What is the initial workup for a pediatric patient with a throat injury and difficulty swallowing?

Initial Workup for Pediatric Throat Injury with Difficulty Swallowing

The initial workup for a pediatric patient with a throat injury and difficulty swallowing should begin with a rapid airway assessment followed by a systematic evaluation of breathing and circulation, with immediate attention to any signs of respiratory distress or airway compromise. 1

Initial Assessment

Airway Assessment

• Approach safely, gently stimulate the child, and call for help immediately if signs of distress are present 1
• Position the child appropriately to maximize airway patency:
  • For children under 2 years: neutral position
  • For older children: chin lift ("sniffing the morning air") with or without jaw thrust
  • Consider placing a pillow or rolled towel under shoulders to improve airway access 1
• Assess for airflow at both the mouth/nose and any tracheostomy (if present) by looking, listening, and feeling 1
• Look for "red flags" indicating potential airway compromise:
  • Stridor, grunting, snoring
  • Accessory muscle use
  • Tracheal tug
  • Sternal, sub-costal, and intercostal recession
  • Anxiety, restlessness, agitation, or confusion 1

Breathing Assessment

• Evaluate respiratory rate (tachypnea >50 breaths/min is concerning) 1
• Assess oxygen saturation via pulse oximetry (maintain SaO₂ >92%) 1
• Apply high-flow oxygen if signs of respiratory distress are present 1
• Consider waveform capnography if available to assess ventilation 1

Circulation Assessment

• Check pulse rate (tachycardia >140 beats/min is concerning) 1
• Assess blood pressure and perfusion 1
• Look for signs of shock or hemodynamic compromise 1

Specific Evaluation for Throat Injury with Dysphagia

History (Focused on Mechanism of Injury)

• Timing and mechanism of throat injury 2
• Duration and progression of swallowing difficulty 3
• Ability to handle secretions 3
• Associated symptoms (pain, voice changes, hemoptysis) 2
• Foreign body possibility (especially in younger children) 1

Physical Examination

• Inspect the oral cavity and oropharynx for:
  • Visible trauma, lacerations, or hematomas
  • Foreign bodies (do not perform blind finger sweeps) 1
  • Mucosal lesions or inflammation 3
• Assess neck for:
  • External signs of trauma
  • Subcutaneous emphysema (may indicate tracheal/laryngeal injury) 1
  • Tenderness, swelling, or deformity 2
• Evaluate voice quality and ability to handle secretions 3

Immediate Management Steps

For Respiratory Distress

• Maintain airway patency using appropriate positioning 1
• Administer high-flow oxygen 1
• If choking or foreign body obstruction is suspected:
  • For visible, easily grasped foreign bodies in the mouth: remove carefully
  • Do not perform blind finger sweeps 1
  • For suspected foreign body with respiratory distress, follow choking protocol:
    • Back blows and chest thrusts appropriate for age
    • Check mouth for visible foreign bodies between attempts 1

For Stable Patients with Dysphagia

• Maintain nil by mouth status until formal swallowing assessment 1
• Position upright if possible to reduce aspiration risk 3
• Consider IV fluids to maintain hydration 1

Diagnostic Studies

Immediate Studies (If Respiratory Distress Present)

• Pulse oximetry and continuous monitoring 1
• Consider arterial blood gas if severe respiratory distress 1
• Portable neck and chest radiographs to assess for:
  • Foreign bodies
  • Subcutaneous emphysema
  • Tracheal deviation 2, 4

Additional Studies (If Stable)

• Flexible nasolaryngoscopy by ENT specialist (if available and patient condition permits) 1
• Consider modified barium swallow or videofluoroscopic swallow study to assess swallowing function 1, 3
• CT imaging of neck if suspecting significant structural injury 4

Consultation and Disposition

• Call for specialist help early - ENT, pediatric anesthesia, and/or pediatric intensive care 1
• Prepare for possible emergency airway intervention if signs of deterioration 1, 4
• Patients with significant throat injuries or dysphagia should be admitted for observation and further management 2
• Consider transfer to a pediatric specialty center if advanced airway management capabilities are not available 4

Common Pitfalls and Caveats

• Children can decompensate rapidly due to smaller airway diameter and limited respiratory reserves 2
• Signs of respiratory distress may become absent as obstruction worsens - absence of stridor in a previously stridulous child may indicate worsening obstruction 1
• Agitation and restlessness may be signs of hypoxia rather than behavioral issues 1
• Avoid multiple attempts at visualization that may worsen edema or injury 4
• Remember that pediatric patients have anatomical differences from adults that affect airway management (higher larynx, larger tongue relative to oral cavity) 2