Removing a foreign body from the child's respiratory tract. The simplest methods for removing solid and liquid foreign bodies from the upper respiratory tract
Contents of the article
Definition
A severe pathology that is life-threatening for patients when foreign bodies enter, during their stay in the respiratory tract and during their removal due to the possibility of lightning-fast development of asphyxia and other severe complications.Classification of foreign bodies in the respiratory tract
Depending on the level of localization, foreign bodies of the larynx, trachea and bronchi are isolated.Etiology of foreign bodies in the respiratory tract
Foreign bodies usually enter the respiratory tract naturally through the oral cavity. It is possible for foreign bodies to enter from the gastrointestinal tract during regurgitation of gastric contents, the crawling of worms, as well as the penetration of leeches when drinking water from reservoirs. When coughing, foreign bodies from the bronchi that had previously entered there can penetrate into the larynx, which is accompanied by a severe attack of asphyxia.Pathogenesis of foreign bodies in the respiratory tract
The immediate cause of foreign body entry is an unexpected deep breath, which carries the foreign body into the respiratory tract. The development of bronchopulmonary complications depends on the nature of the foreign body, the duration of its stay and the level of localization in the respiratory tract, on concomitant diseases of the tracheobronchial tree, the timeliness of removal of the foreign body using the most gentle method, and on the level of qualification of the emergency physician.Clinic for foreign bodies in the respiratory tract
There are three periods of clinical course: acute respiratory disorders, latent period and period of development of complications. Acute respiratory disorders correspond to the moment of aspiration and passage of a foreign body through the larynx and trachea. The clinical picture is bright and characteristic. Suddenly, in the midst of complete health during the day, while eating or playing with small objects, an attack of suffocation occurs, which is accompanied by a sharp convulsive cough, cyanosis of the skin, dysphonia, and the appearance of petechial rashes on the skin of the face. Breathing becomes stenotic, with retraction of the chest wall and frequently recurring bouts of coughing. Entry of a large foreign body can cause instant death due to asphyxia. There is a risk of suffocation in all cases of a foreign body entering the glottis. During subsequent forced inspiration, smaller foreign bodies are carried into the underlying sections of the respiratory tract. The latent period begins after the foreign body moves into the bronchus, and the further the foreign body is located from the main bronchi, the less pronounced the clinical symptoms are. Then comes the period of development of complications.Foreign bodies of the larynx cause the most serious condition of patients. The main symptoms are severe stenotic breathing, sharp paroxysmal whooping cough, dysphonia to the extent of aphonia. With pointed foreign bodies, there may be pain behind the sternum, which intensifies with coughing and sudden movements, and blood appears in the sputum. Choking develops immediately when large foreign bodies enter or increases gradually if pointed foreign bodies get stuck in the larynx due to the progression of reactive edema.
Foreign bodies in the trachea cause a reflex convulsive cough, which intensifies at night and with restless behavior of the child. The voice is restored. Stenosis from constant when localized in the larynx becomes paroxysmal due to the protrusion of a foreign body. Balloting of a foreign body is clinically manifested by the symptom of “pop”, which is heard at a distance and occurs as a result of impacts of a moving foreign body on the walls of the trachea and on the closed vocal folds, preventing the removal of the foreign body during forced breathing and coughing. Ballistic foreign bodies pose a great danger due to the possibility of strangulation in the glottis and the development of severe suffocation. Respiratory disturbance is not as pronounced as with foreign bodies in the larynx, and is repeated periodically against the background of laryngospasm caused by contact of a foreign body with the vocal folds. Self-removal of a foreign body is prevented by the so-called valve mechanism of the tracheobronchial tree (the “piggy bank” phenomenon), which consists in expanding the lumen of the airways when inhaling and narrowing it when exhaling. Negative pressure in the lungs carries the foreign body into the lower respiratory tract. The elastic properties of the lung tissue, the strength of the diaphragm muscles, and the auxiliary respiratory muscles in children are not so developed as to remove a foreign body. Contact of a foreign body with the vocal folds during coughing causes a spasm of the glottis, and the subsequent forced inhalation again carries the foreign body into the lower respiratory tract. In case of foreign bodies in the trachea, a boxy tint of the percussion sound is determined, weakening of breathing throughout the entire pulmonary field, and during radiography, increased transparency of the lungs is noted.
When a foreign body moves into the bronchus, all subjective symptoms cease. The voice is restored, breathing stabilizes, becomes free, compensated by the second lung, the bronchus of which is free, coughing attacks become rare. A foreign body fixed in the bronchus initially causes meager symptoms, followed by profound changes in the bronchopulmonary system. Large foreign bodies are retained in the main bronchi, small ones penetrate into the lobar and segmental bronchi.
Clinical symptoms associated with the presence of a bronchial foreign body depend on the level of localization of this foreign body and the degree of obstruction of the bronchial lumen. There are three types of bronchostenosis: with complete atelectasis, with partial, along with a displacement of the mediastinal organs towards the obstructed bronchus, unequal intensity of the shadow of both lungs, bevel of the ribs, lag or immobility of the dome of the diaphragm when breathing on the side of the obstructed bronchus are noted; with ventilation, emphysema of the corresponding part of the lungs is formed.
Auscultation determines weakening of breathing and vocal tremor, according to the location of the foreign body, and wheezing.
The development of bonchopulmonary complications is facilitated by impaired ventilation with the exclusion of significant areas of the pulmonary parenchyma from breathing; Damage to the walls of the bronchi and infection are possible. In the early stages after aspiration of a foreign body, asphyxia, laryngeal edema, and atelectasis predominantly occur in the area of the obstructed bronchus. Atelectasis in young children causes a sharp deterioration in breathing.
Trachebronchitis, acute and chronic pneumonia, and lung abscess may develop.
Diagnosis of foreign bodies in the respiratory tract
Physical examination
Percussion, auscultation, determination of vocal tremor, assessment of the general condition of the child, the color of his skin and visible mucous membranes.Laboratory research
Common clinical tests that help assess the severity of inflammatory bronchopulmonary processes. Instrumental studiesChest X-ray with contrast foreign bodies and chest X-ray with aspiration of non-contrast foreign bodies in order to detect the Holtzknecht-Jacobson symptom - displacement of the mediastinal organs towards the obstructed bronchus at the height of inspiration. Bronchography, which specifies the localization of a foreign body in the tracheobronchial tree if it is suspected of moving beyond the bronchial wall. X-ray examination allows you to clarify the nature and causes of complications that arise.
