View of Emergency awake tracheostomy for an impending upper airway obstruction in a child while beheading a live fish

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Tabakei L, et al. Pacific Health Dialog 2018; 21(1):39-42. DOI: 10.26635/phd.2018.906

39

Case Report OPEN ACCESS

Emergency awake tracheostomy for an impending upper airway obstruction caused by biting a live fish

Losalini TABAKEI,

¹

Maloni BULANAUCA,

²

Mara VUKIVUKISERU,

³

Jitoko K CAMA

⁴

*

ABSTRACT

Disabling a live fish by beheading or biting the fish head is a traditional practice in Pacific countries such as Fiji. It is a practice that should be abandoned to avoid death from the fish causing an acute upper airway obstruction. Despite the lack of infrastructure and challenges, emergency awake tracheostomy in a child can be done safely in any emergency situation under local anaesthetic with minimal sedation to secure the airway. It is feasible to do it in the rural or remote health centres by a surgeon before any attempt in removing the foreign body causing an impending upper airway obstruction. Alternatively, transfer to a tertiary center for definitive treatment can be safely done once a definitive airway has been secured.

Keywords: emergency awake tracheostomy, airway obstruction, live fish

Beheading or biting of the fish head is a pragmatic and traditional way of disabling a live fish while fishing in the Pacific Islands. It is a technique best used while diving using goggles, fishing from the shoreline with a line, or while swimming in the sea without flippers.

A ten-year-old Fijian boy from a remote Fijian village presented acutely to the village health center with a live fish stuck in his throat after it jumped into his mouth while he was trying to behead or disable it by biting the head with his teeth (Figure 1). Fortunately, he was still able to breath around the fish but had found it very uncomfortable to swallow his own saliva, he was distressed and panicking due the pain associated with the live fish being stuck in his oropharynx causing an impending upper airway obstruction.

Figure 1: Tail of the fish visible through the mouth, with its head and body being stuck in the hypopharynx.

Due to lack of an available helicopter to effect emergency transfer, a surgical team and an anesthetist were driven to the village health centre to arrive at 4pm. The boy was found to be in respiratory distress, gagging, struggling to cough and drooling saliva and blood as he could not swallow. The poor road condition, the size of the fish and the since the fish was seen wriggling a decision was made to remove the fish before it causes airway obstruction. A plan was made to perform an emergency open awake tracheostomy under local anaesthetic and sedation using Ketamine to protect his airway.

*Corresponding author: [email protected]

1 Surgical registrar, Lautoka Hospital, Fiji

2. Consultant surgeon, Labasa Hospital, Fiji

3 Consultant anaesthetist, Lautoka Hospital, Fiji

4 Consultant paediatric surgeon, Waikato Hospital, New Zealand.

Received: 08.01.2017; Accepted: 20.02.2018

Citation: Tabakei L, et al. Emergency awake tracheostomy for an impending upper airway obstruction in a child -an attempt of beheading a live fish. Pacific Health Dialog 2018;21(1):39-42. DOI: 10.26635/phd.2018.906.

Copyright: © 2018 Tabakei L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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40 Figure 2: Awake tracheostomy being performed

under local anaesthetic in a propped-up position to relieve impending upper airway obstruction.

Figure 3: Tracheostomy in position prior to removal of the fish. Note the relief on the boy’s face that he can now breathe easily following the tracheostomy

Figure 4: Under Ketamine anaesthesia, the fish tail was cut off with the visible fins first, then the fish was extracted without any injury to the oropharynx.

Figure 5. The appearance of the fish which had remained intact after removal.

Following dislocation of the fins to free it from the oropharynx and hypopharyx, the spiny rays and fins were then freed which allowed removal of the of the fish using a Magill’s forceps. There was no significant injury to the oropharynx and hypopharynx. He recovered well from the short sedation and was later transferred to a tertiary centre for further monitoring and fibreoptic assessment of his oropharynx. He recovered well and after decannulation of his tracheostomy, he was discharged home.

DISCUSSION

It is odd that in the twenty first century, biting the fish head to disable it is still practiced widely in rural areas of Fiji. This is a practice which has been handed down from generations to generations and the advice usually given to young men and women is to bite the fish head from the side to disable it. The boy in this case had unfortunately bitten the fish head with the fish head entering his mouth, hence as he was trying to bite the fish, it jumped and lodged itself in his hypopharynx. bronchioles^1,2.

Acute asphyxiation due to obstruction and the resultant removal can result in injuries to the hypo and oropharynx from the various spikes and sharp rays of a fish. These injuries could potentially cause swelling with blood asphyxiation and death. Hence, a surgical emergency such as this usually requires an immediate surgical intervention, where the airway management is a priority.

