FOREIGN BODY

Classification | Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

Specific Substances

1) ADHESIVE BANDAGE
2) BOLT
3) BOLTS
4) BUTTON (CLOTHING)
5) CONTACT LENS
6) EMERY BOARD
7) FELT
8) FISH BONE
9) HARD CONTACT LENS
10) IRON MAGNET
11) MAGNET
12) NEODYMIUM MAGNET
13) NAIL
14) NAILS
15) PAPER CLIP
16) SAFETY PIN
17) SCREW
18) SCREWS
19) SILVERWARE
20) SOFT CONTACT LENS
21) STEELWOOL
22) STRAIGHT PIN
23) TOOTHPICK
24) TOOTHPICK, WOOD
25) TOOTHPICK, WOODEN
26) WOOD PELLETS (FUEL FOR STOVE)
27) WOOD TOOTHPICK

Available Forms Sources

1) TYPES OF FOREIGN BODIES: Reported causes of esophageal foreign body include bones, food boluses, coins, buttons, dentures, rocks, small toys or toy parts, fruit pits, wire, pins (safety and straight), hair pins, drawing pens, ballpoint pens, glass, aluminum can-tops, pill ingestion, plastic bread bag clips, toothbrushes, knives, and disc batteries (Nandi & Ong, 1978; Jeffers et al, 1978; Roach et al, 1987; McKaigney et al, 1985; Kapoor et al, 1985; Bailey, 1983; Simon, 1981; Nwafo et al, 1980; Jacobs, 1980; Spitz & Hirsig, 1982; Temple & McNeese, 1983; Hernanz-Schulman & Naimark, 1985; Kirk et al, 1988; Conners et al, 1995; Harned et al, 1997; Bhana et al, 2000; Stricker et al, 2001).
2) MAGNETS

a) The Consumer Product Safety Commission has received 19 reports of injuries (eg; bowel obstruction, volvulus, and bowel perforation) requiring gastrointestinal surgery following the ingestion of magnets contained in toy products. The magnets are rare-earth magnets (commonly a neodymium iron boron magnet or samarium cobalt magnet) (None Listed, 2006).

3) Just about anything may act as a foreign body:

1) Balloons
2) Briquettes
3) Disposable diapers
4) Linoleum floor covering
5) Tablet or capsule
6) Blister pack
7) Glass
8) Porcelain
9) Needles
10) Buttons
11) Parts of clothing
12) Hair
13) Branches
14) Sunflower seeds

a) References: (Brown et al, 2002; Betz et al, 1994; Barki & Zahavi, 1994)

4) Children and the mentally handicapped may ingest coins, buttons, rocks, small toys and toy parts and various metallic objects (Hernanz-Schulman & Naimark, 1985; Betz et al, 1994).
5) In one study of 159 patients, coins were the most common foreign body found in the pediatric age group (Giordano et al, 1981). Ingestion of quarters has been reported in adults who were participating in a tavern game called "Quarters." The participant attempts to catch a quarter in his teeth while drinking a glass of beer as rapidly as possible in which a quarter was placed in the bottom of the beer (Gluck, 1989).

a) The diameters of US coins are: dimes 18mm, nickels 21mm, pennies 17mm, quarters 24mm, half-dollars 30mm, and dollars 26mm and 38mm (Anon, 1989).
b) The diameters of British coins are: 1p 20mm, 20p 21mm, 5p 23mm, 2p 25mm, and 10p 28mm (Anon, 1989).

6) Smooth and blunt foreign objects may be removed by a variety of techniques; however, esophageal foreign bodies must never be considered as benign, and all should be removed if not passed spontaneously (Hernanz-Schulman & Naimark, 1985).
7) Food bolus impaction is another source of esophageal foreign bodies.
8) TASER(R) DART: A Taser dart is an electric weapon used by law-enforcement personnel and the public. It is a metallic cylinder approximately 2 cm long with a barbed spike on one end. Two barbs are fired and, when connected to the skin or clothes of the victim, complete a circuit through which electric current passes. This usually causes the victim to fall to the ground.
9) A 27-year-old man was shot with 2 Taser darts by the police. While in custody the man swallowed one of the darts. The man was treated conservatively (serial x-ray documenting the course of the dart, inspection of the stool, regular diet, bulk laxative, and observation) and the dart passed through and was found in the stool on the fourth day of hospitalization (Koscove, 1987).
10) DISPOSABLE DIAPERS: There were 7 reported incidents of choking injuries and 6 injuries from foreign material associated with disposable diapers between 1979 and 1983 (Johnson, 1986).
11) TOOTH: A 56-year-old male aspirated a carious lower bicuspid during routine tooth extraction. The tooth was successfully removed from the right posterior basilar subsegment using fiberoptic bronchoscopy techniques (Larsen, 1986).
12) BEZOAR DEVELOPMENT: Two children developed bezoar formation resulting in abdominal pain, decreased appetite and foul-smelling diarrhea following the ingestion of large amounts of unshelled sunflower seeds (Tsou et al, 1997).

Overview

Life Support

Clinical Effects

0.2.1)

A) Foreign body exposure includes ingestion of non-medicinal solid objects (such as toys, packaging, or other small objects) that are not expected to be systemically absorbed. Please refer to the DISC BATTERY INGESTION management for button, disc, or small battery ingestions. Foreign body exposure also includes substances that may have potential to cause blockages or injury to tissues when they are aspirated or placed into a body orifice.
B) EPIDEMIOLOGY: Ingestions of foreign bodies is common, but serious effects or deaths are rare. Coins are among the most common foreign bodies swallowed. In an analysis of 10,463 coin exposures, patients had no effect or minor effects in 98.5% of cases involving a dime, 97.8% of cases involving a penny, 94.7% of cases involving a nickel, and 92.6% of cases involving a quarter. Sharp or pointed objects are more likely to cause complications if swallowed.
C) WITH POISONING/EXPOSURE

1) TOXICOLOGY: The most common effects are mucosal irrigation or injury. More severe effects may include GI tract perforation, erosion or obstruction, or airway obstruction.
2) ESOPHAGEAL: The incidence of lodged esophageal bodies is greatest in children younger than 10 years, denture wearers, mentally handicapped, and those with esophageal abnormalities. Most of these objects lodge below the cricopharyngeus muscle.

a) Common symptoms include pain on swallowing, drooling (increased salivation), and dysphagia.

3) ASPIRATION: Cough, tachypnea, wheeze, and stridor unresponsive to pharmacologic therapy are often associated with foreign body aspiration, especially in children. Airway obstruction and aspiration pneumonia are rare complications. However, recurrent pneumonia in a child might raise the suspicion of foreign body aspiration.
4) NASAL: Unilateral purulent rhinorrhea, pain, pattern suggestive of sinusitis, or foul body odor have been associated with nasal foreign bodies.
5) OCULAR: Pain, foreign body sensation, blepharospasm, ciliary flush, decreased visual acuity, retinal toxicity, and corneal abrasion may develop.
6) PERFORATION has been reported following the ingestion of sharp objects. It has been estimated to occur in less than 1% of all ingestions.

Laboratory Monitoring

Treatment Overview

0.4.2)

A) MANAGEMENT OF MILD TO MODERATE TOXICITY

1) Most swallowed foreign bodies that pass the cardiac sphincter and into the stomach will pass through the GI tract without complications. Ingestion of foreign bodies that are large, sharp (eg, pins, razor blades), button batteries, more than one magnet, or a magnet and a metallic foreign body, requires rapid endoscopic or surgical removal. While most airway foreign bodies will be expelled by coughing, some lower airway foreign bodies may not cause immediate symptoms but cause acute airway obstruction after being expelled back through the glotic opening or cause late complications if retained in the lung. It is therefore important that the clinician definitively exclude retained pulmonary foreign body if there is a history of coughing, choking or other airway symptoms.

B) MANAGEMENT OF SEVERE TOXICITY

1) Patients who have are unable to swallow or who have persistent pain require radiographic or endoscopic evaluation for retained esophageal foreign body. Patients with GI tract perforation require surgical management. Patients with gastrointestinal bleeding require endoscopic evaluation and may require surgical or embolic management. Patients with intestinal obstruction will likely require surgical management. Patients with stridor, respiratory distress or other evidence of airway foreign bodies require immediate removal of the foreign body and may require surgical airway management. Patients with pulmonary foreign bodies require surgical or endoscopic removal of the foreign body as well as treatment for infectious complications.

C) DECONTAMINATION

1) PREHOSPITAL: Prehospital decontamination is not indicated for foreign body ingestion.
2) HOSPITAL: Hospital decontamination is not indicated for foreign body ingestion.

D) AIRWAY MANAGEMENT

1) Patients with stridor, respiratory distress or other evidence of airway foreign bodies require immediate removal of the foreign body and may require surgical airway management.

E) ANTIDOTE

1) None.

F) REMOVAL OF FOREIGN BODY FROM ESOPHAGUS

1) Foreign bodies require removal if lodged in the esophagus. Ingestion of foreign bodies that are large, sharp (eg pins, razor blades), button batteries, more than one magnet, or a magnet and a metallic foreign body, requires rapid endoscopic or surgical removal.
2) ESOPHAGOSCOPY: This is the most exact and commonly employed method for removal of esophageal foreign bodies. It is a treatment of choice for removal of foreign bodies when available. Esophagoscopy should be considered in all cases of unexplained swallowing difficulty, even if contrast studies are normal.
3) LARYNGOSCOPY: May be necessary to visualize objects in the pharynx and hypopharynx.
4) LAPAROSCOPY: The Consumer Product Safety Commission has received 19 cases of injuries (eg bowel obstruction, volvulus, and bowel perforation) requiring gastrointestinal surgery following the ingestion of magnets contained in toy products. Multiple magnet ingestion should be treated aggressively despite minimal initial physical findings. Magnets have been removed laparoscopically.
5) FOLEY CATHETER: The use of a fluoroscopically guided Foley catheter to remove smooth and blunt foreign objects has been an effective and uncomplicated technique when used by experienced personnel. Sharp or pointed foreign bodies, disc batteries, pain on attempted extraction, inability to bypass the object with a catheter, total obstruction, evidence of airway compromise, and a struggling unrestrained child are contraindications.
6) GLUCAGON: Glucagon decreases lower esophageal sphincter pressure and does not affect peristalsis. It has been most useful for esophageal meat impactions and for lower esophageal impactions, but effectiveness varies. It is not expected to be effective with upper and middle esophageal obstruction. DOSE: 1 to 2 mg IV over 1 to 2 minutes in a sitting patient. Children: has not yet been established. Nitroglycerin and/or benzodiazepines are also sometimes used to relax esophageal muscles and facilitate passage of impacted food boluses.

