How to manage pediatric oral airway bleeding due to a foreign body?

Management of Pediatric Oral Airway Bleeding Due to Foreign Body

For a child with oral airway bleeding from a foreign body, immediately remove any visible foreign body that can be easily grasped from the mouth, but never perform blind finger sweeps as they can impact the object deeper into the larynx or cause pharyngeal injury. 1

Immediate Assessment and Airway Stabilization

Initial Evaluation

• Assess the child's responsiveness by gently shaking or pinching, and immediately shout for help if unresponsive 1
• Evaluate breathing by looking for chest/abdominal movement, listening at the mouth and nose for breath sounds, and feeling for expired air movement with your cheek 1
• Check for signs of complete versus partial airway obstruction: complete obstruction presents with inability to make any sound, while partial obstruction allows coughing and some vocalization 1

Visible Foreign Body Management

• Perform direct visual inspection of the oropharynx looking for any foreign bodies that can be manually extracted under direct visualization 1, 2
• Remove only visible foreign bodies that can be easily grasped - this is critical to prevent further impaction 1
• Never perform blind finger sweeps of the pharynx as these can push obstructing objects farther into the pharynx, impact a foreign body in the larynx, or damage the oropharynx 1, 3

Management Based on Obstruction Severity

For Mild Obstruction (Child Can Cough and Make Sounds)

• Do not interfere - allow the child to clear the airway by coughing while you observe for signs of severe obstruction 1
• Maintain close observation for deterioration to severe obstruction 1

For Severe Obstruction (Child Cannot Make Any Sound)

For Infants (<1 year):

• Deliver 5 back blows to the middle of the back with the infant in prone position and head lower than chest (hold infant along your forearm) 1
• Follow with 5 chest thrusts with infant supine and head lower than chest, using sharper thrusts at approximately 20 per minute 1
• Check the mouth after each cycle and remove any visible foreign bodies 1
• Repeat this sequence until the object is expelled or the infant becomes unresponsive 1
• Do NOT use abdominal thrusts in infants as they may damage the relatively large and unprotected liver 1

For Children (>1 year):

• Deliver 5 back blows with child in prone position and head lower than chest (across your thighs while kneeling) 1
• After the second round of back blows, substitute abdominal thrusts (Heimlich maneuver) for chest thrusts 1
• Perform subdiaphragmatic abdominal thrusts until the object is expelled or the child becomes unresponsive 1
• Alternate back blows with chest thrusts or abdominal thrusts in subsequent cycles 1

If Child Becomes Unresponsive

• Start CPR immediately with chest compressions - do not perform a pulse check first 1
• After 30 chest compressions, open the airway and look for a visible foreign body 1
• Remove the foreign body only if visible - never perform blind finger sweeps 1
• Attempt 2 rescue breaths and continue cycles of 30 compressions to 2 ventilations 1
• After 1 minute of basic life support, activate emergency medical services (carry infants/small children to the phone; older children may need to be left briefly) 1
• Maintain head tilt and chin lift or jaw thrust to keep airway open during rescue breathing 1

Management of Bleeding

Minor Bleeding

• Manage conservatively with careful observation as most minor bleeding from traumatic suctioning or granulomata settles without surgical intervention 1
• Monitor closely for signs of moderate or severe bleeding 1

Moderate to Severe Bleeding

• Suspect tracheo-arterial fistula if there is moderate bleeding from the stomal site or pulsation of any tracheostomy tube present 1
• Watch for sentinel bleed which occurs in approximately 50% of cases before major hemorrhage 1
• Initiate standard resuscitation measures including IV access and blood product preparation 1
• Prepare for emergency surgical consultation for definitive treatment, which typically involves ligation of the innominate artery 1

Advanced Airway Management

When Basic Maneuvers Fail

• Attempt rescue breathing with positive pressure ventilation even if airway is partially obstructed, ensuring the child exhales most of the artificial ventilation after each breath 1
• Readjust the airway using jaw thrust which is usually the most effective maneuver in infants 1
• Consider advanced airway techniques including videolaryngoscopy, fiberoptic endoscopy, or rigid endoscopy if available and trained personnel present 1

Definitive Foreign Body Removal

• Rigid bronchoscopy under general anesthesia is the gold standard for removal of airway foreign bodies in children 4, 5
• Maintain spontaneous ventilation during bronchoscopy using either volatile or intravenous anesthetic agents 4
• Use endoscope-assisted rigid bronchoscopy especially in children under 3 years of age for better visualization of distal bronchi and foreign bodies 5

Critical Pitfalls to Avoid

• Never use blind finger sweeps - this is the most dangerous error and can push the foreign body deeper or cause direct pharyngeal injury 1, 3, 6
• Do not give laxatives or induce vomiting for ingested foreign bodies as this does not accelerate passage and may cause complications 3
• Avoid barium contrast studies as they can coat the foreign body and increase aspiration risk 3
• Do not delay intervention for imaging in hemodynamically unstable patients with suspected perforation 2
• Ensure correct route of administration if any medications are given - confirm intravenous access and avoid any neuraxial administration 7

When to Escalate Care

Immediate Emergency Intervention Required

• Complete esophageal obstruction with inability to handle secretions requires emergent flexible endoscopy within 2-6 hours 3, 6
• Development of respiratory symptoms suggesting airway involvement requires immediate intervention 3
• Signs of perforation including severe abdominal pain, pneumomediastinum, or subcutaneous emphysema require emergency surgical consultation 3, 2
• Persistent vomiting, severe abdominal pain, or hematemesis warrant immediate emergency care 3

Urgent Intervention (Within 24 Hours)

• Partial esophageal obstruction requires urgent flexible endoscopy 6, 2
• Persistent symptoms despite negative plain radiography should proceed to CT scan followed by endoscopy based on findings 6, 2