What is the immediate management for a patient who choked while eating and is in cardiac arrest, requiring the use of a transport monitor, crash cart, and AED?

Immediate Management of Choking-Related Cardiac Arrest

Begin high-quality CPR immediately with chest compressions at 100-120/min and depth of at least 2 inches, use the AED as soon as it arrives, and attempt to visualize and remove the foreign body during airway management—do not delay CPR to search for the obstruction. 1

Initial Response Sequence

Scene Safety and Assessment

• Verify scene safety and check for responsiveness by tapping the patient and shouting 1
• Simultaneously assess for absence of normal breathing (or only gasping) and check for pulse within 10 seconds 1
• If unresponsive with no breathing/only gasping and no pulse, immediately activate the emergency response system and retrieve the AED/crash cart 1

High-Quality CPR Protocol

Compression Technique

• Start CPR immediately with cycles of 30 compressions to 2 breaths 1, 2
• Push hard (at least 2 inches/5 cm depth) and fast (100-120 compressions/min) 1, 2
• Allow complete chest recoil after each compression 1, 2
• Minimize interruptions in compressions to less than 10 seconds 2
• Change compressor every 2 minutes or sooner if fatigued to maintain quality 2

Ventilation Considerations

• Provide 2 breaths after every 30 compressions, each breath over 1 second with visible chest rise 1
• In choking cases, attempt to visualize the foreign body when opening the airway for ventilations—if visible, remove it 1
• Do NOT perform blind finger sweeps, as this may push the obstruction deeper 1
• If ventilations do not make the chest rise, reposition the airway and try again 1

AED/Defibrillator Use

Immediate Defibrillation Protocol

• Apply AED pads as soon as the device arrives—do not delay for airway management 1
• Follow AED prompts for rhythm analysis 1
• If shockable rhythm (VF/pulseless VT): Deliver 1 shock immediately, then resume CPR for 2 minutes before next rhythm check 1, 2
• If non-shockable rhythm (asystole/PEA): Resume CPR immediately for 2 minutes before next rhythm check 1, 2
• Continue cycles of CPR and rhythm checks every 2 minutes until advanced life support arrives or patient shows signs of movement 1

Airway Management Specific to Choking

Foreign Body Removal Strategy

• During CPR cycles, each time you open the airway for ventilations, look for the foreign body 1
• If the object is visible and accessible, remove it with fingers or Magill forceps 1
• Once advanced providers arrive with laryngoscopy equipment, direct visualization and removal of the obstruction becomes possible 1
• Consider early advanced airway placement (endotracheal intubation) to bypass the obstruction if it cannot be removed 1, 3

Critical Pitfall: Do not delay chest compressions to search for or attempt to remove an obstruction that is not clearly visible—CPR takes priority and chest compressions may help dislodge the object 1, 2

Advanced Life Support Transition

When ALS Arrives

• Continue high-quality CPR while advanced providers prepare equipment 1
• Establish IV/IO access for medication administration 3
• Administer epinephrine 1 mg IV/IO every 3-5 minutes for persistent cardiac arrest 3
• Perform direct laryngoscopy to visualize and remove the foreign body 1
• Place advanced airway (endotracheal tube) once obstruction is cleared, confirmed with waveform capnography 3
• After advanced airway placement, switch to continuous compressions at 100-120/min with 1 breath every 6 seconds (10 breaths/min) 1, 3

Key Quality Metrics

Maintain CPR Excellence

• Each CPR cycle should last exactly 2 minutes before pausing for rhythm assessment 2
• Compression fraction (percentage of time compressions are being performed) should exceed 60%, ideally approaching 80% 2
• Avoid excessive ventilation, which increases intrathoracic pressure and decreases cardiac output 3, 2
• Early defibrillation is critical—survival decreases 7-10% per minute without CPR, and 3-4% per minute with CPR 1

Common Pitfall: In choking-related arrests, providers may focus excessively on airway management and delay compressions—remember that chest compressions themselves may help expel the foreign body and are the priority intervention 1, 2