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Clinical Case 099: To Lose One’s Marbles

A quick clinical case this week – it is a classical problem with kids – the airway foreign body.  I know there are a few ways to skin the proverbial cat – so I want to hear your approach.

The setting is a small ED, no specialists – just the trusty old GP generalist plugging away over a long weekend.

A family arrive at triage in a state of panic.  The Mum is carrying a small child – about 2 years old / 15 kg.

The story:  the kids were all playing in the “other room” when the 6 year old came into the kitchen to tell Mum that Billy had started coughing and choking.  Like a mafia hit – nobody saw nothing….  the kids are all tight lipped about what happened.

Mum found the little guy sitting on the floor in a tripod position.  He was gagging and looked pale.  She tried to calm him, but noted he was breathing “like Darth Vader” – “really loud noises coming from his throat.”  The noises settled once he relaxed a bit and she gave him a cuddle.  She tried to get him to drink some water but he refused.

They all got bundled into the car as potential witnesses and rushed into ED!  On questioning there were innumerable potential objects in the play area that might have been inhaled / swallowed / eaten…

Initial Obs are all normal – no hypoxia or tachypnoea.  He has no audible stridor until…. you try to examine his mouth.

As soon as you make a movement in the direction of his face he starts crying and there is an unmistakable stridor. It sounds like a whistle.  OK – so this is for real – there is something in there!  Auscultation of the chest is clear – but that whistle is everywhere.

OK – We will stop the story there and ask a few questions.

Q1:  Is there any benefit or harm potential in persisting with examination of his throat?

Q2:  Imaging – would you get an Xray?  Will it change your management if you are pretty sure there is an upper airway FB?

Q3:  OK – lets say he is going for an attempted manual extraction in theatre.  What is your Anaesthetic plan?  Or what is the lis tot Do’s and Don’ts in this setting.

Comments

  1. Definitely a super challenging situation.

    I think it is best to wait, and prepare for the worst; call the anethestist, OR crew, before you try ANYTHING, even an x-ray.

    Get the sedation ready, iv lines waiting, etc.

    Then once the crew is there, do the x-ray, start the IV, sedate, and be a bit more aggressive.

    That foreign body might get worse so it is best to be prepared!

    john bennett md
    miami, florida

    • Thanks John
      Problem with my location – closest specialist Anaesthetist is ~ 1600 km away! Several hours by Air retrieval!
      So this is not an option in reality.
      Agree with a lot of preparation and planning prior to any intervention.
      Sedation is controversial in this setting – the loss of spontaneous respiration can be problematic as IPPV might not work from above a “valve like ” FB?
      C

  2. Ouch, what a challenging case.
    Ok, get a pulse ox, and consider the timing of iv access–you know you are going to need it if it comes down to you needing to sedate or even paralyze the kid to get the airway sorted out. Topical EMLA to the feet if you have it to get easier IV access.
    This case is going to take time to sort out. If you have to handle this case on your own, step carefully with each intervention and don’t skip over steps of course.
    I look forward to your diagnostic and therapeutic approach.

  3. Ok, I see the Anesthetist is too far.

    right, then, still think you need to super-prepare for the worst. Of course, I have to mention that dirty word, cricothyrotomy; who wants to do that? But get that tray ready, and, oh my, brush up a bit on it before you even touch that child.
    Then, if the child is not too agitated, get a lateral soft tissue, maybe you can see what you are dealing with.
    If he is too agitated, don’t do it.

    I feel sedation may be necessary. Sure, some people says it will depress the respiration, but sounds like he has a paritally open airway to bag him, while you explore the throat.

    It just seems like a sure disaster if you try to explore that throat with the kid wide awake, but I think you have the best chance, of clearing up the airway, if the child is not fighting you every step of the way, and that mean sedation, slowly, giving the least possible.

    Sure, it is calculated gamble, but the only way, I think.

    The way I look at it, you have a fighting chance if you have a sedated kid.

    No chance if the kid is fighting.

    I had a situation in the ER once, with similar issues.

    An asthmatic about 50 years old on Theodur, and inhaler, having a severe attack.
    Very, very agitated, could not start an IV, would not let us. Nebulizer with no improvement.
    IM steroids given, but patient getting worse, would not let us touch him with an IV.

