Your EMS unit has been dispatched to the scene of a reported 4 y/o child choking. While en route you are informed that the child has choked on some type of plastic while at a birthday party. It is reported that bystanders are attempting to do the Heimlich maneuver. You arrive on scene within 3 minutes.

Anxious adults who direct you to the back yard meet you out front of the home. There, you see a child lying motionless, pale and without any respiratory effort on the patio with someone performing abdominal thrust. Having determined your first impression, you quickly make your way thru the adult onlookers to the child. You approach him from his head.

You determine that the child is unresponsive to painful stimuli. You assess the airway, which reveals no visible foreign bodies in the oral cavity. You attempt to provide ventilation thru a Bag-Valve Mask (BVM) device, connected to Oxygen, but are unable to generate any chest rise even with attempts to re-position the airway. You direct your partner to attempt abdominal thrust by straddling the victim. After 5 attempts you attempt to visualize foreign material in the mouth and ventilate again but with no success. You attempt one more round of abdominal thrust but again find no foreign material and you are still unable to ventilate the child.

While your partner continues BLS clearing maneuvers, you open your airway pack and remove the Laryngoscope and Magill Forceps while your partner prepares an Endotracheal Tube for the patient. You insert the #2 Miller Blade in the airway and upon visualization of the epiglottis you see some bright red material. You insert your Magill Forceps and remove what appears to be a ruptured balloon. After removal of the balloon you also remove your Laryngoscope and attempt to ventilate with the BVM again. You witness good chest rise and fall.

You ventilate the child and instruct your partner to feel for the presence of a carotid pulse. Your partner states that the child does have a carotid pulse and it is getting faster. You direct him to apply the ECG monitor and Pulse Oximeter while you continue to ventilate the child.

Your EMS Supervisor arrives on scene to assist where needed. After 60 seconds of ventilation and a noted heart rate of 100 and a SpO₂ reading of 99% you stop ventilating to see if the child has had return of spontaneous respiratory effort. The child remains apneic. You instruct your supervisor to prepare the ET tube and restraint device. You again perform Laryngoscopy and place a # 5mm ETT thru the vocal cords. You pass the Murphy's Eye approx 2cm below the level of the vocal cords. You remove the Laryngoscope while manually stabilizing the tube. You ventilate with the Bag Valve device via the ETT. Your Supervisor assesses for placement and reports clear, bilateral breath sounds in upper and lower lobes and no ventilation sounds heard over the epigastric region.

You also connect a color metric ETCO₂ device and note that there is a color change indicative of ETCO₂ presence. You secure the ETT placement and note that it is at 14.5cm at the lips. You continue to stabilize the tube despite having been secured. You continue to assist ventilations at 20 times per minute.

You and your personnel place the child on the stretcher. You then carefully transfer him to the ambulance where you begin transport to the local hospital. The patient's mother is in the front of the ambulance while your Supervisor assists you in the back. You relinquish ventilation over to your Supervisor while you perform other tasks.

The child remains unresponsive and apneic but continues to have a palpable pulse and a heart rate in the 110's. You perform your re-assessment, which is unremarkable except for the unconsciousness.

Vital signs are as follows: B/P 116/58, HR 114, RR is zero for spontaneous effort and assisted at 20/minute. You initiate IV access with a 20 gauge to his left forearm. The IV is normal saline at KVO rate. You also place a 10Fr oral-gastric catheter to remove any air that might be trapped in the stomach from the BVM ventilation attempts. You continue to assess and monitor the patient en route. You notify the hospital of your ETA.

You arrive at the Emergency Department where a team of specialists is waiting to care for the patient. You deliver your report and relinquish ventilation to the Respiratory Therapist at the head. You both confirm appropriate ET tube placement and you depart to prepare your ambulance for the next call.