2/16/2014 You can’t make me eat my dinner! Kids put things in the craziest places... 2 year old observed to stuff corn up right nostril PE: vs wnl, playing, Judith Klein, MD FACEP comfortable, corn visible Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Medicine What now? Objectives Nasal foreign bodies Most common place kids put stuff “I put it in my nose”: tricks of the trade Where? -nasal floor “I stuffed it in my ear”: tips for gentle retrieval and -in front of middle when to ask for help turbinate “I ate it”: watchful waiting or time to go get it? Most can be visualized “I inhaled it”: when to worry When to worry: button batteries, > 1 magnet 1
2/16/2014 A few words about button batteries... should i be worried? Electrical conduction across tissue: liquefaction Most objects: Go for it! necrosis Nasal FB aspiration rare! Leakage of caustic ENT if: material (acidic -chronic/inflamed environment) -sharp -stubborn Esophagus: -ulceration within 2 hrs Urgent: button batteries! -perforation within 8 hrs Parent’s Kiss Well that didn’t work.. Sedate: ketamine ideal Good lighting/speculum Topical oxymetolazone/4% lidocaine 1:1 Soft: resp suction catheter, alligator forceps Hard: balloon cath, right angle hook, q tip and glue 2
2/16/2014 Foreign Bodies in Outer Ear Something crawled in there! Most common: beads, tissue, toys Anatomy 3 year old squirming: there’s a bug in my ear Call ENT: sharp, up against TM, sx of perforation, PE: Yup, she’s right and button batteries it’s alive! Urgent: See above, insects What to do? Non urgent: all else Well that didn’t work... Irrigation tecHnique Sedation: ketamine.... Headlight/oto-microscope Soft/insects: alligator forceps, suction catheter Hard: q tip/glue - hold 30 seconds - glue the ear? acetone/3% Insects: mineral oil or lidocaine first H 2 O 2 soaked cotton in ear Contraindications: battery, organic, perforation/tubes Topical abx gtt (e.g oflox) 3
2/16/2014 Who’s got the money? Foreign bodies in the GI tract 3 year old observed to swallow disk battery from 100K/yr: 80% kids (6m-3yr) brother’s microscope 10-20% require intervention PE: playful, no resp Culprits: coins, toys, ?? distress, no drooling, no vomiting Sx: usually only if >72 hours Worried? When to worry? Workup Perforation: neck swelling, crepitus, fever, ill appearing X rays: AP/lateral neck, chest, abdomen Obstruction Sx or high suspicion of Aspiration: wheezing, resp unvisualized bad guy: CT or Esophagus distress (bronchoscopy) MR (non-metallic) Nasty objects: Repeat x ray in 24 hours - >5 cm and/or sharp -disk battery, magnets, lead If in stomach by 24 hrs: most pass 1-2 wks >24 hrs: still in esophagus Trachea Trachea 4
2/16/2014 GI Foreign Bodies Sharp and/or >5cm? button battery? >1 magnet? lead? perforation? obstruction? YES NO Immediate flex endoscopy X-rays: neck, chest, abdomen (Surgery if beyond prox duodenum and Stomach or beyond? sharp, long, magnet) NO YES NO Repeat x ray 24 hours Observe Stomach or beyond? Repeat x ray 2-4 wks YES the toy in the Box Airway Foreign Bodies 2 1/2 year old eating cereal 3500 deaths/yr; peak < 3 yrs Sudden choking-resolved Anatomy: conical airway In ED: playful, VS wnl, no Objects: stridor, hoarseness, cough, -peanuts, popcorn, grapes Adult Infant/toddler lungs clear -round=obstruction What next? Most in bronchi 5
2/16/2014 Diagnosis Symptomatic? Hx: -choking? (76-92% sensitive) Life threatening? Sx/PE: - Back blow/chest - larynx: stridor, hoarse compression (infant) or -bronchi: focal wheeze, cough, BS, Heimlich (child) or nothing! -Intubation/Macgill forceps X ray: (AP/lateral/exp or lat decub) Immediate rigid -only 10% objects visualized bronchoscopy -2/3 normal Trust a choking history! In a nutshell Button batteries are bad First do no harm-SEDATE Too far in? Call ENT Get babygrams for ingestions Trust a choking history even if x rays are negative 6
Recommend
More recommend