    Nasty situation, but the guy heading south.

    Sedation? Of course, the book says, no, but my back was to the wall.

    Gave him Valium 10 mg IM.
    Waiting, praying for about 10 minute, patient stayed same.

    But then in 10 minutes, he let us start the IV, and got better with IV steroids, aminophylline.

  4. David Wong says

    Hi Casey – thanks for posting a real GP anaesthetic dilemma, part of what makes the job interesting and possibly terrifying.
    Q1 – I wouldn’t persist with examing the child and causing more distress. More agitation could cause the FB to move, and then complete airway obstruction.
    Q2 – an x-ray would be worth it, lateral neck and chest. It would at least give you an idea where the FB is.
    Q3 – so you want to do a manual removal in theatre? I would be first phoning a friend – another GP anaesthetist to come in to give you a hand. I would be also speaking to an anaesthetic and/or ENT consultant at your tertiary referral paeds hospital – presumably Princess Margaret in Perth, if it all goes pear shaped I would want their ‘blessing’ that I went ahead. Is there any ENT support around, maybe visiting the Kimberly on outreach?
    I would also clarify the limits of the procedure – are you planning on performing direct laryngosopy only, or a possibly rigid bronchoscopy? My view is that I would be limited to one optimal direct laryngoscopy – see if the FB is above the cords, if it’s below I would bail out and aim to wake the child up.
    My anaesthetic plan would be as follows – in OT with your paeds anaes and resus trolleys, with all your airway kit sized appropriately (guedel, lma, et tubes and surgical), and resus drug calculations written down (with emergency drugs drawn up). I would opt for the inhalational induction with oxygen/sevoflurane, keeping the child spontaneously ventilating, insert an IV with child asleep deep then carefully topicalise the airway using 2% lignocaine (initially I would take a 5ml ampoule and drizzle on the posterior tongue, then further into oropharynx) . You might have a MAD device or a cass needle available but directly spraying the cords can be quite stimulating precipitating laryngospasm.

    The other option I can think of is ketamine imi or iv, but can increase secretions (consider atropine pre med). And also consider iv dexamethasone.

    A hint I read in a paeds anaesthetic text, was that if the FB falls further into the trachea causing total obstruction – to push it distal to allow at least one lung to ventilate. Can’t we just get this child retrieved out? Glad to hear your thoughts…

  5. Kirsty Challen (@KirstyChallen) says

    Casey, where do you find them! 😉

    I asked MrDrC (an anaesthetist who does regular paeds ENT lists) & this was his answer:
    No further examination, gas induction for the kid on mum’s knee – halothane or sevoflurane. Have ENT surgeon ready with a Storz bronchoscope (through which you can oxygenate and with which you can grab objects). Be prepared to cut throat but also be aware that FB may be sublaryngeal & so cricothyroidotomy may not work.

    Then I told him where you were……

    So my answer as an ED person: stop trying to look in kid’s throat.
    Not much point in XR – you know there’s a FB there.
    Gas induction on mum’s knee with well-briefed sensible (even if they aren’t specialist) extra pairs of hands.
    No IV awake as will add to the distress/airway risk but eyeball his veins now and have the IO next to him in case brown stuff and fan meet.
    Wouldn’t do IM anything in him as I think the distress of a sudden stab in the leg might completely finish his airway. I suppose you might think about IN ketamine/fentanyl but it doesn’t sound as though it would be easy to stick a syringe up his nose either?
    Also definitely a high-level cricon – but I would amend that by not feeling his throat now – again, will add to the distress and I would imagine you should be able to find the anatomy at that age/weight.

    Of course there is the potential that the FB is subglottic, in which case you are very FUBARed – need to think about trying to push it past the carina and at least vent 1 lung, but if you are then looking at an aeromedical retrieval that’s going to make the flight physiology truly fun!

  6. Anna Kirby-Bailey says

    I had a baby who was carried into ED arrested after choking on a bottle top.
    I bagged with a water circuit but couldn’t see FB with the laryngoscope.
    After having completed human factors course this reminded me of the difficult scenario and I crashed bleeped Anaethetist but also ENT
    A surgeon luckily was around so we immediately tried to do a Trachy which was difficult
    Anaesthetist eventually got the bottle top out, but baby died a few hours later.
    I feel that we gave the baby the best chance by early airway intervention though.
    If the baby had been awake I guess, as in theatres we could have gassed down then put cannula in.
    Lesson learnt was to get difficult airway kit out immediately as time goes quickly while looking in an airway. It took approx 2-3 cycles for bottle top to be taken out! Everyone should attend the Human Factors course as it makes you aware of the timing.

