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Thread: Emergency Medicine - Foreign Bodies in Ear

  1. #1
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    Thumbs up Emergency Medicine - Foreign Bodies in Ear

    Foreign bodies of the ear are relatively common in emergency medicine. They are seen most often but not exclusively in children.

    Various objects may be found, including toys, beads, stones, folded paper, and biologic materials such as insects or seeds.



    History

    * Most adults are able to tell the examiner that there is something in their ear, but this is not always true. For example, an older adult with a hearing aid may lose a button battery or hearing aid in their canal and not realize it.

    * Children, depending on age, may be able to indicate that they have a foreign body, or they may present with complaints of ear pain or discharge.

    * Patients may be in significant discomfort and complain of nausea or vomiting if a live insect is in the ear canal.

    * Patients may present with hearing loss or sense of fullness.

    Physical

    The physical examination is the main diagnostic tool.

    * Physical findings vary according to object and length of time it has been in the ear.

    * An inanimate object that has been in the ear a very short time typically presents with no abnormal finding other than the object itself seen on direct visualization or otoscopic examination.

    * Pain or bleeding may occur with objects that abrade the ear canal or rupture the tympanic membrane or from the patient's attempts to remove the object.

    * Hearing loss may be noted.

    * With delayed presentation, erythema and swelling of the canal and a foul-smelling discharge may be present.

    * Insects may injure the canal or tympanic membrane by scratching or stinging.

    Causes

    * A patient, caretaker, or sibling intentionally places an object in the ear canal and is unable to remove it.

    * Insects may crawl or fly into the ear.

    DIFFERENTIAL DIAGNOSIS


    Abrasions to ear canal
    Cerumen impaction
    Hematoma
    Otitis externa
    Tumor
    Tympanic membrane perforation

    WORKUP

    No specific laboratory or radiologic studies are recommended. The physical examination is the main diagnostic tool.

    Use an otoscope while retracting the pinna in a posterosuperior direction. A head mirror with a strong light source, operating otoscope, or operating microscope also may be used. Refractory objects may require extraction by an ear, nose, and throat (ENT) specialist.

    TREATMENT

    Prehospital care

    No specific prehospital treatment exists other than transport to a hospital. Occasionally, treating significant pain or nausea may be necessary.

    Emergency department care

    Patients in extreme distress secondary to an insect in the ear require prompt attention. The insect should be killed prior to removal, using mineral oil or lidocaine (2%).

    * Methods of removal

    o Irrigation is the simplest method of foreign body removal, provided the tympanic membrane is not perforated. An electric ear syringe, available in some areas, may be very helpful for irrigation. Use of the commercial product Waterpik is not recommended because the high pressure it generates may perforate the tympanic membrane. Irrigation with water is contraindicated for soft objects, organic matter, or seeds, which may swell if exposed to water.

    o Suction is sometimes a useful means of foreign body removal. Suction the ear with a small catheter held in contact with the object. Grasp the object with alligator forceps. Place a right-angled hook behind the object and pull it out. Form a hook with a 25-gauge needle to snag and remove a large, soft object such as a pencil eraser.

    o Avoid any interventions that push the object in deeper.

    o The physician may need to sedate the patient to attempt removal of the object. Use mild sedation following a procedural sedation protocol.

    * Special instances

    o Cyanoacrylate adhesives (eg, Superglue) may be removed manually within 24-48 hours once desquamation occurs. If adhesive touches the tympanic membrane, remove it carefully, and refer the patient to an ENT specialist.

    o Remove batteries immediately to prevent corrosion or burns. Do not crush battery during removal.


    MEDICATIONS

    After the foreign body is removed, inspect the external canal. For most foreign bodies, no medications are needed. However, if infection or abrasion is evident, fill the ear canal 5 times/day for 5-7 days with a combination antibiotic and steroid otic suspension

  2. #2
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    Thumbs up Emergency Medicine - Foreign Bodies in Nose

    INTRODUCTION

    Nasal foreign bodies occur most frequently in children. Common objects that lodge in the nose include pieces of food, candy, toy parts, beads, pebbles, and paper. Anatomically, foreign objects can be found in any portion of the nasal cavity, most commonly on the floor below the inferior turbinate or immediately anterior to the middle turbinate.

    CLINICAL

    Children typically present soon after someone observes them placing an object in their nose. They also may present after a delay, with signs of infection. Classic delayed presentation is a unilateral purulent nasal discharge. Occasionally, patients may present with the complaint of foul breath. Rarely a patient may present with myiasis—the presence of animal life (screw worms or larvae) in the nasal cavity.

    DIFFERENTIAL DIAGNOSIS

    Epistaxis
    Sinusitis
    Polyps
    Tumor
    Upper respiratory infection (URI)


    TREATMENT

    * Most nasal foreign bodies can be removed easily and safely by emergency physicians. The need for urgent removal is infrequent, and usually adequate time is available to assemble the correct instruments and provide needed anesthesia and sedation. The physician should not attempt removal without appropriate instruments and good control of the patient. Parents are often apprehensive, and children are likely to be agitated and uncooperative. A failed attempt only makes subsequent attempts more difficult.

    * Prior to any procedure, treat nasal mucosa with 0.5% phenylephrine (Neo-Synephrine) to decrease mucosal edema and aerosolized lidocaine for local anesthesia.

    * Because nasal foreign bodies have different sizes, shapes, and locations within the nares, the emergency physician should be familiar with several removal techniques. The most commonly used techniques, described below, include mechanical dislodgement with a hooked probe or forceps, Fogarty or Foley balloon catheter, suction catheter tip, or stick and glue and bag-valve-mask or mouth-to-mouth positive pressure ventilation. Recently, use of a permanent magnet to remove metallic foreign bodies has been described.

    o Hooked probe or forceps: Several authors recommend using a hooked probe or forceps (bayonet or alligator) to remove the foreign object. If the object is small and close to the anterior naris, it can be grasped easily with forceps. However, objects that are large, solid, smooth, or rounded tend to be more difficult to grasp and often are pushed further into the naris with forceps.

    o Balloon catheters: A Fogarty or Foley balloon catheter may be useful for objects that cannot be grasped easily. The Fogarty catheter is preferred to the Foley because the Fogarty is stronger and stiffer and passes by the object more easily. With either device, check the balloon for patency, lubricate the catheter, and advance the deflated balloon past the object. Then inflate the balloon and withdraw the catheter, gently pulling out the foreign body. Complications may include bleeding.

    o Suction catheter: Position a suction catheter in the nares until the tip touches the object. Then turn the suction on to 100-140 mm Hg and retrieve the object while removing the catheter. The addition of a soft, pliable PE tube gives the Frazier suction tube a suction cup tip and allows better adherence to the foreign body's surface. Apply surgical lubricant to the PE tube's flange to further enhance its adherent properties. Although a solid seal is required for suction to be effective, smaller round foreign objects are removed easily with these maneuvers.

    o Cyanoacrylate glue: Apply cyanoacrylate glue to the end of a wooden or plastic applicator stick, then press it against the foreign body for approximately 1 minute to remove a nasal foreign body rapidly. Prevent accidental adhesion to the patient's nasal mucosa.

    o Positive pressure ventilation: Researchers have reported using positive pressure ventilation applied either with bag-valve-mask or mouth-to-mouth to expel nasal foreign bodies forcefully. A theoretical risk of barotrauma to the tympanic membranes or lower airways exists, although this has not been reported. This technique is most likely to be useful with large objects that occlude the entire nasal passage and limit ability to pass a catheter or probe. The unobstructed naris is occluded with a finger, and air is exhaled briskly into the mouth, producing positive pressure behind the object. This may reposition the object so that it can be grasped. In most cases, the object actually pops out. Success rates of 79% have been reported in a prospective study, and parents surveyed rated the procedure less traumatic than an injection and less traumatic than an oropharyngeal examination with a tongue depressor.


    SPECIAL CONSIDERATIONS

    One special consideration is the patient with a small button battery foreign body. Moisture within the cavity creates the potential for current, hydroxide formation, and significant tissue damage. Irrigation and nasal wash should be avoided, and leakage of the battery can cause liquefactive necrosis and organ injury. Immediate removal is necessary.

  3. #3
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    Thumbs up Emergency Medicine - Foreign Bodies in Trachea

    Background

    Foreign body aspiration can result in a spectrum of presentations, from minimal symptoms, often unobserved, to respiratory compromise, failure, and even death.

    This article is not intended to distinguish in detail acute airway obstruction from foreign body aspiration; for these patients, emergency life-saving interventions are needed.

