Handling an Airway Obstruction Is the First and Most Important Step
If you've taken a CPR course, you know about the ABC method, the mnemonic for treating a medical emergency. In the ABC method, each component relies on the one preceding it. But of the three-airway, breathing and circulation-the first and foremost step is airway. If this is not first assessed and managed, the other components will be futile.
The cornerstone of all acute patient management is the respiratory system. But a respiratory emergency, with its rapid onset and the minimal time in which effective therapy must be initiated, can be frightening. There are a number of respiratory problems which can occur on board and, while some are just as common as on land, management of these can be complicated by the maritime environment and the inability to obtain advanced medical care.
In three-part article, I will discuss airway obstruction, asthma, allergic reactions, hyperventilation, chest trauma resulting in rib fractures and the relatively infrequent condition of spontaneous pneumothorax. With the exception of the last item, these conditions can generally be managed without the need for supplemental oxygen, which is not usually included in even the advanced medical kits. (See "The On-Board Medical Kit I and II.")
Airway obstruction occurs when the air passage is blocked by an object, often a small toy or a deflated balloon in a child or a piece of food in an adult. The tongue can even be an obstruction, as when it falls to the back of the throat of an unconscious person. The belief that the patient has swallowed his tongue is actually just the tongue occluding the airway. This is why opening the airway is always the first thing to do when assessing an unconscious person.
The term Café Coronary is a respiratory arrest occurring as a result of airway obstruction. The term also describes the relative similarity in presentation between a choking victim and a heart attack. These attacks often occur while the victim is eating out at a restaurant.
Alcohol is often a contributing factor in an airway obstruction. While eating and imbibing with friends, we're usually not thinking about our chewing and swallowing. People talking and laughing while eating can easily inhale a solid chunk of food. It will be immediately apparent whether the problem is an airway obstruction or a heart attack. Ask the person what is wrong. If he can't speak or make a sound, an airway obstruction is the likely culprit. Since a respiratory arrest can rapidly lead to cardiac arrest, immediate action is required.
The treatment of choice is the Heimlich maneuver. Since you have probably taken a basic CPR course (if you haven't, I strongly recommend that you do), I won't go into the details of the Heimlich. But it's worth reminding that the Heimlich should not be performed on someone who is coughing or who can speak. The technique will be ineffective and may even cause greater problems. As with almost all emergencies we have discussed so far in this column, prevention is the best treatment. Mom's admonitions to "Chew your food" and "Don't talk with your mouth full!" take on renewed meaning in this context.
Asthma is another respiratory emergency that deals with the inability to move air efficiently. Asthma (as defined by the National Asthma Education and Prevention Program) has the following characteristics: 1) airway obstruction or narrowing that is fully or incompletely reversible either spontaneously or with treatment, 2) airway inflammation, and 3) airway hyper-responsiveness to a variety of stimuli.
Asthma is not an insignificant problem in the U.S. as it accounts for close to 2 million emergency-room visits per year. It is estimated to cost more than $6 billion. An asthma attack results from airway constriction (bronchospasm) in response to a stimuli. There is also increased sputum production. These factors impede the flow of air in and, particularly, out of the lung. This causes the lung to become hyperinflated. The movement of air through these narrowed and mucus-clogged pathways gives an asthma attack its characteristic wheezing condition.
Since the airways are hyperactive, only a small stimulus can precipitate an attack. Some potential stimuli in the sailing environs would be irritants like: smoke, diesel exhaust, paint and varnish fumes, or dust from sanding decks or bottom paint. A respiratory infection or exercise can also bring on an attack. It is important to remember that, in the adult population, asthma sufferers usually have their medication with them and will know what to do. If the attack does not end fairly quickly, it will be essential to reach medical help as soon as possible.
Treatment for an asthma attack centers on limiting the symptoms and halting the progression of the attack. The primary treatment for an attack is inhaling medication with an inhaler or puffer. This small device delivers a specific, metered dose of medication directly to the lungs as the patient breathes in. A spacer should be used with an inhaler when it's difficult for some patients to master a puffer. This hollow chamber is attached to the inhaler and as the patient inhales, the medication is released into the enclosed space.
The advantage is that the exact timing of the inhalation and the release of the drug are no longer necessary and the patient will receive a greater concentration of the medication. The drug is a bronchodilator (airway expander) that goes directly to the lung and relaxes the smooth muscle spasm in the airways. These medications, known as beta-agonists, are the first-line choice for acute attacks. There are also a variety of both inhaled and oral agents that are used for the long-term management of asthma. Some act to reduce the reactivity of the airways, while others limit the production of inflammation-causing agents (inflammatory mediators).
If the attack is prolonged and does not respond to the inhaled medication, epinephrine (adrenaline) can be injected directly under the skin. Epinephrine is an extremely potent bronchodilator and can be rapidly administered as a subcutaneous injection (epinephrine 1:1000 concentration, 0.3-0.5ml SQ). Epinephrine has a constellation of other effects on the body. Its use should be limited to only the most severe attacks that are unresponsive to inhaler therapy. Other intravenous medications are also available, but if the attack does not rapidly respond to the initial inhaler therapy, you should be heading toward the nearest port and notifying the authorities.
|Medical Books for the Sailor|
There are a number of medical books written expressly for the sailor's on-board use. Here is a list of sailing medical books that are currently in print.
The Onboard Medical Handbook: First Aid and Emergency Medicine Afloat, by Paul G. Gill, International Marine, published November 1996.
Your Offshore Doctor: A Manual of Medical Self-Sufficiency at Sea, by Michael Beilan, Sheridan House, published November 1996.
Advanced First Aid Afloat, by Peter F. Eastman, Cornell Maritime, published August 1995.
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