(675) A Rare Pediatric Complication: Tracheoesophageal Fistula From Hanging Injury

Introduction: Tracheo-esophageal fistula (TEF) from intentional hanging injury in children is uncommon and to our knowledge has previously been reported only once in pediatric literature with no cases reported in the United States. Traumatic TEF can be a diagnostic conundrum in young patients. We present a pediatric case of an insidious TEF from a hanging event.

Description: A 10-year old male was admitted to the PICU post-cardiac arrest secondary to intentional asphyxiation by hanging. Initial CT/CTA neck was interpreted as negative. Brain MRI was consistent with severe hypoxic-ischemic encephalopathy. Post-extubation ICU stay was prolonged and complicated by paroxysmal sympathetic hyperactivity (PSH) events. PSH coincided with fevers, intermittent hypoxia, increased secretion burden, and emesis of gastric feeds. Feeding intolerance and fevers continued despite empiric antibiotics and transition to transpyloric feeds. Abdominal x-ray to verify enteral tube placement was incidentally concerning for peritoneal free air. Follow-up CT revealed a TEF at C6-C7 and right lung abscess. Initial CT imaging was reassessed and consensus was that the TEF was inconspicuous but present. Surgical repair was recommended. Given the severity of the patient’s neurologic injury, family decision was to focus on comfort measures.

Discussion: TEF from hanging injury is rare and creates diagnostic challenges for intensivists due to infrequent occurrence rates as well as the presence of comorbid complications that can confound the clinical picture. The most common hanging injury complications are anoxic brain injury, postobstructive pulmonary edema, and ARDS. Cervical spine, airway, and vascular injuries are less common with aerodigestive tract injuries being the rarest. The injury profile in pediatrics is hypothesized to be a result of a smaller hanging drop height as well as anatomical differences that make them less prone to cervical injuries. Our case highlights the importance of maintaining a high index of suspicion for TEF from hanging injuries as morbidity can be increased due to nonspecific signs and symptoms. Clinicians should consider judicious use of diagnostic imaging to investigate for TEF in hanging injury cases with increased secretions, recurrent fevers, and/or intolerance of enteral tube feeds.