Student cases

Rocks and Carrots 2, Trachea 0

So, a new addition to our content, med student Case of the Week!  Currently towards the end of their rotations we have our med students present an interesting case that they saw during their time at Lakeland.  My goal is to start getting some of these posted here as well.

The case:  ~1 y.o. child with no past medical history was observed at daycare to have a choking episode and turn blue after possibly putting something in their mouth while playing outside.  Since then the child has been comfortable appearing though does have some wheezing present.  Heart rate is about 125 and oxygen sat 97%.  Child is noted to be well-appearing and in no distress with scant diffuse wheezing appreciated.  The question therefore, is how far to go with the management of this child.  The sat is normal and the kid looks good; homeward bound, right?  Well, maybe not so fast.

The first take-home from this case is to beware of pseudo-normal vital signs.  A healthy child should have a sat of 99 or 100%.  Anything less than that implies there’s something going on (or the triage nurse didn’t leave the sat monitor on long enough).  I pretty commonly re-apply the sat monitor to patients I’m seeing; it’s easy to do.  I’m not saying you have to work up and admit every kid with a not-perfectly-normal sat, but don’t just say 97% is normal and move on.

The next question is the differential of the wheezing.  Is this reactive from some degree of aspiration following the episode or does it mean more?  The child has no past history of asthma (or more technically Reactive Airway Disease at this age).  While stridor wasn’t noted on the chart, our student thought that the sounds might have been more prominent on inspiration in addition.  A chest x-ray is in order:

rock

Complete with a radiologic arrow sign, a rock sitting practically atop the carina.  Let’s just say this child was transferred ASAP to a center where it was bronchoscopically removed.  This is a worse case scenario if there ever was one if the kid codes.  There’s basically no way from an ED standpoint to manually remove it.  Back blows had been administered in the field though could be re-attempted.  In theory a person could use an ET tube to try to push the object deeper into the Right Mainstem and hope to at least oxygenate one lung;  I truly hope I never have to attempt that maneuver.

Aside from the rock, did you appreciate the other abnormality on the chest x-ray?  Most of the times kids aspirate food items that will not be radiolucent.  Let’s first move on to a similar case I got in sign-out a few days ago, an approximately 3 y.o. child who had choked on a carrot, and was now well-appearing.  This child also continued to have sounds that could be auscultated.  The best way I can describe it was a blowing central inspiratory wheeze much looser than the typically more diffuse expiratory wheezes we hear with asthma.  It was lower pitched and more even than the stridor a person hears when auscultating the neck in croup.  He also looked well, here was his x-ray:

hyperinflat

This one is much less impressive, but I do think there is subtle hyperinflation on the right side.  There was certainly hyperinflation on the right in the first case and likely some atalectasis on the left as well, though there was some rotation present.  We also transferred the second well-appearing child out for a bronch; they removed carrot from the left mainstem bronchus.

Decubitus films helped me at least once in the past in trying to prove to myself that hyperinflation was present in a child presenting about 12 hours after an episode with a peanut.  Expiratory films may be more helpful but are harder to obtain in this age group.

The most important lesson to be learned from these two cases is that children can have airway foreign bodies and still be fairly well in appearance.

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