2020 FSA Posters

P084: STUCK BETWEEN A SCREW AND A HARD PLACE
Victor Gonzalez, DO; Carmen Manresa, MD; Lydia M Jorge, MD; Eliane Quintas Silva Varga, MD; Jackson Memorial Hospital/University of Miami

Introduction: Aspiration of foreign bodies is among the leading causes of accidental death amongst pediatric patients younger than 4 years and major cause of morbidity and mortality in children. In this case, we discuss a 3-year-old male who underwent successful retrieval of an aspirated screw with rigid bronchoscopy under general anesthesia.

Case: 3 year-old, 16.3kg male, FTVD with no PMH, presented to ED with hemoptysis, cough, stridor, and foreign body (FB) aspiration. Initial treatment included Albuterol and PA/Lateral CXR. Imaging showed a 5.4cm screw projecting over trachea and right main bronchus without intrathoracic injury. ENT recommended rigid bronchoscopy for retrieval. After ED treatment, patient had nonlabored breathing on room air without stridor. NPO time was >8 hours.

Patient was not premedicated but was taken to OR with parent for induction. In OR, standard ASA monitors were placed and patient was preoxygenated prior to inhalational induction with Sevoflurane. IV access was obtained. The patient was given Glycopyrrolate IV to decrease secretions and transitioned to TIVA with Propofol bolus and infusion. ENT then performed a DL with a Parsons 3 blade and placed a 3.5mm rigid bronchoscope with a ventilation side port, which we connected to circuit. ETCO2 wasn’t obtainable but SpO2 remained 100% with clear breath sounds and equal chest rise throughout. The screw was seen in right mainstem bronchus with sharp point overlying carina but without luminal injury. It was removed via forceps, however, manipulation of vocal cords caused laryngospasm, which we treated with Propofol bolus and continuous positive pressure until resolution. Afterwards, a bronchoscopic exam of the tracheobronchial tree was done to confirm absence of injury. Patient was then given Dexamethasone and Ondansetron IV. During emergence, patient developed expiratory wheezing that resolved with albuterol, after which breathing was regular and spontaneous. Patient was taken to PICU for respiratory monitoring and given 4mcg Dexmedetomidine IV to prevent agitation.

Discussion: The pediatric airway poses a challenge due to relative larger tongue which reduces space for manipulation, as well as more cephalad larynx, longer epiglottis, shorter trachea, and narrowing at cricoid ring. Edema of the cricoid ring can obstruct the upper airway reducing radius and resulting in increased work of breathing (1). Bronchospasm or laryngospasm frequently occur and can be treated by bronchodilators and deepening anesthetic. Ventilation via bronchoscope can be complicated by hypoxia and hypercarbia due to poor ventilation, leak, or inadequate gas exchange. Paired with the increased risk for desaturation, this makes managing aspirated FBs in children particularly delicate.

Lessons Learned:

-Manipulation during FB removal can trigger laryngospasm and bronchospasm due to airway irritation.

-Sedation should be avoided prior to removal of FB.

-After FB removal, it is key to examine tracheobronchial tree to rule out injury.