# Pediatric Choking



## Fox800 (May 18, 2010)

You're working on a double paramedic ambulance, your partner has the same clinical clearance that you do. You are dispatched to an apartment complex for an 18 month old female that is choking. Upon arrival, you find the family members waiting on the sidewalk, holding the child. There is a language barrier and neither you nor your partner understand what the family is saying. It's dark outside, they hand you the child and you walk to your ambulance (since it's hard to see anything), about 15 feet away, to get some light so you can assess the patient. First responders (engine with 4 EMT-B's) are arriving as you step into the ambulance w/child. You see a well-nourished 18 month old female child, crying loudly and quite active. She is not happy that you're holding her/all the attention she's getting. Her skin is pink, warm, and dry. 

After translating, the first responders figure out that her family was feeding her some popcorn when she "passed out" and they called 911 because they thought she was choking. Your physical exam reveals coarse tracheal sounds ("kind of like rhonchi") but clear lung sounds. Vital signs ar HR 180, capillary refill less than two seconds, respiratory rate of 28, SPO2 96%, first responders are working on a BP and the child is quite upset and is making their life hell at trying to get a BP. ECG shows a sinus rhythm. You go to put on an ETCO2 equipped nasal cannula but realize that it won't fit the child's face.

What else would you like to know/do?


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## MrBrown (May 18, 2010)

Send the firefighters back to the station to watch telly and play Scrabopogle 

Have mum or dad come and sit in the ambulance and hold the child

Did she cough up or seem to swallow the popcorn? 

Any sign of increased work of breathing or distress that would suggest an FBAO?


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## Fox800 (May 18, 2010)

MrBrown said:


> Send the firefighters back to the station to watch telly and play Scrabopogle
> 
> Have mum or dad come and sit in the ambulance and hold the child
> 
> ...



Mom is in the front passenger seat per policy. Parents advise that she was "coughing for a little bit and then went limp/passed out." She didn't cough up anything.

Pt. is tachypneic but you don't see any cyanosis/retractions/etc.


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## MrBrown (May 18, 2010)

It sounds like whatever is in there might have passed or still be a partial obstruction.  

Can we get a look in the airway or do a finger sweep?

Any trend in the oxygenation status of the patient, is she getting worse or is there anything to suggest there is still an obstruction?


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## Fox800 (May 18, 2010)

Kiddo is PISSED. You can't see much but you get a decent look in the mouth and you don't see anything abnormal.

SPO2 isn't reading too well. It says "low perfusion" and isn't giving you a reading, but the kiddo keeps kicking off the lead. Partner is working on putting an adhesive SPO2 probe on the pt.'s fingers/toes.

You're holding a pediatric NRB and providing blow-by oxygen as the kid won't let you put it on her face. All of a sudden her eyes roll back in her head and she goes flaccid. By the time you reach for the pediatric BVM and grab it out of the cabinet, she's awake and crying just as loud as before. She was "out" for about 5-10 seconds.

Now what?


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## MrBrown (May 18, 2010)

OK thats bad

We can do one of two things; we can stick with the program, see if she can tolerate a paeds NRB and take the her to the hospital because this is something over my head.

... or we can go off the program and get a little crazy and go for agressive airway management which here basically means putting her to sleep with ketamine and sux and intubating.

I'd not look past tipping her upside down and giving her a couple good back slaps like mum did when I ate the legos.  

For now lets start towards the hospital yeah?


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## Fox800 (May 18, 2010)

Alright, we're transporting to the local peds hospital (level 1 trauma, good place to be). En route, the child has several recurrences of the eyes-rolling-back/flaccid routine. Vital signs remain the same. SPO2 reads "low perfusion" or just beeps with error messages. Child remains crying loudly when awake. The periods of "going limp" last about 5 seconds each.


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## Melclin (May 18, 2010)

Sounds like seizure activity.

Any affects on the monitor or noticeable pulse changes during the 'brief interruption of service'.

Nystagmus?

Temp? Recent hx of illness?

Medical history/ medications?

Was there any muscle tone during the episode?


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## MrBrown (May 18, 2010)

Good thinking mate could be some sort of seizure

Despite what the SPO2 says how does baby look? Like is she well oxygenated, not cyanotic or struggling for breath?


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## clibb (May 18, 2010)

Does the child have any signs of trauma?
The eyes rolling back indicated a chance for brain injury to me.
With the low SPO2, can also indicate some shock.


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## skivail (May 18, 2010)

Can we get a temp?


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## mycrofft (May 20, 2010)

*L-O-C  means G-O*

Temp essential, but getting to a hospital is too. Could be the tipping point in time of a laryngeal or tracheal swelling. Maybe a bit of popcorn loitering by the epoiglottis, seizure disorder, positional apnea from a C1-C2 insult (shaken baby), or underlying cadriopulmonary condition causing syncope with excessive crying or coughing. Didi mau, dinky dau.


