monitor respiratory rate and oxygen saturation.
• Auscultate to identify any abnormal breath sounds.

Circulation with Hemorrhage Control

• Intravenous access is needed for early fluid replacement.
• Preventing hypotension is important; A systolic blood pressure above 90 mmHg is a target goal.
• Assess the patient for any signs of external or internal hemorrhaging.
• Administer direct pressure on external wounds.
• Recognize the possibility of internal bleeding based on the mechanism of injury.
• Expect hypotension/bradycardia (low heart rate) in injured patients ( particularly if the injury is above the 6th thoracic vertebra)
• Medications such as atropine may be required.

Disability: Neurologic Assessment

• Perform an initial AVPU assessment. (Alert, Verbal, Pain, Unresponsive).
• Check pupillary response.
• All trauma patients should be treated as having a spinal injury until proven otherwise.
• High spinal injury diagnoses should involve evaluating key signs such as Priapism, diaphragmatic breathing and anal tone loss.

Exposure/Environmental Control

• Remove clothing to conduct a thorough examination.
• Monitor body temperature; prevent or treat hypothermia.
• Keep the environment warm.

Secondary Survey

• Commence after the primary survey and any life-threatening injuries have been treated.
• Gain a thorough history from the patient, witnesses, or other sources. (AMPLE acronym (Allergies, Medications, Past medical history, Last meal and Events leading to incident))

Neurological Assessment

• Document sensory and motor levels.
• Contact Rehab team after 72 hours.
• Perform hourly neurological checks for 24 hours, decreasing to 4 hourly if stable..
• Note any evidence of brain or spinal cord injury.

Vital Signs (and Autonomic Control)

• Trauma patients frequently have abnormal vital signs; these may be due to factors other than spinal cord injury.
• Monitor heart rate, blood pressure, and temperature continuously and/or hourly.
• Specific issues like bradycardia may require specific treatment.

Blood Pressure

• Loss of autonomic control leads to reduced vasomotor tone, resulting in vasodilation and hypotension.
• Monitor blood pressure closely; maintain a systolic blood pressure above 90mmHg.
• Maintain adequate fluid resuscitation but avoid overload.
• Vasopressors may be needed, and treatment needs to be managed in a critical care/intensive care unit (ICU).

Temperature

• Patients with SCI may lose temperature regulation causing either hypothermia or hyperthermia.
• Monitor temperature frequently, particularly during acute admission.

Potential Complications and Management

• Common complications include pressure sores, autonomic hyperreflexia, pneumonia, urinary tract infections, constipation, deep vein thrombosis, bone demineralisation, latex allergies, and spasticity.
• Manage these issues with prevention and appropriate, timely treatments.