Management of Foreign Bodies in Pediatric Patients

Airway Foreign Bodies

Epidemiology Before the 20th century, aspiration of a FB had a 24 percent mortality rate. Death caused by suffocation following FBA is the leading cause of unintentional-injury mortality in children younger than 1 year. 80 percent of FBA occur in children younger than three years The peak incidence between one and two years of age. Male : Female =2:1

Sites of the FB The majority of aspirated foreign bodies in children are located in the bronchi . The Larynx: 3 % Trachea/carina: 13 % Right lung: 60 % (52 % in the main bronchus) Left lung: 23 % (18 % in the main bronchus) Bilateral lung: 2 %

FOOD & TOYS

Presentation Cough Wheezing, stridor, hoarseness Diminished breath sounds Increased respiratory effort Fever, Cyanosis Altered mental status Severe respiratory distress

Diagnosis Neck AP and Lat view Having a suspicion of aspiration is the most important step in Dx. Neck AP and Lat view CXR— most objects in children are radiolucent ! 若有實物請病人拿著一起照 Atelectasis, hypo/hyperinflation, pneumonia, Rigid bronchoscopy

All low

Delayed Diagnosis Children with lower airway FBs may present with subtle or nonspecific symptoms. May present with fever and S/S of pneumonia days or weeks after chocking. FBA may not be suspected. Parents and physicians may be reluctant to pursue evaluation once the acute choking episode resolved Recurrence of pneumonia is common in these patients.

Management- Life Threatening FBA Complete airway obstruction: Dislodgement using back blows and chest compressions in infants Heimlich maneuver in older children. Oxygenation Intubation as needed Management according to APLS Back blow, chest compressions, and Heimlich maneuver should be avoided in children who are able to speak or cough since they may convert a partial to a complete obstruction.

Management- Suspected FBA If a history presents, FBA should be presumed despite a negative CXR. Flexible bronchoscopy—only Dx, no Tx Rigid bronchoscopy — standard of care Control of the airway Good visualization Manipulation of the object with a wide variety of forceps, Ready management of mucosal hemorrhage Thoracotomy—rarely indicated

Difficult Removal A FB that has been retained for weeks may cause intense airway inflammation and infection that it cannot be removed.  Obtain gram stain and cultures by bronchoscopy.  Antibiotics based on the gram stain, culture  A three- to seven-day course of systemic corticosteroids  Second rigid bronchoscopy for FB removal  Thoracotomy if the 2nd procedure is unsuccessful.

Prognosis When FBA is diagnosed soon after the event, there is usually little damage to the airway or lung parenchyma. The morbidity and mortality may be increased if bronchoscopic evaluation is delayed The longer the foreign body is retained the more likely are complications A foreign body that causes chronic or recurrent distal infection may lead to bronchiectasis

GI Foreign Bodies

Epidemiology There are more than100,000 cases of FB ingestion reported each year in the US, 80% occur in children. The majority occur in children between the ages of 6 months to 3 years. Only 10%—20%will require endoscopic removal Less than 1% require surgery most foreign bodies that reach the GI tract pass spontaneously

Most common trapped places Cricopharyngeal narrowing (C6) ( most common ) The thoracic inlet (T1); Aortic arch (T4); Tracheal bifurcation (T6); Hiatal narrowing (T10-11). Pylorus of stomach

Clinical Symptom/Signs Acute GI FB retrosternal pain, something stuck in the chest dysphagia, refusal of feeds drooling, choking Wheezing, stridor, or cyanosis Long-standing GI FB weight loss aspiration pneumonia, fever, Crepitus, pneumomediastinum, gastrointestinal bleeding.

Diagnostic Tests Biplane radiographs (AP / Lat) of the neck, chest, and abdomen Laryngoscopy Endoscopy . CT with 3-D reconstruction for radiolucent objects Avoid GI contrast studies when possible. Handheld metal detector

Indication of Urgent Intervention When object is sharp, long. A disk battery that is in the esophagus. Airway compromise is present. Evidence of esophageal obstruction Signs or symptoms suggesting inflammation or intestinal obstruction The object in the esophagus for more than 24 hours or if the time of ingestion is unknown.