Differential diagnosis of foreign bodies in the respiratory tract
Carry out with respiratory viral diseases, influenza stenosing laryngotracheobronchitis, pneumonia, asthmatic bronchitis, bronchial asthma, diphtheria, subglottic laryngitis, whooping cough, allergic edema of the larynx, spasmophilia, tuberculosis of the peribronchial nodes, tumor and other diseases that cause various types of breathing disorders and bronchostenosis .Treatment of foreign bodies in the respiratory tract
Indications for hospitalization
All patients in whom aspiration of a foreign body is confirmed or suspected are subject to immediate hospitalization in a specialized department.Non-drug treatment
Physiotherapy of developed inflammatory diseases of the bronchopulmonary system, inhalation therapy; oxygen therapy for severe stenosis.Drug treatment
Antibacterial, hyposensitizing, symptomatic treatment (expectorants, antitussives, antipyretics); inhalation therapy.Surgical treatment
Final visualization and removal of foreign bodies is performed during endoscopic interventions. Foreign bodies are removed from the laryngeal part of the pharynx, larynx and upper parts of the trachea under mask anesthesia using direct laryngoscopy. Foreign bodies from the bronchi are removed by tracheobronchoscopy using a Friedel system bronchoscope under anesthesia. Magnets are used to remove metallic foreign bodies.In adult patients, fibrobronchoscopy is widely used to remove aspirated foreign bodies. In childhood, rigid endoscopy remains of primary importance.
The laryngeal mask greatly facilitates the passage of the fiberscope into the lower respiratory tract.
Indications for tracheotomy for aspirated foreign bodies:
asphyxia due to large foreign bodies fixed in the larynx or trachea;
pronounced subglottic laryngitis, observed when foreign bodies are localized in the subglottic cavity or developed after surgical intervention when removing a foreign body;
inability to remove a large foreign body through the glottis during upper bronchoscopy;
ankylosis or damage to the cervical vertebrae, which does not allow removal of the foreign body by direct laryngoscopy or upper bronchoscopy.
tracheotomy is indicated in all cases when the patient is in danger of death from suffocation and there is no possibility of sending him to a specialized medical institution.
In some cases, thoracic intervention is performed for aspirated foreign bodies. Indications for thoracotomy:
movement of a foreign body into the lung tissue;
a foreign body wedged into the bronchus after unsuccessful attempts to remove it during rigid endoscopy and fibrobronchoscopy;
bleeding from the respiratory tract when attempting endoscopic removal of a foreign body;
tension pneumothorax during aspiration of pointed foreign bodies and the failure of their endoscopic removal;
deep destructive irreversible changes in a segment of the lungs in the area where the foreign body is localized (removal of the affected area of the lungs along with the foreign body in such cases prevents the development of extensive suppurative changes in the lung tissue).
Possible complications when removing aspirated foreign bodies include asphyxia, arrest of cardiac activity and breathing (vagal reflex), bronchospasm, laryngeal edema, reflex atelectasis of the lung or its segment, occlusion of the airways with exhaustion of the cough reflex and paresis of the diaphragm.
When removing pointed foreign bodies, perforation of the bronchial wall, subcutaneous emphysema, mediastinal emphysema, pneumothorax, bleeding, injury to the mucous membrane of the larynx, trachea and bronchi are possible.
Prognosis of foreign bodies in the respiratory tract
Always serious, depends on the nature, size of the aspirated foreign body, its location, timeliness and completeness of the examination of the patient and the provision of qualified medical care, and on the age of the patient. The cause of a serious condition and even death of patients during aspiration of foreign bodies can be asphyxia when large foreign bodies enter the larynx, severe inflammatory changes in the lungs, bleeding from the great vessels of the mediastinum, tension bilateral pneumothorax, extensive mediastinal emphysema, lung abscess, sepsis and other conditions.Foreign bodies of the larynx, trachea and bronchi are especially common in children under 3 years of age. This is due to the fact that children often put coins, buttons and other small objects in their mouths. When inhaled, these objects can enter the larynx and become lodged in it, or descend into the trachea and then into the bronchial tree.
The entry of foreign bodies into the larynx is characterized by the following:
Difficulty in inhaling with a feeling of lack of air (sometimes short-term cessation of breathing due to spasm of the glottis);
blue face and convulsive cough; in children, lacrimation and vomiting;
These symptoms may disappear temporarily and then reappear. The severity of respiratory disorders when foreign bodies enter the
the larynx depends on the degree of narrowing of the lumen of the larynx:
A slight narrowing is manifested by shortness of breath with difficulty (noisy) inhalation, participation of auxiliary muscles in breathing (retraction of the intercostal spaces, supra- and subclavian fossae) during exercise, in infants - during sucking, crying;
With more pronounced narrowing, difficulty breathing with the participation of auxiliary muscles is observed at rest, cyanosis of the skin around the mouth appears during exercise, and anxiety;
Life-threatening narrowing of the larynx is accompanied by severe shortness of breath at rest with difficulty inhaling and exhaling, anxiety or lethargy, cyanosis around the mouth at rest, and the appearance of cyanosis of the entire skin during exercise. If help is not provided, loss of consciousness, convulsions, and respiratory arrest occur.
The entry of foreign bodies into the trachea is characterized by the following:
Paroxysmal cough, during which a popping sound is sometimes heard caused by the displacement of a foreign body;
blue face; vomit.
Narrowing of the tracheal lumen leads to respiratory disorders, including asphyxia when the tracheal lumen is completely closed. Asphyxia can also occur when a foreign body is strangulated in the glottis.
A small foreign body that gets into the respiratory tract can quickly slip into a bronchus of the corresponding diameter.
A long asymptomatic presence of a foreign body in the bronchus is possible. Often an inflammatory process develops in the bronchus and surrounding lung tissue. If a foreign body enters the child’s respiratory tract unnoticed and the foreign body is not diagnosed by a doctor, long-term unsuccessful treatment of the inflammatory bronchopulmonary process is carried out.
If a foreign body is suspected in the larynx, trachea and bronchi, it is necessary to urgently hospitalize the victim.
