While relatively rare in adults, airway foreign bodies create a fairly common pediatric emergency. Young kids put everything in their mouth. This is how they explore the world. These aspirations can be difficult to recognize and often come down to collecting a good history.

An unrecognized aspiration by a 7-year-old boy stands out as one of the most traumatic resuscitation attempts in my career. He was in full-arrest when he was brought in and no one knew why. The family had spent the day at the local pool. He was happily chasing siblings around when he suddenly collapsed. On scene, EMS opened and cleared the airway, intubated him and initiated CPR (back then it was still ABCs). When he arrived in the ER we could not get his oxygen saturations above 90% and chose to re-intubate but despite good tube placement he did not respond to our bagging. We all felt so helpless. The code was eventually called and a brochoscope revealed a small piece of yellow plastic had lodged itself in his lower brochus. Without a witness/history and with no evidence on physical exam, the possibility of aspiration was not our team's focus, but it should have been! In pediatric patients aspiration should always be considered.

The biggest choking hazards for infants and toddlers are food, particularly nuts, grapes and seeds. Older children are more likely to aspirate coins and toys.

The classic presentation of an aspirated foreign body is a sudden onset of choking, coughing, stridor, or wheezing. Of course, infants and toddlers aren’t always considerate enough to aspirate objects when their caregivers are nearby. In these cases, over the course of several days, the retained foreign body can cause inflammation and fever, mimicking pneumonia or bronchiolitis. This is why it is important to always consider foreign body aspiration as a possible diagnosis, especially when the child is lacking traditional symptoms such as congestion or rhinorrhea. - Matthew Szadkowski MD

Foreign Bodies- Aspiration and Ingestion

Background:

Foreign body ingestion and aspiration in children is a common occurrence, with a peak incidence between 6 months and 3 years of age. More than 75% occur in children younger than 5 years of age. The exam can be difficult and it can be hard to determine aspiration versus ingestion at times. In general, ingested (swallowed) foreign bodies will result in inability to swallow, pain with swallowing, and gagging. Children with aspirated foreign bodies will present with persistent coughing, abnormal breath sounds, and respiratory distress.

Swallowed Foreign Body:

Children are at risk for swallowing objects, including coins, pen caps, bottle caps, figurines, magnets, and button batteries. Symptoms of swallowed foreign body that is not passing through includes drooling, inability to swallow food/water, pain with swallowing, abdominal pain, gagging, and vomiting. Stridor can also be heard, if located in the upper esophagus, as it impinges on the trachea. However, the majority of ingested foreign bodies pass spontaneously without complications or interventions.

The two most concerning ingestions are magnets and button batteries.

• Button batteries can cause esophageal burn, perforation secondary to tissue necrosis or fistula formation, which can lead to long-term swallowing difficulties and require multiple operative interventions. Button batteries are removed immediately, as damage to the mucosal membrane is time-dependent.
• Magnets, if more than one is swallowed, can get stuck on opposite sides of the bowel and cause perforation of the bowel or obstruction.

Other considerations with swallowed foreign bodies are size, as objects with a diameter larger than 2.5cm or longer than 6cm are unlikely to pass through successfully. Children who are suspected to have foreign bodies should be transported in a position of comfort and should be kept NPO.

Aspirated Foreign Body:

Children with an aspirated foreign body can vary in their presentations, from severe airway obstruction to subtle asymmetry on auscultation of the lungs. A moderate or high suspicion of foreign body aspiration could be suggested by a history of choking and gagging with subsequent persistent cough and asymmetric pulmonary exam.

Severe respiratory distress can be worrisome, as the object may be obstructing the trachea and cause stridor, hoarseness, and acute respiratory distress and the object must be removed immediately. These patients should be kept calm and in a position of comfort for transport. Keep in mind that the objects can move with coughing and breathing and could potentially move to the trachea from a more distal location. In general, the more distal the foreign body is in the airway, the fewer symptoms the patient may demonstrate. These patients can be brought in with minimal interventions and will ultimately get a chest x-ray and removal of the foreign body in the operating room.

Some exciting news! The 2020 update of the Utah EMS Protocol Guidelines has just been released!

Current Stats

On Monday, April 6, public health researchers at the U.S. Centers for Disease Control and Prevention released the first data set on pediatric COVID-19 cases in the United States.

