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AIRWAY MANAGEMENT AND FBAO

Dr. Prabowo Wicaksono Y.P., SpAn Dr. Wignyo Santosa, SpAn BAGIAN/ SMF ANESTESI FK UNISSULA/ RSI SULTAN AGUNG 2008

AIRWAY MANAGEMENT

Apa ke-khusus-an penanganan pasien gawat darurat ?

Waktu untuk bertindak : terbatas Data dasar untuk bertindak : terbatas

Konsep berfikir yang sederhana Tindakan yang sistematik Ketrampilan yang memadai
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PASIEN TRAUMA/ NON TRAUMA

LIFE SUPPORT Resusitasi Stabilisasi

A = airway B = breathing C = circulation D = disability

TERAPI DEFINITIF/ SPESIALISTIK

Life support

A B C D
Quick Diagnosis Quick Treatment A= Airway, bebaskan jalan nafas, Lindungi C-spine B= Breathing, beri bantuan nafas, tambah oksigen C= Circulation, hentikan perdarahan, beri infus D= Disability/SSP, cegah TIK Pasien obstruksi (A) atau apneu (B) akan mati dalam 3-5 menit Pasien shock berat (C) akan mati dalam 1-2 jam Pasien coma (D) akan mati dalam 1 minggu

Bagaimana mengamankan jalan nafas?


Intubasi trakea = Gold standard

?
Bagaimana pendapat para ahli anestesiologi? 1. Intubasi oleh bukan ahli dapat timbulkan trauma 2. Resiko: hipoksia fatal/ secondary brain damage, vagal reflex bradikardi berat, cardiac arrest 3. TIK naik hanya dapat dicegah dengan obat-obatan 4. Tidak semua fasilitas kesehatan dilengkapi peralatan untuk intubasi trakea
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Trauma wajah berat, dengan potensi obstruksi airway Intubasi trakea ? Setuju
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Obstruksi airway karena lidah terdorong ke hipofaring, lebih sering terjadi.

Intubasi trakea ?
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Pasien mati karena hipoksia, bukan karena tidak terpasang endotrakeal tube (ETT)

Tidak semua masalah airway harus diselesaikan dengan intubasi trakea

Banyak Cara Mengamankan Jalan Nafas


1. Basic/ Manual

A. Chin Lift

B.Jaw Thrust
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C. Head tilt Chin lift


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2. Airway (Alat Bantu Nafas) Dasar

A. Oropharyngeal Airway (OPA) / Guedel

B. Nasopharnygeal Airway (NPA)

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3. Advanced Airway

A. Endotrakeal Tube (ETT)

B. Laryngeal Mask Airway (LMA)

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C. Combitube

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Airway
Menilai jalan nafas

Kesadaran ( the talking patient) Look, Listen and Feel Look


Agitasi (hipoksia)/ tampak bodoh (hiperkarbia) Sianosis Retraksi Accessory respiratory muscle

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Listen
Snoring Gurgling Stridor Hoarness

Feel
Trachea location

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Patients talks clearly ?


Airway is adequate Management: observation and selective intubation Special consideration in : Maxillofacial injury Soft-tissue injury of the neck Facial or neck burns

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Patient is hoarse ?
Laryngeal injury Larngeal/ tracheal burn Management: Evaluate and perform (if necessary): Intubation Surgical airway

Patient cannot respond ?


GCS < 8 Obstruction due to: Tongue Aspiration Foreign body Maxillofacial injury Neck Injury Cyanosis Rocking respirations
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Decreased or no air exchange Face or neck crepitus Neck hematoma or swelling Management : Simple management manuevers: Suction Chin lift Jaw thrust Intubation

Caution !! Protect C-Spine During Airway Management


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Airway Definitive
Pipa dalam trakea dengan balon (cuff) yang dikembangkan. 3 macam: Orotrakeal (Intubasi Oral) Nasotrakeal (Intubasi Nasal) Surgical airway (Krikotiroidotomi/ trakeostomi)

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OBJECTIVE
Clear and protected airway