    The epidemiology of tracheobronchial foreign bodies is bimodal, with peaks at the extremes of age.

    Children aged 1-3 years are particularly at risk because of their increasing independence, lessening of close parental supervision as they become older, and increasing activity and curiosity and because of hand-mouth interactions. Often, foods such as grapes and pieces of hot dogs that are easily handled by older children can be aspirated and occlude the airway. Smaller objects, such as peanuts, are easily aspirated into the bronchi by children.

    Elderly patients, particularly those with primary neurologic disorders and decreased gag reflexes due to alcohol, seizures, strokes, parkinsonism, trauma, and senile dementia, are also at risk of aspiration; any number of objects, food, and stomach contents can be aspirated.

    A third category of at-risk individuals is those undergoing procedures with sedation, particularly dental procedures or emergency intubation.

    The diagnosis is often missed initially, especially in children where the history may be vague and the patient cannot verbalize the events. In as many as 30% of patients, symptoms are treated as those of other common diseases, especially in patients with minimal symptoms. A high index of suspicion is required to make the diagnosis, especially in children and patients who are debilitated.


    Pathophysiology

    Aspirated foreign bodies most commonly are lodged in the right main stem and lower lobe. Aspiration has been documented in all lobes, including the upper lobes, though with less frequency.

    In the United States, peanuts are by far the most commonly aspirated material in children, followed by organic material such as sunflower seeds, pieces of vegetables, and hazelnuts. In other countries, the most common aspirated material remains food items, but the type of food differs from culture to culture.

    In adults, vegetable matter, meat, and bones rank highest, followed by dental and medical appliances. Aspiration of teeth after trauma is occasionally observed.


    Mortality

    Annual death rates from aspiration of foreign bodies range from 350-2000 in the United States. Most are children, particularly aged 1-3 years. The most common etiology of aspiration deaths in children is a toy, with balloons accounting for 29% of deaths. Foods most responsible for aspiration deaths in the United States are hot dogs, candy, nuts, and grapes. The mortality rate of tracheobronchial foreign body aspiration is approximately 1%.


    Sex

    Male predominance is found in most studies, particularly in children. Approximately 60% of patients in the United States are male, depending on the study. Interestingly, in studies from outside the United States, females often predominate.

    Age

    Age frequency is bimodal, with individuals aged 1-3 years and those in the seventh decade of life at higher risk of foreign body aspiration.


    History


    The history leads to diagnosis in most cases.

    In adults, aspiration occurs with choking after eating or choking when holding a foreign body in the mouth. Aspiration should also be suspected in adults with respiratory distress associated with sedation from drugs, alcohol, or trauma; after medical procedures such as sedation or intubation; after facial trauma; and in patients with decreased ability to handle secretions. In particular, patients with strokes, either new or old, are at high risk for aspiration.

    Suspicion of foreign body aspiration in children is raised with sudden paroxysms of coughing when not directly supervised, sudden choking after eating (particularly when an older sibling feeds a younger sibling), or choking and/or coughing when a known, small object or food particle (particularly peanuts) is within reach of the child.

    In children undergoing treatment of new-onset asthma, bronchitis, or pneumonia that is not responding to appropriate treatment (ie, bronchodilators, steroids, antibiotics), consider the possibility of foreign body aspiration, particularly with unilateral wheezing.

    Physical


    Choking or coughing is present in 95% of patients presenting with foreign body aspiration. Stridor is commonly present with upper airway or upper tracheal foreign bodies. Patients may present with respiratory distress, pneumonia, pulmonary edema, or wheezing.

    Children present similarly. Approximately 50% of children have inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase, and medium-to-coarse rhonchi. Tachypnea; nasal flaring; intercostal, subcostal, and suprasternal retractions; and differences in percussion between hemithoraces also are common findings. Fever and central cyanosis are less common. Only rarely do children with a positive history have an examination with completely normal findings.

    Stridor in children or adults indicates a partial upper airway or tracheal occlusion and is an ominous sign. These patients require prompt interventions.

    Causes


    In children, the primary factors leading to aspiration are underlying curiosity about the world and the oral phase of children aged 1-3 years. Loose, small objects and food found around the household increase risk. An older sibling feeding younger children is an important historical clue.

    Objects that tend to stay in the mouth for prolonged periods of time, such as gum, sunflower seeds, or hard candy, also increase risk. Eating while lying supine, especially just prior to falling asleep, increases risk of aspiration.

    Baby powder can be a particularly dangerous aspiration. A symptom-free period may occur before suffocation. Immediate lavage of bronchial system is required in severe cases.

    In adults, factors that increase risk are underlying primary neurologic disorders, such as senile dementia, mental retardation, seizures, strokes, and parkinsonism. Conditions that depress the central nervous system, cause coma, or depress the gag reflex, such as alcohol, narcotics, barbiturates, or benzodiazepines, can increase likelihood of aspiration.

    Meats, bones, and medical and dental appliances are the most commonly aspirated objects in adults. In patients who have sustained facial or dental trauma, including traumatic intubations, who have a missing tooth, the tooth must be presumed to have been aspirated, and radiographic evaluation is needed.


    DIFFERENTIAL DIAGNOSIS

    Bronchitis

    Pneumonia, Aspiration

    Pneumonia, Bacterial

    Pneumonia, Empyema and Abscess

    Pneumonia, Immunocompromised

    Pneumonia, Mycoplasma

    Pneumonia, Viral

    Retropharyngeal abscess

    Acute asthma

    Airway obstruction

    Bronchiolitis

    Croup

    Epiglottitis embolus

    Laryngitis pertussis

    Pulmonary lesions and/or diseases

    Upper respiratory illness


    Lab studies


    CBC and sedimentation rate may be elevated, particularly with chronic foreign bodies. In patients going to the operating room for bronchoscopy, routine preoperative laboratory studies are indicated.

    Imaging studies

    Posteroanterior and lateral chest films are mandatory. Foreign bodies, atelectasis, air trapping, mediastinal shift, compensatory emphysema on the contralateral side, pneumonia, or pneumothorax may be observed.

    Hyperlucency and atelectasis are observed in 63% of cases in children. Bilateral decubitus films may be helpful in children. A foreign object may prevent normal pulmonary collapse when the involved hemithorax is dependent (or on the "down" side, on the radiography table). In very young children, however, decubitus films are not as helpful.

    Fluoroscopy may show Holzknecht-Jacobson phenomena (swinging mediastinum).

    In patients with stridor, a soft-tissue lateral film of the neck may be useful.

    Computed tomography (CT) is rapidly becoming the imaging study of choice in stable patients with suspected aspiration, especially with nonradiopaque objects or in questionable cases. CT is very accurate in identifying and localizing foreign bodies. Consider CT if plain films are not helpful.

    Procedures

    Bronchoscopy may be necessary to assist in making the diagnosis when other tests do not reveal the problem.


    TREATMENT

    Prehospital care

    If the patient is coughing, wheezing, or is stridorous but maintaining an airway, do not attempt to intervene; transport to the nearest facility where definitive treatment can be provided.

    If severe airway compromise or total obstruction occurs, attempt chest compressions, back blows, abdominal thrusts, or the Heimlich maneuver. The method depends on the age of the patient.

    Emergency department care

    Initial supportive therapy includes oxygen administration, cardiac monitor, pulse oximetry, and intravenous line. Definitive airway management may be required.

    In stridorous patients, racemic epinephrine via a nebulizer may be a temporizing measure until bronchoscopy can be performed.

    In patients who are unstable, emergent management in the ED is needed. Magill forceps have been used with some success in the ED for foreign bodies located below the cords but above the cricoid ring. With the laryngoscope, this may be the quickest method of removing foreign bodies above the cricoid ring. The preferred method is an awake examination, allowing the patient to maintain his or her airway.

    In unstable patients, rapid sequence intubation may be needed. In these cases, be prepared with suction and Magill forceps. In emergent situations with tracheal foreign bodies below the level of the vocal cords, intubation may be required. One option is to insert the endotracheal tube all the way to the hub, thus pushing the foreign body down into a mainstem bronchus (normally, the right). The endotracheal tube is then removed to the normal position (normally 20-22 cm at the lips in adults), and the patient is ventilated after ensuring the tip of the tube is not occluded with the foreign body. Even though only one lung will be ventilated, sufficient air exchange and oxygenation should occur to allow the patient to be taken for formal bronchoscopy.

    Extraction by bronchoscopy is the treatment of choice for tracheal foreign bodies.

