Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

37

Section II: Critical Body Systems

The ability to swallow saliva may be impaired, causing the patient to drool. Talking may be dif- ficult or impossible. With a partial obstruction, the first rule of treat- ment is, “Do no harm.” If the patient is not yet in respiratory failure, they will be making their own efforts to dislodge an object or reposition the airway. Except for rolling a patient to drain fluids, any attempt by you to remove an obstruc- tion carries the risk of making it worse. The ideal treatment is urgent evacuation to advanced life support and surgical care.

inhaled or injected epinephrine. The dose is the same as discussed in the protocol for anaphylaxis and asthma detailed later in this text. Lower Airway Constriction Spasm, swelling of the mucous membrane lining, or the accumulation of mucus or pus can cause narrowing of the bronchi and bronchioles, which are the tubes of the lower airway. This is what happens in asthma, bronchitis, and anaphylaxis. The constriction inhibits the movement of air in and out of the alveoli. In the initial stages of lower airway constriction, the patient may have a more difficult time exhaling than inhaling. This can render positive pressure ventilation ineffec- tive, although the rest of the generic treatment for respiratory distress is certainly useful.

Upper Airway

General Principles

6

nasopharynx

tongue

General Principles

MOI: • Swelling (anaphylaxis) • Spasm (asthma) • Infection (bronchitis) Assessment: • Respiratory distress; forced expiration, wheeze, cough • Exposure and sx of anaphylaxis • History of asthma or illness Treatment: • PROP Lower Airway Constriction

9

epiglottis thyroid cartilage vocal cord cricoid cartilage

larynx esophagus

trachea

©2018WMA

When the patient is in respiratory failure or arrest, immediate basic life support techniques are used to clear the airway (see the basic and advanced life support chapter). At this point, the benefit is obvious, and you have nothing to lose by trying. In cases where a foreign object is removed you may certainly take credit for the save. Remember, though, evacuation is prudent if swelling is anticipated, such as after a prolonged obstruction or a burn from hot food. Airway obstruction due to swelling from burns, trauma, or infection is the most difficult to man- age in the field. A partial obstruction carries the anticipated problem of complete obstruction, which can develop quickly in some cases. The patient will naturally find the best airway position, and there is little else you can do to improve on it. A patient with airway obstruction due to swelling is best evacuated urgently to advanced life sup- port and surgical care. In a desperate situation with progressive airway obstruction respiratory failure, you may be able to buy some time with

• Treat the cause (asthma, anaphylaxis) • Evacuate to Advanced Life Support

*

©2018WMA

In severe constriction, inspiration and expira- tion are often prolonged with pronounced wheez- ing and a cough. Sometimes the lower airway noise is loud enough to hear from a distance. Other times you may need a stethoscope or an ear to the patient’s chest. Oxygen saturation will measure below normal. Lower airway constriction by any mechanism is a serious problem when it causes respiratory dis- tress. Your initial response should be PROP; but the ideal treatment is medication. Bronchodilators, such as nebulized albuterol may be helpful in cases of bronchitis or smoke inhalation. Antibiotics may be added for infection. With a history of asthma or anaphylaxis, you can follow the Wilderness Protocols for the emergency use of epinephrine