Synchronized Techniques Resolve Difficult Case of Laryngeal Meat Impaction: A Case Report and Brief Review of Current Management

摘要

Airway obstruction by aspirated foods such as meat represents a true emergency. The management of this crisis is definitely aimed at removal of the foreign object. The removal in some patient is accomplished by emergency physician but when the foreign object is distal to the oropharynx, a great challenge is encountered. We report a case of difficult laryngeal meat impaction unresolved by techniques recommended by American Heart Association (AHA) and European Resuscitation Council (ERC). 1, 2 When the exhausted patient became uncooperative, synchronized techniques of sub diaphragmatic thrust and coughing while on sitting position became a successful alternative. Introduction The techniques of coughing, back blows, chest thrusts, and abdominal thrusts (Heimlich manoeuvre) are well reported and accepted as effective managements of a choking conscious person.3 The abdominal thrust manoeuvre we describe when applied as a single technique is in popular use and highly recommended. Synchronizing abdominal thrust and coughing as a successful intervention for difficult laryngeal food impaction is not mentioned in literatures. Though we heard such combined techniques had been used by laymen, to our knowledge, it has not bee yet reported officially. Case Report A 31 years old lady clutching her neck came in walking to the emergency room 15 minutes after allegedly choked with meat during dinner. She looked anxious, could not speak nor breathe but was able to cough weakly. Vital signs were within normal limits. There was an obvious respiratory distress as manifested by tachypnea, working ala nasai and accessory muscles, and with indrawing chest muscles. Chest rise was symmetric. Decreased equal bilateral air entry was noted on chest auscultation. The highly irritable patient was taken to resuscitation room. Five back blows were done without effect followed by five abdominal thrust (Heimlich maneuver) without success. Alternating five back blows and abdominal thrust were executed continuously for 15 minutes without relief. The patient became more anxious, uncooperative, and complained of exhaustion that she could no longer tolerate further back blows and Heimlich maneuver and insisted on sitting on the bedside. No foreign object was visualized by oral examination. Direct laryngoscopy without sedative was attempted but not tolerated. High concentration of oxygen was administered. While specialist consultant was contacted for possible bronchoscopy, there was a standby preparation for possible cricothyrotomy and endotracheal intubations. The patient was encouraged to keep on coughing but the force of her cough became very weak. X-rays were done; chest X-ray was normal while neck X-ray showed a filling defect of the upper airway below the hyoid bone. (Figure 1)