Accidental introduction of various foreign bodies (most often pieces of food, water or vomit during aspiration from the oral cavity) into the respiratory tract can extremely quickly lead to asphyxia, the development of a terminal condition and death if the victim is not provided immediate assistance. In this regard, measures aimed at the speedy removal of a foreign body from the upper respiratory tract are classified as resuscitation even when the victim does not yet have impaired consciousness and satisfactory cardiac activity remains.
Measures to provide emergency assistance if a foreign body enters the respiratory tract of a conscious adult are as follows:
The victim himself must try to push the foreign body out of the respiratory tract using self-help techniques:
stop talking, call for help; hold your breath; try to take a deep breath;
if it is not possible to inhale, then the foreign body is located in the glottis or subglottic space (below the vocal folds), make 3-5 sharp coughing movements due to the residual air, which is always present in the lungs after normal unforced exhalation;
If you succeed in taking a deep breath, also make 3-5 sharp coughing movements. In this case, exhalation begins with the glottis closed; the pressure in the lower respiratory tract increases sharply, and at the moment of the subsequent reflex opening of the glottis, a stream of air coming from the glottis with very high force and speed pushes out the foreign body.
If the above methods are ineffective, use the following self-help techniques: apply jerky pressure to the pancreas with both hands or sharply lean forward, resting your stomach on the back of the chair and hanging over it. In this case, the increased pressure created in the abdominal cavity is transmitted through the diaphragm to the chest cavity, which helps push foreign bodies out of the respiratory tract (Fig. 4.29).
Rice. 4.29. Self-help techniques for foreign body aspiration: a - quickly tilt the torso forward with the upper abdomen resting on the back
chair; b - push-like pressure with both hands on the upper abdomen.
In the absence of an immediate threat to life, it is impossible to carry out techniques aimed at pushing foreign bodies out of the respiratory tract, since a foreign body from the trachea can displace and become pinched in the glottis, which leads to asphyxia (suffocation). If life-threatening respiratory disorders develop (shortness of breath with difficulty inhaling and exhaling, retraction of the yielding areas of the chest when inhaling, increasing bluishness of the skin, anxiety or lethargy, increased heart rate), before the doctor arrives, assistance to the victim should be provided by any person nearby.
Two methods of mutual assistance are used sequentially:
stand behind the victim, placing your foot between his legs. with the palm of your hand (closer to the wrist) apply 3-4 jerky blows
in the middle of the back at the level of the upper edge of the shoulder blades
Rice. 4.30. First aid for a conscious victim during aspiration of a foreign body:
a - passive removal by pressing the knee on the upper abdomen; b - delivering jerky blows with the proximal part of the palm on
interscapular area of the victim
If there is no effect, continue to stand behind the victim and grab him by the waist with both hands.
Clenching one hand into a fist, press it with your thumb to the victim’s stomach on the midline just above the umbilical fossa, but below the xiphoid process (costal angle).
Grasping the hand clenched into a fist with the hand of the other hand with a quick jerk-like movement, push the victim’s stomach in the direction from bottom to top, from outside to inside (Fig. 4.31).
Rice. 4.31. First aid for a conscious victim during foreign body aspiration: push-like pressure
with both hands on the victim's upper abdomen.
The thrusts should be performed separately and distinctly until the foreign body is removed, or until the victim is unable to breathe or speak, or until the victim loses consciousness.
If the victim has lost consciousness, then lower him to the floor along his leg and perform the following manipulation.
The rescuer's algorithm for removing a foreign body from the respiratory tract of an unconscious victim:
lay the victim on his back; if the victim loses consciousness and lacks breathing
movements, begin artificial respiration using the mouth-to-mouth method;
Perform 2-3 blows of air into the victim’s lungs, controlling the expansion of the chest;
If there is no movement of the victim’s chest during air inflation (it should be assumed that this is caused by the lumen of the respiratory tract being blocked by a foreign body), perform the following techniques:
kneel on the side of the victim lying on his back; turn the victim on his side, facing him; taking your hand
the victim and holding him with one hand in this position;
Using the palm of your second hand, apply 3-4 jerky blows to his back between the shoulder blades;
Turn the victim on his back and check whether a foreign body has entered the oral cavity
Using the palm of your second hand, apply 3-4 jerky blows to his back between the shoulder blades (Fig. 4.32);
Rice. 4.32. First aid for an unconscious victim. Applying jerky strikes with the palm of the hand to the interscapular area
the victim.
remove the foreign body from the oropharynx with your finger.
perform a triple Safar maneuver and try to take two test breaths;
If there are signs of effectiveness of trial insufflations, begin artificial respiration;
If no foreign body is found and test breaths are not effective:
sit astride the victim's thighs, resting your knees on
Place one hand with the heel of the palm on his abdomen along the midline, just above the umbilical fossa, far enough from the end of the xiphoid process.
Place the other hand on top and press on the stomach with sharp jerking movements directed towards the head 5 times
Rice. 4.34. Perform resuscitation measures while sitting over the victim.
check the oral cavity for the presence of a foreign body and remove it; attempt artificial ventilation; repeat the activities in the specified sequence until
the victim will not begin to breathe on his own until surgery is possible or until mechanical ventilation becomes available. In the absence of a pulse, an indirect cardiac massage is performed at the same time.
Attention! It should be remembered that when performing emergency care, the contents of the stomach may enter the victim’s mouth and then into the respiratory tract. To prevent this from happening, after every 5 pressures the victim’s mouth must be checked for the presence of vomit and, if necessary, removed
Method for removing a foreign body from the respiratory tract in obese people and pregnant women
If an obese victim or a pregnant woman is conscious: stand behind the victim, place your foot between his feet, as if taking a step forward, and clasp his chest with your hands exactly at the level of the armpits;
Place the hand of one hand, clenched into a fist, with the thumb on the middle of the sternum, away from the xiphoid process and costal edge, clasp it with the hand of the other hand and perform jerking movements towards yourself until the foreign body comes out or until the victim loses consciousness ;
If the victim has lost consciousness, lower him to the floor along his leg and carry out the next step.
4.24. Measures to provide emergency assistance if a foreign body enters the child’s respiratory tract
The method of eliminating airway obstruction caused by a foreign body depends on the age of the child.
Clean the upper respiratory tract with your finger blindly, since at this moment you can push the foreign body deeper;
Apply pressure on the abdomen in children under one year of age, since there is a risk of damage to the abdominal organs, especially the liver.