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## Aidey (May 20, 2010)

I would suspect seizure activity, and that it was simply coincidence that the kid was eating when the first one happened. Aside from the other concerns mentioned, my other concern would be that this kid is hyperventilating and low CO2 is causing "corrective" LOC.


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## mycrofft (May 20, 2010)

*Seizure could prompt the kid to aspirate.*

Two for one deal.
Can you crike a kid?


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## dave3189 (May 20, 2010)

What about something as simple as a vasovagal syncope episode with all of the emotional distress of whats going on?


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## alphatrauma (May 20, 2010)

Maintain airway > continue to monitor > transport


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## CAOX3 (May 21, 2010)

Do they have any other children.  First time parents usually report the worst and usually are not a reliable source of information in my expereince.

Kids crying = good sign.

Kids fussing = good sign.

Any inspiratory stridor?

Hows her color?  She nice and pink or blue on the tips?

I guess a SZ is a  possibility, she been sick, temp anyone else at home sick?

As was stated above by alpha monitor airway and transport.


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## Aidey (May 21, 2010)

She is screaming bloody murder and warm, pink and dry. If there was some sort of aspiration I don't believe it is causing an acute issue. 

Do we get to find out what was actually going on?


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## Fox800 (May 21, 2010)

Melclin said:


> Sounds like seizure activity.
> 
> Any affects on the monitor or noticeable pulse changes during the 'brief interruption of service'.
> 
> ...



No effect on the monitor/pulse changes. No nystagmus. No temperature, didn't ask about recent history of illnesses. No medical history. Child loses muscle tone during episodes.


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## Fox800 (May 21, 2010)

MrBrown said:


> Good thinking mate could be some sort of seizure
> 
> Despite what the SPO2 says how does baby look? Like is she well oxygenated, not cyanotic or struggling for breath?



Pink/warm/dry skin, capillary refill <2 sec, no cyanosis noted anywhere, no retractions/head bobbing/see-saw breathing.


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## Fox800 (May 21, 2010)

clibb said:


> Does the child have any signs of trauma?
> The eyes rolling back indicated a chance for brain injury to me.
> With the low SPO2, can also indicate some shock.



Family reports no trauma. Pt. was being held by family when all of this started.


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## Fox800 (May 21, 2010)

CAOX3 said:


> Do they have any other children.  First time parents usually report the worst and usually are not a reliable source of information in my expereince.
> 
> Kids crying = good sign.
> 
> ...



Not their first child/no "new parent issues" so to speak. You do hear "coarse" sounds when you listen to tracheal sounds with your stethoscope. Lung sounds are clear everywhere. Nice pink color. No fever.


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## Fox800 (May 21, 2010)

I'll throw in this bit: when you get to the hospital and transfer care, their initial SPO2 reading is 27%. Child is still awake and alert. That's correct...twenty-seven percent. Both you and the tech say "that can't be right" with good harmony.


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## MonkeySquasher (May 21, 2010)

Fox800 said:


> I'll throw in this bit: when you get to the hospital and transfer care, their initial SPO2 reading is 27%. Child is still awake and alert. That's correct...twenty-seven percent. Both you and the tech say "that can't be right" with good harmony.




Okay, so lets recap.  We have an 18-m/o female who is becoming increasingly inconsolable and has frequent periods of flaccidly unresponsive.  HR is elevated, unknown BP, RR is on target, cap refill was good, O2 sat was either falsely high, or is now falsely low.  Skin is warm, pink, and dry.  No fever, no med Hx, allergies, medications.  No trauma.  However, noted "hoarse" sound from trachea.

So only "significant" findings are the flaccid unresponsiveness, the "hoarse" sound, and possibly the SPO2 reading.

The O2 sat is clearly incorrect.  The child would be showing signs of hypoxia LONG before then, and be dead to boot.  Out of all possible causes of falsely low SPO2, I'd say vasoconstriction.  Severe peripheral vasoconstriction pulls blood away from the capillary beds, leading to a low reading.

Possible causes...

- Hypoxia or hypoxemia.  This would explain the unresponsiveness and flaccidness.  Trachea problem could cause the low O2 sat which causes syncope.  This could be due to some "choking" as they stated, a FBAO, etc.  However, the kid SHOULD become bradycardic prior to unresponsiveness.

- Atonic seizures.  The child would have the period of flaccid unresponsiveness, and the child waking up angry, and this can happen multiple times a day.  No other seizure activity fits, as the rest involve non-flaccid muscle activity.

- Vaso-vagal syncope.  The vasoconstriction would cause the 27% reading, and the cerebral vasoconstriction causes syncope.  This could be caused by a FBAO causing a vagal response by rubbing the carotid sinus, because if it's popcorn and she's 18-m/o, it could be really big compared to her narrow funnel of an airway.

- Some other sort of wacky baroreceptor disorder causing wild changes in BP to cause the constriction/dilation and cause the low SPO2 reading and syncope.