    Bronchoscopy is performed with general anesthesia in the operating room for children, with inhalational induction generally preferred. Adults may tolerate awake or sedated bronchoscopy if nebulized lidocaine (4%) is used. Complications of bronchoscopy generally are uncommon and self-limited. However, in-hospital mortality is reportedly 1-2%, partially attributable to large tracheal foreign bodies lost during a procedure. The lost foreign body may become lodged in the subglottic region, causing complete airway obstruction.

    If initial bronchoscopy is unsuccessful, a repeat attempt usually is performed. Rarely, a second attempt is unsuccessful, and thoracotomy is necessary. If the foreign body has expanded (as can occur with organic matter) or is larger than the subglottic region, a tracheostomy may be required.


    MEDICAL THERAPY

    Preoperative steroids and antibiotics may reduce complications such as airway edema and infection.

    Prior to bronchoscopy, consider methylprednisolone succinate (125 mg IV in adults and 2 mg/kg IV; not to exceed 125 mg in children) or dexamethasone (Decadron) (10-12 mg in adults and 0.03-0.3 mg/kg in children) and broad-spectrum antibiotics such as cefazolin (1 g IV in adults and 25 mg/kg IV; not to exceed 1 g in children) or nafcillin (1 g IV in adults and 25 mg/kg IV; not to exceed 1 g in children), which provide coverage for hemolytic streptococci and Staphylococcus aureus.


    DISCHARGE


    Admit patients with suspected foreign body aspiration to the hospital. Discharge depends on the individual clinical course and whether complications such as pneumonia, abscess, and hypoxia develop or persist.




    Aspirated foreign body (backing to an earring) lodged in the right main stem bronchus.


    A tooth (molar) was dislodged during intubation and can be observed in the right hilum. It was not noticed on initial review of this film.


    A tooth (molar) was dislodged during intubation. The patient developed a lobar pneumonia from the tooth, which on this radiograph has migrated to the left hilum. Attempts at removal by bronchoscopy were unsuccessful, and the tooth was removed surgically.

  4. #4
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    Thumbs up Emergency Medicine - Foreign Bodies, Gastrointestinal

    Background

    People with foreign bodies in the gastrointestinal (GI) tract commonly present to the ED for evaluation. Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally.

    Presentations of patients with GI foreign bodies can range from the patient in extremis to the patient with subtle or chronic findings without a clear history. Most of the literature covering GI foreign bodies is anecdotal, with the exception of some recent studies on esophageal foreign body removal techniques.

    Pathophysiology

    The entire GI tract can be involved. The oropharynx is well innervated, and patients can typically localize oropharyngeal foreign bodies. Scratches or abrasions to the mucosal surface of the oropharynx can create a foreign body sensation. Chronic foreign bodies or perforations can cause infections in surrounding soft tissues of the throat and neck.

    The esophagus is a tubular structure approximately 20-25 cm in length. Patients can usually localize foreign bodies in the upper esophagus but localize them poorly in the lower two thirds of the structure. The esophagus has 3 areas of narrowing: the upper esophageal sphincter (UES), which consists of the cricopharyngeus muscle; the crossover of the aorta; and the lower esophageal sphincter (LES). These areas are where most esophageal foreign bodies become entrapped. Structural abnormalities of the esophagus, including strictures, webs, diverticula, and malignancies, increase the risk of foreign body entrapment, as do motor disturbances such as scleroderma, diffuse esophageal spasm, or achalasia.

    Once a foreign body has reached the stomach, it has greater than a 90% chance of passage. Once coins reach the stomach, they have virtually a 100% chance of passage. Objects longer than 6 cm may become entrapped by either the pylorus or the duodenal sweep, and objects larger than 2 cm in diameter also may fail to pass the pylorus. When a foreign body has reached the small bowel, the only structural impediment to passage is the ileocecal valve. Rarely, a foreign body may become entrapped in a Meckel diverticulum.

    Mortality/Morbidity

    An estimated 1500 deaths occur annually from foreign bodies in the upper GI tract.1

    * Potential complications of oropharyngeal foreign bodies include abrasions, lacerations, and punctures, with associated abscesses, perforations, and soft-tissue infections.
    * Esophageal foreign bodies can also cause abrasions, punctures, and perforations, with resultant injuries or infections to surrounding structures, including abscesses, pneumomediastinum or mediastinitis, pneumothorax, pericarditis or tamponade, fistulas, or even vascular injuries to the aorta or pulmonary vasculature. Additionally, button batteries can rapidly create esophageal necrosis.
    * Complications from foreign bodies in the stomach and small intestine typically involve perforation and associated infection, including peritonitis.

    Sex

    In children with swallowed foreign bodies, the incidence in males and females is equal. In adults, the incidence of accidentally swallowed foreign bodies is slightly higher in men than in women, and the incidence of intentionally swallowed foreign bodies is much higher in men than in women.

    Age

    Patients with foreign bodies in the upper GI tract usually fall into 1 of 3 categories: (1) children, (2) psychiatric patients and prisoners, and (3) edentulous patients.

    * Children account for 75-80% of patients with foreign bodies in the upper GI tract, with a preponderance at age 18-48 months.
    * The objects involved also differ by group. Children typically ingest objects they pick up and place in their mouths, such as coins, buttons, marbles, crayons, and similar items. In contrast, adults are more prone to ingest food boluses, chicken or fish bones, fruit pits, dentures, or toothpicks. Prisoners and psychiatric patients may present with bizarre objects, including multiple objects.
    * The site of entrapment of esophageal foreign bodies also differs with age groups, with about 75% of children having entrapment at the UES and about 70% of adults having entrapment at the LES.


    CLINICAL

    History

    * Oropharyngeal foreign bodies
    *
    o Patients with oropharyngeal foreign bodies normally present with a foreign body sensation, especially after eating chicken or fish, although a variety of other objects, including toothpicks, may be involved.
    o They may have variable degrees of discomfort, from minor to more severe, such as drooling or an inability to swallow.
    o Rarely, patients may have airway compromise, typically in delayed presentations with subsequent infection or perforation.
    o Patients can usually localize the foreign body sensation in the oropharynx.
    * Esophageal foreign bodies
    *
    o Adults with esophageal foreign bodies usually present acutely, with a history of ingestion. A foreign body sensation or vague discomfort in the epigastrium suggests that the foreign body is entrapped at the LES.
    o Dysphagia is the norm in adults. If the obstruction is complete, an inability to handle secretions is common. The classic adult presentation is the person with dentures who has had some alcohol and is eating meat. Incomplete chewing leads to an impaction at the LES. Adults should be asked about the use of dentures, alcohol intake, and circumstances surrounding the ingestion.
    o In children with esophageal foreign bodies, the history may be less clear. As many as 35% of children with esophageal foreign bodies are asymptomatic; the history is given by a parent who has seen the child with an object in his or her mouth and suspects the child might have swallowed it. Such reports must be taken seriously and investigated. Gagging, vomiting, and neck or throat pain are common presentations. Children with chronic esophageal foreign bodies may also present with poor feeding; irritability; failure to thrive; fever; stridor; or pulmonary symptoms, such as repetitive pneumonias from aspiration. Large esophageal foreign bodies at the UES can cause tracheal impingement in children, with resultant stridor or respiratory compromise.
    * Stomach/small intestine foreign bodies
    *
    o Patients with foreign bodies in the stomach or small intestine may present with a history of swallowing an object, which has passed through the esophagus.
    o Patients may present with vague symptoms such as fever, abdominal pain, or vomiting.

    Physical

    * The physical examination typically is not helpful, but the oropharynx, neck, chest, lungs, heart, and abdomen should be carefully examined.
    * Occasionally, a foreign body in the oropharynx can be visualized and removed. In cooperative patients, indirect laryngoscopy or fiberoptic nasopharyngoscopy provides better information than a direct examination.
    * In children, tracheal compression and stridor suggest a large foreign body at the UES.
    * Complete obstructions can cause drooling and the inability to swallow.
    * Delayed presentations may be accompanied by signs of infection, including peritonitis.

    Causes

    The typical cause of swallowed GI foreign bodies is accidental.

