Hot Seat #154: 16mo concern for foreign body ingestionPosted on: June 5, 2020, by : Marci Fornari
Marci Fornari, MD, Children’s National Medical Center
CC: Foreign Body Aspiration
HPI: 16 month old ex-FT female with no PMHx presents with concern for foreign body aspiration. Parents were feeding her dinner when she seemed to choke on a piece of apple. She coughed a few times but did not spit up any food or vomit. She had no respiratory distress or cyanosis during the episode. No stridor or drooling since the episode occurred. After the coughing episode resolved, her parents noticed that she could take small sips of liquids, but she could not eat solids. When she was given solid foods she would spit them out. Due to this concern, parents took her to an OSH ED where she had a CXR that showed tracheal deviation. She was transferred to the CNMC ED for further workup. On arrival to the CNMC ED her vital signs were stable and she had no signs of respiratory distress. The OSH CXR was uploaded and the tracheal deviation was confirmed by our radiologist.
PMHx: born full term with no complications, no hospitalizations, no medications
Family Hx: no asthma, no airway anomalies, no congenital heart disease
Social Hx: Lives at home with mom and dad, no daycare
Constitutional: no fevers, tolerating small sips of liquids but no solid foods
Skin: no rashes
ENMT: no nasal congestion, no drooling, no change in voice or cry
Respiratory: +coughing episode, no SOB, no wheeze, no stridor, no cyanosis
Gastrointestinal: no vomiting, no diarrhea
Neuro: no AMS, no LOC
Allergies: no seasonal, food or medication allergies
T 36.8 C, HR 106, RR 26, BP 101/50, SpO2 99%
General: sitting in mom’s lap smiling, no acute distress
Skin: warm, dry, no rash
Head: normocephalic, atraumatic
Neck: supple, tracheal midline, no lymphadenopathy
ENT: TMs normal, no drooling, no foreign objects or lesions visible in the oropharynx
CV: regular rate and rhythm
Respiratory: no increased WOB, lungs clear to auscultation bilaterally, no wheeze, no stridor
GI: soft, non-tender, non-distended
Neuro: developmentally normal, moves all extremities, walks independently, says ma-ma and da-da
You decide to keep the patient NPO and obtain a repeat CXR (AP & Lateral views) to re-assess the airway. The repeat CXR shows persistent rightward tracheal deviation.
ENT was consulted due to concern for tracheal deviation. ENT recommended admission for bronchoscopy to evaluate the airway. General surgery was consulted due to concern for foreign body in the esophagus. given that she was so well appearing they recommended a PO trial, however, initially they recommended admission for EGD.
GI was consulted who recommended an esophagram. The general surgery resident then called back to say that the surgery attending recommended a CT neck and chest with IV contrast to evaluate the airway and assess for foreign body.
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