The Toddler with a Fish Bone and a Full Stomach

Competing risks:

1. Airway: Foreign body at C6 - risk of partial obstruction, edema, and difficulty intubating; drooling suggests esophageal obstruction with possible aspiration risk
2. Aspiration: Full meal 3 hours ago + esophageal obstruction → high aspiration risk
3. Urgency: Retained foreign body with fever and drooling suggests possible perforation or mediastinitis - this is a true emergency

Sequencing:

• Do not delay for gastric emptying - the risk of perforation/mediastinitis outweighs aspiration risk
• Preoxygenate with 100% O2 for 3 minutes
• Rapid sequence induction with cricoid pressure (debated but reasonable here) and suction ready
• Head-up positioning if tolerated
• Cuffed ETT - but the ENT needs access; discuss whether the ETT can be placed or whether the procedure is done with the patient breathing spontaneously under deep volatile anesthesia

Key decision: For rigid esophagoscopy, the ENT often prefers spontaneous ventilation to avoid positive pressure pushing the object distally. Discuss the plan explicitly - this is a shared airway decision.

Key point: The exam tests that airway and aspiration risks are managed, not eliminated, and that the surgeon's needs (spontaneous ventilation, shared airway) must be negotiated.

Technique for spontaneous ventilation with a shared airway:

• Inhalational induction with sevoflurane in 100% O2, keeping the child breathing
• Maintain deep anesthesia - the child must not buck or cough, which could dislodge the object or cause perforation
• Topicalization: Lidocaine 4% to the airway (limited dose - max ~3 mg/kg in children) to blunt reflexes
• Avoid muscle relaxants until the airway is secured and the surgeon is ready
• Positioning: Head-up, with suction immediately available
• Monitoring: Continuous SpO2, capnography via nasal cannula or side-stream, and vigilance for desaturation

Risks of spontaneous ventilation:

• Movement, coughing, laryngospasm
• Hypoventilation and hypercapnia
• Aspiration of gastric contents if the child regurgitates

Mitigation:

• Deep anesthesia before instrumentation
• Have a plan to convert to controlled ventilation if desaturation occurs
• Suction ready; consider NG tube placement after the object is removed

Key point: The exam tests that spontaneous ventilation is a negotiated technique with specific risks, and that topicalization and depth of anesthesia are the tools to make it safe.

Immediate actions (in order):

1. Call for help and announce desaturation
2. Remove the rigid scope if it is obstructing the airway - the scope may be compressing the trachea or the object may have moved
3. Ventilate with 100% O2 - if spontaneous ventilation is inadequate, convert to controlled ventilation with a mask or ETT
4. Suction the oropharynx
5. Reposition - head-up or lateral
6. Check for pneumothorax or subcutaneous emphysema (perforation)
7. If unable to ventilate: consider emergency cricothyrotomy or tracheostomy (rare in a 2-year-old but possible)

After stabilization:

• Reassess the object position with fluoroscopy
• Discuss with ENT whether to proceed, remove under direct vision, or abort and return
• Consider whether the object has perforated (fever, crepitus, mediastinal air)

Key point: The exam tests that desaturation during shared-airway procedures is managed by removing the offending instrument and re-establishing ventilation, not by persisting with the procedure.