Written patient consent was kindly provided by the mother of this patient for reporting and publication of this case report. Although pediatric trauma benefits from specialized pediatric care, at times, nonpediatric centers are required to provide initial management. The ability to create and execute an airway strategy in a safe and patient-centered manner is essential, no matter how unusual the situation.
A previously well 12-kg, 19-month-old toddler presented to our trauma-referral hospital after a witnessed fall onto a metal straw that impaled her hard palate. She had no loss of consciousness and cried immediately. No attempt was made to remove the straw.
On examination, she was somewhat somnolent after receiving 1 mg morphine intravenously (0.08 mg/kg) but rousable. Airway examination revealed a metal straw firmly embedded in her hard palate (Figure 1). There was significant blood in her mouth as well as dripping from the end of the straw. Maximal mouth opening was difficult to assess. Her oxygen saturation on room air was 99%, and all other vital signs were stable.
In a combined decision between anesthesia and emergency medicine personnel, the child was transferred to the operating room to secure her airway before transferring her to our tertiary care children’s hospital for definitive care. She was taken to the operating room on her mother’s lap and sitting up. Pulse oximetry, electrocardiogram, and noninvasive blood pressure were continuously monitored in transit, and 2 anesthesiology staff members were in attendance.
Airway management requires an airway strategy: a coordinated series of plans within the context of the situation and the patient’s individual needs.1 This begins with assessing the “4 corners” of possible airway interventions2: bag valve mask or facemask ventilation, use of a supraglottic device, endotracheal intubation, and surgical airway. Both bag valve mask and supraglottic device use were viewed as difficult or impossible without moving the straw. Tracheal intubation by direct laryngoscopy was considered possible although sweeping the tongue to the left might be limited.
GlideScope (Verathon Inc., Bothwell, WA) videolaryngoscopy (VL) was our first choice for 2 reasons. First, the viewing screen would allow all team members to visualize the airway supporting a “shared mental model”3 of the airway. Second, force on soft tissues might be less than that applied by direct laryngoscopy.4 We also used a flexible bronchoscope in combination with VL to enable navigation around the straw. In addition, various sizes of straight and curved direct laryngoscope blades and styletted endotracheal tubes were prepared.
An emergency surgical airway in this age group is problematic, particularly outside a dedicated pediatric center with pediatric otolaryngologists providing expertise in performing rigid bronchoscopy or tracheotomy.5 The cricothyroid membrane is not developed sufficiently to accommodate a commercially available cricothyrotomy device until approximately 8 to 10 years of age.6 Surgical tracheotomy was considered; however, in our adult trauma center, even with the presence of a general trauma surgeon, pediatric tracheotomy would not be easy or rapid. A 14-gauge Ravussin catheter7 (VBM Medical Inc., Noblesville, IN) was prepared for needle cricothyrotomy should it be required. Unfortunately, we discovered that the Enk Oxygen Flow Modulator (Cook Medical Inc., Bloomington, IN), used as a coupling device to low-pressure oxygen, was missing from our difficult airway cart. A “homemade” device consisting of three 3-way stopcocks plus oxygen tubing was assembled but was a poor substitute.
Airway strategy equipment was assembled on a large operating room table in the anticipated sequence of use. The airway strategy was articulated by the anesthesiologist in charge with feedback from team members before initiation of the strategy, including the patient’s mother. The airway team consisted of 1 anesthesiologist in charge, 2 anesthesiologists performing the airway management procedures, 2 respiratory therapists, 3 nurses, 1 adult general surgeon, and the mother. Unfortunately, otolaryngology was not onsite at our tertiary care center and was not available for the procedure. Roles of each team member were clearly delineated and confirmed.
The initial tracheal intubation attempt was performed with no additional sedation, because the child was fairly sedated after her initial dose of morphine. Glycopyrrolate (10 μg/kg) was given to dry secretions, as a vagolytic, and to help avoid bradycardia should hypoxia or a vagally mediated cardiac response occur.8 Our strategy also addressed the probability that the first attempt at tracheal intubation may fail but would serve to deliver more information regarding the patient’s airway, helping to guide further management.
Given the significant amount of blood in her mouth, we questioned the efficacy of topical airway anesthesia; therefore, none was given. The toddler was kept sitting on her mother’s lap throughout. The bronchoscopist stood on the patient’s right side with a 3.4-mm fiberoptic bronchoscope loaded with a 4.5-mm inner diameter cuffed endotracheal tube, and the VL operator was on the left. Screens for both were in alignment on the left side of the operating room table so that all team members could visualize the airway utilizing both screens simultaneously. Throughout her management, as seen in Figure 1, a respiratory therapist provided blow-by oxygen by holding a facemask near the toddler’s face. Nasal oxygen was not used given the trajectory of the metal straw and possibility of insufflation of cranial structures.
With the unusual injury, patient age, acuity, and potential anxiety triggered by the situation, we identified auditory space as a limited resource; we, therefore, addressed this in our airway strategy. Observers, although not asked to leave, were instructed to keep both the physical and auditory working space clear.
