Foreign Bodies and Their Removal Part 1 - “you’ve got to know when to hold ‘em, know when to fold ‘em, know when to walk away and know when to run…” - Kenny Rogers Dr. Arleigh Trainor, MD FACEP FAAEM Chief Division of Emergency Medicine USD SSOM Education Coordination Emergency Department Sanford USD Medical Center

Objectives Review some common foreign bodies. Review: which foreign bodies in what locations should be removed by Emergency Medicine Physicians which should be removed by specialists which should not be removed unless they begin to cause issues. Review common foreign body removal techniques.

Disclosures - none Employee of Sanford USD Medical Center and Sanford School of Medicine - University of South Dakota

The Eyes Have It …. Be the reporter History Exam Equipment : Snellen chart, topical anesthetic, cotton swab, needle ( blunt or 18 g, fluorescein stain ( strip or drops), opthalmoscope. Optional ( spud, burr drill, Wood’s lamp, slit lamp). Schiotz or tonopen. Visual acuity Look at the eye, evert the lid, do a fundoscopic exam, stain it, look at it with a blue light ( this is on your opthalmoscope) or with a Woods lamp or with a slit lamp.

Trick to dispense drops Both adults and children drip onto medial canthus https://www.aliem.com/2009/10/trick-of-trade-super-sensitive-to/

Make your own fluorescein eye drop https://www.aliem.com/2015/06/tricks-of-the-trade-fluorescein-eye/

Why everyone freaks out…. Is it in the eye or just imbedded in the surface? Seidel’s sign https://youtu.be/ugBh 3A1dePc

Now what? https://vimeo.com/62213688 https://www.racgp.org.au/afp/2017/march/managing-corneal-foreign-bodies-in-office-based-general-practice/ In the globe with rupture - imaging ( orbit CT) Corneal FB What is it? Does it need to come out now or later? organic, should come out if possible, consult and refer ( up to specialist if need immediate or next day) inorganic, come out but if not causing further damage consult and refer ( up to specialist) rust rings A. Corneal rust ring; B. Use of moist cotton tip; C. Further removal with 25G hypodermic needle; D. 15 blade scalpel https://vimeo.com/62213688

Ears, tears and fears…or if it’s bigger than your elbow don’t put it in your ear! History Exam - Let there be light! Be calm and carry on ( do they need a little something?) Numb it up! Irrigate/suction/pick/glue/magnet? Refer ( now or later?) - if perforation typically need to refer.

How can I see in there? Old school - otoscope https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/ Old school - otoscope New school - pediatric glide scope, lighted curette

Irrigate Only warm water! Beware of COWS, also alcohol, 2% lidocaine, mineral oil, colace. Drown the suckers! Contraindicated with organic material, perforated TMs, h/o ear surgery, disc batteries https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/

Suck it out! Frazer suction butterfly tubing Yankauer suction Hognose https://accessemergencymedicine.mhmedical.com/data/books/reic2/reic2_c169f010.png

Pick it! Alligator forceps Tweezers Cotton swab with glue Ball hook Magnets https://www.aliem.com/2015/08/trick-of-the-trade-ear-foreign-body-removal-with-modified-suction-setup/ https://www.aliem.com/2009/06/sneak-peak-ent-of-trade/

https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/

What did you put in your nose? History Exam Get it out of there! mother’s kiss technique and modified version. Suction ( catheter) Pick Glue Foley/Katz extractor http://pemplaybook.org/podcast/foreign-bodies-in-the-head-and-neck/

Don’t put that in your mouth! History Exam Imaging Now or later?

Fishbone Hurricane spray DL/VL McGill forceps https://dailyem.wordpress.com/2013/09/03/foreign-body-sensation-in-throat-but-no-np-scope/

Food impaction Glucagon? Nitro? Endoscopy

http://rebelem.com/question-tradition-glucagon-food-boluses/

Coins Not just history but potential for ingestion Where is it? Imaging vs metal detector? How far to transfer if needed? Endoscopy,foley catheter removal, bougeinage, observation http://pemplaybook.org/podcast/foreign-bodies-in-the-head-and-neck/

https://www.aafp.org/afp/2005/0715/p287.html

https://hqmeded.com/pediatric-esophageal-coin-bougienage/ https://www.youtube.com/watch?v=k9cG1T20kl0

Batteries and magnets Guideline Consult - nuff said! http://pemplaybook.org/podcast/foreign-bodies-in-the-head-and-neck/

https://www.poison.org/battery/guideline