    * Young children often put any object they find into their mouths and may accidentally swallow them.
    * Older children also put smooth objects, such as coins or marbles, in their mouths and may swallow them. However, because their esophagi are greater in diameter than those of young children, foreign body lodgment in this location is less common in older children.
    * Children who are abused may present with GI foreign bodies after being forced to swallow objects; however, this is rare.
    * The most common cause of GI foreign bodies in adults involves food that does not pass through the esophagus because of underlying mechanical problems.
    * In adults, accidental swallowing involves toothpicks, dentures, and other objects.
    * Psychiatric patients may swallow a wide variety of objects, including multiple objects, large objects, and bizarre items.
    * Prisoners may swallow objects either to hide them from authorities or to seek medical care. In the case of razor blades, they often tape the sharp edge to avoid injury.
    * People who smuggle drugs may swallow multiple condoms (usually double wrapped) filled with cocaine or heroin. This is called "body packing," as opposed to "stuffing," which occurs when the patient attempts to elude arrest by swallowing packets of drugs in their possession.


    DIFFERENTIALS

    Disk Battery Ingestion
    Esophageal Perforation, Rupture and Tears
    Foreign Bodies, Rectum
    Foreign Bodies, Trachea
    Mediastinitis
    Obstruction, Small Bowel
    Pediatrics, Foreign Body Ingestion
    Pediatrics, Gastrointestinal Bleeding
    Retropharyngeal Abscess

    Other Problems to be Considered


    Dysphagia
    Esophageal carcinoma
    Esophageal stricture
    Failure to thrive
    Intestinal perforation
    Odynophagia
    Peritonitis
    Pneumomediastinum


    Lab Studies


    * Most patients with GI foreign bodies do not require any laboratory studies. Exceptions are patients who present with signs and symptoms consistent with infection or complications, in which case a CBC may be indicated, and patients who require preoperative studies.

    Imaging Studies

    * Radiography
    *
    o Plain radiographs are indicated for every patient with a known or suspected radiopaque foreign body in the oropharynx, esophagus, stomach, or small intestine. Plain radiographs are also mandated for children in whom any ingestion of a radiopaque foreign body is suspected. Keep in mind, however, that in cases of nonradiopaque foreign bodies, imaging studies rarely have any influence on management, except in delaying endoscopy or CT scanning.
    o In small children, a mouth-to-anus radiograph can be obtained. In older children and adults, posteroanterior (PA) and lateral chest radiographs provide better localization.
    o Radiopaque objects are easily seen and localized on the radiograph.
    o Plain radiographs typically have been used in patients who have swallowed bones, although the yield is low, with only 20-50% of endoscopically proven bones visible on plain radiographs. Xeroradiography does not increase this yield.
    o Coins are usually seen in a coronal alignment on anteroposterior (AP), or frontal, radiographs
    *
    o If the foreign body is in the trachea, it presents in a sagittal orientation because the tracheal rings are incomplete in the posterior aspect.
    o In adults with food impactions, a plain radiograph may be indicated to search for imbedded bony fragments if techniques, such as LES-relaxing agents or bougienage, are being considered. If endoscopy is used to treat the patient, plain radiographs are not indicated.
    * Barium or Gastrografin swallow
    *
    o Barium swallow may be indicated in cases of ingestion of nonopaque foreign bodies, such as toothpicks or aluminum soda can tabs, although CT scanning is a much better imaging modality and should be used as the first choice when available.
    o A barium or Gastrografin swallow, without cotton balls, can sometimes outline the foreign body, but, again, the yield is very low.
    o Barium swallow can be used for food impactions; however, most authorities believe that it adds nothing to the evaluation and delays definitive treatment.
    o Contrast studies are not useful in detecting foreign bodies in the stomach or small intestine.
    o Barium is contraindicated in cases in which esophageal perforation is suspected. Gastrografin may be used if a study is needed.
    * CT scanning
    *
    o In one study, CT scanning was superior to plain radiographs for localization and identification of foreign bodies in 83-100% of cases. CT scanning is highly reliable in localizing foreign bodies in the esophagus.2, 3
    o CT scanning is now considered the imaging modality of choice to locate nonradiopaque foreign objects in the oropharynx or esophagus. However, the application is probably unwarranted in every case of acute bone dysphagia, as only a minority (17-25%) of patients who sense a foreign body after eating chicken or fish has a bone present.
    o CT scanning is also the imaging modality of choice in cases of suspected perforation or abscess.
    * Metal detectors: Handheld metal detectors have been shown to be accurate in determining if a coin has been swallowed and may be a useful noninvasive screening tool in children with a suspected coin ingestion. However, the specificity of localization is poor, especially in differentiating LES impaction from coins in the stomach.

    Procedures


    * Endoscopy
    *
    o Emergent endoscopy is indicated for patients whose airway is compromised or who show signs of complications.
    o Urgent endoscopy is indicated for patients who have swallowed aluminum soda can tabs or toothpicks, since these objects are not visible on plain radiographs and both have a relatively high incidence of complications. If the history is clear, proceed to endoscopy; if unclear, CT scanning may be used to confirm the presence of the foreign body before endoscopy.
    o Endoscopy is absolutely indicated for foreign bodies that are sharp, nonradiopaque, or elongated; for multiple foreign bodies; or for possible esophageal injuries.
    o Endoscopy is the most commonly used technique for active management of impacted esophageal foreign bodies. Endoscopy has been traditionally used for the visualization of the esophagus and the removal of foreign bodies.
    o Endoscopy is indicated for patients with foreign bodies in the stomach or proximal duodenum if the foreign bodies are larger than 2 cm in diameter or longer than 5-7 cm or for oddly shaped foreign bodies such as open safety pins.
    o Endoscopy is safe and effective but relatively expensive.


    TREATMENT

    Prehospital Care

    The patient should be transported in a comfortable position. Patients with airway compromise may need acute airway management. Patients unable to tolerate secretions are often most comfortable in the sitting position, holding a suction catheter that they may use intermittently.
    Emergency Department Care

    The treatment of patients with suspected foreign bodies can be straightforward in cases such as those that involve ingestions of radiopaque objects that can be easily localized on plain radiographs.

    In cases involving suspected oropharyngeal foreign bodies, which usually present with a foreign body sensation, the evaluation and treatment is complicated by the fact that the physical examination is usually unhelpful; only a minority (26% in one study) of patients have any pathology at all as seen on endoscopy, and imaging studies are either unhelpful (plain radiography or barium swallow) or expensive (CT scanning).

    For nonradiopaque foreign objects, plain radiographs are not helpful, and while studies, such as barium swallows or CT scanning, may help to confirm or localize a foreign body, they may only delay definitive treatment.

    Because of the broad range of presentations of GI foreign bodies, a tiered approach is appropriate.

    * Patients in an unstable condition
    *
    o Patients with airway compromise; drooling; inability to tolerate fluids; or evidence of sepsis, perforation, or active bleeding are considered to be in an unstable condition.
    o Treatment includes airway management as indicated, followed by urgent endoscopy
    #

    * Patients who have ingested button batteries are considered to be in an unstable condition. The presence of a button battery in the esophagus is a medical emergency because necrosis of the esophageal wall may occur within hours. These button batteries must be expeditiously removed. Button batteries in the stomach can be allowed to pass but must be monitored radiographically to observe for disruption of the battery. Follow-up radiographs are needed in 24-48 hours. If the battery is still in the stomach, endoscopic removal is indicated.
    * Patients who are drooling may be more comfortable holding a suction catheter and using it as needed.

    # Patients in a stable condition
    #

    * For patients who sense an oropharyngeal foreign body, perform direct and indirect oropharyngeal examination and fiberoptic nasopharyngoscopy, if available in the ED; remove any visualized foreign bodies.
    * Radiographically localize radiopaque objects. If the foreign body is sharp, elongated (>5 cm in esophagus, >6 cm in stomach or small intestine), or multiple in number, refer for endoscopy. Sharp objects, such as pins, razor blades, toothpicks, and chicken bones, should be removed endoscopically on an urgent basis because up to 35% of these sharp objects perforate the bowel wall if not removed. Most smaller, sharp foreign bodies, such as straight pins, transit the GI tract without difficulty, as the peristaltic action carries the blunt end first; however, many authorities recommend endoscopic removal for these as well.7 If the foreign body is smooth or blunt, consider the following modalities .

    #

    *
    o Endoscopy
    o Foley catheter removal
    o Bougienage
    o Sphincter relaxation if lodged at LES
    * For patients whose history strongly suggests an ingestion of a nonopaque foreign body such as a plastic object, toothpick, or aluminum soda can tab, consider CT scanning and refer for endoscopy. When the history is less clear about the definitive swallowing of a nonradiopaque foreign body, obtain CT scanning and refer for endoscopy if the foreign body is localized in the oropharynx or esophagus.
    * Button batteries in the stomach can be allowed to pass but must be followed radiographically to observe for disruption of the battery. Follow-up radiographs are needed in 24-48 hours. If the battery is still in the stomach, endoscopic removal is indicated.
    * Smooth foreign bodies, such as coins or marbles, almost always transit the GI tract without any difficulties. Coins lodged in the distal esophagus of healthy children spontaneously pass into the stomach in up to 60-80% of cases, usually within several hours of presentation.
    * Note that the use of meat tenderizer is contraindicated in patients with food boluses at the LES, as meat tenderizer may cause necrosis of the esophagus.
    * People who body pack, those who ingest carefully wrapped packets of drugs, such as heroin or cocaine, should be admitted for observation. Whole-bowel irrigation is frequently used to aid passage. Endoscopy is generally avoided because instrumentation of the packets may result in rupture.

