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.

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