Obstruction FBAO - Conscious Child
Hey! How about the Kids.
FBAO - Conscious Child
A child according to guidelines suggested by the American Heart Association is any patient that is more than one year old and less than 8 years old. In other areas of emergency medicine, we are cautioned by our instructors not to refer to children as "little adults." Because in other areas of emergency medicine, children do not react the same way that adults react. However, in this instance, (Foreign Body Airway Obstruction) the procedure for clearing the airway of an obstructed child is the same as the procedure used for an adult, with one exception. We use less force on the child, because (dare I say it?) they are just "little adults." So take a look at the illustration, and I think you'll agree that all of the foregoing text explaining the procedure for an adult patient need not be repeated here.
FBAO - Unconscious Child
A child according to guidelines suggested by the Ame... Wait a minute. This sounds very familiar. oooo - Deja Vu... Hey listen the unconscious kid (uh.. child) is the same as the unconscious adult, because they are just little adults (every one of my instructors just shivered, I'd say they all turned over in their graves, but they ain't dead yet.) Just use less force. Look at the illustration for an unconscious choking adult, imagine that the patient is much shorter, understand that instead of "straddling the patient's hips," our knees may actually be as low as "straddling the patient's feet" (depending on how short the patient actually is.)
FBAO - InfantAn infant according to guidelines suggested by the American Heart Association is any patient that is less than one year old. This is actually a very small portion of the population and consequently, there is only a small chance that you, as a first aide provider, will actually encounter a choking infant.
First of all, understand that this patient (less than a year old) will not respond appropriately to the question "Are you choking? You are going to have to evaluate this situation (or potential situation, or envisioned situation, or created situation, or planned situation) by different methods. You are going to have to rely on your powers of observation and your ability to "assess" the patient through the apparent "signs" that are available. In order to understand how a choking infant will "present" (that's medical jargon for "what they're going to look like" and "how they're going to react,") you need to know a little about hypoxia and the reaction of the body to hypoxia. According to the On-Line Medical Dictionary hypoxia is defined as: "Reduction of oxygen supply to tissue, below physiological levels despite adequate perfusion of the tissue by blood." In layman's terms, the blood (for a number of reasons) isn't carrying enough oxygen to satisfy the demand at the cellular level. Of interest here, is the fact that infants do not react to hypoxia the way we would expect. Let's discuss what we would expect, first, then discuss how an infant is different. To best understand the adult reaction to hypoxia, I'll ask that you look into your own past a little. Think back to a time when you had a rather significant head cold. Jew jus couldid breed tru jawr doze ad awl. Your sinuses were completely blocked and breathing seemed to be an effort. At bedtime, you took some Benedryl, or maybe some of the "nighttime, sniffling, sneezing, coughing, aching, stuffy head, fever, so you can rest and have a good day" medicine (you know, Nyquil.) At any rate, the Benedryl, and the "nighttime, sniffling, sneezing" part of Nyquil, are the same generic drug. Diphenhydramine Hydrochloride, a very effective antihistamine, stops the sniffling and sneezing because it stops the runny nose. This drug also has a major sedative effect (that means it puts you to sleep.) This side effect is so dramatic that the drug is marketed under other names (like Nytol,Sominex, and others) to help induce sleep. The next time you're in a pharmacy, look at the labels on some of the over the counter medications for colds and medications for sleep. You'll find that most have diphenhydramine hydrochloride as one of the ingredients. So...back to your cold. You take some of this diphenhydramine stuff and get into bed and fall asleep almost immediately. After a short time, because you are having trouble breathing through your nose, you subconsciously open your mouth to breath. After a short period of mouth breathing, during which time you actually fall into a deeper sleep (aided by the medication,) your mouth becomes very dry, and subconsciously you close it to moisten your lips, tongue, and the lining of your mouth. Because you are in a state of deep sleep, you will probably not re-open your mouth, and you enter a state called "sleep apnea" (a state where a sleeping person stops breathing.) Hypoxia starts to develop and the oxygen level in the blood starts to drop. Sensors in the blood stream, monitoring oxygen levels, tell the brain that oxygen is needed in the blood, and the brain begins the reaction to hypoxia. First reaction is to increase the respiratory rate (or number of breaths per minute.) Well now, let's see. You're breathing at a rate of zero (0,) let's assume that the body doubles the breathing (respiratory) rate. Two times zero equals zero (2X0=0.) The respiratory rate has not increased and the level of oxygen in the blood continues to drop. The brain shifts into second gear and reacts by instructing the heart to beat faster (the second of three reactions to hypoxia.) A resting pulse of 60 may go as high as 120. But the breathing rate is still zero and consequently, the body is just circulating blood (without oxygen) around the body more rapidly. The amount of oxygen in the blood continues to drop and the brain employs the third of three reactions to hypoxia (in an adult,) and that is, to raise the level of consciousness. At this point, you sit bolt upright in bed, open you mouth, "suck" in as much air as you possible can, you feel your little heart just a-thumpin' away, and your level of consciousness has just "broken through" the sleepiness caused by the diphenhydramine hydrochloride. You ARE experiencing the effects of hypoxia in the normal adult body. To recap.