    # Foley catheter removal
    #

    * Foley catheter removal is another widely used technique for the removal of single, smooth, blunt, radiopaque foreign bodies.
    * Foley catheter removal is contraindicated in patients with foreign bodies that have been present for more than 72 hours, those with a history of esophageal disease or surgery, those who are experiencing respiratory distress, and those who are uncooperative.
    * This procedure is performed under fluoroscopy with immediate availability of emergency airway equipment and personnel capable of emergency airway management.
    * In this procedure, the patient is placed in a head-down position, and a #12-#16 Foley catheter is passed orally past the foreign object under fluoroscopic guidance. The balloon is inflated, and the catheter is pulled out with the foreign body. The success rate for this procedure has been reported as 85-100%. Complications, including epistaxis, dislodgment of the foreign body into the nose, laryngospasm, hypoxia, and aspiration, have been reported at rates of 0-2%.
    * Foley catheter removal should be attempted only by those familiar with its use. Until ED personnel become comfortable with this procedure, it should be performed under controlled conditions with immediate backup available for complications.

    # Bougienage
    #

    * Smooth esophageal foreign bodies, such as coins, lodged at the LES in children have been advanced successfully into the stomach by using bougienage.
    * Indications for this procedure are a smooth foreign body, lodged less than 24 hours, with no underlying esophageal disease or respiratory distress.
    * Dilator size is selected according to the patient's age; the dilator is advanced gently through the mouth and esophagus to the stomach with the child in a sitting position, essentially in the same manner as is used in passing a nasogastric tube. Often, topical anesthesia is used for the oropharynx.
    * A repeat radiograph is used to confirm passage into the stomach.
    * Published success rates for this procedure are 83-100%, and complication rates in limited studies are 0%

    # Relaxation of the lower esophageal sphincter
    #

    * Foreign bodies lodged at the LES can be managed by relaxation of the LES, although in some studies, success rates associated with this technique are no greater than those associated with watchful waiting.
    * Typically, glucagon is used, with or without a gas-forming compound. The patient is administered 1-2 mg of glucagon intravenously (0.02-0.03 mg/kg in children, not to exceed 0.5 mg) followed by ingestion of E-Z Gas mixed with 240 mL of water. The use of carbonated beverages if E-Z Gas is not available in the ED has been reported.
    * The published success rates for this procedure range from 12-50%, which may not be any better than spontaneous passage with no interventions, especially with coin ingestions in children.12
    * Nitrates, such as sublingual nitroglycerin and nifedipine, have been used less widely; a risk involved with this procedure is creating significant hypotension in the patient.
    * This procedure does not work in patients with structural abnormalities.# If the workup is negative for a foreign object, discharge the patient with analgesics as needed and refer for follow-up in 24 hours. If the patient is still symptomatic at recheck, refer for endoscopy.
    # Esophageal coins: Four generally broadly accepted approaches to management of esophageal coins in children are as follows: endoscopic removal, Foley catheter removal, bougienage, and "watchful waiting," which is based on the fact that up to 80% of coins at the LES will pass spontaneously within 24-48 hours with no interventions. The watchful waiting approach is used only in patients with single coins, who are able to handle secretions with no difficulties, and who have no pain or distress, and no stridor or drooling. After ascertaining location of the coin at the LES, the child is discharged with follow-up arranged in 24 hours for repeat radiography. Each of the 4 modalities is relatively site or regionally accepted based on training and experience of local practitioners.


    MEDICATION

    Smooth-muscle relaxation agents may be used to relax the LES, thereby allowing the passage of foreign bodies lodged in this location.

    Drug Category: Gastrointestinal agents

    These agents may improve peristaltic activity in the GI tract.

    Glucagon (GlucaGen) - 1-2 mg IV, repeat in 10-20 min prn

    Sodium bicarbonate, citric acid, and simethicone - 1 packet mixed with 240 mL of water administered PO


    Further Inpatient Care

    * Patients in an unstable condition including drooling, stridor, inability to handle secretions, signs of perforation or bleeding:
    *
    o Manage airway and refer for urgent endoscopy.
    o Patients with button batteries in the esophagus are considered to be in an unstable condition.
    * Patients in a stable condition
    *
    o Oropharyngeal foreign bodies: If ED evaluation is negative for a foreign body, discharge with follow-up, generally with an ear, nose, and throat (ENT) specialist in 24 hours. If ED evaluation is positive for a foreign body that cannot be removed under direct visualization, refer to an ENT specialist for endoscopy.
    o Esophageal foreign bodies: In cases that involve sharp, elongated, or multiple foreign bodies, refer the patient to a gastroenterologist for urgent removal. For patients with entrapped smooth foreign bodies, if treatment in the ED does not result in removal or passage into the stomach, refer to a gastroenterologist for endoscopy. In children with coins at the LES, watchful waiting may be used if the patient is stable, with follow-up and repeat radiography in 12-24 hours; if the coin has not advanced to the stomach by that time, refer for endoscopy.
    o Stomach or small intestine foreign bodies: Patients with smooth, blunt objects that are less than 2 cm in width or 6 cm in length should be discharged to home. Serial radiographs are generally not needed. Instruct patient to return if fever, vomiting, or abdominal pain occurs. Those with sharp or large foreign bodies in the stomach should be referred to a gastroenterologist for endoscopic removal. Serial radiographs are indicated for sharp or large foreign bodies in the duodenum or small intestine. In most cases, refer to a surgeon or gastroenterologist in 24 hours for follow-up examinations, radiographs, and intervention.
    o People who body pack should be admitted to a monitored setting and are typically treated with whole-bowel irrigation or observation alone. If they develop signs of drug toxicity, this indicates rupture of one of the drug-containing packages and mandates resuscitative measures and surgical consultation for possible surgical removal.

    Further Outpatient Care

    * For adults with resolved esophageal foreign bodies, referral to a gastroenterologist in 24-72 hours is mandatory because a large percentage of these patients have underlying structural abnormalities, including malignancies, and follow-up endoscopy is needed.
    * In children with resolved esophageal foreign bodies, no follow-up is needed.

    Complications

    * Oropharyngeal foreign bodies - Esophageal or pharyngeal scratches, abrasions, lacerations, or perforations; retropharyngeal abscess; soft-tissue infection or abscess
    * Esophageal foreign bodies - Mucosal scratches or abrasions; esophageal necrosis; retropharyngeal abscess; esophageal stricture; esophageal perforation leading to paraesophageal abscess, mediastinitis, pericarditis/tamponade, pneumothorax, pneumomediastinum, tracheoesophageal fistula, and vascular injuries, including aortoesophageal fistulas
    * Stomach and small intestine foreign bodies - Small-bowel obstruction; perforation with intra-abdominal infection, peritonitis, and sepsis




    Coin (quarter) lodged at the level of the cricopharyngeus muscle.



    Coin lodged at the level of the aortic crossover.



    Coin lodged at the lower esophageal sphincter.



    A screw in the stomach; peristaltic action will carry the screw through the GI tract with the blunt end (head) leading and the sharp end trailing.

  5. #5
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    Thumbs up Emergency Medicine - Foreign Bodies in Rectum

    Background

    Controlled studies of patients with rectal foreign bodies have not been conducted, and the literature is largely anecdotal. These patients usually present to the ED because of pain, often after multiple attempts to remove the object. Presentation is often delayed because of embarrassment. The keys to adequate care for these patients are respect for their privacy, evaluation of the type and location of the foreign body, determination if removal can be performed in the ED or if operative referral is needed, and use of appropriate techniques for removal. Caregivers should refrain from making disparaging or comical remarks concerning the nature of the problem and prevent invasions of the patient's privacy by curious hospital staff.

    Pathophysiology

    Rectal foreign bodies usually are inserted, with the vast majority of cases as a result of erotic activity. In these cases, the objects are typically dildoes or vibrators, although almost any object can be seen, including light bulbs, candles, shot glasses, and odd or unusually large objects such as soda bottles, beer bottles, or other large objects.