G) ENDOSCOPIC PROCEDURE

1) FLEXIBLE endoscopy for removal of objects that are smooth, blunt, and of less than two weeks' duration. RIGID endoscopy an alternative indicated for FB of the pharynx at the level of the cricopharyngeus muscle, acutely symptomatic patients, and for removal of objects of prolonged duration, batteries, and sharp FB.

H) PATIENT DISPOSITION

1) HOME CRITERIA: Patients who have inadvertently swallowed small foreign bodies (smaller than a dime) that are round and smooth and who are asymptomatic can be managed at home. Patients who have swallowed larger foreign bodies, patients with choking episodes or any concern for foreign body aspiration, and patients who are symptomatic should be referred to a healthcare facility for evaluation and management. Patients who swallow foreign objects in a self harm attempt should be referred to a healthcare facility.
2) OBSERVATION CRITERIA: Asymptomatic patients without esophageal or tracheal abnormalities who are found to have an esophageal coin esophagus can be discharged for observation at home for 12 to 24 hours. They should return for reevaluation and if the coin has not passed it should be removed.
3) ADMISSION CRITERIA: Patient with evidence of airway or GI obstruction, perforation or bleeding should be admitted. Patients with suspected foreign body aspiration should be admitted.
4) CONSULT CRITERIA: Toxicologist should be consulted if there is a question of possible systemic toxicity (ie ingestion of a lead fishing weight). A gastroenterologist should be consulted for endoscopic removal of large or sharp gastrointestinal foreign bodies. A pulmonologist should be consulted for broncoscopic removal of suspected airway foreign bodies.

I) PITFALLS

1) Failure to investigate coingestion of more dangerous objects, such as sharp objects or disk batteries. Consider aspiration of a foreign body in any patient with wheezing, bronchitis or pneumonia that does not improve with standard therapy.

J) DIFFERENTIAL DIAGNOSIS

1) Patients may have an allergic reaction, infection, tumor or other causes of airway or GI obstruction. Patients may have pain on swallowing from mucosal injury that feels like a foreign body.

0.4.3)

A) EMERGENCY TREATMENT OF FOREIGN BODY ASPIRATION IN AN INFANT

1) Partial Obstruction: Allow patients cough reflex to extrude the object.
2) If airway completely obstructed (loss of sound, ineffective cough, stridor, increased respiratory difficulty, cyanosis) and patient remains conscious:

a) 1) Give up to 5 back blows given with the heel of the hand between the shoulder blades (head down, draped over forearm or lap).
b) 2) If unsuccessful, turn the child supine draped over thigh with head lower than trunk. Deliver 5 chest thrusts (place two fingers on the lower half of the sternum and deliver thrusts in the same manner as chest compressions for CPR).
c) 3) If unsuccessful, head tilt-chin lift for foreign body examination and visualization.
d) 4) Repeat as necessary.

3) If the infant becomes unconscious:

a) Perform CPR, but look into the mouth BEFORE giving breaths. Open mouth using a head tilt-chin lift and remove foreign body only if visualized.
b) Attempt rescue breathing followed by chest compressions (using 2 fingers) in a ratio of 2:30.
c) Repeat as necessary.

B) EMERGENCY TREATMENT OF FOREIGN BODY ASPIRATION IN A CHILD OR ADULT

1) If the individual is conscious, perform subdiaphragmatic abdominal thrusts (Heimlich maneuver). Repeat until the foreign body is expelled or the victim loses consciousness.
2) If the victim loses consciousness, place supine and begin CPR.
3) Look into the mouth BEFORE giving breaths. Open mouth using a head tilt-chin lift and remove foreign body only if visualized.
4) Attempt rescue breathing followed by chest compressions in a ratio of 2:30.
5) Repeat as necessary.

Range Of Toxicity

Clinical Effects

Heent

3.4.2)

A) WITH POISONING/EXPOSURE

1) NECK EMPHYSEMA: Subcutaneous emphysema at the sternal notch or neck may be associated with esophageal perforation caused by foreign body ingestion (Hernanz-Schulman & Naimark, 1985).

3.4.3)

A) WITH POISONING/EXPOSURE

1) PAIN CHARACTERISTICS: Eye pain is experienced as a "foreign body sensation," especially with blinking, or as a sharp, stabbing pain.

a) Eye pain is often unilateral (Brownstein & Hodge, 1988) and localized in the lateral aspect of the upper lid regardless of the actual location of the foreign body or abrasion. The discomfort is relieved with topical anesthetics, which helps distinguish this pain from the deep pain of iritis, glaucoma, and other ocular conditions.
b) PAIN MECHANISM: The sensation is transmitted by the nasociliary branch of the ophthalmic division of the fifth cranial nerve.

2) PHOTOPHOBIA is a common but not usually prominent symptom. It is due to the ciliary spasm that may be associated with severe cases (Sprague, 1980).
3) BLEPHAROSPASM is a common effect, and its presence may necessitate the use of a topical anesthetic to permit the examination.
4) LACRIMATION: The secretion and discharge of tears is a common finding.
5) MIOSIS: The common finding of miosis is probably related to secondary ciliary spasm.
6) CILIARY CONGESTION demonstrated by circumcorneal flush is common with acute corneal injury.
7) VISUAL ACUITY may be normal or slightly decreased, depending on the site and extent of the abrasion (Klein, 1979).
8) ABRASION: An abrasion may be visible grossly under a strong light. A strong tangential beam may show an otherwise unnoticeable abrasion by casting a shadow on the iris. Minute corneal abrasions may not be apparent on exam, although they may be symptomatic.
9) PENETRATION: Deep wounds that penetrate the corneal epithelial basement membrane (Bowman's) into the stroma will be cloudy, with edema at the edges (Duke-Elder, 1977).
10) RETINAL TOXICITY: A 40-year-old experienced acute retinal toxicity after a piece of metal was propelled into his eye. It is postulated that the toxicity was caused by a bimetallic electrochemical reaction of a galvanized steel particle (a segment of steel wire with a partial zinc coating), and the effects may have been enhanced by the delay in removal of the object (Steel et al, 1998).

3.4.5)

A) WITH POISONING/EXPOSURE

1) NASAL FOREIGN BODY: Unilateral purulent rhinorrhea, pain, pattern suggestive of sinusitis, or foul body odor have been associated with nasal foreign bodies (Stegman, 1987).
2) CASE REPORT: A middle-aged man presented to the emergency department with an obstructed nasal airway and distention of his nostrils approximately 45 minutes after spraying polyurethane foam insulation into his oral and nasal cavities in a suicide attempt. At presentation, the patient's vital signs were stable with no evidence of respiratory distress. There were only traces of foam in his oral cavity and oropharynx. After hardening of the foam, removal from the oral cavity and from both nostrils with forceps was uneventful. A nasopharyngoscopy showed no evidence of pharyngeal edema, erythema, or foreign body, and a chest radiograph was normal. There was mild erythema of the nasal mucosa that appeared to be resolved 48 hours later (Sowerby et al, 2011).

3.4.6)

A) WITH POISONING/EXPOSURE

1) IRRITATION: Throat irritation has been reported following coin ingestions (White, 2000).
2) INFLAMMATION: A report described 2 cases of plastic screw head covers lodging in the palate. Both cases developed inflammation at the site of impaction, and defied diagnosis by parent or physician (Raine & McLennan, 1984).
3) Variations among the locations of an aspirated foreign body based on anatomical differences among children and adults have been identified. Children were more likely to have obstructions in the proximal airway (74%) (larynx, trachea, and right and left main bronchi), while most obstructions in adults were lodged in the right bronchial tree (69%) (Baharloo et al, 1999).

Cardiovascular

3.5.2)

A) AORTIC ANEURYSM

1) WITH POISONING/EXPOSURE

a) CASE REPORT/PEDIATRIC: A 14-month-old boy developed an aortic pseudoaneurysm 4 months after successful removal of an open safety pin, point down, in the midesophagus, which had perforated the anterior esophageal wall. Removal produced brief but profuse bleeding. The pseudoaneurysm was resected without complications (Schumacher et al, 1986).

Respiratory

3.6.2)

A) HYPERVENTILATION

1) WITH POISONING/EXPOSURE

a) Due to compression of the membranous trachea, tachypnea is often a primary presenting symptom in children, the elderly, and mentally handicapped (Hernanz-Schulman & Naimark, 1985; Handler et al, 1981) .

B) COUGH

1) WITH POISONING/EXPOSURE

a) Symptoms of cough, wheeze, and stridor unresponsive to pharmacologic therapy are often associated with foreign body aspiration. This is especially true in children (Smith et al, 1974).
b) CASE REPORTS

1) In one report, an 18-month-old and an 11-month-old died after a second coughing and choking incident resulting from an aspirated foreign body. Unfortunately, the foreign body was not identified following the initial coughing and choking episode after the actual aspiration occurred (Humphries et al, 1988).
2) Cough productive of green sputum, fever, and shortness of breath was noted in a 35-year-old man following neurosurgery. Chest x-ray revealed a foreign body in the right lower lobe bronchus. The object was later removed and identified as the end of a mercury thermometer (Marik & Ballhausen, 1991).

c) CASE SERIES

1) In a review of 25,394 cases of coin exposures, the most frequently related respiratory symptom was coughing/choking (6.8%) (White, 2000).