Oxygenation
Positive pressure ventilation

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Basic Airway Manuever


1. Chin Lift
Tidak boleh akibatkan hiperekstensi leher. Aman untuk C-spine pada korban trauma

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2. Jaw Thrust
Pegang pada angulus mandibulae, dorong mandibula ke depan (ventral ). Aman untuk C-spine pada korban trauma

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3. Head tilt Chin lift


Gabungan antara manuver Head tilt dan Chin lift. Head tilt: meletakkan telapak tangan di dahi, kepala diekstensikan. Pada pasien trauma: hati-hati cedera pada C-spine.

Pada pasien multipel trauma dengan suspek cedera cervical, manuver yang paling aman : Jaw Thrust. Bila dengan Jaw Thrust tidak bisa buka airway: lakukan Head Tilt Chin Lift dengan ekstensi kepala minimal. Airway tetap merupakan prioritas, meski terdapat cedera Cspine.
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Jangan Lakukan !!

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Airway Dasar
1. Oropharyngeal Airway (OPA)
Menahan lidah tidak jatuh ke belakang . Fasilitas suction. Mencegah lidah/ ETT tergigit Merangsang muntah pada pasien sadar/ setengah sadar. Hati hati pada anak dapat lukai jaringan lunak.

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Oropharyngeal Airway/Guedel

NO: 0

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How to measure the right size of Oropharyngeal Airway


Komplikasi Obstruksi total Laringospasme

Muntah

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Cara Pemasangan Oropharyngeal Airway


Dimasukkan mulut dg lengkungan menghadap palatum. Setelah masuk separuh panjangnya, putar 180 hingga lengkungan menempel pada lengkungan lidah.

1. 2. 3.

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2. Nasopharyngeal Airway (NPA)

Jalan nafas buatan dengan ujung di belakang lidah. Hati hati pada fraktur basis cranii. Indikasi: Pasien setengah sadar dengan nafas spontan. Lebih dapat ditoleransi pasien daripada OPA, kecil kemungkinan rangsang muntah.
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Nasopharyngeal Airway
Komplikasi Kerusakan mukosa nasal Laryngospasme

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Cara Pemasangan Nasopharyngeal Airway


Cara pemasangan: beri jelly pelicin, didorong memasuki lubang hidung hingga ujung pipa terletak di orofaring. Arah ujungnya datar menyusur dasar rongga hidung, arah menuju anak telinga (tragus).

1.

2.

3.

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3. Advanced Airway
A.Endotrakeal Tube (ETT)
Keuntungan :
Menjaga jalan nafas terbuka Mengurangi risiko aspirasi Sebagai fasilitas suction trakea Sebagai fasilitas pemberian oksigen konsentrasi tinggi

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Endotrakeal Tube (ETT)


Komplikasi
Hipoksia Trauma Muntah-aspirasi isi lambung Hipertensi Disritmia jantung Intubasi satu paru Intubasi esofagus Cardiac arrest akibat vagal reflex
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Persiapan Intubasi Endotrakeal


1. Alat:
A. Laryngoscope
Terdiri dari : Blade (bilah) dan Handle (gagang). Pilih ukuran blade yg sesuai. Dewasa : no 3 atau 4 Anak : no 2 Bayi : no 1 Pasang blade dengan handle Cek lampu harus menyala terang.

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Laryngoscope

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Menyiapkan Laryngoscope
1. 2.

3.

4.

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Memegang Laryngoscope
Memegang laryngoscope selalu dengan tangan kiri

Posisi tangan yang betul adalah memegang pada handle, bukan pada pertemuan blade dan handle

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Melepas Laryngoscope
Memasang dan melepas laryngoscope selalu dengan sudut 45

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B. Endotrakeal Tube (ET)


Pilih ukuran yang sesuai: (ID: Internal Diameter) Dewasa : ID 6.5 , 7 atau 7.5 Atau sebesar kelingking kiri pasien Anak : ID = 4 + (Umur : 4) Bayi : Prematur : ID 2.5 Aterm : 3.0 3.5 Selalu menyiapkan satu ukuran dibawah dan diatas. Pilih ET yang High Volume Low Pressure (ETT putih/ fortex) Bila memakai yg re-useable, cek cuff dan patensi lubang ET.

