KIDS PUT THINGS IN THE CRAZIEST PLACES...
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1 KIDS PUT THINGS IN THE CRAZIEST PLACES... YOU CAN T MAKE ME EAT MY DINNER! 2 year old observed to stuff corn up right nostril Judith Klein, MD FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Medicine PE: vs wnl, playing, comfortable, corn visible What now? OBJECTIVES NASAL FOREIGN BODIES I put it in my nose : tricks of the trade I stuffed it in my ear : tips for gentle retrieval and when to ask for help I ate it : watchful waiting or time to go get it? I inhaled it : when to worry Most common place kids put stuff When to worry: button batteries, > 1 magnet Where? -nasal floor -in front of middle turbinate Most can be visualized
2 A FEW WORDS ABOUT BUTTON BATTERIES... SHOULD I BE WORRIED? Electrical conduction across tissue: liquefaction necrosis Leakage of caustic material (acidic environment) Esophagus: -ulceration within 2 hrs -perforation within 8 hrs Nasal FB aspiration rare! ENT if: -chronic/inflamed -sharp -stubborn Urgent: button batteries! 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
3 SOMETHING CRAWLED IN THERE! 3 year old squirming: there s a bug in my ear PE: Yup, she s right and it s alive! What to do? FOREIGN BODIES IN OUTER EAR Most common: beads, tissue, toys Anatomy Call ENT: sharp, up against TM, sx of perforation, button batteries Urgent: See above, insects Non urgent: all else IRRIGATION TECHNIQUE WELL THAT DIDN T WORK... Sedation: ketamine... Headlight/oto-microscope Soft/food: alligator forceps, suction catheter Insects: mineral oil or lidocaine first Contraindications: battery, organic, perforation/tubes Hard: q tip/glue -glue the ear? acetone/3% H 2O 2 soaked cotton in ear Topical abx gtt (e.g oflox)
4 WHO S GOT THE MONEY? FOREIGN BODIES IN THE GI TRACT 3 year old observed to swallow disk battery from brother s microscope PE: playful, no resp distress, no drooling, no vomiting Worried? 100K/yr: 80% kids (6m-3yr) 10-20% require intervention Culprits: coins, toys,?? Sx: usually only if >72 hours WORKUP WHEN TO WORRY? X rays: AP/lateral neck, chest, abdomen Perforation: neck swelling, crepitus, fever, ill appearing Obstruction Sx or high suspicion of unvisualized bad guy: CT or MR (non-metallic) If benign: rpt x ray in 24 hours If in stomach: most pass 1-2 wks Trachea Esophagus Trachea Aspiration: wheezing, resp distress (bronchoscopy) Nasty objects: - >5 cm and/or sharp -disk battery, magnets, lead >24 hrs: still in esophagus/ stomach
5 GI FOREIGN BODIES Sharp and/or >5cm? button battery? >1 magnet? lead? perforation? obstruction? YES NO Immediate flex endoscopy (Surgery if beyond prox duodenum and sharp, long, magnet) NO X-rays: neck, chest, abdomen Stomach or beyond? YES Repeat x ray 24 hours Observe Repeat x ray 2-4 wks THE TOY IN THE BOX AIRWAY FOREIGN BODIES 2.5 year old eating cereal Sudden chokingresolved In ED: playful, VS wnl, no stridor, hoarseness, cough, lungs clear What next? 3500 deaths/yr; peak < 3 yrs Anatomy: conical airway Objects: -peanuts, popcorn, grapes -round=obstruction Most in bronchi Adult Infant/toddler
6 DIAGNOSIS SYMPTOMATIC? Hx: -choking? (76-92% sensitive) PE: -larynx: stridor, hoarse -bronchi: focal wheeze, cough, BS, or nothing! X ray: (AP/lateral/exp or lat decub) -only 10% objects visualized -2/3 normal Life threatening? -Back blow/chest compression (infant) or Heimlich (child) -Intubation/Macgill forceps Immediate rigid bronchoscopy 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
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