C) CHEST PAIN

1) WITH POISONING/EXPOSURE

a) Chest pain has been reported following coin ingestions (White, 2000). Severe substernal chest pain that radiates to the neck may indicate an esophageal perforation (Bradley, 1978).
b) The victim's localization of the site of an object is often not reliable since sensory innervation of the esophagus is not specific for location (Hernanz-Schulman & Naimark, 1985). Pain from lower esophageal foreign bodies may be referred to the upper chest, although pain from upper esophageal foreign bodies is usually not referred to the lower chest. Sensation of foreign body in the throat is more accurate for location.

D) CHOKING

1) WITH POISONING/EXPOSURE

a) Choking or gagging during meals may be seen in adults and children with esophageal foreign body (Humphries et al, 1988; Binder & Anderson, 1984; Nandi & Ong, 1978) . Choking may also be seen in cases of air-impelled coins that are accidentally forced in the trachea or esophagus by aerosol inhalants (Hannan & Pratt, 1984; McGonagle & Reams, 1984).

E) RESPIRATORY OBSTRUCTION

1) WITH POISONING/EXPOSURE

a) Airway obstruction and aspiration pneumonia are rare complications (Handler et al, 1981; Bradley, 1978) . In children, airway obstruction may simulate clinical signs of croup or asthma (Gay et al, 1986). In some cases, mechanical obstruction can lead to death (Bhana et al, 2000).
b) CASE REPORT: At autopsy, a 79-year-old woman was found to have what appeared to be a tablet that completely occluded the right lower lobe bronchus and may have contributed to her development of pneumonia and her eventual death. She had entered the hospital after 6 weeks duration of anorexia, general malaise, night sweats, and exertional breathlessness (Hill et al, 1981).
c) Variations among the location of an aspirated foreign body based on anatomical differences among children and adults were detected. Children were more likely to have obstructions in the proximal airway (74%) (larynx, trachea, and right and left main bronchi), while most obstructions in adults were lodged in the right bronchial tree (69%) (Baharloo et al, 1999).
d) CASE REPORTS/PEDIATRIC: Three children ranging from 4 to 10 years of age died following unintentional aspiration of part of a ballpoint pen. Postmortem results revealed that in all 3 cases, death was a result of mechanical airway obstruction (Bhana et al, 2000).
e) CASE REPORT/PEDIATRIC: Heliox (helium and oxygen mixture at a ratio of 60% oxygen and 40% helium) was used successfully in a 22-month-old girl as a temporizing measure for severe, intermittent airway obstruction due to aspirated sunflower seeds. Vital signs were blood pressure 119/76 mmHg, respiratory rate 66 breaths/min, heart rate 160 bpm, and pulse oximetry 90%. During bronchoscopy, a single sunflower seed was removed from the right mainstem bronchus (Brown et al, 2002).

F) BRONCHOSPASM

1) WITH POISONING/EXPOSURE

a) Wheezing has been reported on initial presentation in children following an ingestion of a coin (Savitt & Wason, 1988a).

G) ATELECTASIS

1) WITH POISONING/EXPOSURE

a) In a 20-year retrospective review of clinical experience, atelectasis was more common among adults than children following aspiration of a foreign body, while air trapping was observed most often in children (Baharloo et al, 1999).

H) FOREIGN BODY IN PHARYNX

1) WITH POISONING/EXPOSURE

a) CASE REPORT/PEDIATRIC: A 13-month-old girl had a 3-day history of fevers, constant drooling, and an inability to take anything by mouth. A foreign body in the retropharynx was demonstrated by multiple-view neck roentgenograms. On removal, the foreign body was identified as an aluminum foil tab from a juice container. The child did well following removal of the tab (Ross & Janik, 1988).

Neurologic

3.7.2)

A) ABSCESS

1) WITH POISONING/EXPOSURE

a) CASE REPORT/PEDIATRIC: A 13-month-old boy had signs and symptoms characteristic of meningitis with a past medical history of rigid endoscopy for the removal of an esophageal coin (the coin had been located in the esophagus asymptomatically for weeks prior to removal) 2 weeks prior to admission (Louie et al, 2000). A CT of the brain indicated a brain abscess (5 x 4.4 cm that effaced the right ventricle) that was surgically drained. Streptococcus milleri was cultured, and the patient was treated with a 6-week course of intravenous antibiotics; the toddler recovered.

Gastrointestinal

3.8.2)

A) DYSPHAGIA

1) WITH POISONING/EXPOSURE

a) The classic presentation is a history of swallowed foreign body or food bolus. Patients may be asymptomatic or develop symptoms minutes to hours after ingestion. Symptoms of foreign body ingestion differ between adults and children. Adults typically present with pain or discomfort on swallowing, a persistent sensation of a foreign body, blood-stained saliva, or a history of gagging or choking with meals. In children, symptoms usually include refusal to eat, increased salivation, pain on swallowing, or vomiting (Nandi & Ong, 1978).
b) Pain on swallowing is the most common symptom of esophageal foreign body in adults; children may also complain of pain or discomfort (Nandi & Ong, 1978).
c) Common symptoms of foreign body ingestion are pain on swallowing, drooling (Galli-Tsinopoulou et al, 2003; Nandi & Ong, 1978), dysphagia, or increased salivation (Conners et al, 1995; Anon, 1989; Pons, 1983) .
d) There may be pain in the neck or throat, which is aggravated by swallowing. If the esophagus or trachea is perforated, subcutaneous emphysema may be detected.

B) STRICTURE OF ESOPHAGUS

1) WITH POISONING/EXPOSURE

a) IMPACTION SITES: The esophageal foreign body usually impacts (lodges) in one of 4 primary sites (Chaikhouni et al, 1985; Hernanz-Schulman & Naimark, 1985; Nahman & Mueller, 1984):

1) At the level of the cricopharyngeus muscle;
2) At the level of the aortic arch and left main stem bronchus;
3) At the esophagogastric junction;
4) Or at any pathologic site of narrowing.

C) VOMITING

1) WITH POISONING/EXPOSURE

a) Vomiting may develop in patients with complete esophageal obstruction (Hernanz-Schulman & Naimark, 1985; Nandi & Ong, 1978). Vomiting may be bloody if laceration has occurred (Hernanz-Schulman & Naimark, 1985).

D) RUPTURE OF ESOPHAGUS

1) WITH POISONING/EXPOSURE

a) Perforation is an acute emergency and may be life-threatening. It is more common with sharp objects, prolonged impaction, disc batteries, and overly aggressive removal by unskilled personnel.
b) Abdominal rigidity may be seen with lower esophageal perforation.
c) The incidence of perforation is 0.6% to 1.0% of all foreign bodies (Stricker et al, 2001; Maitra, 1980).
d) Asymptomatic esophageal perforation in a child following ingestion of a coin has been reported (Nahman & Mueller, 1984).

E) FOREIGN BODY IN DIGESTIVE TRACT

1) WITH POISONING/EXPOSURE

a) Perforation is possible following the ingestion of sharp objects. In one case, a 9-year-old asymptomatic girl ingested a 3.0 cm long pin, which had pierced the fundus as noted by subdiaphragmatic gas on abdominal x-ray, and was successfully removed from the embedded wall. In another case, a 20-month-old with fever for 4 days had apparently ingested a 6.2 cm hair pin (time of ingestion was not determined) that had broken into 2 parts. One part of the pin was in the stomach, and the other portion was found in the left hemithorax. Both pieces were removed by endoscope. The child was treated with antibiotics and recovered without sequelae (Stricker et al, 2001).

1) The authors suggested that long and pointed foreign bodies that are 3 cm or longer should be removed. These perforations may result in no initial symptoms as was observed in the first case report (Stricker et al, 2001).

F) LOSS OF APPETITE

1) WITH POISONING/EXPOSURE

a) Feeding difficulty has been reported in children following an unrecognized ingestion of a coin (Majid et al, 1979).

G) EXCESSIVE SALIVATION

1) WITH POISONING/EXPOSURE

a) Increased salivation and drooling are common in both adults and children (Hernanz-Schulman & Naimark, 1985; Pons, 1983).
b) Inability to swallow saliva is a frequent sign of meat impaction (Giordano et al, 1981).
c) CASE SERIES: In one study of 40 consecutive patients with esophageal foreign bodies, hypersalivation was the only physical finding that was always associated with abnormal esophagoscopy findings (Allen, 1979).
d) CASE REPORT/PEDIATRIC: A 4-year-old child presented to the emergency department with drooling and vomiting following a reported ingestion of a red flower. Physical examination was normal and laboratory analysis revealed normal hematologic and biochemical values. Gastric lavage produced food and small pieces of plant leaves, which were not toxic. The patient continued drooling and was unable to swallow. A chest radiograph revealed an esophageal obstruction from a metal flower-shaped pendant that was subsequently removed, resulting in the patient's recovery (Galli-Tsinopoulou et al, 2003).

H) METAL FOREIGN BODY IN ABDOMEN

1) WITH POISONING/EXPOSURE

a) MAGNETS

1) The Consumer Product Safety Commission has received 19 cases of injuries requiring gastrointestinal surgery following the ingestion of magnets contained in toy products. The magnets are rare-earth magnets (commonly a neodymium iron boron magnet or samarium cobalt magnet). There have been 19 cases of injuries requiring gastrointestinal surgery which have included bowel obstruction, volvulus, and bowel perforation (None Listed, 2006).

a) CASE REPORT/PEDIATRIC (FATALITY): A 20-month-old toddler died after complaining of abdominal pain and became lethargic with a visibly distended abdomen. He was taken to the emergency department where he developed cardiopulmonary arrest and resuscitation efforts failed. During resuscitation an x-ray was performed and a large object (measuring 30 mm by 6 mm) was noted. At autopsy, 9 cylindrical magnets, 6 mm in diameter, were "stacked" in the abdomen and had magnetically joined across 2 loops of the intestine, causing a volvulus that compromised blood supply to the bowel, eventually leading to perforation and sepsis. The magnets had become dislodged from a sibling's toy building set (None Listed, 2006).
b) CASE REPORT/PEDIATRIC: An 8-year-old boy presented to the emergency department with severe abdominal pain. Abdominal radiograph showed a radiodense circular foreign body in the right lower quadrant, and he was taken to the operating room on day 2 for exploratory laparotomy. Two magnets tightly adhered between 2 segments of bowel were found and successfully removed. The tissue held between the magnets was ischemic, but the patient made a full recovery and was discharged on postoperative day 4 (Adu-Frimpong & Sorrell, 2009).

b) COINS

1) CASE SERIES: Based on reporting to the Toxic Exposure Surveillance System (TESS) from 1993 through 1999, 25,394 coin ingestions were reported. Outcome analysis for 10,463 coin exposures were followed. Of those cases, only 12 patients had a major effect (0.11%), and no fatalities were reported. An inverse relationship between coin size and "no effect" or "minor effect" was observed: dime (98.5%), penny (97.8%), nickel (94.7%) and quarter (92.6%), respectively (White, 2000).

a) Of those that developed symptoms, the most frequently observed gastrointestinal effects were vomiting (2.5%) and abdominal pain (1.3%) (White, 2000).
b) CASE SERIES: Of 30 children with a coin lodged in their esophagus, 9 were asymptomatic (Anon, 1989).
c) CASE REPORT: A 22-year-old woman presented to the emergency department with a 3-week history of progressively worsening abdominal pain as well as intermittent vomiting. Physical examination showed hypoactive bowel sounds with abdominal tenderness. CT of the abdomen revealed a large inflammatory mass and a metallic object located in the right lower quadrant of the abdomen. The patient confirmed that she had intentionally swallowed a penny 3 weeks prior to presentation. Surgery showed a large stricture and partial perforation at the ileocecal valve where the penny was found. It is believed that the high zinc content, released from the partially oxidized coin, may have contributed to the development of significant inflammation (Tupesis et al, 2004).

I) RESPIRATORY COMPLICATION

1) WITH POISONING/EXPOSURE

a) ATYPICAL PRESENTATION: Children, the elderly, and the mentally handicapped may present with an atypical picture (eg, respiratory symptoms due to an inflammatory reaction after several days' impaction) (Hernanz-Schulman & Naimark, 1985).

J) BEZOAR

1) WITH POISONING/EXPOSURE

a) CASE REPORTS/PEDIATRIC: Two children developed bezoar formation resulting in abdominal pain, decreased appetite, and foul-smelling diarrhea following the ingestion of large amounts of unshelled sunflower seeds (Tsou et al, 1997). Radiological exam showed a large area of impacted stool and the appearance of "wood splinters" in one of the children. Following disimpaction, both children recovered without incident.

K) ULCER OF ESOPHAGUS

1) WITH POISONING/EXPOSURE

a) CASE REPORT: An 18-year-old man complained of a foreign body sensation in his throat approximately 5 days after intentionally ingesting a cup of glue in a suicide attempt. An upper endoscopy showed a long, flat, barlike material attached to the esophageal mucosa from the proximal to the distal end, and protruding into the stomach lumen. Examination of the esophageal mucosa revealed longitudinal ulcers. The extracted foreign body was hardened glue that was fragmented into 3 sections. The patient recovered without further sequelae (Kim et al, 2004).

L) FOREIGN BODY IN RECTUM

1) WITH POISONING/EXPOSURE

a) CASE REPORTS: Two patients presented to the emergency department after spraying foam insulation into the rectum. The first patient, a 30-year-old woman, initially developed abdominal pain and nausea. At examination, her vital signs were stable and her abdomen was diffuse and tender with no evidence of distention. Digital rectal examination indicated a foreign body and an abdominal x-ray revealed distended bowel loops. Fleet enema and mineral oil administration was unsuccessful in expelling the insulation, necessitating surgical removal of the foam insulation. A sigmoidoscopy indicated no remaining foam or any evidence of perforation. The second patient, a man in his late twenties, complained of abdominal pain at presentation. His vital signs were stable and a rectal examination indicated the presence of a foreign body. Abdominal radiographs revealed a large foreign body extending into the sigmoid colon. Surgical removal of the insulation was successful and the patient recovered uneventfully (Sowerby et al, 2011).

Genitourinary

3.10.2)

A) VAGINAL ULCER

1) WITH POISONING/EXPOSURE

a) CASE REPORT/PEDIATRIC: A 12-year-old girl presented with a 3-day history of abdominal pain and fever. Abdominal radiography showed a radiopaque mass in the lower abdomen. Gray vaginal discharge with a metallic smell was noted on a pelvic examination, and a cylindrical battery was found within the vaginal cavity. Two vaginal ulcers were reported, one anteriorly corresponding with contact at the positive terminal of the battery, and one posteriorly corresponding with contact at the negative terminal. The patient recovered following daily vaginal irrigation for 10 days and administration of antibiotics for 7 days (Yanoh & Yonemura, 2005).

B) BURN

1) WITH POISONING/EXPOSURE

a) CASE REPORT: A 5-year-old girl presented with a 2-day history of pelvic pain and brownish vaginal discharge. Microscopic examination of the urine revealed the presence of erythrocytes and inflammatory cells and examination of the outer labia demonstrated severe reddening with brown appositions. A vaginoscopy done under general anesthesia showed the presence of an alkaline battery (size AAA). After removal of the battery, circular necrotic lesions of the vaginal wall were observed; however, there was no evidence of fistulas or other abnormalities. Following antibiotic therapy and insertion of a urinary catheter for 5 days, the patient's condition improved. The brownish vaginal discharge persisted for several weeks. A repeat vaginoscopy, performed 3 weeks post-presentation revealed coverage of the burns with a fibrinous layer, and a third vaginoscopy 3 months post-presentation demonstrated complete resolution. No long term issues were reported at one year follow-up (Semaan et al, 2015).

Summary Of Exposure

a) Common symptoms include pain on swallowing, drooling (increased salivation), and dysphagia.

Vital Signs

3.3.3)

A) WITH POISONING/EXPOSURE

1) FEVER: Patients may appear febrile and diaphoretic (Hernanz-Schulman & Naimark, 1985); this presentation usually occurs 18 to 30 hours after ingestion (Stricker et al, 2001; Nahman & Mueller, 1984) and suggests aspiration or perforation.

Laboratory Monitoring

Monitoring Parameters Levels

4.1.1)

A) Obtain a chest radiograph in any patient with suspected foreign body aspiration. Air trapping with asymmetry of the lungs suggests obstruction from a foreign body.
B) If a radiopaque foreign body has been ingested, radiographs of the chest and abdomen can facilitate localization of the foreign body to assist in subsequent management.
C) Radiographs may be required to evaluate for retained objects, but many objects are not radio-opaque. Contrast studies may be used in some cases.
D) Handheld metal detectors may be useful in detecting metallic foreign bodies (eg coins); however these devices cannot localize the exact position or shape of an object. These devices are not useful in detecting sharp objects (ie safety pins, push pins). Radiographic imaging is necessary to confirm the location.
E) Obtain CT scan imaging in patients with symptoms suggestion GI obstruction or perforation or in patients with symptoms suggesting foreign body aspiration.

4.1.2)

A) Arterial blood gases and/or pulse oximetry may be helpful in assessing the level of respiratory compromise in a patient with a partial obstruction.
B) Obtain CBC in patients suspected of an esophageal perforation.

4.1.4)

A) OTHER

1) ULTRASOUND

a) Ultrasound was used to localize a needle that had passed through the duodenum into the liver in one infant (Barki & Zahavi, 1994).

2) OTHER

a) SCREENING TOOL (METAL DETECTORS)

1) BACKGROUND: Metal detectors that work on the principle of linear detection technology are able to detect a metal object in proximity to the sensor by absorbing a small portion of the signal, which is constantly monitored and compared at a frequency of 20,000 times per second. The difference in amplitude causes an alarm signal by an audio sound and a light emitting diode. Purportedly, linear technology is able to detect all metals: ferrous, non-ferrous, pure and alloy, at any angle or plane (Doraiswamy et al, 1999).
2) CASE STUDY: Handheld metal detectors (HHMD) may be effective for identifying ingested coins and coin-like objects, but may be less effective for detecting sharp objects such as push pins and safety pins. In a study involving 40 pediatric patients ages 3 to 173 months, HHMD positively identified the presence of 27/27 ingested coins and button batteries. However, HHMD identified only 4/8 sharp metal objects including push pins and safety pins (Saz et al, 2010).
3) CASE STUDY: A prospective study of 186 stable children with a history of ingesting a metal foreign body (MFB) were scanned with a metal detector and received radiography. Of the 186 children, 181 had a confirmed positive audio-visual signal along with a radiographic study which confirmed the presence of a radio-opaque foreign body. In addition, 2 children swallowed an aluminum ring pull (non-radio opaque) which was diagnosed with the metal detector (Doraiswamy et al, 1999).

a) IMPLICATIONS: The authors suggested that uncomplicated MFB ingestions could be confirmed and localized with the aid of metal detectors. However, metal detectors CANNOT localize the exact position or shape of the object which would require radiographic imaging.

4) COIN LOCATION: In one report, handheld metal detectors were used to determine coin location in a pediatric population. A sensitivity of 98% (53/54) was observed for coin detection and 98% (81/83) in determining coin location as esophageal (Bassett et al, 1999).
5) ACCURACY: In a prospective study comparing handheld metal detector (HHMD) localization with radiography, with both experienced and non-experienced practitioners, HHMD scanning was an accurate and inexpensive screening tool. No statistically significant difference between the 2 groups of investigators was observed. The authors suggested that proficiency could be obtained with minimal practice and that the HHMD would be an appropriate early detection tool for esophageally impacted foreign bodies, while decreasing expense and radiation exposure to patients. (Seikel et al, 1999).

Radiographic Studies

1) Plain films may aid in locating a foreign body including glass (Dickinson, 1989; Gron et al, 1986) and determining its position and size.
2) Lateral and anteroposterior (AP) neck views, as well as chest films (including lateral views) are most useful. These may miss non-radio dense objects.
3) Clinical judgement should always be used, based on individual patient circumstances.
4) Symptoms or absence of symptoms cannot accurately predict the location of a swallowed coin in children (Schunk et al, 1989; Caravati et al, 1989; Chaikhouni et al, 1985; Hodge et al, 1985; Conners et al, 1995). A radiograph of neck, chest, and abdomen in all children with a history of coin ingestion may be prudent; however, this recommendation is controversial.
5) In a consensus survey of the POISINDEX system Editorial Board and Regional Poison Centers, the majority (11/14, 78.5%) routinely recommended radiographic studies in some asymptomatic children with a history of coin ingestion. In most facilities (9/14, 64%) this recommendation was restricted based on varied age and/or coin size criteria. The most consistent criteria was age of 2 years or younger and coin sizes of a penny or larger (Consensus, 1990).
6) Routine telephone follow-up to document passage of the coin is not usually done by Poison Centers, with routinely performing follow-up calls (4/14, 28.6%) of Poison Centers. The caretaker should be told to call back or consult a physician if the coin is not observed to pass (Consensus, 1990).
7) One author suggests that it may be reasonable to reserve radiographic studies for those children in whom the coin has not passed in the stools within a reasonable amount of time. This author suggested 10 days based on two times the average time taken for passage of foreign objects (Spitz, 1971; Anon, 1989).
8) In a retrospective review of 141 consecutive patients with a history of a foreign body ingestion, 122 foreign bodies in 114 patients were found by plain chest and abdominal x-ray (Suita et al, 1989). No foreign bodies were found in 25 of these 141 patients. In 2 children, a plastic foreign body passed in the stool.
9) XERORADIOGRAPHY: Neck xeroradiography is a better procedure for non-radiodense objects because it gives better soft tissue visualization and edge enhancement (Hernanz-Schulman & Naimark, 1985).
10) CONTRAST STUDIES: Barium swallow is indicated for patients who are clearly symptomatic, those with chest pain and possible obstruction, children with recurrent respiratory tract infections unresponsive to usual therapy, and those with suspected ingestions involving hazardous materials (sharp objects, chicken bones). Gastrografin(R) should be utilized in lieu of barium if perforation is suspected because it is less toxic to tissues than barium in the event of extravasation.

1) Obtaining a lateral chest x-ray in addition to an anteroposterior (AP) view in asymptomatic coin ingestion may help confirm esophageal vs tracheal location. One report describes an asymptomatic 8-year-old girl who presented to the emergency department approximately 3 hours after ingesting a quarter. An AP chest x-ray showed the coin aligned in the sagittal plane, which is consistent with a tracheal location. However, a lateral chest x-ray confirmed an esophageal location (Raney & Losek, 2008).

Treatment

Life Support

Patient Disposition

6.3.1)

6.3.1.1) ADMISSION CRITERIA/ORAL

A) Patients requiring general anesthesia for endoscopic foreign body removal and those with esophageal lacerations, perforation, or other serious complications require hospital admission (Binder & Anderson, 1984).

6.3.1.2) HOME CRITERIA/ORAL

A) Patients who undergo successful removal of the foreign body without the use of general anesthesia and with no complications may be discharged home.
B) Patients with minor discomfort due to esophageal abrasions may be followed on an outpatient basis.
C) Patients should be instructed concerning symptoms of vomiting, continued pain, fever, and chills.
D) Asymptomatic patients who swallow a smooth, round object smaller than a penny may be followed on an outpatient basis. In a consensus survey of the POISINDEX system Editorial Board and Regional Poison Centers, the majority (11/14, 78.5%) routinely recommended radiographic studies in some asymptomatic children with a history of coin ingestion. In most facilities (9/14, 64%) this recommendation was restricted based on varied age and/or coin size criteria. The most consistent criteria was age of 2 years or younger and coin sizes of a penny or larger (Consensus, 1990).
E) Routine telephone follow-up to document passage of the coin is not usually done by Poison Centers, with 4/14 (28.6%) of Poison Centers routinely performing follow-up calls. The caretaker should be told to call back or consult a physician if the coin is not observed to pass (Consensus, 1990).

6.3.1.3) CONSULT CRITERIA/ORAL

A) Consultation with an otolaryngologist or gastroenterologist may be needed if endoscopy is planned. Surgical consultation is necessary in cases of esophageal perforation. A toxicology consult may be indicated if the foreign body is toxic.

6.3.1.5) OBSERVATION CRITERIA/ORAL

A) COIN INGESTION: A conservative strategy of watchful waiting for 12 to 24 hours at home may be appropriate for children with asymptomatic esophageal coin ingestion initially confirmed by x-ray and no history of tracheal or esophageal abnormalities if coin ingestion was recent.

1) In a retrospective study, 37 children ages 8 months to 13 years with asymptomatic esophageal coin ingestions less than 24 hours earlier were managed with a period of watchful waiting at home for 8 to 18 hours after initial x-ray confirmation. None of the 37 children had a history of tracheal or esophageal surgery. Thirty-three of the 37 children (89%) had spontaneously passed the coin upon repeat chest x-ray up to 18 hours later. Complications did not develop in any of the children managed conservatively with observation (Nafousi et al, 2012).
2) A review of the literature based on several retrospective and 1 prospective study supported a period of watchful waiting for 8 to 16 hours in children with asymptomatic esophageal coin ingestion and no tracheal or esophageal abnormalities (Waltzman, 2006).

6.3.3)

6.3.3.1) ADMISSION CRITERIA/INHALATION

A) All patients with an upper airway foreign body (excluding the nose) require admission for immediate removal or for observation to an intensive care unit depending on the clinical situation. The urgency and level of care is reflected by the degree of obstruction and respiratory distress.
B) Approximately 45% of patients will require up to 3 days of hospitalization (Harboyan & Nassif, 1970).

6.3.3.2) HOME CRITERIA/INHALATION

A) Because of the risk of subsequent edema and complications from the removal of the foreign body, patients with other than a nasal foreign body should not be discharged home.

6.3.3.3) CONSULT CRITERIA/INHALATION

A) An otolaryngologist may be helpful in the immediate management of the obstructed airway.
B) A surgeon or pulmonary specialist capable of performing bronchoscopy should be utilized for lower respiratory tract obstructions.

6.3.3.4) PATIENT TRANSFER/INHALATION

A) Airway stabilization is required before transport can be considered. The transport vehicle and personnel must represent the maximum capability for resuscitation and airway maintenance.

6.3.4)

6.3.4.3) CONSULT CRITERIA/EYE

A) Follow-up examination should be done in the emergency department or by the patient's primary physician 24 to 48 hours after injury. Wounds that indicate nonhealing require consultation with an ophthalmologist.
B) Consultation with an ophthalmologist is indicated in the presence of the following:

1) Rust rings.
2) Deep foreign bodies (through Bowman's membrane) or intraocular foreign body (Brownstein & Hodge, 1988).
3) Deep corneal wounds (inadequate treatment may lead to a defect in corneal transparency due to scarring, vascularization of the cornea, or misalignment of an edge).
4) Evidence of more extensive ocular damage such as marked visual loss, hyphema, new pupil irregularity, perforation, or ruptured globe (Keeney, 1975).

Monitoring

Oral Exposure

6.5.3)

A) MONITORING OF PATIENT

1) Obtain a chest radiograph in any patient with suspected foreign body aspiration. Air trapping with asymmetry of the lungs suggests obstruction from a foreign body. If a radiopaque foreign body has been ingested, radiographs of the chest and abdomen can facilitate localization of the foreign body to assist in subsequent management. Obtain CT scan imaging in patients with symptoms suggestion GI obstruction or perforation or in patients with symptoms suggesting foreign body aspiration. Radiographs may be required to evaluate for retained objects, but many objects are not radio-opaque. Contrast studies may be used in some cases.

B) REMOVAL OF FOREIGN BODY

1) FOREIGN BODY REMOVAL: The choice of laryngoscopy, esophagoscopy, Foley catheter or pharmacologic measures may vary depending on the individual case and the location of the foreign body.
2) MAGNETS: The Consumer Product Safety Commission has received 19 reports of injuries (eg, bowel obstruction, volvulus, and bowel perforation) requiring gastrointestinal surgery following the ingestion of magnets contained in toy products (None Listed, 2006). Multiple magnet ingestion, or ingestion of a magnet along with a metallic foreign body that would be attracted to the magnet, should be treated aggressively (often surgically) despite minimal initial physical findings (Dutta & Barzin, 2008).

a) LAPAROSCOPY: A 4-year-old boy ingested two magnets in 2 separate days. Although he had only mild symptoms, a fistula developed between the cecum and terminal ileum. Both magnets were removed by laparoscopic instruments, leaving 2 enterotomies that were repaired laparoscopically (Dutta & Barzin, 2008).

C) ENDOSCOPIC PROCEDURE

1) Esophagoscopy is the most exact and commonly employed method of removal of esophageal foreign bodies (Hernanz-Schulman & Naimark, 1985; Webb et al, 1984; Chaikhouni et al, 1985; Binder & Anderson, 1984; Bendig, 1986).

a) It is a safe procedure in children when carried out by experienced personnel (Venkateswarlu et al, 1988).
b) Esophagoscopy should be considered in all cases of unexplained swallowing difficulty, even if contrast studies are normal (Spitz & Hirsig, 1982).

2) Endoscopy may also be considered in asymptomatic patients with a positive history of foreign body ingestion, even when physical examination and x-ray findings are negative; delays beyond 24 to 48 hours may be hazardous to the patient (increased risk of perforation) (Cohen, 1981).

a) Endoscopic technique was successful in removing pins (ie, straight pin and hair pin) following perforation in two children (a toddler and a 9-year-old) (Stricker et al, 2001).
b) Patel et al (1989) reported the removal of ingested parts of a broken thermometer utilizing an endoscopic "end hood" and a suction technique in a 60-year-old man following a recent gastric operation. The "end hood" was made from a length of transparent tubing cut from the tip of an F32 Argyle(R) chest drainage catheter which was attached to the distal end of a gastroduodenoscope with a strong suction channel.