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ETT dissposible (Low Pressure High Volume)

ETT re-usable (High Pressure Low Volume) Tidak dianjurkan.

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C. Spuit 20 cc. D. Stylet (bila perlu). E. Handsgloves steril. F. KY jelly. G. Forcep Magill (bila perlu). H. AMBU Bag dg kantung reservoir dihubungkan dengan sumber oksigen.

I. Plester untuk fiksasi ETT. J. Oropharngeal Airway. H. Alat suction dg suction catheter . K. Stetoscope.
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2. Obat Emergency
- Sulfas Atropin (SA) dalam spuit - Adrenaline dalam spuit.

3. Pasien
Informed consent mengenai tujuan dan resiko tindakan.

Ingat resiko/komplikasi intubasi bisa berakibat fatal !!!

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Persiapan Intubasi Endotrakeal

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Langkah langkah Intubasi Endotrakeal


Ventilasi tekanan positif dan Oksigenasi Harus dilakukan sebelum intubasi. Dada harus mengembang selama ventilasi diberikan. Oksigenasi dengan oksigen 100% (10 L/menit). Bila intubasi gagal (waktu >30 detik), lakukan ventilasi dan oksigenasi ulang, bahaya hipoksia !!!

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Posisi Tangan Saat Ventilasi Tekanan Positif


Ibu jari dan jari telunjuk menekan face mask ke bawah sambil mempertahankan sekat yg tidak bocor antara face mask dan penderita.

Jari tengah, jari manis dan kelingking pada ramus mandibula, mendorong ke atas sambil membuka airway.
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INTUBASI TRAKEA

Singkirkan lidah ke kiri Cari Epiglotis

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POSITION OF THE TIP OF LARYNGOSCOPE BLADE

LIDAH VALEKULA EPIGLOTIS

Trakea

Esofagus !!! Sniffing Position Mambantu Visualisasi laring

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ELEVASI LARINGOSKOP
Gunakan kekuatan tangan untuk mengangkat. Jangan diungkit dg menggunakan gigi seri atas sebagai titik tumpu (awas patah!!).

Arah elevasi laringoskop

Jangan diungkit !!!

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INTUBASI TRAKEA

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INTUBASI TRAKEA
Plica Vocalis Epiglotis Trakea

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BURP MANUEVER
Menekan kartilago krikoid ke bawah, atas, kanan (Back, Up, Right Pressure= BURP) Membantu visualisasi plika vokalis Dilakukan oleh asisten yg membantu intubator
ADAMS APPLE

BURP

THYROID

CRICOID

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INTUBASI TRAKEA
G. H.Intubasi endobronkhial

Ujung distal cuff

Cara cegah intubasi endobronkhial: Masukkan ETT hanya sampai ujung distal cuff lewati plica vocalis
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TEKNIK INTUBASI TRAKEA


Buka mulut dengan tangan kanan, gerakan jari menyilang (ibu jari menekan mandibula, jari telunjuk menekan maksila) Pegang laringoskop dg tangan kiri, masukkan melalui sisi sebelah kanan mulut, singkirkan lidah ke samping kiri Cari epiglotis. Tempatkan ujung bilah laringoskop di valekula (pertemuan epiglotis dan pangkal lidah) Angkat epiglotis dg elevasi laringoskop ke atas (jangan menggunakan gigi seri atas sbg tumpuan !!!) untuk melihat plika vokalis Bila tidak terlihat, minta bantuan asisten utk lakukan BURP manuver (Back, Up, Right Pressure) pada kartilago krikoid sampai terlihat plika vokalis Masukkan ETT, bimbing ujungnya masuk trakea sampai cuff ETT melewati plika vokalis Kembangkan cuff ETT secukupnya (sampai tidak ada kebocoran udara) Pasang OPA Sambungkan konektor ETT dg ambu bag. Beri ventilasi buatan. Cek suara paru kanan = kiri, Awas intubasi endobronkial !! Fiksasi ETT dengan plester