Special Condition — Food impaction Meat impaction may be treated expectantly if the patient can manage the secretions. ( < 12hr ) Endoscopy is the preferred method for remova IV glucagon (1mg) to relax esophageal smooth muscle  Controversial Sublingual Nifedipine (10mg) to reduce LES pressure. Proteolytic enzymes to dissolve a meat bolus not recommended, many complication reported.

Special Condition — Coin ingestion 35 percent of children with a coin lodged in their esophagus will be asymptomatic Coins in the esophagus lie in the frontal plane; coins in the trachea lie in the sagittal plane Foley catheter extraction The airway must be secured with endotracheal intubation. less effective after 24 h May be done under fluoroscopic guidance. Watch for aspiration. Should be an option secondary to PES

Special Condition — Button Battery A button battery lodged in the esophagus is a true emergency Perforation may occur as soon as 6 h after ingestion. Lithium cells are associated with more adverse outcome. If the button battery is lodged in the esophagusCXRPES Batteries that passed the esophagus need not be retrieved if asymptomatic, unless the cell is not passing pylorus after 48 h. Most batteries pass through the body within 48 to 72h. All patients with signs and symptoms of gastrointestinal tract injury require immediate surgical consultation.

Special Condition — Sharp objects Objects > 5cm long and > 2cm wide rarely pass the stomach. Big Objects and those with extremely pointed edges ( open safety pins, razor blades) must be removed before they pass the stomach. All patients should have an initial X-ray and PE. Children who have swallowed a sharp object (other than sewing needles) but are asymptomatic can be managed conservatively. Arrange serial radiographs. Remove the object at the first sign of perforation even if the patient remains asymptomatic.

Techniques for FB Removal Magill forceps Rigid endoscopy Flexible endoscopy Foley catheter Penny pincher technique Surgery

ENT foreign bodies

Foreign Bodies in ENT Are common in children in one- to six-year-old age group. Insets, hair beads, toy parts, paper wads, eraser tips, and food. Complications may occur due to long duration, hazardous material, or attempts at removal

Foreign Bodies in ENT Immobilization device Otoscope with an operating head Nasal speculum Headlight or lamps Alligator forceps Wire loop or curette Suction apparatus, including catheters of various sizes Irrigating devices 8-French Foley catheter or Fogarty catheter Topical vasoconstrictors (phenylephrine, cocaine )

EAC irrigation Small inorganic objects can be removed from the external auditory canal by irrigation. The solution should be at body temperature This volume can be achieved using a 20 to 50 mL syringe attached to plastic tubing from a butterfly needle, irrigate with brisk flow. Contraindicated if the tympanic membrane is perforated or if the FB is button battery.

Live insects Live insects should be killed before removal by irrigation or forceps. These insects can be killed by instilling alcohol or mineral oil into the auditory canal.

Mouth-to-mouth Blow Oral positive pressure also has been used to remove nasal foreign bodies . In one study, mouth-to-mouth blowing by the parent successfully removed 15 of 19 nasal FBs (79 percent) with no complications . In this study, all foreign bodies were visible with anterior rhinoscopy, and the median time since insertion was four hours (range one hour to two weeks). The children were allowed to sit or stand, depending upon their preference. The unaffected side of the nose was occluded and the parents were instructed to firmly seal their mouth over the child's mouth and give a short, sharp puff of air into the child's mouth. This technique has the advantage that it does not require physical restraint.

Thanks For Your Attention !

Reference Emergency Medicine-A comprehensive study 7th ed. J.E. Tintinalli et al. Nelson Textbook of Pediatrics, 18th ed. Kliegman et al. UpToDate 2008 vers. 16.2 Textbook of Pediatric Emergency Medicine Fleisher et al. 2006. 。