• 2,572 pediatric cases among 149,082 total cases
• Pediatric cases make up 1.7 percent of the cases examined
• Of the 2,572 pediatric cases, nearly 60 percent were in children ages 10 to 17. Those younger than one year made up 15 percent
• 57 percent were male
  
• Children requiring hospitalization tend to be the youngest and those with underlying health conditions
  
• The study reported 3 pediatric deaths but was unable to cite COVID-19 as the cause of death until further investigation is complete

COVID-19 Numbers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Isolating with Teens

"Teenagers are actually wired to want to be outside of the house, away from us parents, hanging out with their friends, learning how to be independent. And so, it is very difficult for what we are asking them to do,” says Dr. Mickelson. Here are 7 simple tips for parents to remember for their children’s mental health during COVID-19 isolation restrictions:

1. Come from a place of understanding and make space for disappointment and sadness
2. Make space for relief and joy
3. Expect friction regarding social lives
4. Allow for privacy and time alone
5. Treat teenagers as problem-solving partners
6. Watch for signs of depression
7. Seek professional help if needed

New COVID-19 and Telehealth Resources Website

The Utah Telehealth Network recently launched a new COVID-19 and Telehealth Resources webpage to provide all the information, links, and tools we have regarding COVID-19 in one convenient location.

An Ounce of Prevention

As there have been likely increases in drugs and chemicals (e.g., medications, disinfectant products) being brought into the homes and a rise in the purchase of gun sales, we ask you to consider promoting the following prevention recommendations:

Drug and chemical safety recommendations:

• Read all warning labels and follow directions on the label before using medications or products that may be poisonous
• Educate children about drug and chemical safety
• Store drugs and chemicals safely, up and away and out of children’s reach
• Call the Utah Poison Control Center at 800-222-1222 immediately for any kind of poisoning

Firearm safety recommendations:

• Store firearms unloaded in a locked container
• Store firearms separate from ammunition
• Educate children about firearm safety

Additional information on these topics can be accessed on the following websites:

• CDC Home and Recreational Safety Poisoning Prevention page
• American Academy of Pediatrics Gun Safety Page

Please know we will work with you to continue prevention efforts to keep our children safe and to provide you with the resources and tools you need. We also encourage you to visit the Education Development Center COVID-19 Resource Page during this time for additional ideas and practices to share with your communities, partners, or even use at home. EDC will continue to develop this resource page as the situation evolves.

Jennifer Leonardo

Children’s Safety Network Director

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything pediatric related? Shoot an email to the address below and look for her response in our next newsletter.

tdickson@utah.gov

Help improve your agency and emergency department’s readiness to take care of pediatric patients and participate in a national quality improvement project!

The national EMS for Children program, with the help of the National EMSC Data Analysis Research Center (NEDARC), will be launching a second national survey.

June 2020, the National Pediatric Readiness Project will launch the 2020 Assessment. This assessment will be sent to nurse managers and medical directors of all emergency departments across the country to evaluate structural processes and policies in place to be ready for pediatric patients. Those who take the assessment will get immediate feedback with a gap report comparing your score with previous scores (if taken in the past) and comparing you with similar emergency departments across the country. These scores have been linked to outcomes such as mortality from critical illness, and participation in the project is very important for the Utah Department of Health to better understand the state of pediatric preparedness in Utah.

There is an extreme need for blood. Not only have the usual donation volumes gone down but sick Covid-19 patients will need bypass and ECMO which requires LARGE volumes of blood. Please consider donating and encouraging others to do so.

During the blood drives, American Red Cross representatives are mitigating risk around COVID-19 exposure through specific actions including using sterile collection kits, spacing beds six feet apart (when possible), having hand sanitizer available, using antiseptic scrubs, completing temperature checks for all participants upon entering, and disinfecting areas touched by others.

Find a blood drive near you.

To be more in line with the National Program and other state EMSC Programs we are saying goodbye to our "EMSC block" and introducing the new Utah EMSC bear! Contact our Program Manager Brianne Glenn (brianne.glenn@utah.gov) if you'd like a .png or .jpeg of the new logo.

Our daily thoughts are with you as it seems that COVID-19 has consumed our practice!

In that light, we are pleased to provide you with this important information from our strategic partners at Pulsara. Pulsara is offering EMS and healthcare organizations a FREE, HIPAA-compliant, video-enabled platform that can be accessed on any smart device for a limited number of users. Please see the pdf attachment for more information and feel free to SHARE with any interested parties!!

Kathy Robinson, RN

Strategic Partnerships Director

National Association of State EMS Officials

201 Park Washington Court

Falls Church, VA 22046

Ph: 703.538.1799 Ext 1894

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

OR use the dedicated EMS follow up email PCH-EDRTU-EMS@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Brianne Glenn (brianneglenn@utah.gov) to find out how you can help.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth