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Foreign bodies

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by

Gareth Hardy

on 27 January 2015

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Transcript of Foreign bodies


Foreign Bodies
He needs a cric
and thoracotomy!!
It's his only chance
dammit!!!
I've put something
up by bottom.
Can you get it out
for me?
Foreign
bodies
up
noses

Foreign
bodies
in ears

Foreign
bodies in
throat

Swallowed
foreign
bodies

Inhaled foreign
bodies

PR foreign bodies
PV foreign bodies
Nasal
Foreign
Bodies
Removal
'Mother's kiss'
Instrumentation
Homer
5 years old

Presents with mum who says he has pushed a piece of lego up his nose.

They have tried to get him to blow his nose but without sucess.

Homer is very well, seems very amused.
Mum is not so impressed.
What do you do?
Analgesia?
Remember:
Always try mothers kiss
(maybe with a straw?)

Check the other nostril!
CAUTION WITH UNCOOPERATIVE KID
Who needs referral?
Next week?
Today?
Jacqueline (78) attends the ED

Cleaning her ears with cotton buds, the tip has broken off and she cannot remove it.


What do you do?
Removal -

suction?
hook?
irrigation? (if TM OK)
Tips:

Ask about and look for signs of TM injury (bleeding, hearing loss)

Again, caution with wriggling children

Suction can scare kids

Analgesia


Who gets referred?
BAN THE BUD!
45 year old gentleman
Eating fish last night
c/o FB sensation in R side of throat
what do you do?

why do we care?
My approach.... other people will do this differently
Take a look!

Patients are
pretty good
at localising
where these
things are
If easily visible, remove with crocodile forceps.

Good lighting, tongue depressor and some topical lignocaine make this easier
Complications are rare
..... but nasty

Nothing like a retro-pharyngeal
abscess or a oesophageal
perforation to put you off
your fish!
"To infinity, and beyond!"
If visible, but can't get out, refer to ENT (ideally within 24 hours)


If nothing seen, then reassure, but ENT follow up within 2 days
Many patients will have no fish bone (68% in one cohort), but those that do, 33% were lodged too distal to see in ED
What about a XRAY?

Not much use....

Specific, but not sensitive.

Let ENT do them if they like.....
Oesophageal
food
bolus
Homer (now all grown up)
Presents complaining of
being unable to swallow.

Was eating steak for lunch and a piece got 'stuck'
What do you do?
Poor evidence.... Small samples, poor methods, often used with other treatment.
Might work
Small risk of perforation
Poor evidence base, no good RCT
But.... probably harmless.
Again, poor evidence
Small sips of fizzy drink
may dislodge food bolus
Causes vomiting
Couple of incidecnes of
oesophageal tears.
Most will need endoscopy.

Most will have oesophageal abnormality, so gastro f/u is needed.
GOLD STAR TO WHOEVER SAID
"AIRWAY"
Acute foreign body aspiration
COMPLETE OBSTRUCTION IS AN EMERGENCY

PATIENT WILL DIE UNLESS AIRWAY SECURED
First aid

Oxygen

CALL EVERYONE
Partial obstruction due to foreign body can be difficult to diagnose.

Beware the child who suddenly develops severe stridor during the day, with no preceding URTI.
Foreign body in LOWER respiratory tract

Can present with an acute SOB/wheeze

Difficult diagnosis if no definite history of choking or foreign body (about 15% cases)

Suspect if history of foreign body in mouth, choking, sudden onset in 1-2 yr old.

Small objects or food (nuts are common)

Not always visible on xray, may look like a pneumonia, or an area of air trapping.

Needs rigid bronchoscopy to remove


SWALLOWED COINS
Very common

If coin makes it stomach, then no worries.


But how do we tell?
History?

Xray?

Metal detector?

Coins lodged in the oesophagus can cause serious complications
Waylon (45)
Presents to ED 6 hours after inserting can of deodorant into his rectum.
He has been unable to remove it
What do you do?
HISTORY
What things must we consider here?

Remember.... very distressing to patient.
We are not here to judge.
EXAMINATION
Priority is to exclude.....
REMOVAL

Often tricky.... main limiting factor is patient discomfort


A (small!) speculum may be helpful if tolerated.

A foley catheter placed behind the object may break any suction and allow gentle traction

Many will require surgical referral
Vaginal foreign bodies
Usually straightforward....


Rule out serious injury
Consider possibility of assault
REMOVAL IS USUALLY SIMPLE
Consider foreign body ion children presenting with chronic discharge

Refer to gynaecology if FB suspected in child.

Child protection?
Gareth's tip - push forceps through finger of latex glove first, so the object can be quicly wrapped and disposed of....
Body stuffers and packers
Often brought by police, requesting a search.
Can self present if symptomatic, either with obstructive symptoms, or severe toxicity if packs have leaked or burst.
Police may be keen for intimate examinations to be done as they suspect patient is hiding drugs.

WE CAN'T DO THIS WITHOUT CONSENT
Snake (36) is brought to the ED by police
They are sure he has hidden packets of heroin in his rectum.
Snake is well, and is refusing a PR.
What do you do?
AXR may show packets
CT might be better
Still need consent for imaging!
Management
Severe toxicity or obstruction

Manage toxidromes as normal

Packets need removing endoscopically or surgically
Failure to pass GI packets. The largest case series so far suggests surgical management after 5 days even if asymptomatic
If asymptomatic and refusing treatment, can be discharged with advice
Full transcript