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Teknik Oral

2
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3
4
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5
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Teknik Nasal

2
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4
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5
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MENCEGAH KOMPLIKASI INTUBASI TRAKEA

Dilakukan oleh tenaga terlatih Alat-alat intubasi lengkap : laryngoskop & pipa trakea berbagai ukuran Intubasi dilakukan < 30 detik Dilakukan penekanan pada kartilago krikoid (BURP Manuever) Pilih pipa trakea high volume low pressure cuff

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RJP DENGAN PASIEN TERPASANG ETT


Pasien dengan intubasi trakhea, bantuan ventilasi tidak perlu sinkron dengan kompresi dada pada saat RJP

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3. Advanced Airway
B. Laryngeal Mask Airway

Keuntungan : Teknik pemasangan lebih mudah Trauma lebih sedikit Tidak membutuhkan laringoskop Kerugian :Tidak melindungi terhadap aspirasi
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Laryngeal Mask Airway

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Foreign Body Airway Obstruction (FBAO)

Conscious Adult Choking


Steps Involved in Relief of FBAO ( Conscious)
1. To confirm that the victim is choking, ask: Are you choking? If the victim is choking, he will not be able to Speak, Breathe or Cough. If YES, say I am trained, can I help? 2. If the victim is upright, the rescuer stands behind the victim. If the victim is sitting, the rescuer kneels down and positions himself behind the victim. Put your arms around the victims abdomen. Place fist with thumb side against victims abdomen in the mid line about 2 fingers breadth above the navel and well below the tip of the xiphoid. Give quick inward and upward thrusts in one motion into the victims abdomen until the foreign body is expelled or the victim becomes unconscious.
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3.

ADULT HEIMLICH MANEUVER


Look for the Universal Sign of the victim's hand across their throat . . . . . . .

if the victim is making sound or moving air, encourage them to cough. If the victim is not making sound, or is turning color, intervene. Announce to the victim that you know the Heimlich Manuver and can help! Have someone activate emergency medical system - CALL 911.
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Stand behind the victim with your arms wrapped around the victims chest. Feel for the victim's xiphoid process with your right hand.

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Make a fist with your left hand and place it (THUMB IN) below the right hand.

Wrap the right hand over the left hand. Give inward and upward thrusts towards the shoulder blades. Repeat this until either the obstruction is removed, or the victim becomes unconscious. If the victim becomes unconscious, assist them to the ground and perform C.P.R. CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE.

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Subdiaphragmatic abdominal thrust (the Heimlich maneuver) administered to a conscious (standing) victim of foreign body airway obstruction.
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Subdiaphragmatic abdominal thrust (the Heimlich maneuver) administered to a conscious (standing) victim of foreign body airway obstruction.
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CHILD HEIMLICH MANUVER


Look for the Universal Sign of the victim's hand across their throat.

If the victim is making sound or moving air, encourage them to cough. If the victim is not making sound, or is turning color, intervene. Announce to the victim that you know the Heimlich Manuver and can help! Have someone activate emergency medical system - CALL 911.
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If you are alone, perform Heimlich Manuver first, then call 911, because children need air !!!

Stand behind the victim with your arms wrapped around the victims chest. Feel for the victim's xiphoid process with your left hand. Make a fist with your right hand and place it (THUMB IN)below the left hand.

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Wrap the left hand over the right hand. Give inward and upward thrusts towards the shoulder blades. Repeat this until either the obstruction is removed, or the victim becomes unconscious.

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If the victim becomes unconscious, assist them to the ground and perform C.P.R.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE.


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INFANT HEIMLICH MANUVER


Intervene if the infant is turning color, or is not making sound !!!

Place victim flat on his/her back with their head to your right, on a hard surface.

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With your left hand cupped in a "C" shape, grab the infant by the jaw and rest the remainder of your arm across the infant's body.