The diagnosis of foreign body aspiration is based on a witnessed event, the presence of a foreign body in the oral cavity, symptoms of coughing or gagging. On examination, respiratory distress, wheezing or rhonchi maybe present. An x-ray may show over-inflated lung fields. Those that are diagnosed late often present with persistent lung collapse or pneumonia of the affected lung lobe.

A bronchoscopy should be done in all cases of suspected foreign body aspiration or inhalation

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41 by the surgeons. ¹Larger foreign bodies like

peanuts, peas or metallic pieces usually get lodged into one of the main bronchi’s and in very rare occasions, the foreign body gets stuck in the main trachea resulting in death from asphyxiation. A live fish as in our case could result in death if the fish was small enough to cause complete tracheal obstruction or large enough to cause obstruction at the hypopharynx. This boy was very fortunate that the fish was not big enough to cause complete obstruction. Any attempt at removing the live fish before protecting the proximal airway could have had a detrimental outcome.

Removing inhaled foreign bodies require surgical expertise with the use of a rigid bronchoscope or an open surgery in some cases. Transfer to a referral hospital was not an option in this case. A rigid bronchoscope with appropriate size for children is not widely available in Fiji.

In sub-divisional hospitals or rural health centers where general anaesthesia is not an option, all children with suspected foreign body inhalation are referred to the tertiary centres for management. However, an emergency awake tracheostomy might still be necessary in the immediate period with a complete or impending obstruction of the airway to save a life. The endoscopic or surgical removal of the cause of the obstruction can be done later in the major centres under general anaesthetic once the airway has been secured. The less traumatic and faster procedure in these acute upper airway obstructions would be to do a surgical cricothyroidotomy, which can be performed safely by rural doctors in adult patients to achieve an adequate airway. In children, this cricothyroidoyomy would be far more challenging to do due to the smaller anatomy of the neck and airway compared to adult patients.

Hence, a tracheostomy via a percutaneous or surgical approach is always an option. As demonstrated with this case, an open awake tracheostomy in any emergency situation where a definitive airway is required following an impending upper airway obstruction can be done safely by a surgeon who should be able avoid damage to the cricoid cartilage in children.

Emergency awake tracheostomy under local anaesthetic have not been reported. This technique may save lives in developing countries and can also be recommended for adults with impending airway obstruction in a developed setting or tertiary centre. ³ A retrospective review of 40 cases of tracheostomy in those under 12 years of age in Papua New Guinea reported that 80% of these tracheostomies were performed to relieve an upper airway obstruction.⁴ The majority (85%) had undergone planned

tracheostomies, whereas the other 15%

underwent emergency procedures.⁴ An emergency tracheostomy was performed in a 15 month old to remove a laryngeal foreign body where three connected vertebral bones of a dried fish were found.⁵

Fish is the main source of proteins in the Pacific region and most other developing countries. This would explain why fish bones were found to be the commonest cause of foreign body (90.25%) encountered in the pharynx of Melanesian children.⁶ Live fish inhalation or live fish causing aero digestive tract obstruction has been reported mostly in adults with detrimental outcomes and deaths. Those that had survived had undergone an emergency tracheostomy prior to any retrieval of the live fish. We are aware of two other case reports that have been published from other developing countries where live fish had been the cause of the obstruction in the aero digestive tract in children.^{7, 8} One of these children had to have an emergency tracheostomy in Bangladesh as in our case and the other was fortunate to have the fish removed in the operating room with minimal trauma to the pharynx in India. Live fish inhalation has also been reported in adults where blind orotracheal has been done with success ⁹and death could still result if the live fish lodged itself at the carina where the orotracheal or tracheostomy would still fail without removal of the fish ¹⁰. In other emergencies of upper airway obstruction such as laryngeal trauma, other studies endorsed the use of emergency tracheostomies in children, over intubation while a laryngeal mask can be used while awaiting either procedure¹¹. It is one of the most challenging acute emergency problems and the immediate goal is to achieve a definitive airway to save lives, which could mean performing an awake tracheostomy under local anaesthetic if feasible and safe. Any surgeons in either developing or developed countries should be able to perform this safely in any acute upper airway obstruction.

Several guidelines for tracheostomy in children have been published but nothing will prepare any medical personnel well in-advance when one encounters an emergency with an upper airway obstruction.¹² This can be a technically difficult procedure and anyone performing this procedure should also be aware of the potential complications such as bleeding, asphyxiation, obstruction, dislodgment of the tracheostomy and granulation tissue around the stoma. ^13,14,15 As was in our case report, emergency awake tracheostomy in children can be done safely and efficiently without any complication.

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42 CONCLUSION:

Emergency awake tracheostomy should be done with maximum care to save lives in children with impending airway obstruction. This should be done in a timely manner before complete airway obstruction occurs. It can be a technically challenging procedure to do in any health service, especially if the child is very young and uncooperative, but it will save lives even in remote health centres in any developing countries.

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