    Less commonly, rectal foreign bodies are inserted in an attempt to conceal the object, typically weapons such as knives, or drug packets.

    Some rectal foreign bodies are initially swallowed and then transit through the GI tract. Examples of the latter include toothpicks, popcorn, bones, and sunflower seeds.

    Rectal foreign bodies can be classified as high-lying or low-lying, depending on their location relative to the rectosigmoid junction. This distinction is important. Objects that are above the sacral curve and rectosigmoid junction are difficult to visualize and remove, and they are often unreachable by rigid proctosigmoidoscope. Low-lying rectal foreign bodies are normally palpable by digital examination and are candidates for ED removal.

    Frequently, delay in presentation and multiple attempts at self-removal lead to mucosal edema and muscular spasms, further hindering removal. Rectal lacerations and perforations may occur but are less common than other complications.

    Mortality/Morbidity


    * Mortality is rare and results from bleeding, rectal perforation or laceration, and infectious complications.
    *

    * Morbidity is somewhat more common and primarily the result of rectal laceration or perforation.

    Race

    The few published series that list race note no significant differences.

    Sex

    Prevalence is higher in males than in females by a ratio of approximately 28:1.

    Age

    Age distribution is bimodal, with peaks in the 20s (anal erotism) and 60s (thought to be secondary to the use of foreign objects for prostatic massage). Most patients are in the age range of 20-30 years.



    CLINICAL


    History

    * Patients with rectal foreign bodies are usually aware of their presence and often present requesting removal. They may also present with rectal pain or bleeding, and less often, abdominal pain.
    *
    * Patients who have ingested foreign bodies that become lodged in the rectum may present with rectal pain or bleeding, constipation, pain with defecation, pruritus, or diffuse abdominal pain. Symptoms of peritonitis or bowel obstruction also may be present. The usual etiologic objects are sunflower seeds, toothpicks, or bones, and the ingestion is typically unknown.
    *
    * Patients with rectal foreign bodies may be too embarrassed to mention the foreign body at triage but usually admit the etiology to the physician. Maintain a high suspicion index of rectal foreign body in psychiatric patients or prisoners who present with rectal pain or bleeding.
    *
    * The vast majority of patients with rectal foreign bodies present because of an inability to remove the object. Some patients claim to have sat or fallen on the object. Older patients may state they were engaged in therapeutic prostatic massage or breaking up fecal impactions when the object was lost. Occasionally, objects such as thermometers or enema tips may become lost. Most patients, however, admit to the history of insertion by self or a partner.
    *
    * Typically, multiple failed attempts at self-removal have occurred. Ascertaining whether the patient attempted any instrumentation in these attempts is important because this increases the risk of perforation or laceration. Length of time since insertion and presence of rectal or abdominal pain, fever, or rectal bleeding are important elements of the history. The type of object should be determined because fragile or sharp foreign bodies deserve special consideration.
    *
    * Patients should be asked if the foreign body is the result of assault because this is more likely to result in a serious injury. Notify the legal authorities if the patient has been assaulted.

    Physical


    * Assess vital signs and general appearance. Fever or hypotension may indicate infection or bleeding. Perform an abdominal examination. Absent bowel sounds, rigidity, or peritoneal signs suggest perforation. The foreign body, especially if large or in a high-lying position, can occasionally be palpated.
    *

    * A rectal examination should be deferred in patients with known or suspected rectal foreign bodies, especially in prisoners or psychiatric patients, until the location and type of foreign body has been ascertained radiographically. In some cases, dangerous objects such as guns or sharp objects (eg, needles, razor blades) are inserted rectally in an attempt to hide the object or, in the case of psychiatric patients, to injure the examiner. The main purpose of the rectal examination is to check for the presence of blood and the position of the foreign body.


    DIFFERENTIALS

    Other Problems to be Considered

    Rectal wall perforation
    Rectal wall laceration
    Fecal impaction


    Lab Studies

    * A hematocrit may be useful if bleeding is present. Obtain a white blood cell count with differential when infection is suspected. Obtain routine preoperative laboratory studies for patients who are operative candidates (eg, patients with signs of peritonitis, sepsis, or perforation, or with rectal foreign bodies that cannot be removed in the ED).

    Imaging Studies


    * A flat plate radiograph of the abdomen or pelvis is indicated. The foreign object can be identified and localized in most cases.
    *

    * A lateral pelvic film sometimes gives additional information regarding orientation of the foreign body, particularly whether its position is high- or low-lying.
    *

    * An upright chest radiograph is indicated if perforation is suspected.


    TREATMENT

    Prehospital Care

    Transport the patient in a comfortable position. Fluid resuscitation is indicated in cases of hypotension caused by sepsis or hemorrhage.

    Emergency Department Care


    * Perform a rectal examination if no dangerous or sharp foreign body is visible on radiographs. The presence of frank blood is an indication of laceration or perforation, and the patient should be referred to a surgeon for evaluation. If the foreign body is palpated on rectal examination, the object is considered to be low-lying and a candidate for ED removal. Objects that can be removed in the ED should be smooth, nonbreakable, and nonfriable, thus excluding thin glass objects such as light bulbs.
    *
    * Patients with rectal foreign bodies often develop rectal edema or spasm. Successful removal usually requires direct visualization, which is greatly facilitated by provision of adequate sedation and analgesia. Under direct visualization with an anoscope or proctoscope and adequate lighting, the object is grasped with forceps or snares. Retractors may also be used. Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. In these cases, inserting a Foley catheter beyond the foreign object breaks the suction seal and facilitates removal. Generally, limit extraction attempts in the ED to approximately 30 minutes.
    *
    * After removal, a repeat examination, preferably direct, using the anoscope or proctoscope is indicated to evaluate for rectal injuries.
    *
    * Occasionally, a high-lying rectal foreign body may be palpable on abdominal examination. If the patient is cooperative, a manual transabdominal attempt to manipulate the foreign body into a low-lying position can be made. If successful, ED extraction can then be attempted.

    Consultations


    * Consult a general surgeon in the following situations:
    *
    o When laceration, perforation, or infection is evident

    o High-lying objects that cannot be converted to low-lying

    o Glass objects, with the possible exception of thick, sturdy unbroken objects

    o Breakable or friable objects

    o Sharp or nonsmooth objects

    o Dangerous objects

    o Those for which extraction attempts in the ED have been unsuccessful

    * The usual treatment of these patients by surgery includes attempted visualization and removal under general anesthesia using flexible rectosigmoidoscopy. In rare cases, a laparotomy is needed.


    Further Inpatient Care


    * Arrange for evaluation and treatment of patients who are not candidates for ED removal. Patients with subsequent noncomplicated operating room removal are typically discharged after recovery.

    Further Outpatient Care


    * Refer most patients who have had ED extraction to a general surgeon for follow-up in 24-48 hours. Some patients with simple extractions can be reevaluated in the ED in 24-48 hours.

    In/Out Patient Meds

    * Discharge patients on oral analgesics, such as nonsteroidal anti-inflammatory drugs or narcotic medications, as indicated. Antibiotics generally are not indicated in patients discharged home from the ED.

    Complications

    * The most common complications are rectal laceration and perforation, which are diagnosed by direct visualization. Refer questionable cases to a general surgeon. Other complications include infection with abscesses and sepsis.




    Typical appearance of a vibrator in the rectum.



    Vibrator in the rectum. The patient attempted self-removal with a pair of salad tongs, which also became lodged, resulting in two rectal foreign bodies. Multiple attempts at self-removal are typical in patients with rectal foreign bodies.

  6. #6
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    Thumbs up Emergency Medicine - Pediatrics, Foreign Body Ingestion

    Background

    As children explore the world, they will inevitably put foreign bodies into their mouths and swallow some of them.

    Most swallowed foreign bodies pass harmlessly through the gastrointestinal (GI) tract. Foreign bodies that damage the GI tract, become lodged, or have associated toxicity must be identified and removed. Children with preexisting GI abnormalities (eg, tracheoesophageal fistula, stenosing lesions, previous GI surgery) are at an increased risk for complications.

    Although adults most often present to the ED after ingestion of radiolucent foreign bodies (typically food), children usually swallow radiopaque objects, such as coins, pins, screws, button batteries, or toy parts. Although children commonly aspirate food items, it is less common for small children to present because of foreign body complications due to food ingestion.