The rescuer’s algorithm for removing a foreign body from the child’s respiratory tract:
if a foreign body is visible, remove it using a clamp; You can help a child up to one year old by holding him in your hand.
“rider” position with the head lowered below the body (Fig. 4.35):
Rice. 4.35. Clearing the upper respiratory tract from a foreign body (Heimlik maneuver) in children under one year of age.
At the top - shifting to the right hand and patting. Below - shifting to the left hand and pressing on the chest.
Place the child on the rescuer’s arm in the “rider” position with the head lowered below the body, face down, and the back up, while supporting the head with the hand around the lower jaw. If the child is too large to be placed on the forearm, he is placed on the hip so that the head is lower than the body;
With the second hand, quickly strike four times with the proximal part (closer to the wrist) of the palm on the back between the shoulder blades;
Place the child on the rescuer’s second arm on his back (stomach up) so that the victim’s head is lower than his body during the entire reception;
With your other hand, apply four pressures to the child’s chest.
If a life-threatening condition develops in young children, the following technique can also be used:
Take the child by the legs and hold him upside down (for a short time!);
tap him on the back in this position several times (Fig.
Rice. 4.36. Method for removing foreign bodies from the respiratory tract in young children
In older children or adults, use the Heimlik maneuver - a series of subdiaphragmatic pressures (Fig. 4.36).
Rice. 4.37. Heimlich maneuver in children
After clearing the airways and restoring their free patency in the absence of spontaneous breathing, begin artificial ventilation of the lungs
4.25. First aid for fainting.
Fainting is a sudden short-term loss of consciousness caused by insufficient blood supply to the brain. Fainting can even occur in
physically strong and balanced people, weakened by intoxication, malnutrition, lack of sleep, overwork. Sometimes the cause of fainting can be standing motionless for a long time or a sudden transition to a vertical position after staying in bed for many days. In some cases, loss of consciousness is caused by a lack of oxygen in the inhaled air (for example, at high altitudes).
In addition, fainting can be caused by severe pain, emotional stress (conflict situation, type of blood), or the use of vasodilating drugs. The unconscious state is usually preceded by a sharp deterioration in health: weakness increases, nausea, dizziness, noise or ringing in the ears appear. Then the person turns pale, begins to yawn, breaks out in a cold sweat and suddenly loses consciousness. The pupils are dilated, their reaction to light is slow, the pulse is weak, breathing is rapid, the muscles are relaxed. Consciousness is usually restored quickly.
First aid should be aimed at improving blood supply to the brain and ensuring free breathing. Unbutton the victim's shirt collar, free the chest and stomach from the clothing that is constricting them. If the victim is in a stuffy, poorly ventilated room, open a window, turn on a fan, or take the unconscious person out into the air.
Position the person so that the legs are elevated by 20–30 cm (Fig.
Rice. 4.38. Position of the victim during fainting.
Wipe your face and neck with cool water. Pat the cheeks and, if possible, let the victim smell a cotton swab soaked in ammonia.
If you lose consciousness, there is always a danger of the tongue retracting or vomit getting into the respiratory tract. Therefore, when providing first aid, it is necessary, first of all, to ensure airway patency. To do this, the victim lying on his back must be turned on his side. To do this you need to do the following:
the victim from a supine position in
lying position
In this position, the supply of blood to the brain, and therefore oxygen, improves, the tongue does not sink and mucus, blood, and stomach contents do not flow into the respiratory tract. The victim regains consciousness faster. To avoid hypothermia, cover it with outer clothing or a blanket.
TEST QUESTIONS
1. What is the essence of the algorithm I SEE-HEAR-FEEL, the method of its implementation.
2. List the signs of clinical death.
3. What does the ABC algorithm mean?
4. List the measures to ensure the restoration of airway patency in adults.
5. In what cases should you not tilt the victim’s head back?
6. List the methods of performing mechanical ventilation.
7. The procedure for performing artificial respiration using the mouth-to-mouth method.
8. List the signs of effectively performed artificial ventilation.
9. The procedure for performing artificial respiration using the mouth-to-nose method.
10.Method of introducing an oropharyngeal airway.
11.Methods of using an Ambu-type breathing respirator.
The main reasons, in addition to trauma to the larynx with subsequent development of edema and asphyxia, are the following:
1) retraction of the root of the tongue (often);
2) entry of a foreign body;
H) flooding of the respiratory tract with liquid.
Let's look at each of them in more detail.
I. Recession of the root of the tongue is a fairly common and absurd cause of the unjustified death of a victim who is unconscious in a supine position.
In this case, the root of the tongue, due to gravity and due to the lack of Control from the cerebral cortex, sinks and blocks the flow of air through the oropharynx into the trachea. To restore the patency of the airways, as discussed above, you can do the following: you need to tilt the victim’s head back, creating the so-called hyperextension of the head (Fig. 17). 
Throwing back the head is achieved in various ways: the resuscitator is positioned either at the head of the victim or facing him and, holding the back surface of the neck with the fingers of both hands, gently tilts the head of the victim back, while simultaneously fixing the cervical spine; Also, throwing back the head can be done by hyperextending the head, when one hand of the resuscitator is placed on the victim’s forehead, and the second is placed under the neck from the inside (or holding the lower jaw) and movements of the hands are made in mutually opposite directions.
You can also use a cushion from improvised means (scarf, muffler, headdress, etc.), which is placed either under the victim’s neck or under his shoulder blades. This technique in most cases allows the root of the victim’s tongue to move away from the posterior wall of the larynx (Fig. 18). 
In order to find out whether the victim’s airways are passable or not, it is necessary to carry out the so-called test diagnostic exhalation (TDB) - i.e., following the mechanical ventilation technique, try to breathe into the victim’s airways 2-3 times, feeling the patency of the airways for the jet air (no resistance when inhaling) and visually checking the rise of the chest (Fig. 19).
However, in almost 20% of people, due to the individual anatomical features of the neck structure, maximum extension of the head does not provide a sufficient degree of patency of the upper respiratory tract. And therefore, if the PDV fails, it is guaranteed to eliminate the retraction of the tongue root if you carry out the so-called Safar triple move (named after the American resuscitator who developed this method), which includes the following three steps
Throwing back the head;
Moving the lower jaw forward;
Opening the mouth.
In this case, the resuscitator can be located either at the head of the victim or facing him.
