Marble Mouth- Oropharyngeal Foreign Bodies in Kids

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In this blog and podcast we review the complexity of the oral foreign body (FB) in kids and why this disease process is so tough to handle.

There are 4 important branch points in the care of these kids. Let's address them in order.

1. ROUTE OF MEDICATION ADMINISTRATION

• This is the first decision and depends on the age, weight, and acuity of the child.

• The routes to consider are Intranasal (IN), Intramuscular (IM), Intravenous (IV) and Intraosseous (IO). 

  • Check out our guideline for IN medication administration

• You will need an angiocath, an atomizer, a needle for IM, and an IO gun.

• All should be available at the bedside to respond to a child's changing condition.

2. MEDICATION CHOICE

• Remember K.I.S.S. - Keep It Simple Stupid.

• You need to know a few medications well.

• In my mind there are three medictions to know here: midazolam, ketamine and succinylcholine.

• With these medications, we can take the child from slightly sleepy to full rapid sequence administration (or anywhere in between).

3. RETRIEVAL

Magill Forceps - https://en.wikipedia.org/wiki/Magill_forceps

• We want bedside suction as well as devices to remove the FB.

• Magills forceps are great for this given the curve after the handle and looped forceps.

• Consider a foley to pass past the FB, inflate the balloon, and pull back to dislodge.

4. AIRWAY

• We need the appropriate equipment to intubate from above, but also prep for the surgical or needle airway from below.

• An improvised needle cricothyrotomy with a bag valve mask is fine for jet ventilation, but commercially available devices are better as they are less likely to splinter at the skin or cause a pneumothorax.

• Links to these jet ventilation devices are listed below. No one device is recommended over others. 

  • Ventrain

  • Enk Oxygen Flow Modulator

  • Rapid O2

Peds Foreign Body Case Reports:

Duggan LV, Theron R, Hodgson AL, Kozak FK. Airway Management and Definitive Care of a Toddler Following Impalement Injury by a Metal Straw. A Case Rep. 2016 Oct 1;7(7):143-5.[pubmed]

Park EJ, Espinel AG, Shah RK, Reddy SK. Challenging airway in a paediatric patient impaled by a freezer pop stick. BMJ Case Rep. 2017 Aug 3;2017. pii: bcr-2017-220620. [pubmed]

Saricicek V, Sahin L, Mizrak A, Sen E. Endotracheal intubation of a paediatric patient with an umbrella wire embedded in the palate to the posterior wall of the nasopharynx using a GlideScope video laryngoscope. BMJ Case Rep. 2014 Oct 23;2014. pii: bcr2014204478. [pubmed]

Rocuronium IM literature:

Kaplan RF, Uejima T, Lobel G, Goudsouzian N, Ginsberg B, Hannallah R, Coté CJ, Denman W, Griffith R, Clarke C, Hummer K. Intramuscular rocuronium in infants and children: a multicenter study to evaluate tracheal intubating conditions, onset, and duration of action. Anesthesiology. 1999 Sep;91(3):633-8. [pubmed]

Reynolds LM, Lau M, Brown R, Luks A, Fisher DM. Intramuscular rocuronium in infants and children. Dose-ranging and tracheal intubating conditions. Anesthesiology. 1996 Aug;85(2):231-9. [pubmed]

Other helpful links!

Down East Guideline on Pediatric Sedation

Down East Pediatric Intranasal Medication Administration Guideline

Pediatric Foreign Bodies Lecture, Amber Richards MD, Maine Medical Center PEM faculty

Peer Reviewed by Jeff Holmes MD