Joseph, a 13 month old boy, is bought in to the emergency department after his mother found him choking and gagging in the kitchen next to a container of spilled nuts. He appears alert and has increased work of breathing with audible stridor and subcostal retractions. His colour is normal. He is coughing intermittently. His vital signs are; RR 66/min, HR 160/min, BP 88/56, Temp 37.1ºC, SaO2 93% with blowover O2.
The following five questions refer to Joseph's clinical scenario.
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Question 10 Which one of the following is the most likely diagnosis? |
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| Croup |
| Laryngeal foreign body |
| Anaphylaxis |
| Epiglottitis |
| Bacterial tracheitis |
| Check answer |
ExplanationThe majority of deaths from foreign body inhalation occur in preschool children. A high Menu of suspicion is required. The diagnosis is more likely if there is a sudden onset of respiratory distress associated with coughing, gagging or stridor. Infectious causes may present this way but one would expect a history of prodromal symptoms, such as runny nose. Anaphylaxis is a possibility, although there is likely to be presence of facial swelling and a urticarial rash. |
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Question 11 Which one of the following is your first step in management? |
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| Heimlich manoeuvre |
| Nebulised adrenaline |
| Back blows |
| Obtain IV access and prefer for intubation and ventilation |
| No intervention |
| Check answer |
ExplanationWith a suspected inhaled laryngeal foreign body, it is important not to distress the child by doing procedures. If the child is coughing, as in this case, he should be allowed to do so as a spontaneous cough is the most likely measure to remove a foreign body. |
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Question 12 Which one of the following is your next step in management? |
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| Immediate direct laryngoscopy with Magills forceps to remove foreign body |
| Chest and neck x-ray |
| Urgent ENT/anaesthetic review |
| Nebulised adrenaline |
| Perform a finger sweep of the mouth. |
| Check answer |
ExplanationUrgent ENT/anaesthetic review. It is important to obtain help from people with advanced airway skills as soon as possible. |
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Question 13 While waiting for the ENT registrar, you note that the child's cough is becoming less effective and he appears to be losing consciousness. Which one of the following is your next step in management? |
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| Back blows followed by chest thrusts if needed |
| Back blows followed by abdominal thrusts if needed |
| Surgical airway |
| Immediate direct laryngoscopy with Magills forceps to remove foreign body |
| Commence CPR |
| Check answer |
ExplanationIn the choking child or infant who loses consciousness or where the cough becomes ineffective, five back blows followed by five chest thrusts should be used. The mouth should then be checked. |
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Question 14 Following the back blows and chest thrusts, you note the child is no longer breathing. Which one of the following is your next step in management? |
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| Repeat back blows and chest thrusts |
| Back blows and abdominal thrusts |
| Surgical airway |
| Immediate direct laryngoscopy with Magills forceps to remove foreign body |
| Commence CPR |
| Check answer |
ExplanationThe correct answer is: Commence CPR |