Lift the infant with your left hand and invert the victim so their body is resting across the rescuer's left arm with the legs straddling your arm. Lower the victim's head.

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With the infant's back towards you, perform 5 back blows at the level of the infant's shoulder blades with the heel of your right hand.

Back blow in an infant.


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Sandwich the infant between both arms, supporting the head with your right hand. Invert the victim to the right arm, facing upwards with the legs straddling your right arm and move the victim to the level of your chest.

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Take the left hand,and extend the middle 3 fingers. Place them on the infant's chest with the index finger in the center of the chest at the nippleline. Raise the index finger and depress sternum 1 inch using the remaining 2 fingers. Perform 5 compresions (Chest Thrust)

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Look in the infant's mouth to see if the foreign body has been displaced.

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If no air goes in, reposition the head and try again. If no response after 1 minute, call emergency medical system dial-911 Return to victim and continue the Heimlich Manuver. CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE. 83

Steps Involved in Relief of FBAO ( Conscious to Unconscious)


1.
2.

Ask: Are you choking?


Perform abdominal thrusts (Heimlich maneuver) / For pregnant and very obese victims, perform chest thrusts.

If the victim becomes Unconscious, 3. Position the victim on his back and call Help! Call 995

4.
5. 6.

Open the airway Perform Head-Tilt-Chin Lift


Push chin down and check mouth for foreign body object If foreign body is seen, If foreign body is seen, insert the index finger of the other hand down along the inside of the cheek and deeply into the throat. Use a hooking action to dislodge the foreign body and maneuver it out of the mouth./ Take precaution not to force the foreign body deeper into the throat. This maneuver is known as the finger sweep. 84

Finger Sweep
Check for Foreign Body use Push chin down If foreign body is seen, insert the index finger of the other hand down along the inside of the cheek and deeply into the throat.

Use a hooking action to dislodge the foreign body and maneuver it out of the mouth./ Take precaution not to force the foreign body deeper into the throat. This man oeuvre is known as the finger sweep.
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Steps Involved in Relief of FBAO ( Conscious to Unconscious)


7. 8. Check breathing Look, Listen and See If there is no breathing, attempt to ventilate (1st ventilation). If the chest does not rise, reposition victims head and reattempt to ventilate (2nd ventilation) If the chest does not rise again, give 30 chest thrusts. The hand position for chest thrusts is the same as chest compression performed in CPR.

9.

10. Repeat S/N 4 to 8 until there are 2 successful ventilations, and check the breathing.

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The Self-Administered Heimlich Maneuver


1. To treat ones own complete FBAO, make a fist with one hand, place the thumb side on the abdomen above the navel (2 fingers breadth) and below the xiphoid process, grasp the fist with the other hand, and then press inward and upward toward the diaphragm with a quick motion. If unsuccessful, the victim can also press the upper abdomen over any firm surface such as the back of a chair, side of table, or porch railing. Several thrusts may be needed to clear the airway.

2.

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Chest Thrust
May be used as an alternative to Heimlich Maneuver. It is performed on obese or pregnant victim. 1. To confirm that the victim is choking, ask: Are you choking? If the victim is choking, he will not be able to Speak, Breathe or Cough.

If YES, say I am trained, can I help?


2. If the victim is upright, the rescuer stands behind the victim. If the victim is sitting, the rescuer kneels down and positions himself behind the victim.

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3. Place your arms under the victims armpits to encircle the chest. Place one fist with thumb side on the middle of the breastbone. Grasp fist with the other hand and give successive quick backward thrusts.. Deliver each thrust firmly and distinctly with the intent of relieving the obstruction until the foreign body is expelled or the victim becomes unconscious. When the victim becomes unconscious, the rescuer should activate emergency medical services by dialing 995 for an ambulance and begin CPR.

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Chest thrust administered to a conscious victim (standing) of foreign body airway obstruction.

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Chest thrust administered to an unconscious victim (lying) of foreign body airway obstruction.
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