Choking child

CHOKING
Choking (object in airway): Partial or complete obstruction of the airway can be due to a foreign body (e.g., food, a bead, toy, etc.)
Webster's New World Medical Dictionary

OUTLINE
EPIDEMIOLOGY CLINICAL MANIFESTATIONS PHYSICAL EXAMINATION INVESTIGATIONS PAEDIATRIC LIFE SUPPORT

Epidemiology
Description

Who? causes

2/3 are boys 73% < 3 years old

Nuts in 1/3 of cases.
raw carrot, apple, dried beans, popcorn, sunflower, watermelon seeds, toys, marbles, balloons, coins Smooth or round objects: hotdogs, grapes, nuts and candies

In review of 1068 foreign body aspiration in children;

Larynx Trachea Right main bronchus Right lower lobe bronchus Right middle lobe bronchus Left main bronchus Left lobe lobe bronchus Bilateral 3% 13% 52% 6% <1% 18% 5% 2%

Why children prone to Foreign Body Aspiration?

Toddlers lack discretion concerning objects ingested Exploring the environment by oral tactile sensation Lack of molar teeth and thus chew food poorly Often engaged in playing while eating

Phase of choking
Coughing , gagging and choking. @ Airways obstruction Asymptomatic interval The foreign body becomes lodged, reflexes fatigue, and the immediate irritating symptoms subside

Initial event

Clinical manifestations
Laryngeal foreign body
Complete obstruction: -rapidly asphyxiates the child which cause sudden death (45%mortality) Partial obstruction: -hoarseness, aphonia, cough, stridor, and dyspnea

Tracheal foreign body

Choking and aspiration (90%) Stridor (60%)

Bronchial foreign body

Fever, cough,shortness of breath,wheezing Symptoms might occur late (weeks after obstruction)

Investigations
Larynx Neck radiograph Chest radiograph

Trachea

Neck radiograph Chest radiograph

Bronchus PA and lateral chest radiograph Expiratory phase: obstructive emphysema (air trapping) with persistent inflation of obstructed lung Shift mediastinum toward opposite side

Chest radiograph 5 years old girl with persisting cough demonstrate left lung air trapping

Left lateral decubitus chest radiograph demonstrates right mediastinal shift. A watermelon seed was found in the left main stem bronchus during bronchoscopy

Treatment
Removal of foreign body; Laryngoscopy Bronchoscopy

Complication
Atelectasis due to prolonged airway obstruction Bronchiectasis due to chronic infection Lung abscess

Paediatric Basic Life Support

Paediatrics chain survival

1. Prevention 2. Basic CPR 3. Early access to EMS (emergency medical services) 4. Early paediatric advanced link support life

FBAO

Assess severity

Paediatric foreign body aspiration algorithm

Effective cough

Ineffective cough

Unconcious

Encourage cough

Open airway Finger sweep if FB is seen Attempt ventilation Start CPR

Obstruction relieved

Conscious

5 back blows 5 abdominal thrusts

Infant - CONSCIOUS
1. Confirm severe airway obstruction. Check for serious breathing difficulties, ineffective cough, no strong cry, dusky color 2. Give up to 5 back flows and 5 chest thrusts. Repeat till FA is dislodged or victim becomes unconscious.

If infant is not responding, use 2 fingers to deliver 5 chest thrusts to middle of breastbone just below level of nipples.

Infant- UNCONSCIOUS
1. Call for help 2. Open airway (head-tilt-chin-lift), look for foreign body. If a foreign body is visible, perform a single finger sweep to remove it. Then try to ventilate. If still obstructed, reposition head and try to ventilate again. 3. Start CPR 4. Repeat step 2 and 3 until effective.

Place an unconscious infant on a hard surface.

Look for anything lodged in the airway. Use only your pinky to remove it.

Child
CONSCIOUS Ask are you choking? Give abdominal thrusts (Heimlich maneuvre) Repeat thrusts until effective or victim becomes conscious UNCONSCIOUS Call for help Open airway and look for obvious FB. If there is, attempt to remove with a single finger sweep. The try to ventilate. If still obstructed, reposition head and try to ventilate again. Start CPR Repeat steps 5 and 6 until effective

Prevent Choking
Keep small items such as coins, marbles, half deflated balloons, nuts and buttons away from children. Do not let a child run or play while eating. Do not let your older child feed a younger one unsupervised. No whole grapes, sweets and nuts for your child until hes at least four years old. Avoid taking your medicines in front of children. They tend to imitate.

References
1. 2. 3. 4. 5. Kliegman, Behrman, Jenson & Stanton (2008). Nelson Textbook of Paediatrics (18th Eds). Saunders. Chernick & Boat (1998). Kendigs Disorders of the Respiratory Tract in Children. emedicine. Airway Foreign Body. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 11: Pediatric Basic Life Support. Handbook of Healthcare Provider (4th Eds). Basic Life Support Guidelines 2005. Penang Cardiopulmonary Resuscitation Society.