3) In a case series involving 339 pediatric patients with foreign body ingestion, endoscopy was attempted in 37 patients, with a success rate in 34 patients (91.9%). A successful extraction was reported in 32 of the patients, with the remaining two patients undergoing endoscopy to fragment and advance impacted food boluses. Three patients required surgery to remove the object ingested. One patient swallowed a large coin that would not progress, the second patient had a trichobezoar that obstructed the gastric outlet and the third patient had swallowed bed linens which caused a gastric obstruction. No complications or death were reported (O'Brien et al, 2001).
4) TECHNIQUES

a) FLEXIBLE: Flexible endoscopy may be used for removal of objects that are smooth, blunt, and of less than two weeks' duration; it is also of value in cases where a rigid endoscope cannot be used (eg, severe cervical osteoarthritic disease) (Giordano et al, 1981; Ricote et al, 1985; Bendig, 1986). It is the method used in the majority of adults an older children with esophageal foreign bodies.
b) RIGID: Rigid endoscopy is an alternative. It is most commonly used in young children in whom removal of the foreign body with a balloon catheter is not feasible (Morrow et al, 1998). It is also sometimes used in adults with esophageal foreign bodies that are not smooth and blunt, such as bones (Eliahar et al, 1999). Major disadvantage is the need for general anesthesia and higher complication rate.

1) Diagnosis of pulmonary foreign bodies may be difficult. In one study, 19% of patients with insufficient evidence to warrant open tube bronchoscopy were found, using flexible fiberoptic bronchoscopy, to have foreign bodies present (Wood & Gauderer, 1984).

5) DISADVANTAGES: Included are the need for IV sedation, the possibility of esophageal perforation, and aspiration of the foreign body from the oropharynx, anesthetic complications, and cost (Hernanz-Schulman & Naimark, 1985; Conners, 1997; Harned et al, 1997). Endoscopy is the most common cause of esophageal perforation, especially in patients with cervical osteoarthritis (Wright, 1980; Brady & Johnson, 1977). Complications during foreign body removal via flexible fiberoptic endoscopy occur less often than with the rigid scope (Brady & Johnson, 1977).
6) Biliary stone baskets have been used effectively for removal of blunt objects (eg, soft food boluses and hard spherical objects). The technique has no value for coins and other discoid objects (Shaffer et al, 1986). Successful magnetic removal of disc batteries has been reported (Volle et al, 1989).

D) LARYNGOSCOPY

1) This procedure may be necessary to visualize objects in the pharynx and hypopharynx. Foreign bodies visible during indirect or direct laryngoscopy can usually be removed with forceps or a clamp (Pons, 1983). Preparations for emergent airway management should be made before beginning this procedure because of the potential risk of airway obstruction during manipulation.
2) CONTRAINDICATIONS: Laryngoscopy is contraindicated if epiglottitis is suspected, unless appropriate precautions are taken.

E) FLUOROSCOPY FOR FOREIGN BODY LOCALIZATION

1) The use of a Foley catheter under fluoroscopic guidance to remove smooth and blunt foreign bodies has been an effective and uncomplicated technique when used by experienced personnel (McGuirt, 1982; Rubin & Mueller, 1987). It is the procedure of choice for removal of coins impacted in the esophagus in many institutions (Harned et al, 1997; Conners, 1997).

a) In one study, 98 of 100 children were successfully treated with this technique with no complications (Campbell et al, 1983).
b) In another study, 35 of 38 children were successfully treated with this technique. Three children required foreign body removal by endoscopy (Rubin & Mueller, 1987).
c) Multiple coins and coins that have been in place for several days have been successfully removed using this technique (Harned et al, 1997).

2) TECHNIQUE

a) Children are wrapped in multiple bed sheets and a padded jaw block is inserted.
b) The patient is placed in prone oblique position, and the fluoroscopy table is turned to a relatively steep head-down position.
c) After topical pharyngeal anesthesia, the catheter is inserted orally, and the tip is advanced just beyond the foreign body; the balloon is then inflated with contrast media, and the catheter is slowly withdrawn under fluoroscopic guidance to ensure that the foreign body is moving out.
d) The patient should inspire fully and hold his breath while the Foley catheter is withdrawn rapidly, pulling the foreign body past the glottis and epiglottis into the hypopharynx. The patient then should immediately spit out the foreign body or it is removed with a finger sweep (Harned et al, 1997).

3) CONTRAINDICATIONS

a) Sharp or pointed foreign bodies, disc batteries, pain on attempted extraction, inability to bypass the object with a catheter, total obstruction, evidence of airway compromise and struggling in frightened, restrained children are contraindications (McGuirt, 1982; Dunlap, 1981). Thickening of the tracheoesphageal interface with focal narrowing of the adjacent trachea is a relative contraindication (Harned et al, 1997).
b) Prior esophageal symptomatology or operation, repeated episodes of foreign body lodgements, marked discrepancy between coin size and esophageal size and all foreign bodies other than coins, should undergo oral rigid endoscopic removal in order to prevent injury (Jona et al, 1988).

4) ADVANTAGES of this technique over endoscopy include cost-effectiveness due to lack of operating room costs, no need for general anesthesia, and ability to perform the procedure in outlying areas lacking adequate anesthesia and endoscopy facilities (McGuirt, 1982; Campbell et al, 1983; Rubin & Mueller, 1987).
5) DISADVANTAGES relative to endoscopy include the possibility of airway compromise, failure to recognize underlying or associated esophageal disease, failure to remove a second unidentified foreign body, and painful manipulation in the unanesthetized patient (McGuirt, 1982; Jackson & Hawkins, 1986).
6) COMPLICATIONS include aspiration, epistaxis, vomiting and esophageal injury (Conners, 1997).

F) BOUGIENAGE

1) Blind esophageal bougienage was successful in removing 100% of 83 esophageal foreign bodies in one literature review (Conners, 1997).
2) In an observational case series, 620 children with coins acutely lodged in their esophagus were treated with either endoscopy (n=248) or bougienage (n=372); 355 (95%) children had a successful bougienage with an average length of stay of 2.2 hours. Seventeen patients with an unsuccessful bougienage underwent endoscopy. Endoscopy was successful in 247 patients with an average length of stay of 6.1 hours. One patient developed postendoscopic stridor and underwent urgent rigid bronchoscopy, revealing subglottic edema (Arms et al, 2008).
3) COMPLICATIONS: Intramural perforation, subacute mediastinitis, tracheoesophageal fistula, and long-term residual injury to the esophagus have been associated with blind esophageal bougienage for coin ingestion in children (Jona et al, 1988).

G) SURGICAL PROCEDURE

1) DENTURES: The risk of perforation during endoscopic removal of dentures is very high due to their rigidity, large size, and ragged edges; removal by elective esophagotomy is recommended (Nwafo et al, 1980; Aghaji et al, 1988).

H) GLUCAGON

1) Glucagon decreases lower esophageal sphincter pressure and does not affect peristalsis (Marks & Lousteau, 1979).

a) It has been used as a primary mode of treatment in a number of cases of esophageal meat impaction (Handal et al, 1980; Marks & Lousteau, 1979; Glauser et al, 1979) (Trenknew et al, 1983).
b) It is also useful for lower esophageal impactions, but since it has no apparent effect on the muscles above the lower esophageal sphincter it is not expected to be effective in patients with upper and middle esophageal obstruction (Trenkner et al, 1983).
c) Although no controlled studies are available, isolated case reports suggest dramatic results. It is relatively free of complications and does not preclude the use of other therapeutic modalities (Pons, 1983).

2) DOSE: 1 to 2 mg IV over 1 to 2 minutes in a sitting patient (Hernanz-Schulman & Naimark, 1985). The dose for children has not yet been established.

a) In considering doses used to treat food impaction, intravenous glucagon 1 mg was no more beneficial than a dose of 0.5 mg in reducing lower esophageal sphincter (LES) pressure in a randomized, double-blind, crossover study of normal subjects. Reduction in LES pressure was significant after administration of a 0.25 mg dose and after a 0.5 mg dose, but the decrease after 1 mg did not differ significantly from that produced by the 0.5 mg dose. Esophageal motor function was assessed with the use of an intra-esophageal multilumen catheter and pneumohydraulic infusion pump (Colon et al, 1999).

3) ADVERSE EFFECTS: Nausea, vomiting, diarrhea.
4) PRECAUTIONS: Caution in patients with history of insulinoma or pheochromocytoma.
5) MONITORING PARAMETERS: Blood glucose level.

I) CONTRAINDICATED TREATMENT

1) PAPAIN: Esophageal meat impactions have been dissolved with the proteolytic enzyme papain. Although it is harmless on a normal esophagus, papain may cause damage to a esophageal wall that is compressed and ischemic due to foreign body impaction.
2) Perforation occurred in 2 of 90 cases reported in the literature (Cavo et al, 1977) and papain is not recommended because of the 2% mortality rate associated with its use (Giordano et al, 1981; Goldner & Danley, 1985).

J) COMPLICATION

1) ABRASIONS: This is the most common and benign of complications. Patients may complain of foreign body sensation. Treatment is unnecessary, symptoms will resolve in 4 to 5 days.
2) LACERATIONS: The primary problems with lacerations is blood loss. Patients need to be monitored in the hospital for evidence in increased bleeding.
3) PERFORATION: Perforation is an acute emergency. The incidence of perforation is 0.6% to 1% of all foreign body ingestions. Mortality is high if left untreated, but is less than 20% if surgery is done within 12 hours, 36% if done within 24 hours, 64% between 24 to 48 hours and 85% after 48 hours (Hernanz-Schulman & Naimark, 1985).

K) EXPERIMENTAL THERAPY

1) HELIOX

a) Heliox (helium and oxygen mixture at a ratio of 60% oxygen and 40% helium) was used successfully in a 22-month-old girl, as a temporizing measure for severe, intermittent airway obstruction due to aspirated sunflower seeds (Brown et al, 2002).

1) PRECAUTION: The use of heliox is not recommended in patients with hypoxia requiring greater than 40% to 50% oxygen (Brown et al, 2002).

