Reality Training: Unresponsive teen after intentional asphyxiation

How will you care for a teenager who intentionally asphyxiated himself and is now unresponsive with agonal respirations?


You are dispatched to a residence for an unresponsive 14-year-old male patient after choking. You arrive to find frantic parents leading you to the basement, where the patient is unresponsive on the floor. He has a belt around his neck.

The other teens on scene tell you they were "playing a choking game," where they tried to asphyxiate themselves to the brink of unresponsiveness in an attempt to gain a "head rush" and achieve an euphoric state. The patient did this by wrapping a belt around his neck, securing it to the top of a door as it is closed in the frame to create a hanging-point.

This case presents a number of airway issues. First, the patient has had an hypoxic-asphyxiate event. He also has a strong potential for airway trauma due to the hanging mechanism.

Maintaining the ABCs are crucial for this patient. BVM management, supplemental oxygenation, basic airway adjunct insertion and proper airway positioning are all indicated. Taking into account the patient’s potential airway trauma, cervical spine motion restriction is an additional consideration.

Clinical findings
The most immediate treatment is to remove the belt from the patient's neck to end the airway compromise. Next, your partner starts to provide ventilations to the patient while you gather some more information.

  • BP: 116/78
  • Pulse: 110
  • Respirations: 6
  • SpO2: 92 percent, room air
  • ETCO2: 54 mm Hg
  • GCS: 3

Looking at his initial vital signs, his respirations are low so you manage them by assisting ventilations. His ETCO2 is high because he is retaining CO2 due to low respirations.

A normally shaped capnography waveform with a higher amplitude is present and sinus tachycardia is noted on the monitor. You find no evidence of other trauma, his friends are insistent upon no alcohol or drug use and his parents verify that the patient has a clear medical history with no prescriptions.

Transport destination
While transporting him to an appropriate pediatric medical/trauma center is preferred, for the purpose of resuscitation, he is an adult. He has reached the age of puberty. This means he receives adult rescue breathing rates, medication dosing and resuscitation equipment.

Transport time should have some bearing on the upcoming decision to intubate; especially in a rapid sequence intubation (RSI) scenario. For this patient, BLS airway management is working, and physician-level assessment and care is urgently needed. Because of the mechanism of injury, however, the necessity to adequately secure the patient’s airway is warranted. Though RSI can be a single-paramedic skill in some places, it’s a complicated procedure that really requires extensive airway management and pharmacology experience, so it may not always be the best practice. Since you are a two-paramedic crew, you decide to add a short period of on-scene time to perform RSI.

Complication to care
This case is not just a cut-and-dry "ventilate, package and transport" kind of call. You really need to be concerned about this patient’s airway. 

His mechanism is similar to a hanging. You need to consider c-spine injury, larynx and tracheal trauma and the potential for bleeding and swelling in the tissues around the airway structures and into the trachea as strong possibilities. There is also a potential for great vessel damage in his the neck. 

Because of these factors, this patient's airway needs stability and security. When you attempt to insert an oral airway, the patient has an intact gag response. Two nasal airways are inserted to start, but your gut tells you that this patient needs more airway management (and, by the way, your gut is right!).

Endotracheal intubation
Here's why this patient needs an endotracheal tube. Since you are worried about the potential for airway swelling, trauma and bleeding, this patient needs direct tracheal access; not just oropharynx access with a supraglottic device.

The patient has a need for visualized airway insertion and an intact gag reflex so rapid sequence intubation — chemical sedation and paralysis — is indicated for paramedics who are authorized to perform the procedure. 

Recognizing this need, you turn to your partner and you both get the same concerned look. Your  standing orders are for adult RSI, not pediatric RSI. Are you still sure this patient is an adult?

Not taking any chances or wasting any time, your partner starts to prep your airway equipment while you make a quick phone call to the emergency department. This is your report:

"Medic-1 to ED, I need a doc for orders. We’re on scene with a 14-year-old male that is unresponsive with agonal respirations from a witnessed hanging event. The patient had a belt around his neck on arrival and was witnessed hanging from a doorway by his friends. This is not a suicide attempt. We removed the belt. He has an intact gag reflex, respirations at 6, we’re ventilating at 10, pulse is 110 with sinus tach, SpO2 was initially 92 percent on room air and has increased with ventilations, ETCO2 was in the 50s and is now in the 30s with assisted ventilations. Swelling and redness are noted on his neck. Requesting orders for pediatric RSI."

The doctor gives permission for pediatric RSI.

Patient disposition
Critical thinking plays heavily into this call. Could you have maintained that patient’s airway with ventilations after inserting NPAs and placing a cervical collar? Sure.

Could you have tried minimal sedation to help facilitate advanced airway placement? I guess.

Would a supraglottic airway have worked to provide ventilations? Yes, unless swelling displaced the airway.

Would all of these actions provided the best treatment path or at least limit the patient’s risks of future immediate complications like airway closure from edema, aspiration, bleeding or allow for direct tracheal access? No.

There’s a right time for supraglottic airways. There’s a right time for basic airway management. And there’s a right time for RSI. This patient fits the right time for RSI.

Share your thoughts about the management of this complex case in the comments and consider these additional questions:

As an EMT, what signs would you look for indicating that ventilations are becoming more difficult and less effective? As a paramedic, what medications can you administer to facilitate intubation, without having access to paralytics?

As a provider, how would you have managed this complicated case?

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