The first attempt with the GlideScope VL revealed a good view of the glottis with no signs of patient discomfort. When the flexible bronchoscope was inserted into her hypopharynx, the patient vomited. Because she was sitting up and no additional sedation had been given, she was able to clear her vomitus easily.
With the patient now more alert, we were able to obtain a better airway examination. Her mouth opening was not restricted by the presence of the straw and her oropharynx was easily visualized and did not appear to be bloody or traumatized. She was surprisingly calm given the circumstances, responsive to her mother, and was able to phonate without distress. All bleeding appeared to be originating from the hard palate. This examination, together with information obtained during the first attempt with VL, led to the decision to induce general anesthesia. Induction of anesthesia was performed with propofol (3 mg/kg), remifentanil (2 μg/kg), and succinylcholine (2 mg/kg). Direct laryngoscopy using a size 1 straight blade revealed a Cormack-Lehane Grade 1 glottic view, and a 4.0-mm cuffed styletted endotracheal tube was passed. Oxygen saturation was maintained above 93% and heart rate above 90 beats per minute throughout the procedure. A propofol infusion was used to maintain sedation during transportation to British Columbia Children’s Hospital.
Plain x-rays were obtained before transport with the lateral skull x-ray seen in Figure 2. It was noted the straw was not straight but was manufactured with an angulation. This was now embedded, along with approximately 8 cm of total straw length, above the hard palate.
After transfer to our dedicated children’s hospital, she underwent a computerized tomography scan with 3-dimensional reconstruction appearing in Figure 3. The metal straw entered the left side of the mouth passing cranially through the hard palate along the bony nasal septum and continuing posterosuperiorly. The tip of the straw lay adjacent to the floor of the skull base at the ventral aspect of the body of the sphenoid. A small linear density at the tip of the tubular straw was noted, thought to be a displaced segment of hard palate. Fortunately, no evidence of vascular or orbital injury was identified.
She was taken to the operating room for endoscopic assessment of the nasal and oral cavity. Once it was established that no major structures or significant vessels were violated, the straw was removed. The bony and soft tissue core of the hard palate was identified and removed from the palatal hole so it would not act as an oral foreign body. The left nare was repacked with 1 quarter-inch gauze in ointment, and the hard palatal defect/hole was lightly filled with Surgicel (Ethicon, Somerville, NJ). The patient was transferred, intubated, and ventilated to the pediatric intensive care unit for overnight observation.
The next morning, the palate was again examined, and a small clot was noted. The nasal packing was removed, and no bleeding took place. The patient was extubated and discharged home with a prescription of amoxicillin. On follow-up 1 week later, apart from the palatal hole with healing granulation tissue and a soft audible whistling noise on breastfeeding, the patient was perfectly fine.
We found it useful to have a clearly articulated airway strategy including the plan for a second or more tracheal intubation attempts and omitting further sedation or pharmacologic paralysis until more information about the child’s airway was obtained. The presence of a calm mother was also extremely helpful. Although our hospital is in the process of developing an organized airway team,9 the care of this patient benefitted from excellent coordinated communication between emergency medicine and anesthesiology personnel. The situation also helped us uncover gaps in our airway equipment such as the absence of an Enk Oxygen Flow Modulator, normally stocked on our difficult airway cart.
Fortunately for this patient, no vital structures were damaged by the metal straw, despite embedding close to her skull base. A brief Internet search revealed several marketed reusable types of stainless steel and aluminum straws as well as acrylic and glass straws. A public health warning on the hazards of using such noncollapsible, potentially harmful straws in small children should perhaps be considered.
1. Cook T, Woodall N, Frerk C. 2011. 4th National Audit Project (NAP4): Major Complications of Airway Management in the UK
. Available at: https://rcoa.ac.uk/nap4
. Accessed January 19, 2016.
2. Law JA, Broemling N, Cooper RM, et al.; Canadian Airway Focus Group. The difficult airway with recommendations for management—part 2—the anticipated difficult airway. Can J Anaesth. 2013;60:11191138.
3. Brindley PG, Beed M, Duggan LV, Hung O, Murphy MF. Updating our approach to the difficult and failed airway: time to ‘stop and think.’ Can J Anaesth. 2016;63:373381.
4. Russell T, Khan S, Elman J, Katznelson R, Cooper RM. Measurement of forces applied during Macintosh direct laryngoscopy compared with GlideScope® videolaryngoscopy. Anaesthesia. 2012;67:626631.
5. Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 2010;111:10161025.
6. Law JA, Broemling N, Cooper RM, et al.; Canadian Airway Focus Group. The difficult airway with recommendations for management—part 1—difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth. 2013;60:10891118.
7. Ravussin P, Freeman J. A new transtracheal catheter for ventilation and resuscitation. Can Anaesth Soc J. 1985;32:6064.
8. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007;105:344350.
9. Mark LJ, Herzer KR, Cover R, et al. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg. 2015;121:127139.