Inhalation Exposure

6.7.2)

A) FINDING OF RESPIRATORY OBSTRUCTION

1) An upper airway foreign body obstruction presents as a medical emergency necessitating immediate airway stabilization by either removal of the material or surgical intervention. The clinical presentation will usually reflect acuteness and location of obstruction.

B) REMOVAL OF FOREIGN BODY

1) ACUTE OBSTRUCTION: Immediate removal is mandatory. Abdominal thrusts are done more often in the prehospital environment. Manual removal using Magill forceps and direct laryngoscopy is more often done prehospital by paramedics or in the emergency department or operating room.

a) ADULTS: A series of subdiaphragmatic manual abdominal thrusts should be performed first, followed by finger sweep if unconscious, and attempt to ventilate; sequence may need to be repeated.
b) CHILDREN

1) RESPONSIVE CHILD: GIVE WITH VICTIM STANDING OR SITTING: Give up to 5 quick inward and upward abdominal thrusts (Heimlich maneuver), avoiding the xiphoid process or the lower margins of the rib cage. Continue the series of up to 5 thrusts until the foreign body is expelled or becomes unresponsive. Stand or kneel behind the victim, arms directly under the victim's axillae, encircling the victim's torso (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005).
2) RESPONSIVE INFANT: Back blows are delivered while the infant is supported in the prone position. After 5 back blows with heel of hand high between the shoulder blades, if the object has not been expelled, give up to 5 chest thrusts. Repeat the sequence as necessary until the object has been dislodged or the infant becomes unresponsive (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005).
3) UNRESPONSIVE CHILD: If obstruction is not relieved, open victim's mouth using the head tilt-chin lift. If foreign body is visualized, it may be manually extracted by a finger sweep. Do not use blind finger sweep. If no spontaneous respirations result, attempt to ventilate the patient. If the 2 breaths are ineffective, perform a series of 30 chest compressions. Repeat as necessary (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005).
4) UNRESPONSIVE INFANT: If obstruction is not relieved, open victim's mouth using the head tilt-chin lift and attempt to visualize the foreign body. If foreign body is visible, remove it with a finger sweep. Do not use blind finger sweep. If no spontaneous respirations result, attempt to ventilate the patient. If the 2 breaths are ineffective, deliver 30 rapid chest thrusts (similar to cardiac compressions) using 2 fingers (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005).

2) INVASIVE TECHNIQUES

a) If the above procedures fail, laryngoscopy followed by bronchoscopy should be immediately available. Surgical intervention to establish an adequate airway is indicated on rare occasions.

3) BRONCHIAL FOREIGN BODIES

a) These require immediate airway stabilization if necessary, followed by bronchoscopy if the object has been present for over 24 hours.
b) In more recent aspirations, attempts at vigorous pulmonary care (percussions, clapping, coughing) are sometimes effective if there is no respiratory distress. However, if the object is vegetable matter (eg, nuts), bronchoscopy should be done urgently.

C) AIRWAY MANAGEMENT

1) GENERAL: Definitive care of the choking victim in the emergency department consists of a variety of means, primarily laryngoscopy or bronchoscopy with manual removal. Prehospital care is very important in this process, since the earlier a patient with complete airway obstruction obtains relief, the better the prognosis. Paramedics may use laryngoscopy and Magill forceps for manual removal. In the field, alternatives for removal include manual chest thrusts, manual abdominal thrusts, and back blows.
2) MANUAL THRUST

a) INDICATIONS

1) GENERAL: In infants under one year of age, the rapid, high increase in pressure resulting from back blows may expel or loosen the foreign body; this may then be followed by a chest manual thrust producing a more sustained increase in pressure and airflow. In older children and adults, most experts suggest a series of manual abdominal thrusts. If this fails, the head tilt-chin lift should be used to open the patient's mouth and remove the foreign body if visualized. Do not attempt blind sweeps with the finger. If this fails, try standard cardiopulmonary resuscitation (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005; Abman et al, 1984) (AHA, 1994)(Greensher & Mofenson, 1982; Torrey, 1983).
2) CHILDREN: The optimal method for relief of obstruction is controversial. Some authors suggest that the manual (chest) thrust should be used in combination with back blows in children less than one year of age, since abdominal thrusts in children may produce intraabdominal organ damage (Greensher & Mofenson, 1982; Torrey, 1983). Others argue that the risk is minimal (Heimlich, 1975) 1982). Currently, the American Heart Association (2005) and the International Liaison Committee on Resuscitation (ILCOR) (2003) recommend the use of the subdiaphragmatic abdominal thrusts (Heimlich maneuver) if the victim is a child one year of age or older. The combination of back blows and chest thrusts continues to be recommended in infants under one year (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005).

b) MECHANISM: The manual abdominal thrust produces a more sustained increase in pressure and airflow in the respiratory passages and may further assist in the dislodgement and movement of the foreign body (Day et al, 1982). Back blows produce an instantaneous increase in pressure in the respiratory passages that may result in either partial or complete dislodgement of a foreign body, but there is theoretical evidence that back blows may produce a complete obstruction from a partial obstruction (Day et al, 1982). Although there are no controlled studies, the bulk of the literature suggests that any one technique may not be consistently effective in the immediate removal of a foreign body in the upper airway, and, therefore, successive techniques may be used appropriately.

3) BACK BLOWS

a) INDICATIONS

1) GENERAL: In infants under one year of age, the rapid, high increase in pressure resulting from back blows may expel or loosen the foreign body; this may then be followed by a chest manual thrust producing a more sustained increase in pressure and airflow. In older children, most experts suggest a series of manual abdominal thrusts. If this fails, the head tilt-chin lift should be used to open the patient's mouth and remove the foreign body if visualized. Do not attempt blind sweeps with the finger. If this fails, try standard cardiopulmonary resuscitation (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005; Abman et al, 1984) AHA, 1994; (Greensher & Mofenson, 1982; Torrey, 1983).
2) CHILDREN: The optimal method for relief of obstruction is controversial. Some authors suggest that the manual (chest) thrust should be used in combination with back blows in children less than one year of age, since abdominal thrusts in children may produce intraabdominal organ damage (Greensher & Mofenson, 1982; Torrey, 1983). Others argue that the risk is minimal (Heimlich, 1975). Currently, the American Heart Association (2005) and the International Liaison Committee on Resuscitation (ILCOR) (2003) recommend the use of the subdiaphragmatic abdominal thrusts (Heimlich maneuver) if the victim is a child one year of age or older. The combination of back blows and chest thrusts continues to be recommended in infants under one year.
3) ADULTS: The Heimlich maneuver is the only method recommended for foreign-body airway obstruction. Back blows may not be as effective as the Heimlich maneuver in the adult and may complicate the training method (ECC Committee,Subcommittees and Task Forces of the American Heart Association, 2005).

b) MECHANISM: The manual abdominal thrust produces a more sustained increase in pressure and airflow in the respiratory passages and may further assist in the dislodgement and movement of the foreign body (Day et al, 1982). Back blows produce an instantaneous increase in pressure in the respiratory passages that may result in either partial or complete dislodgement of a foreign body, but there is theoretical evidence that back blows may produce a complete obstruction from a partial obstruction (Day et al, 1982). Although there are no controlled studies, the bulk of the literature suggests that any one technique may not be consistently more effective in the immediate removal of a foreign body in the upper airway, and, therefore, successive techniques may be used appropriately.

4) LARYNGOSCOPY

a) INDICATIONS: Magill forceps and Kelly clamps have been used successfully to remove upper airway foreign bodies but should only be employed with direct visualization of the foreign body. A laryngoscope or tongue blade and flashlight may also be used (King, 1977; Eller & Haugen, 1973; AHA, 2000).
b) COMPLICATIONS: Edema or laceration of tissue (Bergeson et al, 1978); recurrent obstruction secondary to only partial removal of the foreign body (Trott, 1979).

5) BRONCHOSCOPY

a) INDICATIONS: Bronchoscopy is the definitive therapy for removal of a foreign body in the tracheobronchial tree.

1) If the foreign body has been aspirated within 24 hours and there is no respiratory distress, a trial of bronchodilators and postural drainage for 24 hours is indicated before bronchoscopy is performed (Aytac et al, 1977; Law & Kosloske, 1976).
2) Some authors recommend bronchoscopy under general anesthesia. Coordinated efforts between the endoscopist and the anesthesiologist are required. Special care must be addressed to anesthetic methods (Cohen et al, 1980). Kosloske (1982a) was successful in removing 40/41 aspirated foreign bodies using bronchoscopy and general anesthesia (Kosloske, 1982a).
3) In a retrospective case review of 191 patients (age range 2 months to 14 years) who underwent bronchoscopy for suspected foreign body aspiration, 106 patients were admitted to the hospital within 24 hours, and a foreign body was removed in 75 cases (70.7%). The remaining 85 patients presented to the hospital beyond 24 hours and foreign bodies were extracted in 31 patients who had previously been treated for other respiratory conditions (pulmonary infections, pneumonia, bronchiolitis or allergic asthma). From all the bronchoscopy reports reviewed in this study, 19 inorganic and 104 organic foreign bodies were found, and most involved the upper respiratory tract (right bronchial tree n=53, left bronchial tree n=41) or the larynx or trachea (n=29). (Ezer et al, 2011).

b) TECHNIQUES: Use of a mini optical telescope (Kobayashi & Shima, 1982), Fogarty embolectomy catheter (Kosloske, 1982), or a 3.2 mm or 5.3 mm fiberoptic bronchoscope (Vauthy & Reddy, 1980) can facilitate removal. One author reports the use of a wire stone basket passed through the biopsy channel of a fiberoptic bronchoscope in an adult (McCullough, 1985).