To move the lower jaw forward, you need to place four fingers of each hand behind the corners of the lower jaw and, resting your fingers on its edge, push it forward so that the lower teeth are in front of the upper teeth.
Moving the lower jaw forward creates conditions for guaranteed movement of the root of the tongue from the posterior wall of the larynx, thereby eliminating one of the most common causes of airway obstruction.
If in a real situation for some reason it is impossible to perform the “triple technique” in the classical way, then tongue retraction can be eliminated using any of its varieties or modifications: the hook method, in which the resuscitator’s thumb is placed behind the victim’s front lower teeth (second the hand fixes the head by the forehead) and pulls the lower jaw forward (Fig. 20).
Also, the advancement of the lower jaw forward can be achieved with the victim’s head thrown back and fixed back, by grasping his lip and pulling it anteriorly.
It would be more convenient and reliable to eliminate the sunken root of the tongue by using an air duct - a special device that follows the contour of the human oropharynx for artificial ventilation of the lungs. In car first aid kits, as well as in rescue packs, there should be three types of air ducts for the main age categories: children, adolescents and adults.
II. Ingestion of a foreign body into the respiratory tract. As is known, the act of inhalation is an active process, in which the surrounding air is “sucked” into the respiratory tract and, ultimately, the lungs of a person (Fig. 23);
During the act of swallowing (liquids, food), the entrance to the respiratory tract is closed with a special device - a tongue located below the root of the tongue and directly connected to it. Therefore, a foreign body or foreign object, being in the human oral cavity, can enter the respiratory tract when the tongue simply does not have time to block the entrance to it. This situation is possible when eating food, when a person coughs, sneezes, laughs, talks, or simply mechanically consumes food while thinking about something. If a foreign body enters the victim’s respiratory tract, he will cough, clutch his throat, and be motorically and emotionally restless (Fig. 24).
In this case, you cannot waste a second, since within 1-2 minutes the victim may lose consciousness due to sudden blockage of the airways and developed hypoxia (oxygen starvation) of the brain. Therefore, if it is recorded that a foreign body has entered the victim’s respiratory tract, it is necessary to immediately begin decisive and competent actions (Fig. 25). It makes sense to ask a short and informative question to the victim (for example, “Are you choking?” or “Do you need help?”) and, having received an affirmative answer (with a nod of the head, for example), perform the following actions:
1) ensure stability for yourself and the victim (position yourself correctly on the side of the victim, grab the shoulder farthest from you);
2) slightly tilt it forward and make 5-6 sharp blows with an open palm between the shoulder blades (Fig. 26). The purpose of this method is to specifically shake the difficult cell, which allows the foreign body to either change its position inside the upper respiratory tract or move in one direction or another, thereby increasing the chance of saving the victim.
In a small child, a foreign body is removed by placing it in a supine position (on the hand or knee of the resuscitator) and gently tapping the palm (or its edge) on the interscapular area (Fig. 27). If this method does not bring the expected success (the victim answers the question “Can you breathe?” in the negative or does not answer at all), the following steps should be taken:
1) provide stability for yourself and the victim (correctly position your leg, standing behind the victim);
2) clasp it with your hands around the waist and, placing the fist of one hand at a point located above the navel and below the sternum, covering it with the palm of the second hand (Fig. 28), apply push-like pressure on the stomach of the victim of the navel towards the diaphragm (Fig. 29).
When performing this method, increased pressure is created in the abdominal cavity, which is transmitted through the diaphragm to the chest cavity, and, thanks to the residual air always present in the lungs, the foreign body is removed from the victim’s respiratory tract, similar to the principle of operation of the pneumatic mechanism. This method is called the Heimlik maneuver (named after the resuscitator who first successfully used it), or the lock method.
The Heimlik maneuver should not be used on children under 1 year of age or pregnant women!
But if for some reason the victim has lost consciousness (the above methods were ineffective, assistance was not started in a timely manner, or you are faced with the fact of an existing loss of consciousness as a result of a foreign body entering the respiratory tract), then you can try to remove the foreign body with your fingers, but at the same time being extremely careful not to push a foreign object deeper into the throat; To do this, press the victim’s tongue and lower jaw with your thumb and forefinger, lifting the chin up. In this case, the tongue will move away from the back wall of the pharynx; which will make it possible to see an object stuck there that was not noticed before (Fig. 30).
With one or two fingers of one hand, try to pick up the foreign object from behind, like a hook, and carefully remove it (Fig. 31). If you were unable to pull out the object with your fingers, then you need to perform the following steps:
1. Turn the victim on his side, facing the person providing assistance (to control the result), and perform sliding blows with an open palm between the shoulder blades (Fig. 32).
2. Lay the victim on his back, turn his head to the side, place the base of the palm in the subdiaphragmatic area and, covering it with the other hand, apply sharp pressure to the victim’s stomach (Fig. 33). This method simulates the Heimlik maneuver, and therefore it is also not applicable to children under 1 year of age.
3. Lay the victim on his stomach, place either hand (to create support) under the chest, tilt the victim’s head back, fix it with your hand behind the forehead; make sliding sharp blows with an open palm between the shoulder blades.
Rice. 55. Triad of indicators that are indications for cardiopulmonary resuscitation
§2. ARTIFICIAL RESPIRATION TECHNIQUE
Artificial respiration is used when breathing stops.
Due to respiratory arrest, the supply of oxygen to the brain stops and after 5-7 minutes the cells of the cerebral cortex die, so techniques to restore breathing must begin immediately!
Modern artificial ventilation using the “donor” method has three advantages over other previously used methods based on changes in chest volume, namely:
a) in the exhaled air of the “donor” the oxygen content reaches 17%, which is sufficient for absorption by the victim’s lungs;
b) exhaled air contains up to 4% carbon dioxide, which, when entering the victim’s body, excites the respiratory center and stimulates the restoration of independent breathing;
c) compared to other techniques, it provides a larger volume of air entering the victim’s lungs.
The only drawback of the “donor” method of artificial ventilation of the lungs is the presence of a psychological barrier - it is difficult to force yourself to breathe into the mouth or nose of another, sometimes a stranger and stranger, especially if he has previously vomited. This barrier must be overcome in order to save the life of a dying person.
