The aspiration of FBs in children is not uncommon; however, delayed diagnosis may lead to medical complications, including death, when aspiration (or ingestion) is unwitnessed (Azurara and Lemos 2016). Indeed, clinical signs of respiratory distress after FB aspiration may be absent in 13–29% of cases (Oboodi et al. 2019; Boufersaoui et al. 2013). In this case, the aspiration was unwitnessed, and the child was not thought to be choking.

The removal of aspirated FBs must be completed with caution, as upsetting the child may make the situation worse. If the site of lodgment within the oropharynx is accessible, removal with long forceps may be considered. Alternatively, urgent operating room transfer for rigid bronchoscopy is considered the standard of care for removal of less-accessible items, particularly for sharp objects, as the physician can better visualize and remove the FB as well as provide better ventilation for patients (Azurara and Lemos 2016; Ludemann and Riding 2007).

It has been noted that sharp or pointed FBs may directly injure the pharynx and/or esophagus and promote impaction within the anatomically narrow lumen (Ludemann and Riding 2007). Also, most pointed metallic FBs are impacted such that the tip is pointed superiorly (as seen in our case) (Ludemann and Riding 2007). Furthermore, it is noted that the tip of the pin appears to have injured the underside of the epiglottic base, as evidenced by focal punctate congestion/hemorrhage at this site (see Fig. 1 C–D). It is uncertain whether this trauma occurred while the child was still alive or during intubation attempts. Given this, it is noted that the possibility of vagal inhibition (with resultant cardiac arrest) may have arisen due to reflex respiratory obstruction, as described in prior studies on this topic (Bamber et al. 2014; Byard 1996). It is also noted that during autopsy, the risk for sharps injury may exist, and this case provides an example of the importance of visualizing structures during autopsy prior to reaching hands or digits into occluded cavities and luminal spaces.

In our case, the aspirated push pin was not detected during the acute resuscitative efforts. This may have been due to multiple reasons:

  1. 1)

    The provided history by the family member suggested the child was not choking, only vomiting.

  2. 2)

    The push pin may have been difficult to visualize by paramedics due to the presence of foam in the upper airway and the plastic portion of the push pin being clear.

  3. 3)

    We must infer esophageal placement of the ETT as the push pin fully occluded the trachea.

As a result, it may have been assumed that an occlusive FB was unlikely with an appropriately positioned ETT in place. Given this consideration, we have changed our in-house protocols to leave the ETT in situ prior to medical imaging so ETT placement can be confirmed prior to commencement of autopsy dissection.

In conclusion, the diagnosis of aspirated FBs may be elusive in the absence of someone witnessing the choking event. First responders and clinicians ought to be mindful that children with aspirated FBs may have atypical presentations. Finally, we demonstrated the value of postmortem imaging as a tool to assist in diagnosis and promote safety (i.e., avoiding sharps injury) during the autopsy.

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