What is the management approach for asphyxial deaths?

Management Approach for Asphyxial Deaths

The immediate management of asphyxial deaths requires rapid repositioning of the victim to supine position, clearing the airway, and initiating cardiopulmonary resuscitation with emphasis on ventilation, as ventilations are more important than compressions alone in asphyxial arrests. 1

Initial Assessment and Positioning

• Immediately reposition victims found in positions associated with aspiration and positional asphyxia (face down, prone, or in neck/torso flexion positions) to a supine position for proper assessment 1
• If the victim is in recovery position and it impairs ability to determine presence of signs of life, immediately reposition supine 1
• Avoid unnecessary cervical spine immobilization in drowning victims unless circumstances suggest spinal injury, as this can impede adequate airway opening 1

Airway Management and Ventilation

• The first and most important treatment for asphyxial victims is immediate provision of ventilation 1

• Clear any obstruction from the airway:

  • For foreign body obstruction in conscious victims, consider Heimlich maneuver (rapid inward and upward pressure on epigastrium) 2
  • For laryngeal edema, consider epinephrine inhalation 2
  • If these methods fail, consider cricothyroidotomy or transtracheal ventilation 2

• For healthcare providers:

  • Use appropriate bag-mask ventilation technique with proper mask size and seal 1
  • Use self-inflating bag with volume of at least 450-500 mL for infants/young children and 1000 mL for older children/adolescents 1
  • Attach oxygen reservoir to deliver high oxygen concentration (60-95%) 1
  • Maintain oxygen flow of 10-15 L/min for pediatric bags and at least 15 L/min for adult bags 1

CPR Technique for Asphyxial Arrest

• For asphyxial arrests, ventilations combined with compressions are superior to compression-only CPR 1
• Animal studies show that in asphyxial cardiac arrest, ventilations added to chest compressions improve outcomes 1
• In pediatric patients, outcomes from chest compression-only CPR were no better than if no bystander resuscitation was provided for asphyxial arrest 1
• Provide high-quality chest compressions with minimal interruptions 1
• For two-rescuer CPR, one rescuer should deliver at least 100 compressions per minute continuously while the ventilation rescuer delivers 8-10 breaths per minute 1

Defibrillation Considerations

• For pediatric patients with asphyxial arrest who develop ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT):
  • Use manual defibrillator when available (preferred for infants) 1
  • First energy dose: 2 J/kg 1
  • Second dose (if needed): 4 J/kg 1
  • If manual defibrillator unavailable, use AED with pediatric attenuator for children <8 years 1
  • Resume chest compressions immediately after shock 1

Prevention and Management of Secondary Insults

• Correct hypoxemia promptly as it significantly worsens outcomes 3
• Maintain systolic blood pressure ≥100 mmHg and mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 3
• Prevent and manage secondary injuries including:
  • Hypoxemia (occurs in ~20% of TBI patients) 3
  • Arterial hypotension (episodes of systolic BP <90 mmHg for ≥5 minutes increase neurological morbidity) 3
  • Cerebral edema (leads to increased intracranial pressure) 3
  • Fever (common in neuro-intensive care and associated with unfavorable outcomes) 3

Monitoring During Resuscitation

• Continuously monitor:
  • Oxygen saturation
  • Capnography
  • Arterial blood pressure
  • Core temperature
  • Cardiac telemetry 3
• Perform laboratory assessments including arterial blood gases, serum lactate, electrolytes, and glucose 3

Special Considerations for Different Types of Asphyxia

• For drowning victims:

  • Rescue breathing is usually performed once the victim is in shallow water or out of water 1
  • Mouth-to-nose ventilation may be used if pinching the nose is difficult 1

• For positional asphyxia:

  • Often accidental, occurring when victim's body assumes a position compromising effective respiration 4
  • Diagnosis requires knowledge of exact circumstances and original positioning 4

• For food bolus choking:

  • Higher risk in individuals with neurological diseases, intellectual disability, cognitive impairment, or psychiatric conditions 5
  • Requires rapid intervention to clear the obstruction 5

Common Pitfalls to Avoid

1. Delaying ventilation in favor of compressions in asphyxial arrests - ventilations are crucial in these cases 1
2. Unnecessary cervical spine immobilization in drowning victims without evidence of trauma, which can delay effective airway management 1
3. Failing to recognize positional asphyxia, especially in patients with history of substance abuse 4
4. Overlooking the combined nature of asphyxia (e.g., positional asphyxia combined with airway obstruction) 4
5. Placing victims in recovery position without continued monitoring for signs of airway occlusion, inadequate breathing, or unresponsiveness 1

By following this structured approach to managing asphyxial deaths, healthcare providers can optimize chances for survival and minimize secondary injuries in these time-critical emergencies.