Before starting artificial respiration it is necessary (Fig. 56):
1. Place the victim in an appropriate position: lay him on a hard surface, place a cushion of clothing under his shoulder blades and unfasten the clothing that is making breathing difficult. Tilt your head back as much as possible.
Rice. 56. Preparing for artificial respiration
2. Move the lower jaw forward (a), then move your fingers to the chin and, pulling it down, open your mouth; with the second hand placed on the forehead, tilt your head back (b).
3. Make sure that the airway is open, for which you need to tilt your head back, lightly pressing the palm of one hand on your forehead and holding your neck from below with the other hand;
4. If the victim’s jaws are tightly clenched, they should be carefully moved apart with some flat object (spoon, screwdriver, knife, etc.) and a roll of bandage or cloth should be placed between the teeth;
5. Examine the oral cavity with a finger wrapped in a scarf or gauze, free it from vomit, mucus, blood, sand. Removable dentures need to be removed. If the tongue is stuck, turn it out with the same finger.
6. Conduct a test blowing of air into the mouth or nose.
All these preparatory manipulations must be carried out quickly, but carefully and carefully, since they can worsen the already critical condition of the victim.
If the victim's chest rises when air is inhaled, immediately begin artificial respiration.
To perform artificial respiration, the rescuer stands on either side of the victim. Apply a gauze pad or handkerchief to the victim’s mouth or nose, depending on the method of artificial respiration.
2.1.Mouth-to-mouth artificial respiration method
Algorithm of actions when performing mouth-to-mouth artificial respiration:
1. Pull the lower jaw anteriorly and downward with one hand, and pinch the nose with the fingers of the other hand.
2. Constantly monitor the position of the head (it should be thrown back), ensuring patency of the airways and non-retraction of the tongue;
3. Stand on the right side. With your left hand, holding the victim’s head in an tilted position, at the same time cover the nasal passages with your fingers. With your right hand you should push your lower jaw forward and upward. Use your thumb and middle finger to hold the jaw by the zygomatic arches.
4. Use your index finger to open the oral cavity.
5. The tips of the ring finger and little finger (4th and 5th fingers) control the pulse beat on the carotid artery.
6. Bend over to the victim, press your lips tightly to his open mouth and exhale smoothly, observing its effectiveness in straightening the chest (Fig. 57).
Rice. 57. Artificial ventilation of the lungs using the mouth-to-mouth method.
7. After straightening the chest, remove the mouth from the victim’s lips and stop squeezing the nose to ensure the air escapes from the lungs on its own.
The volume of air blown into an adult is 0.8-1.2 liters.
For infants, only short blows are used (to avoid rupture of the lungs), while the volume of blown air is equal to the volume of the buccal space with inflated cheeks).
Inflation of air should be carried out every 5 seconds for adults (12 times per 1 minute), for children every 3 seconds (20 times per 1 minute).
The intervals between breaths and the depth of each breath should be the same.
2.2. Mouth-to-nose artificial respiration method
Used when artificial respiration through the mouth is not possible (injury to the tongue, jaw or lips).
The position of the victim, the frequency and volume of air blown in, and the preliminary treatment measures are the same as with mouth-to-mouth artificial respiration. The victim's mouth should be tightly closed. Insufflation is performed into both nostrils. After completing the insufflation, give the victim the opportunity to exhale passively (Fig. 58).
Rice. 58. Artificial ventilation of the lungs using the mouth-to-nose method.
Cover your mouth with any clean cloth beforehand for hygienic purposes. At the moment of inflation, use your eyes to control the rise of the chest. The frequency of respiratory cycles is 12-15 per 1 min, i.e. one blow in 5 seconds.
When signs of spontaneous breathing appear in the victim, artificial ventilation of the lungs is not stopped immediately, continuing until the number of spontaneous breaths corresponds to 12-15 per minute. At the same time, if possible, synchronize the rhythm of inhalations with the recovery breathing of the victim.
2.3. Rules for artificial respiration using “mouth–S-shaped tube–mouth” (air duct)
Algorithm of actions when performing artificial respiration using an S-shaped tube (air duct):
1. Bend your head, open your mouth and insert the tube in the direction opposite to the curvature of the tongue and upper palate (Fig.).
Rice. . Carrying out artificial respiration using an S-shaped tube (air duct)
2. Having passed to the middle of the tongue, turn the S-shaped tube by 180 0 and advance to the root of the tongue.
3. Inject air .
4. Take a deep breath, grasp the end of the tube protruding from the mouth and forcefully blow air into it, ensuring a tight seal between the victim’s mouth and the tube.
5. Exhale.
If, with correctly performed techniques for restoring airway patency, it is not possible to blow air into the victim’s lungs, the presence of a foreign body in the respiratory tract should be assumed. You should immediately begin removing the foreign body from the respiratory tract!
§3. REMOVAL OF FOREIGN BODIES FROM THE UPPER RESPIRATORY TRACT
Obstruction of the upper respiratory tract can be suspected if:
à the victim is conscious, suddenly loses the ability to speak, breathe or cough and/or gives a signal that he is suffocating (for example, convulsively clutching his neck);
à in an unconscious victim, despite the apparent patency of the airways, the lungs do not inflate;
à Inhalation of a foreign body was confirmed.
3.1. Removal of a foreign body with obstruction of the upper respiratory tract
For victims with blockage of the upper respiratory tract by a foreign body, the following actions must be taken (Fig. 59):
1. If the victim is in consciousness, ask him about the presence of suffocation. Try to convince him to remove the foreign body yourself - cough and spit out. If this is not possible, the Heimlich maneuver should be used - compression (pushing) of the abdomen until success is achieved or until the victim loses consciousness.
2. To the victim unconscious must be given a horizontal position. If you suspect the presence of a foreign body, open your mouth. Use one or two fingers wrapped in cloth to clean your mouth and throat.
3. Using your index and middle fingers, remove the foreign liquid substance.
The liquid foreign substance is removed by turning the patient's head to the side. A victim with a suspected spinal injury is not recommended to turn his head to the side or tilt it forward, so as not to aggravate the damage to the spinal cord. If you still need to turn the victim’s head to one side, then you should turn the patient himself to one side and, together with an assistant, support his head, neck and chest in the same plane.
Solid foreign bodies are removed from the pharynx using the bent index finger or the index and middle fingers like tweezers.
Rice. 59. Removal of a foreign body from the respiratory tract: a, b - passive removal; c - position of the victim for active removal of the foreign body.
