Airway Obstruction and Tracheotomy

CPR classes are important for everyone to take, but standard chest compressions and breaths are most helpful in normal times, when there are ICUs and respirators readily available. One thing  CPR class teaches you that does have relevance to off-grid survival is how to deal with an airway obstruction.

An airway obstruction most commonly occurs as a result of food lodging in the back of the throat and cutting off respiration. This can be treated successfully with knowledge and limited supplies. Early diagnosis and quick action is the key.

Some signs of an airway obstruction are:

 
• Difficulty breathing
• Noisy breathing, sometimes called “stridor“.
• Inability to talk; you need air to speak.
• Inability to cough for the same reason.
• The patient’s skin turning blue (called “cyanosis,” which is due to lack of oxygen circulating in the blood)
• Decreasing level of consciousness as oxygen levels drop.

Photo by Jim Bryson

THE CONSCIOUS VICTIM

 
If you see a conscious adult in sudden respiratory distress, ask quickly: Are you choking? If they can answer you, there is still air passing into their lungs. If it’s a complete blockage, they will be unable to speak. They’ll be clearly agitated and holding their throat, but they’ll hear you and (frantically) nod their head “yes”. This is your signal to act.

So what should you do for an adult in this situation? Quickly tell the victim that you’re there to help them and immediately get into position for the Heimlich maneuver, otherwise known as an “abdominal thrust”. Get behind the victim and make a fist with your right hand. Place your fist above the belly button and below the breastbone (also called the sternum); then, wrap your left arm around the patient and grasp the fist. Make sure your arms are positioned just below the rib cage. With a forceful upward motion, thrust your fist abruptly into the abdomen. You might have to do this multiple times before you dislodge the foreign body.

In old movies, you might see someone slap the victim hard on the back; this is not as likely to dislodge a foreign object as the abdominal thrust and might waste precious time. If you have to use a blow to the back. do it right in the center of the upper back with the victim bent over so that the torso is parallel to the ground. In this way, gravity might help the foreign object drop out of the mouth. Back blows are considered more effective in an infant: place the baby over your forearm (facing down) as if holding a football and apply several blows with the heel of your hand to the upper back.

THE UNCONSCIOUS VICTIM

If your patient loses consciousness and you are unable to dislodge the obstructive item, place the victim flat on their back and straddle them across the hips. Open their mouth and make sure that the object can’t be removed manually. If not, give several, say five, upward abdominal thrusts with the heels of your palms (one above the other) and check oral cavity again; you might have partially dislodged it.

PERFORMING  A TRACHEOTOMY TO SAVE A LIFE

An extreme method that can be used to open an airway is the “tracheotomy”. This procedure, also called a cricothyroidotomy, involves cutting an opening in the windpipe below the level of an obstruction. Tracheotomy should be performed only when an airway obstruction completely prevents the ability to breathe and all other methods have proved unsuccessful.

To perform a tracheotomy, you will need a sharp blade and some sort of tube, such as a firm plastic straw. A towel under the shoulders will tilt the head into a position that will make it easier to define structures. Of course, a good first aid kit is always good to have, but there might not be time for antiseptics; you are performing this procedure because someone becoming cyanotic and may die in the next few minutes.

(Aside: It should be noted that there are syringe sets for this purpose commercially available by prescription.)

In austere settings, the procedure goes as follows:

Start at the Adam’s apple, also known as the laryngeal prominence, on the front of the neck. It’s seen easily in men, less so in women. Move about 1 inch down the windpipe until you feel a second bulge. This is the cricoid cartilage.

Make a vertical incision through the skin with your knife or a razor blade in the crease between the laryngeal prominence and the cricoid cartilage. This incision can be about an inch long, and is superior (in my opinion) to a horizontal incision in that it can be extended upwards or downwards if you entered the skin at the wrong location. A vertical incision will also avoid cutting laryngeal nerves that help control speaking and swallowing.

 
A curved Kelly clamp or a finger could be used to stretch the incision for better visualization of the structures beneath. Once under the subcutaneous tissue, you’ll find the greyish cricothyroid membrane. Make a horizontal incision through it. It should be noted that some make a vertical or cross-shaped incision to make a larger opening through more of the windpipe. It’s harder, however, to cut through cartilage than membrane. In any case, the incision should allow passage of air into the lungs.

Be careful not to cut too deeply. Your incision through the membrane only needs to be a half-inch deep or so. Deeper and you may penetrate the back of the airway, cutting the esophagus underneath the windpipe. Once opened, there may be a audible rush of air or a “pop” as the incision is made. The base of the scalpel can be used to make the opening larger. Don’t remove your scalpel from the incision until you’ve placed an open tube in the trachea. There normally isn’t a lot of blood; direct pressure should control any significant bleeding.

Place something hollow in the opening to maintain a clear airway. A “trach” tube would be great, but a straw might do in a pinch. Thread it 1-2 inches down the windpipe; doing this makes it less likely to fall out (commercially-made tubes can be tied around the neck to secure it in place).

 
If the patient fails to breathe on their own despite a successful tracheotomy, you may need to perform CPR rescue breaths through the tube you inserted.

I don’t have to tell you that this is a dangerous procedure. A lot can go wrong and your equipment will likely be inferior to what is really needed. Remember, however, that the patient is dying and is already unconscious from lack of oxygen; it may be your last resort.

 
Only consider performing a tracheotomy when help is not on the way and you have tried every other option first. Even a successful tracheotomy is only good for about 72 hours before a more permanent solution is needed. That’s only one of the hard realities that medic must face in times of trouble.

(Final Note: For those that aren’t acquainted with my work, I focus on what to do when there are no modern medical personnel or facilities available, as in a wilderness or survival setting. In normal times, seek modern and standard medical care whenever and wherever it exists.)

Joe Alton, MD

Learn more about how to deal with medical issues in disasters and epidemics with a copy of the 3 category #1 Amazon bestseller “The Survival Medicine Handbook“, with over 250 5-star reviews.