- I would say Hyperventilation causing hypocapnia, causing cerebral vasoconstriction, causing syncope.  However, the RR isn't anywhere near fast enough to cause that.

So, to solve this...  What are the vitals like prior to, during, and after the syncope episodes?  If the kid goes Brady, it's something hypoxia-related.  If the kid's RR goes nuts, it's probably Hypocarbia.  If it involves the BP, it could be Vagal or baroreceptor-related.  If it's none of those, I'll have to say it's an atonic seizure.


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## mycrofft (May 21, 2010)

*Change probe on monitor.*

OK, _denoument_, please.


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## ah2388 (May 22, 2010)

def key to know v/s before, during, and after the syncope.  This is prob a situation where I'd be on the phone with a doc and id be seriously considering tubing the child.


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## CAOX3 (May 22, 2010)

ah2388 said:


> def key to know v/s before, during, and after the syncope.  This is prob a situation where I'd be on the phone with a doc and id be seriously considering tubing the child.



You want to tube this kid?

Care to explain why?

Your kidding right?


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## ah2388 (May 22, 2010)

i guess i may have mistook unresponsiveness to mean apneic...long day...

with that being said, in this specific case it may not be warranted, although i imagine that if the pt was showing signs of poor perfusion, I would like to think id be pretty quick at taking aggressive steps to manage this pt's airway.


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## Melclin (May 22, 2010)

MonkeySquasher said:


> - Atonic seizures.  The child would have the period of flaccid unresponsiveness, and the child waking up angry, and this can happen multiple times a day.  No other seizure activity fits, as the rest involve non-flaccid muscle activity.
> 
> - Vaso-vagal syncope.  The vasoconstriction would cause the 27% reading, and the cerebral vasoconstriction causes syncope.  This could be caused by a FBAO causing a vagal response by rubbing the carotid sinus, because if it's popcorn and she's 18-m/o, it could be really big compared to her narrow funnel of an airway.



Ahhh you beat me to it. I was ganna say absence seizure (I though you could get absence seizures with atonicity, but then I guess they'd just be called atonic seizures) or atonic seizure. 

I considered vagal stimulation 2ndry to FBAO but you would expect to see some changes in heart rate wouldn't you?

If the SPO2 reading is correct...some kind of atrial septal defect maybe? My understanding of pulse oximeters is that they are accurate only down to a certain saturation, lower than that they tend to be inaccurate. It could be that the kid has a much higher (although still very low) SpO2.


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## MonkeySquasher (May 22, 2010)

Melclin said:


> I considered vagal stimulation 2ndry to FBAO but you would expect to see some changes in heart rate wouldn't you?
> 
> If the SPO2 reading is correct...some kind of atrial septal defect maybe? My understanding of pulse oximeters is that they are accurate only down to a certain saturation, lower than that they tend to be inaccurate. It could be that the kid has a much higher (although still very low) SpO2.



I also considered the bradycardia that should happen 2* to the vagal, which is why I wanted the vitals before/during/after.  ;D

Yeah, I thought about a heart defect, but figured it HAD to have been picked up by 18mo, wouldn't it?  It'd be so extremely rare to have a child go 18-months and then suddenly be this awkwardly symptomatic.

But if the SPO2 was even semi-correct, how is the child so pink and warm and responsive?  If that was somehow correct, there's no way the kid's pulse would be that high.


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## Melclin (May 22, 2010)

MonkeySquasher said:


> I also considered the bradycardia that should happen 2* to the vagal, which is why I wanted the vitals before/during/after.  ;D
> 
> Yeah, I thought about a heart defect, but figured it HAD to have been picked up by 18mo, wouldn't it?  It'd be so extremely rare to have a child go 18-months and then suddenly be this awkwardly symptomatic.
> 
> But if the SPO2 was even semi-correct, how is the child so pink and warm and responsive?  If that was somehow correct, there's no way the kid's pulse would be that high.



Vagal: Yep, gotcha.

ASD: I think depending on the degree of shunting, ASD can become symptomatic at many different ages. I don't anything more about it than that so my go to spot is eMedicine. 

http://emedicine.medscape.com/article/162914-overview

SpO2: Yeah I agree with you about the SpO2, just throwing ideas around. I have a feeling that its supposed to mean more than just a faulty reading seeing as though these scenarios are the zebras and not the horses - the low saturation reading might be a clue...or it might be a confuser to get some over zealous EMT to start bagging a perfectly well pt due to a faulty reading.

Other than that, I'm tagging out of this one for exam week :wacko:


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## MonkeySquasher (May 25, 2010)

-bump-

So are we ever going to get the outcome?  I want the diagnosis!  haha


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## vienessewaltzer (May 25, 2010)

I'm rather interested too.  I'm not very good at diagnosis yet, but I like reading these and following the thought process of other medically inclined individuals.


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## Fox800 (Jul 2, 2010)

The child was diagnosed with a foreign body aspiration. She was RSI's and taken to the OR for emergency bronchoscopy.


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