    Pathophysiology

    Esophagus

    Most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at 1 of 3 typical locations. The most common site of esophageal impaction is at the thoracic inlet. Defined as the area between the clavicles on chest radiograph, this is the site of anatomical change from the skeletal muscle to the smooth muscle of the esophagus. The cricopharyngeus sling at C6 is also at this level and may "catch" a foreign body. About 70% of blunt foreign bodies that lodge in the esophagus do so at this location. Another 15% become lodged at the mid esophagus, in the region where the aortic arch and carina overlap the esophagus on chest radiograph. The remaining 15% become lodged at the lower esophageal sphincter (LES) at the gastroesophageal junction.

    Children with preexisting esophageal abnormalities (eg, repair of a tracheoesophageal fistula) are likely to have foreign body impaction at the site of the abnormality. If a child with no known esophageal pathology has a blunt foreign body lodged at a location other than the 3 typical locations described above, the possibility of a previously unknown esophageal abnormality should be considered.

    Pointed objects, such as thumbtacks, may become impaled and, therefore, lodged anywhere in the esophagus. Small objects, such as pills, may adhere to the slightly moist esophageal mucosa at any point.

    Stomach/lower gastrointestinal tract

    Once a swallowed foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve. Other exceptions include pointed or toxic foreign bodies or objects too long (ie, >6 cm) or too wide (ie, >2 cm) to pass through the pyloric sphincter. Another important exception is the child who has swallowed more than one magnet; reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to necrosis of intervening tissues, sometimes with severe sequelae.1

    Children with known GI tract abnormalities are more likely to encounter complications. Previous surgery may cause abnormalities of peristalsis, increasing the likelihood of foreign body impaction. For example, children who have had surgery to correct pyloric stenosis are more likely to retain a foreign body in the stomach.

    Previously unsuspected lower GI tract abnormalities may present as a complication of foreign body ingestion. For example, a small foreign body may become lodged in a Meckel diverticulum.

    Impacted foreign bodies

    A foreign body lodged in the GI tract may have little or no effect; cause local inflammation leading to pain, bleeding, scarring, and obstruction; or erode through the GI tract. Migration from the esophagus most often leads to mediastinitis but may involve the lower respiratory tract or aorta and create an aortoenteric fistula. Migration through the lower GI tract may cause peritonitis


    Mortality/Morbidity

    * Most foreign bodies pass harmlessly through the GI tract and are eliminated in the stool.

    * Systemic reactions, such as from nickel allergy, are unusual but have been reported, typically in massive ingestions or occupational exposures.
    *

    * Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring, or perforation.

    o Foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia, or other respiratory disease.

    o Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
    *

    * Complications of removal procedures may lead to iatrogenic morbidity or mortality from the procedure or from accompanying sedation/anesthesia.

    Sex

    * The male-to-female ratio in young children is 1:1.
    *
    * In older children and adolescents, males are more commonly affected than females.

    Age

    Children of all ages ingest foreign bodies. However, incidence is greatest in children aged 6 months to 4 years. This reflects the tendency of small children to use their mouths in the exploration of their world. Younger children may be "fed" foreign bodies by older children or be intentionally given foreign bodies by abusive adults. In the teenaged years, concomitant psychiatric problems, mental disturbances, and risk-taking behaviors may lead to foreign body ingestion.


    CLINICAL

    History

    * Children commonly come to medical attention after a caregiver witnesses the ingestion of a foreign body or after a child reports an ingestion to a caregiver.
    *

    * Alternatively, the child may present because of signs or symptoms of a complication of ingestion.
    *

    * Occasionally, the caregiver discovers a foreign body that has passed in the stool and brings the child in for evaluation.
    *

    * Children with significant complications of foreign body ingestion may be initially asymptomatic.
    *

    * Children may have vague symptoms that do not immediately suggest foreign body ingestion.
    *

    * When caring for children, always keep the possibility of foreign body ingestion in mind.
    *

    * Esophageal foreign body symptoms
    *
    o Dysphagia

    o Food refusal, weight loss

    o Drooling

    o Emesis/hematemesis

    o Foreign body sensation

    o Chest pain, sore throat

    o Stridor, cough

    o Unexplained fever

    o Altered mental status

    * Stomach/lower GI tract foreign bodies
    *
    o Abdominal distention/pain, vomiting

    o Hematochezia

    o Unexplained fever

    Physical

    * Specific physical examination findings are unusual.
    *

    * Physical findings may suggest complications of foreign body migration, such as peritoneal irritation or rales.
    *

    * Abrasions, streaks of blood, or edema in the hypopharynx may be evidence of proximal swallowing-related trauma. Inspection of the oropharynx may occasionally reveal an impacted foreign body.
    *

    * Drooling or pooling of secretions suggests an esophageal foreign body but may be due to an esophageal abrasion as a result of a swallowed foreign body.

    Causes

    * Most cases occur as children discover and place small objects in their mouths.
    *
    * Repeated cases may suggest a chaotic home environment and neglect.
    *
    * Children with known GI tract abnormalities or previous complications of foreign body ingestion are more likely to have complications.
    *
    * Older children may be seeking attention or be manifesting psychological abnormalities.
    *
    * Ingestion of unusual foreign bodies may suggest an underlying abnormality. For example, a well-established association exists between toothbrush ingestions and bulimia in teenaged girls.


    DIFFERENTIALS

    Appendicitis, Acute
    Disk Battery Ingestion
    Esophagitis
    Foreign Bodies, Trachea
    Gastritis and Peptic Ulcer Disease
    Gastroenteritis
    Munchausen Syndrome
    Obstruction, Large Bowel
    Obstruction, Small Bowel
    Pediatrics, Appendicitis
    Pediatrics, Gastroenteritis
    Pediatrics, Gastrointestinal Bleeding
    Pediatrics, Intussusception
    Pediatrics, Pyloric Stenosis
    Pediatrics, Reactive Airway Disease
    Pharyngitis
    Pneumonia, Aspiration
    Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum

    Other Problems to be Considered

    Foreign body aspiration
    Gastrointestinal obstruction
    Esophageal stricture
    Failure to thrive
    Meckel diverticulum
    Psychiatric diseases - Autism, bulimia, mental retardation, personality disorders


    Lab Studies

    * Children with foreign body ingestion typically do not require laboratory testing.
    *

    * Laboratory studies may be indicated for workup of specific complications, such as potential infection.

    Imaging Studies

    * Chest/abdominal radiography

    o Most foreign bodies ingested by children are radiopaque (in contrast to inhalation, in which most are radiolucent).
    o
    o If the swallowed object may be radiopaque, a single frontal radiograph that includes the neck, chest, and entire abdomen is usually sufficient to locate the object.
    o
    o If the object is below the diaphragm, further radiographs are generally unnecessary (in the absence of previous GI disorders, such as repaired pyloric stenosis).
    o
    o If the object is in the esophagus, frontal and lateral chest radiographs are necessary to precisely locate and better identify the object and to be sure that the foreign body is not, in fact, two adherent objects. Lateral views of button (disk) batteries reveal a distinctive 2-step border, as opposed to the smooth borders of most coins. Frontal views may suggest a corresponding ring just inside the outermost ring of the battery.
    o
    o Coins and similarly shaped objects may be localized to the esophagus or the airway by their position on a frontal radiograph.
    o
    o With rare exceptions, coins in the esophagus appear in the coronal orientation (ie, coin seen as a disk on frontal view), while coins in the trachea appear in the sagittal orientation (ie, coin seen from the side on frontal view).
    o
    o If the ingested object is radiolucent, the object's location may be inferred from effects (eg, airway compression) seen on plain radiographs. However, such findings are not reliable.
    o
    o Radiolucent objects in the esophagus may be better visualized by repeating the study after having the child drink a small amount of dilute contrast. This should not be done if endoscopy is planned.
    o
    o Special care must be taken if the esophagus could possibly be obstructed or perforated.
    o
    o When a foreign body is strongly suspected on clinical grounds, visualization by endoscopy, which has the added advantage of allowing removal of the object, may be the most efficient method of management.
    *
    * CT scan or MRI is rarely indicated but may enhance the detection of foreign bodies or complications (eg, perforations) in special cases.

    Other Tests

    * Metal detectors
    *
    o The use of handheld metal detectors to identify the location of ingested metallic objects (especially coins) has proven sensitive and specific. In the case of aluminum (eg, flip top of a soda can), a metal detector may be more sensitive since aluminum is often radiolucent. The operator should have experience with this modality before using it for patient care.

    o Patients with coins localized to the abdomen may be safely observed. However, patients with coins localized in the esophagus probably should have the exact locations confirmed by plain radiography.