  7. Tim Leeuwenburg says

    Had one of these a while back. The case was one of my drivers for the ‘Access to difficult airway kit for rural GP anaesthetists’ survey and paper in 2012.

    Keep calm.

    Sit patient up, waft O2 by mask if will tolerate. Nasal specs will be tolerated and can be used for apnoeic diffusion oxygenation.

    Get a colleague in. Team brief. The radiographers are usually the doctors, so may not be time to faff with imaging if pateint deteriorating.

    Set up. Check once, check twice. Cookslet card for drug doses or NETS calculator. Ditto ET tube diameter and lengths.

    Get help on the phone and telemed – share the cognitive load.

    Discuss airway plan. Mark the CTM. Decide NOW if needle or knife.

    Gas induction with sevo, ApOx.

    Quick look and remove with Magills if in glottic opening. Spray the cords with lignocaine. Slick colleague getting IV (or IO) access at same time….then back to help with airway inc via CTM if obstruction above.

    If not, small COETT via Frova oxygenating bougie on low flow.

    May end up with pushing the darn thing down one bronchus and ventilating on one lung.

    Like David, I agree this is essence of rural medicine – this sort of case can present ANYWHERE. We dont have the luxury of specialist assistance nor fancy bronchoscopes and AFOI etc. but we need to have plan for this sort of thing.

    How did yours end up?

  8. Dr.Richard Lewis says

    Lateral neck xray is always valuable, and CXR. The child is undistressed upright, so should tolerate the xrays fine, and information is potentialy valuable: ie you know what you are about to deal with.
    If the xrays show FB above cords, then you should be able to retrieve it up there.
    If it’s below the cords, you need a ventilatinng bronchoscope and optical forceps. Having removed many peanuts, bits of Lego etc from tracheas and bronchi, they can be very difficult and you need the right equipment. If it’s in a bronchus, should be able to fly to Perth. If it’s in the trachea: obviously not totally obstructing, but might do en route to Perth / Darwin. So needs to be retrieved or pushed into bronchus. If you have a fibroptic bronchoscope, probably only option is to push FB into a bronchus then transfer.

  9. Thanks All for your comments.

    In response to my questions – here is how I would do it [noting that the options to depachyfy a feline are many…]

    Q1: I would not examine the kid any further, I would retreat to the far corner of the cubicle and get rapport via Mum by talking to her, getting low and making her laugh / smile – it really sends great signals to scared kids if the parent in the room is joking and smiling at the doctor – kids take their cues from Mum usually – so use this to your advantage. You need the kid to trust you later. I would apply EMLA etc and not even mention needle in earshot. There is a time for that later.

    Q2: A bit of variation in the comments around Xray – is it worth it? In my opinion – YES! I have had a few of these cases and knowing what and where you are looking for is gold. Nothing worse than going through the drama of a gas down etc then being unable to find the FB – or worse still seeing it but not having appropriate kit to pull it out. I would ask the tech to accept a pretty shoddy CXR and 2 neck views – no need for a perfect image, just enough to say what and where! I have had a few surprises over the years and think Xray is likely to help planning – both whether it is right to do an attempted extraction, and how to do it. You look silly going in trying to grad a wet marble with McGills forceps – it is impossible !!

    Q3: Pretty much what Tim said below. Double set up for supra & sub glottic rescue airways. Gaseous induction with Sevo, maintaining respiratory drive, get IV access once deep, give a bit of fentanyl etc… then wait and have a look, attempt extraction with the device you planned of run set 2 – when the Xray showed you what it was. It is tough to set up a new kit / change plan in the midst of a precarious airway induction – so it has to be smooth and quick. The ssoner you can get it out the better.. And I like Richard’s comment below – if it is already below the cords then leave it or push it into a bronchus. Tough to attempt to pull it out if you are not familiar with operating bronchoscopes – this is not the time to learn!

    Casey

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