Journal of Hospital & Medical Management

Introduction

frequent in adults. Symptoms can range from cough, dyspnea, choking, and acute asphyxiation leading to cardiorespiratory arrest. Poor neurological status, irrespective of the primary cardiac arrest arrhythmia, is the predominant cause of death among survivors of OHCA [1]. Clinical manifestations vary according to the degree of airway obstruction in some cases making the correct diagnosis requires a high level of clinical suspicion combined with detailed history and exam.

Prehospital cardiopulmonary arrest carries poor prognosis with survival rate less than 10% [2]. Large food bolus obstruction occurs primarily in mentally impaired elderly patients, those with swallowing difficulties post stroke, children [3] or edentulous patients.

Meat is the commonest food product causing bolus obstruction and particularly so in patients with pre-existing esophageal strictures. Meat impaction resulting in esophageal obstruction is an urgent problem and the bolus should be removed within hours [4] Foreign bodies such as coins, batteries and toys form the majority of foreign bodes ingested by children [5,6]. Patients with esophageal motility disorders often achieve diagnosis after their first obstruction.

Case Representation

A 74 year old gentleman brought to ED by NAS (National Ambulance Service) having collapsed at home, CPR initiated by Neighbors brought to ED with ROSC from witnessed cardiopulmonary arrest. 2-3 cycles of CPR completed prior to EMS arrival.

Management and Outcome

Patient was self-ventilating on arrival but was intubated and ventilated in ED secondary to persistent low saturation despite seemingly adequate ventilation. No foreign body visualized during intubation.

Patient suffered two further cardiac arrests (PEA) in ED 2-3 cycle of CPR initiated by ED team 2 mg of adrenaline was given with ROSC each time (Figure 1).

Figure 1: Patient suffered two further cardiac arrests (PEA) in ED 2-3 cycle of CPR initiated by ED team 2 mg of adrenaline was given with ROSC each time.

A flexible bronchoscope was introduced through the tube and large meat bolus (3-4 cm) retrieved using endoscopy biopsy forceps with improvement in respiratory status and patient subsequently admitted to ICU.

Patient extubated after 4 days, treated for aspiration pneumonia and discharged from hospital after 21 days with no neurological deficit [7] (Figure 2).

Figure 2: Patient extubated after 4 days, treated for aspiration pneumonia and discharged from hospital after 21 days with no neurological deficit.

Discussion

Tracheobronchial Aspiration is life threatening, early recognition is vital. This case highlights importance of early CPR in OHCA, advantages of flexible bronchoscopy and endoscopic biopsy forceps in retrieval of foreign body. Flexible bronchoscopy allows for a more comprehensive airway survey and has an overall 90% success rate for retrieval [8].

Community CPR initiatives have had numerous early successful resuscitations. This also highlights the importance of early CPR in OHCA.

References

1. Laver S, Farrow C, Turner D, Nolan J (2004) Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 30: 2126–2128.
2. Nolan J (2018) The Lancet: Foreign body (FB) aspiration in adults is an uncommon but potentially life-threatening event, accounting for 0.16-0.33% of adult bronchoscopic procedure. J Thorac Dis 7: 59-69
3. Panieri E, Bass DH (1995) The management of ingested foreign bodies in children--a review of 663 cases. Eur J Emerg Med 2:83-87
4. Webb WA (1995) Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 41:39-51
5. Schunk JE, Harrison AM, Corneli HM, Nixon GW (1994) Fluoroscopic foley catheter removal of esophageal foreign bodies in children: experience with 415 episodes. Pediatrics 94:709-714.
6. Denney W, Ahmad N, Dillard B, Nowicki MJ (2012) Children will eat the strangest things: a 10-year retrospective analysis of foreign body and caustic ingestions from a single academic center. Pediatr Emerg Care 28:73-74.
7. Chae HS, Lee TK, Kim YW, Lee CD (2012) Two cases of steakhouse syndrome associated with nutcracker esophagus. Dis Esophagus 15:330-333.
8. Mise K, Jurcev Savicevic A, Pavlov N (2009) Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc 23:1360-1364.