    Procedures

    * Endoscopy
    *
    o Endoscopy (esophagoscopy) may be diagnostic and therapeutic.

    o Children who require extensive radiologic investigation may be best served by referral to a pediatric gastroenterologist or surgeon for endoscopy, which is safe and highly effective.


    TREATMENT

    Prehospital Care


    * Most children who have swallowed a foreign body do not require specialized care.
    *
    * Patients with drooling may require suction.
    *
    * Children benefit by being allowed to remain with their parents and being allowed to assume a position of comfort.
    *
    * Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Children should not routinely be intubated to protect their airways.
    *
    * Similarly, do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.


    Emergency Department Care


    The usual goal of ED management is to localize the position of the ingested foreign body. Patients with drooling, marked emesis, or altered mental status (from excess vagal stimulation) may require supportive measures to protect the airway.

    Most patients should undergo radiographic imaging as described above. Metal detectors may be used to locate metallic foreign bodies. Even radiopaque foreign bodies may be difficult to localize. Referral for endoscopy should be considered.

    Remember that children with no symptoms may have impacted foreign bodies and that children with foreign body sensation or pain may not. Radiographs of about 15% of children presenting to the ED after witnessed coin ingestions do not show a coin. This suggests that not all foreign bodies whose ingestions were witnessed were really ingested.

    * Esophageal foreign bodies

    o Objects found within the esophagus should generally be considered impacted. Because impacted esophageal foreign bodies may lead to significant morbidity (and even mortality), removal of impacted esophageal foreign bodies is mandatory. An important exception is blunt esophageal foreign bodies (except button [disk] batteries) that are well tolerated and are known to have been in place for less than 24 hours (see Spontaneous passage below).
    o
    o Endoscopy (esophagoscopy) is by far the most commonly used means of removal and is usually the procedure of choice. Most children with esophageal foreign bodies are stable. Endoscopy usually can be delayed until the child's stomach is emptied and a surgical team is assembled. However, pointed objects should be removed as rapidly as possible to avoid further injury to the esophageal mucosa. Impacted button (disk) batteries are notorious for rapidly causing local necrosis and should be removed from the esophagus without delay.
    o
    o Because endoscopy is relatively invasive and expensive, 2 other methods of esophageal foreign body removal have been investigated and are probably more cost-effective when used appropriately. Both have been performed most commonly on children with esophageal coins.
    o
    + Foley catheter method: Blunt foreign bodies may be removed by use of a Foley catheter. The patient is restrained in a head-down position on a fluoroscopy table, and an uninflated catheter is inserted distal to the object. The catheter is then inflated and gently withdrawn, drawing the foreign body with it. Progress is typically monitored fluoroscopically. This procedure is performed without radiographic monitoring at some centers with extensive experience. Only experienced personnel should perform this procedure, and it should be reserved for healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure.
    +
    + Bougienage method: Blunt esophageal foreign bodies may be advanced into the stomach with a bougie. While the child is sitting upright, the lubricated instrument is gently passed down the esophagus, dislodging the object. The object is then expected to pass through the rest of the GI tract; thus, this procedure should not be performed on children with known lower GI tract abnormalities. A brief observation period and a repeat radiograph should follow any removal procedure to rule out retained foreign bodies and other complications (eg, pneumomediastinum). Because any esophageal foreign body may pass spontaneously, chest radiography should be performed immediately prior to any removal procedure. Again, only experienced personnel should perform this procedure, and it should be reserved for healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure.
    +
    + More recently, use of Magill forceps for removal of foreign bodies high in the esophagus has been described.
    o
    o Spontaneous passage: Blunt foreign bodies located at the LES often spontaneously pass within several hours of ingestion. This has been best studied in coin ingestions. Previously healthy children may be given food and drink and have repeat radiographs 24 hours following ingestion. Often, the coin passes through the LES, and a removal procedure can be avoided. Although blunt foreign bodies located in other areas of the esophagus are less likely to spontaneously pass, this strategy may be an appropriate alternative for stable children with normal esophageal anatomy and a foreign body in the thoracic inlet or the mid esophagus. This may be most successful in asymptomatic children.
    o
    o Complications: Children with significant complications, such as airway involvement, peritonitis, or hematemesis (possibly heralding exsanguination from an aortoenteric fistula), should be referred to an appropriate surgeon without delay.
    *
    * Stomach/lower GI tract

    o Most swallowed foreign bodies harmlessly pass through the GI tract once they have reached the stomach. Treatment of children with known abnormalities of the GI tract or previous problems with foreign bodies should be discussed with a specialist, preferably one familiar with the child.
    o
    o Unusual foreign bodies: Very sharp or pointed objects may perforate the GI tract (sewing needles are notorious). Therefore, such objects should be endoscopically removed from the stomach. If such an object has passed into the intestines, early consultation with a surgeon is recommended. Objects that are too long (eg, >6 cm) or too wide (eg, >2 cm) to pass through the pyloric sphincter should be removed from the stomach.
    o
    o Button (disk) batteries in the stomach or intestines do not need to be removed immediately, as they generally pass through the lower GI tract without difficulty. Button batteries retained in the stomach or at a fixed spot in the intestines should be removed. One strategy is to instruct families to observe the stool for the battery and to return for a repeat radiograph if it is not passed in 2-3 days. If a battery is still in the stomach at that time, it should be endoscopically removed. If it is in the intestines, its progress should be intermittently monitored via radiographs, to be sure it is progressing.
    o
    o Body packers (ie, patients who have ingested wrapped packages of drugs to avoid detection during transport) are at risk of death if the packets rupture. Such patients should be hospitalized and whole-bowel irrigation considered. Consultation with a poison control center is suggested.


    MEDICATION

    Although drugs such as glucagon, benzodiazepines, and nifedipine have been successfully used to relax the lower esophageal sphincter in adult patients with esophageal foreign bodies, these measures are generally unsuccessful in children.

    The use of meat tenderizer (papain) to attempt to digest meat impacted in the esophagus is no longer recommended. Such usage may severely injure the esophagus.


    Further Inpatient Care

    * Children who require endoscopic foreign body removal are usually taken directly to the operating room or endoscopy suite or are admitted preoperatively. These patients should be given nothing by mouth (NPO) and be given glucose-containing intravenous fluids until the procedure.
    *
    * Preprocedure radiographs to verify the location of the foreign body are recommended, as some foreign bodies may pass into the stomach while awaiting endoscopy.
    *
    * General anesthesia often is used for endoscopic foreign body removal. However, sedation performed by experienced personnel may be successful in selected cases.

    Further Outpatient Care

    * After an esophageal foreign body is removed, children with uncomplicated courses do not need to undergo further evaluation.
    *
    * A healthy child with repeated foreign body impaction or impaction at an unusual site should be evaluated for an underlying esophageal disorder.
    *
    * Most children with foreign bodies in the stomach or lower GI tract have no complications.
    *
    * Patients with known abnormalities of the GI tract, previous problems with foreign bodies, or unusual foreign bodies may require special treatment.
    *
    * Caregivers of discharged children should be alerted to return if signs or symptoms of the occasional complication (eg, abdominal pain or distention, hematochezia, unexplained fevers, constipation, vomiting) develop.
    *
    * In general, straining of the stool for the foreign body is unnecessary.
    *
    * Except in special instances, serial radiographs to document progress are unnecessary. The continued presence of a metallic foreign body may be documented by serial metal detector scans.

    Transfer

    * Most children do not require a removal procedure, and they may be treated at any facility capable of obtaining radiographs of children.
    *
    * Children who require foreign body removal procedures should be referred to a facility with experienced personnel.
    *
    * Familiarity with pediatric airway emergencies is essential.

    Deterrence/Prevention

    * Parents and other caregivers of children should be cautioned about leaving small objects where young children may find them and place them into their mouths. This is especially common at times of unusual activity, such as parties, holidays, when visitors are present in the home, or during travel.

    Complications

    * Esophageal foreign bodies
    *
    o Mucosal abrasion

    o Esophageal stricture/obstruction

    o Retropharyngeal abscess

    o Failure to thrive

    o Esophageal perforation may lead to mediastinitis, pneumothorax, pneumomediastinum, aortoesophageal fistula formation (and resulting hemorrhage), and tracheal compression.

    * Stomach/lower GI tract foreign bodies
    *
    o Mucosal abrasion

    o Intestinal obstruction

    * Intestinal perforation may lead to peritonitis and sepsis.





    A swallowed coin lodged at the thoracic inlet.



    A swallowed radiolucent object (plastic guitar pick) is made visible in the upper esophagus after ingestion of barium.

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