1) Flexible fiberoptic bronchoscope is most commonly employes, especially in adults or older children (Swanson et al, 2002) (Zavala, & Rhodes, 1975)(Hiller et al, 1977; McCullough, 1985; Larsen, 1986).
2) Behera et al (1988) successfully removed a plastic whistle from two 13-year-old boys using a flexible fiberoptic bronchoscope with the help of an alligator biopsy forceps (Behera et al, 1988).
3) Removal of foreign bodies using a rigid bronchoscope is still commonly performed in young children in many centers (Cohen et al, 2001; Swanson et al, 2002).

c) EFFICACY: In one study, the foreign body was removed successfully in 56 of 63 (89%) children on whom bronchoscopy was performed (Aytac et al, 1977). In another series, removal of inhaled foreign bodies by bronchoscopy was successful in 56 of 57 patients; one patient required segmentectomy because of a fragment of a spike in the lung parenchyma (Kero et al, 1983).

1) Bronchoscopic extraction was used in all but one of 97 children with tracheobronchial tree aspiration. The remaining patient required transthoracic extraction (Svensson, 1985).

d) FINDINGS: In two studies, foreign bodies identified at bronchoscopy were located at the following sites: right bronchus (105), left bronchus (85), and trachea (12); bilateral foreign bodies were found in 7 cases. No foreign body was found in 29 cases (Brown, 1973; Brown & Clark, 1983).

1) Baharloo et al (1999) observed that although aspirated foreign bodies are most often located in the right bronchial tree in adults, children had no statistically significant difference between objects being located in the right or left bronchial tree.

a) In children, the majority (74%) of aspirated foreign bodies were lodged in the proximal (larynx, trachea and left and right main bronchi) airways, with the remaining being found in the more distal and lobar bronchi. Adults were more likely to have obstructions in the right bronchial tree (69%).

6) PULMONARY CARE

a) INDICATIONS: Intensive postural drainage in combination with inhaled bronchodilator therapy was successful in as many as 80 percent of children with a foreign body in the tracheobronchial tree (Aytac et al, 1977; Law & Kosloske, 1976). However, this modality should not be used if the foreign body has been present for over 24 hours (Law & Kosloske, 1976) or if vegetable material (eg, a peanut) has been aspirated and causes a partial obstruction.

7) CRICOTHYROTOMY

a) INDICATIONS: Surgical intervention is appropriate if total respiratory obstruction is present, the foreign body is above the cricoid cartilage and cannot be removed, and other means of establishing the airway are unsuccessful. Needle cricothyrotomy is contraindicated with complete upper airway obstruction below the cricoid membrane.

1) A small pediatric endotracheal tube placed through the cricothyrotomy incision enhances the speed and safety of the procedure (Schecter & Wilson, 1981).

8) INTUBATION, ENDOTRACHEAL

a) INDICATIONS: On the rare occasion when the foreign body can be visualized at the vocal cord level but cannot be removed and a surgical airway cannot be established (eg, via cricothyrotomy), intubation may successfully push the foreign body into one of the main stem bronchi. This may allow ventilation and oxygenation of at least one lung.

9) VENTILATION, PERCUTANEOUS TRANSTRACHEAL

a) INDICATIONS: Alternative airway management when oral or nasal intubation is time-consuming, dangerous, unsuccessful, or contraindicated (Barash, 1992) (Nakatsuda, 1992)(Benumof, 1994). In general, this is a temporary procedure; oxygenation can be maintained for approximately 30 minutes; beyond this point, progressive hypercapnia due to inadequate ventilation occurs (Manning & Blanda, 1995).
b) CONTRAINDICATIONS: Relative coagulopathy; complete airway obstruction (controversial, especially if large (8.5 Fr) catheter is used) (Manning & Blanda, 1995).
c) COMPLICATIONS: Subcutaneous emphysema; hemorrhage, most often involving the thyroid; aspiration; esophageal perforation with gastric dilation; catheter kinking, laryngeal pneumatocele.

10) LARGE BORE NEEDLE

a) INDICATIONS: Insertion of a large bore needle into the airway through the cricothyroid membrane may provide a temporary emergency airway in adults when other alternatives do not exist. This technique should not be used in children because the needle can slip from the larynx or trachea into an adjacent major cervical vessel (Donald, 1985).
b) TECHNIQUE: Palpate the space between the inferior surface of the thyroid cartilage and the upper surface of the cricoid; place the tip of a 14- or 16-gauge needle in the midline anterior neck over this site and push the needle through the skin, underlying soft tissue, and cricothyroid membrane. Extremely efficient ventilation can be established when the cannula is attached to a positive-pressure source; a Saunder's type ventilator apparatus delivering oxygen at 50 psi can maintain adequate respiratory exchange (Donald, 1985).

D) RESPIRATORY COMPLICATION

1) Diagnosis of pulmonary foreign bodies may be difficult. In a study by Wood & Gauderer (1984), 19% of patients with insufficient evidence to warrant open tube bronchoscopy were found, using flexible fiberoptic bronchoscopy to have foreign bodies present (Wood & Gauderer, 1984).

E) EXPERIMENTAL THERAPY

1) HELIOX

a) Heliox (helium and oxygen mixture at a ratio of 60% oxygen and 40% helium) was used successfully in a 22-month-old female, as a temporizing measure for severe, intermittent airway obstruction due to aspirated sunflower seeds (Brown et al, 2002).

1) PRECAUTION: The use of heliox is not recommended in patients with hypoxia (requiring greater than 40% to 50% oxygen) (Brown et al, 2002).

F) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

6.8.2)

A) DIAGNOSTIC PROCEDURE

1) SLIT LAMP EXAMINATION

a) INDICATIONS: Slit lamp examination is useful for detecting minute corneal abrasions and for removal of foreign bodies. It is also useful to evaluate associated or differential conditions (eg, narrow angle glaucoma, iritis, and various keratopathies).

2) OPHTHALMOSCOPY

a) Inspection of all levels from the cornea to the retina should be included in all eye trauma.

3) TONOMETRY

a) Tonometry is used if the picture is at all suggestive of glaucoma.

B) CORNEAL FOREIGN BODY

1) The management of corneal foreign body/abrasion is usually straightforward after more serious problems (eg, globe penetration, glaucoma, and herpetic or bacterial keratitis) have been ruled out. Treatment consists of removal of the foreign body, relief of ciliary spasm, administration of analgesics and topical antibiotics, analgesics, and eye patching for 24 to 48 hours.

C) REMOVAL OF FOREIGN BODY

1) After local anesthesia has been obtained, foreign bodies under the eyelids or on the conjunctiva can usually be swept away with a moistened cotton applicator stick. Foreign objects imbedded in the cornea can sometimes be irrigated or swept away with an applicator but more often must be lifted out with an eye spud or 25-gauge hypodermic needle.

D) ANTIBIOTIC

1) Topical antibiotics are instilled into the eye to prevent infection of the cornea.
2) SODIUM SULFACETAMIDE 10%: 1 to 2 drops instilled in affected eye every 3 to 4 hours as needed.

E) MYDRIATIC-CYCLOPLEGIC

1) The instillation of a short-acting (8 to 48 hours) cycloplegics is recommended for relief of pain due to ciliary spasm.
2) HOMATROPINE or TROCAINAMIDE: 1 to 2 drops instilled in affected eye.

F) APPLICATION OF EYE PAD

1) A firm double patch should be applied for 24 hours.

G) ANALGESIC

1) May be necessary for symptomatic relief during the first 12 to 24 hours.
2) CODEINE WITH ACETAMINOPHEN: 1 to 2 tablets every 3 to 4 hours as needed.

H) CORTICOSTEROID

1) Topical steroids have no place in the treatment of the abraded cornea. They can be dangerous, especially when combined with antibiotics, as they predispose to fungal ulcers and herpetic keratitis. Experimentally, a statistically significant delay in corneal reepithelialization can be demonstrated with the use of steroids, as well as poorer quality healing in histological section. This effect may be both transient and clinically insignificant, but recognition of possible adverse effects is advised (Petroutsos et al, 1982). Decreased tensile strength and collagen content after corneal ulceration with steroid use has also been demonstrated (Phillips & Arffa, 1983).
2) Concomitant use of steroids for an associated traumatic iritis should only be done on the advice of an ophthalmologist who will see the patient on a daily basis.
3) Early use of topical steroids with chemical or thermal burns may slow healing but also decreases inflammatory response and ulceration; LATE use in these patients may INCREASE ulceration (Phillips & Arffa, 1983). As this area is controversial, as well as fraught with complications, initiation of steroid therapy should be done only on the advice of the ophthalmologist who will closely follow the patient.

I) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Abstracts

Range Of Toxicity

Summary

Minimum Lethal Exposure

1) Death from esophagoaortic fistula has been reported in children who had no symptoms after swallowing coins (Vella & Booth, 1965).
2) A death has been reported from complications related to the acute toxic phase of chronic copper poisoning in a mentally disturbed individual that was found, at autopsy, to have 275 US coins in the stomach (Yelin et al, 1987).

Maximum Tolerated Exposure

1) The most common foreign body ingested are coins. Half-dollars and dollars have not been ingested based on some studies of coin ingestions (Anon, 1989).
2) CASE SERIES - Based on reporting to the Toxic Exposure Surveillance System (TESS) from 1993 through 1999, 25,394 coin ingestions were reported. Outcome analysis for 10,463 coin exposures were followed. Of those cases, only 12 patients had a major effect (0.11%), and no fatalities were reported. An inverse relationship between coin size and "no effect" or "minor effect" was observed: (dime 98.5%), penny (97.8%), nickel (94.7%) and quarter (92.6%), respectively (White, 2000).

General Bibliography

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FeedBack

FOREIGN BODY

Classification | Detailed evidence-based information

Therapeutic Toxic Class

Specific Substances

Available Forms Sources

Life Support

Clinical Effects

Laboratory Monitoring

Treatment Overview

Range Of Toxicity

Heent

Cardiovascular

Respiratory

Neurologic

Gastrointestinal

Genitourinary

Summary Of Exposure

Vital Signs

Monitoring Parameters Levels

Radiographic Studies

Life Support

Patient Disposition

Monitoring

Oral Exposure

Inhalation Exposure

Eye Exposure

Summary

Minimum Lethal Exposure

Maximum Tolerated Exposure

General Bibliography