1. Management of Foreign Bodies
in Pediatric Patients

2. Airway Foreign Bodies

3. 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

4. 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 %

5. FOOD & TOYS

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

7. 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

8. All low

9. 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.

10. 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.

11. 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

12. 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.

13. 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

15. GI Foreign Bodies

16. 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

17. 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

18. 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.

19. 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

20. 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.

22. 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.

23. 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

25. 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.

26. 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.

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

28. ENT foreign bodies

29. 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

30. 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 )

31. 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.

32. 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.

33. 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.

34. Thanks For Your Attention !

35. 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 。