3. Then try ventilate the lungs. Slow, strong inflations can push air past the foreign body. During ventilation attempts, advancement of the mandible may help relieve obstruction by expanding the larynx and nasopharynx.
4. If ventilation is impossible, do 6 -10 compressions (pushes) of the abdomen or chest followed by cleansing the oropharynx with a finger and repeating the attempt at ventilation.
5. If this does not help, turn the patient on his side and apply 3 -5 hits on the back, then clear the oropharynx with your finger and attempt ventilation.
6. If this does not work, then try again abdominal compression-digital examination-ventilation-blows to the back-digital examination-ventilation until you succeed.
This must be done quickly!
3.1.a. Back blows to remove a foreign body from the upper respiratory tract of a victim who is in a standing or sitting position and has not lost consciousness
Produced as follows ( rice. 60):
ð on the patient’s back in the area between the shoulder blades with the lower part of the palm, 3-5 sharp blows are applied several times;
ð if possible, tilt his head as low as possible to increase the applied force of the blow;
ð if signs of suffocation appear (the victim grabs his neck), ask him to cough and spit out sputum.
Rice. 60. Blows to the back to remove a foreign body from the respiratory tract in victims who have not lost consciousness
3.1.b. Impacts on the back of a victim with complete blockage by a foreign body in an unconscious victim who is in a lying position
Produce as follows (Fig. 61):
ð the victim is given a position on his side so that his face is turned to the person providing assistance, and his chest is opposite the knees of the resuscitator;
ð in the area between the shoulder blades, the victim is given 3-5 sharp blows with the lower part of the palm.
Rice. 61. Blows to the back to remove a foreign body from the respiratory tract in victims who have lost consciousness
3.1.c. Chest compression in pregnant or obese victims
Used in pregnant or obese victims chest compression, which is less dangerous than blows to the back/
Algorithm of actions:
1. The person providing assistance should stand behind the victim and wrap his/her arms around him/her at chest level.
2. Place your fist with the thumb side towards the middle of the sternum, avoiding pressing on the xiphoid process and ribs.
3. Clasp your fist with your other hand.
4. Perform 6-10 chest compressions.
5. Clean the oropharynx with your finger.
6. Try to inflate the lungs.
7. Repeat again 6-10 chest compressions, etc. until ventilation can be achieved or until a qualified assistant with appropriate equipment arrives to remove the foreign body under visual control.
3.1.g. Compression of the abdomen at the height of inspiration, if the victim is conscious
Algorithm of actions:
1. Stand behind the victim and grab his (her) waist (Fig. 62).
2. Make one hand into a fist.
3. Place your fist on the victim’s stomach with the side where the thumb is located, along the midline of the abdomen, slightly above the navel and below the xiphoid process;
4. Holding your fist tightly with your other hand, press your fist into your stomach with quick upward pressure.
Rice. 62. Abdominal compression
Pressures are repeated, each of which is separate, in the form of clear movements.
The person providing assistance must be prepared to catch the victim if he or she loses consciousness. If this happens, gently lower him/her to the floor and lay him/her horizontally, face up.
3.1.d. Compression of the victim's abdomen at the height of inspiration if he is unconscious
Algorithm of actions:
1. Place the victim on his back.
2. Clean the oropharynx with your finger and try to remove the foreign body.
3. Try ventilation.
If there is no effect, compression of the abdomen is performed in the subdiaphragmatic area.
Algorithm of actions:
1. Kneel on one side or the other of the victim or above the victim, with your legs spread wide (riding on the victim’s hips);
2. Place the lower part of the palm of one hand on the victim’s stomach along the midline, slightly above the navel and below the xiphoid process;
3. Place the second hand on top of the first and press on the stomach with a quick movement up the midline.
Do not apply pressure to the right or left of the midline.
3.2.First aid for a child if a foreign body enters the respiratory tract
The child is suffocating and cannot scream, makes whistling noises, tries in vain to cough, and the face begins to turn blue.
If another person is nearby, have one of you call for emergency help while the other begins the first aid techniques described below. If you find yourself alone, call emergency services if it can be done quickly. Then proceed with the first aid techniques described below.
Do not take unnecessary action if the child is coughing, breathing or screaming.
Do not try to grab an object stuck in the child's throat with your fingers: you can push it even deeper.
If the child stops breathing, do not begin resuscitation until the airway is clear.
Do not attempt the following first aid techniques unless you are absolutely sure that your child is choking. Start them only when the child loses the ability to cough and scream, or when the coughing and screaming suddenly weaken.
Even if you managed to clear the child’s airways from the foreign body and the child seems completely healthy to you, consult a doctor.
3.3. Technique for clearing the airways of a child when a foreign body enters
Algorithm of actions:
1. Place the baby face down on your arm so that his chest is in your palm, and clasp the lower jaw with your thumb and forefinger.
2. Sit down and rest your hand with the child on your thigh or knee.
3. Lower the child’s head below his body.
If the child has only partial airway obstruction and is conscious and able to breathe while in an upright position, do not lower his head.
4. Within 5 seconds, with the palm of your free hand, apply 4 sharp blows to the back between the shoulder blades (Fig. 63a).
5. Transfer the child to the other hand, face up.
6. Place your hand on your thigh or knee.
7. Keep the child's head lower than his body.
8. Place two fingers of your free hand on the baby’s sternum just below the nipples (Fig. 63b).
9. Within 5 seconds, sharply press your fingers 4 times on the sternum so that the sternum drops 1.5-2.5 cm each time (Fig. 63d).
10. Place the child face down on the other hand again and give him 4 more blows to the back.
Continue alternating the two techniques (4 blows to the back, 4 pressure to the sternum) until the foreign body is expelled or until the doctor arrives.
Do not use abdominal compressions on small children or newborns.
Rice. 63. Clearing a child’s airways from a foreign body
§4. TECHNIQUE OF INDIRECT HEART MASSAGE
Cardiac massage is a mechanical effect on the heart after it has stopped in order to restore its activity and maintain continuous blood flow until the heart resumes functioning. Indications for cardiac massage are all cases of cardiac arrest. The heart can stop contracting for various reasons: spasm of the coronary vessels, acute heart failure, myocardial infarction, severe trauma, lightning or electric shock, etc.
