Pediatric emergency medicine trisk 820

TRAUMA TO THE LARYNX AND TRACHEA
Foreign Body
Goals of Treatment
Laryngeal or tracheal foreign bodies can result in life-threatening partial or
complete airway obstruction. The goal is to safely remove the object as soon as
possible to prevent or reverse any respiratory compromise. Care must be taken to
avoid converting a partial airway obstruction into complete airway compromise,
and to avoid advancing the foreign material with resultant aspiration into the
lung.
CLINICAL PEARLS AND PITFALLS
Disc batteries should be removed as soon as possible to avoid caustic
injury.
Clinicians should have a high suspicion for foreign body in a child with
sudden onset of stridor, persistent cough, or respiratory distress.
Back blows and the Heimlich maneuver are not performed on the
breathing child as these can cause the object to lodge further into the
airway. These techniques are reserved for complete airway obstruction.

Current Evidence
Foreign bodies lodged in the laryngeal inlet or trachea cause severe distress and
often present with coughing, wheezing, and biphasic stridor. Tracheal/bronchial
foreign bodies can cause either lung hypoventilation due to compete obstruction
or hyperinflation due to a check-valve effect of the object.

Clinical Considerations
Clinical Recognition
Foreign bodies trapped in the laryngeal inlet can cause significant acute upper
airway obstruction. The child usually presents with severe coughing, hoarseness,
and significant respiratory distress. The larger challenge for emergency clinicians
is recognizing foreign body aspiration when the event was not witnessed directly,
and the child is not acutely compromised. Presenting symptoms such as cough,

stridor, and examination findings such as wheezing and decreased aeration are
nonspecific and seen commonly in routine pediatric illnesses such as croup,
bronchiolitis, and asthma. One should be suspicious of airway foreign body in


any child with sudden onset of symptoms or when there is a history consistent
with ingestion or aspiration.
Triage
Children with a laryngeal or tracheal foreign body usually present in distress with
hoarseness, coughing, stridor, or wheezing. If the child is able to phonate, air is
moving through his or her larynx, indicating only partial obstruction. Efforts
should be made to allow the child to assume a position of comfort. Invasive
examination and interventions such as IV placement should be avoided when
possible, as crying may result in worsening of the airway obstruction. Complete
or near complete obstruction requires emergency airway management.
Initial Assessment
The history may include a witnessed ingestion or sudden onset of the above
symptoms with no other etiology noted. Examination findings may include stridor
with upper airway foreign bodies, and wheezing, persistent cough, focal
decreased aeration with lower airway foreign bodies. Asymmetric hyperinflation
or areas of lung collapse are rarely detectable without radiologic evaluation.
Management
Do not perform back blows or Heimlich maneuver to treat the child who is still
breathing as objects may become further lodged in the airway. Children in severe
distress should be taken to the OR for emergent removal under direct
laryngoscopy and bronchoscopy. For children who are not breathing, back blows
or the Heimlich maneuver should be done. If unsuccessful with resultant
progression to depressed mental status, laryngoscopy should be performed to
assess for glottic foreign material that can be removed with forceps.
For those in mild or moderate distress, plain films may help identify

radiopaque objects or show low lung volumes or hyperinflation in the setting of
radiolucent objects (see Fig. 106.3 ). A normal chest radiograph does not rule out
foreign body. In stable patients, fluoroscopy or CT can add diagnostic value
though this needs to be balanced against the higher doses of ionizing radiation for
these studies, and the likelihood that findings will influence subsequent
management. Alternatively, if there is high clinical concern for foreign body
despite negative radiographs, consideration should be given to urgent
bronchoscopy without further imaging. Those with low suspicion of foreign body
should have thorough follow-up and reevaluation. Development of symptoms in
the interim period should prompt appropriate further investigations as indicated.


FIGURE 106.3 Chest radiograph of a child with bronchial foreign body. A: Inspiratory film
demonstrates only subtle hyperaeration of right lung. B: Expiratory film shows accentuated
hyperaeration on the right side secondary to air trapping (“check-valve” phenomenon) by the
foreign body in the right mainstem bronchus. In addition, the mediastinum is displaced to the
left.

LARYNGEAL AND TRACHEAL TRAUMA
Goals of Treatment
Blunt and penetrating laryngeal and tracheal should be promptly identified to
prevent and reverse any respiratory compromise from obstruction or bleeding.
The primary goal for the emergency clinicians is to determine who requires
urgent airway management and how to most safely accomplish this. Fiberoptic


visualization or surgical intervention may be required. When acute airway
management is not a concern, the aim is to identify which patient with minimal or
no symptoms warrants advanced imaging and/or surgical consultation to avoid
missing injuries to these critical structures that have the potential to progress (see

Chapter 112 Neck Trauma for further details).
CLINICAL PEARLS AND PITFALLS
Patients with blunt trauma to the anterior neck should also be
evaluated for cervical spine injury.
Any patients with penetrating injuries to the central third (i.e., zone 2) of
the neck should be considered for surgical exploration even if stable.
Patients with penetrating injuries to zones 1 and 3 of the neck should
initially undergo MRA/MRV to assess for vascular injury prior to other
interventions including exploration.

Current Evidence
Blunt trauma can cause mucosal lacerations, hematomas, vocal cord injury, or
fractures of the bony or cartilaginous larynx and trachea. Penetrating trauma
results in additional risk to the airway and vasculature, as covered in Chapter 112
Neck Trauma .

Clinical Considerations
Clinical Recognition
Blunt injuries to the neck often present with neck pain, hoarseness, cough, or
hemoptysis. Some patients may have relatively mild symptoms despite injury.
Neck swelling, or visible injury such as ecchymosis and abrasions may be
identified on examination.
Triage
Patients with significant respiratory distress or penetrating injuries to the neck
should be emergently evaluated and surgical specialty consultation pursued.
Those without acute compromise of the airway, breathing, or circulation should
be seen expeditiously and monitored frequently for clinical deterioration.