Removal of a foreign body lodged in the larynx using morphine as a sedative

Abstract

Obstruction of the upper airway by foreign material is a relatively frequent occurrence [1], and the basic life support guidelines for managing such an obstruction are well described [1,2] and include the use of a laryngoscope and Magill’s offset forceps in the unconscious patient [1]. There are no guidelines for upper airway obstruction in advanced life support which include the possible use of drugs [3,4]. We report on the successful removal of a foreign body from the larynx by direct laryngoscopy by ambulance personnel using morphine sedation in a patient with spasm of the masseter muscles. An ambulance with two paramedics was sent to a restaurant where a woman was reported lying unconscious on the floor. The time from dispatch to arrival on the scene was 4 min. The paramedics found a 57-year-old cyanotic woman lying on her side with some paradoxical movements of the thorax but no apparent movement of air. Repeated abdominal thrusts both with the patient lying on the floor and sitting up [1] were unsuccessful as was an attempt to remove the obstruction by chest compressions [5]. An attempt to ventilate the patient by a self-inflating bag, valve and mask with 100% oxygen was not very successful, and an attempt to use a laryngoscope and Magill’s forceps was made impossible by masseter spasm. An intravenous cannula was placed and the patient received 20 mg morphine intravenously. The masseter muscles relaxed rapidly, and a piece of meat lodged in the larynx was easily removed with Magill’s forceps. The patient could now be ventilated easily. She received 0.8 mg naloxone, and started to breathe after 1 min. She woke up 3 min later, and after 1 h in hospital she was symptom-free, but had no recollection of what had happened. In this case the paramedics were faced with the option of attempting to relax the patient’s masseteric spasm with drugs or wait for severe hypoxia to alleviate the problem. The use of drugs is to be recommended as hypoxia causes a serious risk of cardiac arrest. The paramedics in Oslo are not permitted to use the anaesthetic agents or muscle relaxants generally used by anaesthetists, and have a standing order to use benzodiazepines only if sedation is vital. In this case they instead chose to use morphine based on the premise that its effects could be rapidly reversed whether they were successful or unsuccessful in their attempt to remove the foreign body. They had previously used morphine 30 mg intravenously with success in a head injury patient who required immediate intubation after being instructed to do so by a physician over the radio. The physician found an attempt at intubation without the use of drugs to be contraindicated due to the risk of a significant increase in the intracranial pressure with coughing and straining. The paramedics in Oslo have little experience in the use of alternative drugs such as benzodiazepines, and do not carry the benzodiazepine antagonist flumazenil. Even if they did, our case mix is such that it is very unlikely that they would ever have experienced using flumazenil, while they do have a lot of experience using naloxone for opioid overdose with airway obstruction and inadequate ventilation. They handle over 1000 cases of opioid overdose a year comprising :10% of all ‘lights and siren’ ambulance calls. Morphine can be a good adjunct in the hands of experienced paramedics in situations where sedation/relaxation and the possibility of rapid reversal is required, but the method is not without hazards, and must not be used without a lot of experience in handling airway problems and opioid use. * Corresponding author. Present address: Department of Anesthesiology, Ullevaal University Hospital, N-0407 Oslo, Norway. Fax: +47 22119857; e-mail: p.a.steen@ioks.uio.no