Signs of sudden cardiac arrest:
Q severe pallor;
Q loss of consciousness;
Q disappearance of the pulse in the carotid arteries;
Q cessation of breathing or the appearance of rare, convulsive breaths;
Q pupil dilation.
There are two main types of heart massage: indirect, or external (closed), and direct, or internal (open).
Indirect cardiac massage is based on the fact that when pressing on the chest from front to back, the heart, located between the sternum and the spine, is compressed so much that blood from its cavities enters the vessels. After the pressure stops, the heart straightens and venous blood enters its cavity (Fig. 64).
Every person should master indirect cardiac massage. In case of cardiac arrest, it should be started as soon as possible. The most effective cardiac massage is started immediately after cardiac arrest.
The effectiveness of blood circulation created by cardiac massage is determined by 3 signs: the occurrence of pulsation of the carotid arteries, constriction of the pupils and the appearance of spontaneous breaths.
Algorithm of actions when performing indirect cardiac massage:
(Fig. 65, 66):
1. Lay the victim on his back on a hard surface.
2. Stand to the left of the victim.
3. Place the palm of one hand on the lower part of the victim’s sternum (2 fingers above the edge of the xiphoid process).
4. Place the palm of your other hand on top of it.
The fingers of the first hand should be slightly raised and not put pressure on the victim’s chest.
5. With a vigorous movement of the arms, straightened at the elbow joints, press on the sternum to a depth of 4-5 cm in adults and 1.5-3 cm in children.
6. After each pressure, give the chest the opportunity to straighten on its own, without removing your hands from the chest.
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Rice. 66. Position of the patient and those providing assistance during chest compressions
Perform chest compressions with frequency 100 movements in 1 minute!
Signs of cardiac recovery:
ð the appearance of a pulse in the carotid artery;
ð reduction of pallor or bluishness of the skin.
When a pulse appears in the carotid artery, compression of the chest is stopped, but one must be prepared to resume it at any time, since repeated cardiac arrests are not uncommon.
Methods for removing foreign bodies from the oral cavity: solid foreign bodies from the oral cavity are removed with two fingers, like tweezers, or with improvised means: a napkin, a scarf, a towel, which is used to wrap 2 fingers and insert them into the oral cavity.
Removal of various types of liquids aspirated into the respiratory tract is carried out mainly by creating a drainage position for the victim. In case of drowning, aspiration of blood, regurgitation of stomach contents (regurgitation is the spontaneous outflow of liquid contents from the stomach and its possible entry into the respiratory tract - aspiration), the victim is placed so that the head end of the body is 30-40 0 lower than the foot end. To do this, you can take advantage of the unevenness of the soil, or dig a hole in the sand where you can tilt the victim’s head. In small children, drainage can be accomplished by lifting them upside down by their legs.
Methods for removing foreign bodies from the larynx: a foreign body can be removed from the larynx using several techniques, the essence of which is a sharp increase in intrapulmonary pressure and the release of an additional 0.35-0.94 liters of air from the lungs, with which the foreign body is removed.
A). A blow to the back. The resuscitator performs 3-4 taps with the base of the palm in the interscapular area along the spine. The second hand is placed on the sternum.
B). Chest compression method. For victims who are in a standing or sitting position and have not lost consciousness, the resuscitator covers the chest with both hands at the level of the lower third of the sternum, then performs 4 energetic compressions of the chest “towards oneself”. In patients lying down and unconscious, this method is not applicable.
IN). Abdominal compression method. The victim lies down, the resuscitator kneels on one side or another of the victim. One hand, clenched into a fist, is inserted into the epigastric region in the direction of the diaphragm (without pressing on the spine), then the first hand is struck with the fist of the second hand 3-5 times. Less traumatic (in pregnant and obese victims) are chest compressions in the lower 1/3 of the sternum, which are carried out similar to external cardiac massage.
All of these methods can also be used for laryngospasm. The effectiveness of these methods depends on the size and shape of the foreign body, as well as its location. They do not guarantee absolute success! However, when establishing the fact of aspiration of a foreign body in a patient, conscious or unconscious, with severe cyanosis, ineffective cough, complete obstruction (lack of cough), any procedure that may be effective is justified, since it is an act « despair».
· Restoring airway patency is carried out using a number of techniques that allow you to move the root of the tongue away from the back wall of the pharynx. The most effective, simple and safe for the patient are the following:
· The method of throwing back the head and lifting the chin with two fingers. One palm is placed on the patient’s forehead, with two fingers of the other they lift the chin, tilting the head back and pushing the lower jaw forward and up. Thus, a mechanical obstacle to the air flow is eliminated;
· When clearing the airway in a patient with a suspected injury to the cervical spine, it is necessary to use advancement of the lower jaw without extension of the head in the cervical spine. The resuscitator is placed on the side of the victim's head. The bases of the palms, which are placed in the zygomatic area, fixes the head from possible displacement to the surface on which assistance is provided. II-V (or II-IV) with the fingers of both hands grabs the branch of the lower jaw near the auricle and pushes it forward (up) with force, shifting the lower jaw so that the lower teeth protrude in front of the upper teeth. Use your thumbs to open the victim’s mouth. The horizontal ramus of the mandible should not be grasped, as this may lead to the mouth closing.
5. Take two rescue breaths
· In all cases, it is preferable to use manual or automatic respirators. Try to avoid hyperventilation. The volume of inhaled air should be within 6-8 ml/kg of ideal body weight for an adult patient. Respiration rate 8-10 per minute;
· If there is no respirator, it is necessary to ensure the tightness of the airways during forced inhalation.
To perform artificial pulmonary ventilation (ALV):
ü Pinch the victim’s nose with the thumb and forefinger;
ü Having tightly clasped the patient’s lips, make two slow, smooth
forced inhalation, lasting up to 2 seconds;
ü If the air does not pass into the lungs during forced breaths (there is no excursion of the chest), try again - open the airways again, take 2 breaths. If the repeated attempt is unsuccessful, the oral cavity is sanitized. If after sanitation forced breaths remain unsuccessful, they move on to removing the foreign body.
· When using the mouth-to-mouth, mouth-to-nose method, perform forced inhalation slowly, lifting the lips from the victim’s face between breaths to perform passive exhalation. It is advisable to use expiratory devices “mouth – device – mouth”, “mouth – device – nose”;
· If the resuscitator is unwilling or unable to perform artificial respiration, he should perform only chest compressions.
