Migrating tracheobronchial foreign body (betel nut) causing recurrent cardiac arrest in a child: case report
CCCF ePoster library. Desai S. Oct 27, 2015; 117384; P80
Sachin Desai
Sachin Desai
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P80


Topic: Case Report


Migrating tracheobronchial foreign body (betel nut) causing recurrent cardiac arrest in a child: case report



Sachin Desai

Pediatric Critical Care, B C Childrens Hospital, Vancouver, Canada

Introduction: Foreign body inhalation is common in children and can be life threatening if not recognized appropriately. It can cause long term problems such as bronchiectais and recurrent pulmonary infection. We report a case of migrating foreign body and sudden cardiac arrest due to its movement within tracheobronchial tree

Objectives: To describe unusual complication of a foreign body

Methods: case report

Results:

One year old girl was being evaluated on outpatient basis for persistent cough and intermittent breathlessness since previous two weeks. On examination, child looked well, afebrile, stable vital parameters including room air saturation. There was no respiratory distress. Air entry (AE) was absent on left side. Child had history of patent ductus arteriosus. But on clinical examination no murmur heard. Chest X ray showed complete opacification and atelectasis of left lung. She was sent for cardiac evaluation and echo demonstrated isolated PDA without haemodyanamic significance. She had CT chest to rule out any other vascular anomaly causing bronchial compression. Chest CT showed collapse of left lung and no vascular malformation. Parents could not recollect any history of chocking or gagging prior to onset of symptoms. Decision was made to perform bronchoscopy. While she was on her way to ward, she became unresponsive and was admitted to emergency. On examination she was unresponsive, bradycardic (HR <20/min) and cyanosed. CRP was commenced and she was intubated. She required adrenalin and return of spontaneous circulation (ROSC) was obtained after 3 minutes. Post arrest, she was admitted to pediatric ICU. As the episode of arrest was unexplained, bronchoscopy was postponed and she was kept ventilated and sedated. She required high pressure on ventilator for adequate gas exchange. She was nursed in left side up to mobilise secretions and improve atelectasis on left side. She underwent vigorous physiotherapy and endotracheal suctioning. While on ventilator, she had another episode when her heart rate dropped to less than 10/min with hypotension. She was commenced on CPR and required adrenalin following which she had ROSC. Following this episode, she had improved AE on left side but significantly decreased AE on right side. Chest X ray showed improved aeration on left with emphysema on right side. We suspected migration of foreign body to right main bronchus. Next morning, she underwent rigid bronchoscopy and a piece of betel nut was removed from right main bronchus. With possible source of betel nut, parents mentioned that she might have had it during marriage ceremony which happened in their house few weeks back. Betel nut (also called as areca nut) and its leaf are considered auspicious and used in marriage and religious ceremonies in India. Post removal of foreign body, baby was extubated and discharged next day.



Conclusion: We believe that two episodes of cardiac arrest were secondary to movement of piece of betel nut in tracheobronchial tree causing vagal stimulation. Mechanism of movement during first event may be due to high expiratory flow rate during coughing. During second episode, it could be physiotherapy, positioning and suctioning that may have caused migration. Along with other consequences of tracheobronchial foreign body, it should be kept in mind that it may lead to life threatening event as a result of its movement within tracheobronchial tree.

References:

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