1. Increased respiratory rate.
2. Increased heart rate.
3. Increased level of consciousness.
Now the babies.
The normal reaction to hypoxia in a small infant is exactly the opposite of what it is in an adult. There is a DECREASED respiratory rate, a DECREASED heart rate and a DECREASED level of consciousness. The baby has not yet developed the "self-protective" mechanism necessary to increase those vital signs. What this means is that you will NOT see these eyes filled with "genuine FEAR," as you did when you looked into the eyes of the conscious choking adult. Because babies (and children) are NOT little adults, you may not see a blue/gray complexion, because the kids (babies and children) "compensate" longer and are able to keep body functions within normal limits longer than adults and subsequently do not show signs of deterioration during an event as early on as adults. What does all of this mean to YOU? It means that when assessing a baby, look very carefully for breathing effort, and if you don't see it, but the baby "seems" to be okay, and the baby "seems" to look okay, there is a good possibility that, if the baby is not breathing at a depth and a rate that you can see, that the baby is indeed NOT BREATHING in spite of the fact that the baby looks fine. Act accordingly.
For a baby that is obstructed, we will not be performing abdominal thrusts. The vital internal organs are positioned very close together in this patient. Those organs have not yet "migrated" into their final positions in the body. It is very likely that the liver is not exactly where you might expect it to be or the gall bladder might be closer to the kidneys than you thought. And, besides, your hand in comparison to the size of the baby is monstrous. We need another way to create increased pressure in the lungs of this baby. We will be performing "back blows" and "chest thrusts" on this baby, instead of the abdominal thrusts that we did on the adult and child. A picture is worth a thousand words. Take a look. Notice that the baby is positioned on the arm of the rescuer, stomach against the rescuer's arm for half of the procedure (back blows) then turned over, with the baby's back against the rescuer's arm for the second half of the procedure (chest thrusts.) The back blows are intended to deliver a significant blow to the baby's back using the heal of the rescuer's hand and placing the blow on the baby between the shoulder blades high on the back (where we are less likely to damage the baby's tender little spine.) The chest thrusts are intended to depress the baby's sternum (the flat breast bone in the center of the chest) enough to compress the lungs and increase the pressure in the lungs, hopefully popping the obstruction out of the airway. Both procedures, back blows and chest thrusts, are performed with the baby's head slightly lower than the rest of the baby's body. Do 4 or 5 back blows, followed by 4 or 5 chest thrusts and repeat the cycle until the obstruction is removed or you are relieved by the emergency medical squad. Please note that the procedure is the same, whether the baby is conscious or unconscious. Your "follow-up," after the procedure is, however, different. If conscious, and the airway is subsequently cleared by either the back blows or the chest thrusts, the baby will start crying. (Heck, you've just been "beatn' the bejabbers outa the little thang.) If you found the baby and it was unconscious before the attempts to clear the airway, your first effort, before any back blows or chest thrusts would be to try and ventilate the baby using a mouth to mouth-and-nose technique (your mouth is large enough to cover the baby's mouth and nose, No! that's not an editorial on how LOUD you are.) If your attempt to ventilate this baby is initially unsuccessful you should re-evaluate the position of the baby's head and try the ventilation again. If still unsuccessful, then the back blows and chest thrusts are next. Just a word about the position of the baby's head. Unlike adults and children, babies have VERY flexible airways. Consequently, this baby's head should not be hyperextended. That position may actually block the airway. The position of choice here is described as a "Neutral Position." With the baby on your arm and the back of the baby's head in the palm of your hand, the whole package should "look" straight. Another way to evaluate this "neutral" position is to look at the baby's nose and make sure that an imaginary line drawn from the tip of the baby's nose, through the tip of the baby's earlobe, is at right angles to the baby's spine (back.) After completing 4-5 back blows and 4-5 chest thrusts on this unconscious baby, attempt to ventilate the baby again. If unsuccessful, evaluate the head position again, and re-attempt the ventilation. More back blows and chest thrusts are in order, if the second attempt is unsuccessful. Continue this process until you are successful, or until relieved by the emergency medical team.
None of the foregoing is intended to replace an accredited CPR class. In such a class, the student is offered the opportunity to practice on manikins, under the watchful eye of an instructor. The learning experience is not only more complete, in a class, but also more lasting. Enroll today, before any of this is needed.