You’re sitting in intake when all of a sudden a new patient pops onto your board with the chief complaint “fish bone stuck in throat”.
You go to meet the patient, a 30 year old otherwise healthy gentleman who says that he has had the sensation of something stuck in his throat ever since he had some fish five nights ago. He says he feels something is stuck on the left side of his throat, and it worsens with swallowing and turning his neck. He has no fevers, chills, nausea, vomiting, shortness of breath, odynophagia, drooling or stridor.
On exam, he’s well appearing and comfortable with normal vital signs. He’s not drooling, has no stridor or crepitus. His Mallampati score is 1 and no foreign body is visualized. You get a CT scan of the neck, which shows a fish bone lodged approximately at the level of the tonsillar crypt.
You call ENT but they tell you they’re in the OR and it’ll be three more hours before they can come down to see the patient.
Your other option is you can also have the patient wait for outpatient endoscopy as he has no signs of airway compromise or infection despite having the fishbone in his throat six days. Unfortunately, he tells you he’s leaving the country tomorrow so he can’t go to any follow up appointments.
What’s an EM doc to do?
There have been a few case reports of using direct or video laryngoscopy to help visualize a foreign body, followed by retrieval with alligator forceps.
Prior to trying this, it’s important to provide adequate anesthesia as well as decrease secretions for your best chance of success. For this, I use the awake intubation procedure listed on EMCrit for awake intubation, since you’re essentially performing the first steps of an intubation without actually passing a tube.
First, dry them out and prevent the gag reflex ~15 min before anesthetizing:
Glycopyrolate 0.2 mg IVP, suction out the mouth
Zofran 4mg to prevent a gag reflex
Then, anesthetize with 5 cc of 4% lidocaine nebulized @ 5 liters per min, have the patient gargle with roughly 3cc of 2-4% viscous lidocaine (pressed to the back of the oropharynx with a tongue depressor) and finally, spray the epiglottis and the top of the cords with a Mucosal Atomizer Device (MAD).
Some mild sedation can also be given, dependent on physician preference.
After successful anesthetization and sedation, you can then use either direct laryngoscopy or video laryngoscopy to visualize the foreign body and retrieve it with forceps.
Remember, this technique should be reserved for patients who are stable without any sign of airway obstruction.
Special thanks for this TR pearl goes to Dr. Nusbaum, beloved Elmhurst chief and champion dumpling eater.
Scott Weingart. Podcast 145 – Awake Intubation Lecture from SMACC. EMCrit Blog. Published on March 16, 2015. Accessed on July 3rd 2017. Available at [https://emcrit.org/emcrit/awakeintubation/].
Ann Arens, David Bosch, Britney Andersen and Peter Pryor. Gone Fishin. Emergency Physicians Monthly. Published on December 16, 2011. Accessed on July 3rd 2017. Available at [http://epmonthly.com/article/gone-fishin/]