IAEM Clinical Guideline 12 Freign Bdies: The Emergency Department Management f Inhaled and Inserted Objects in Children Versin 1 August 2018 Authr: Dr Susan Uí Bhrin Adapted with Permissin frm the Jint Paediatric Hspitals Guideline Cmmittee. Guideline lead: Dr Áine Mitchell, in cllabratin with the IAEM Guideline Develpment Cmmittee and Our Lady s Children s Hspital, Crumlin, Dublin, Ireland. DISCLAIMER IAEM recgnises that patients, their situatins, Emergency Departments and staff all vary. These guidelines cannt cver all clinical scenaris. The ultimate respnsibility fr the interpretatin and applicatin f these guidelines, the use f current infrmatin and a patient's verall care and wellbeing resides with the treating clinician
GLOSSARY OF TERMS ED FB ENT APLS SpR Emergency Department Freign bdy Ear, Nse and Thrat Advanced Paediatric Life Supprt Specialist registrar 2 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
Freign Bdies: The Emergency Department Management f Inhaled and Inserted Objects in Children INTRODUCTION Freign bdies are a cmmn cause f presentatin t the paediatric Emergency Department (ED). Small bjects may be aspirated r inserted int the ear r nse. As this is cmmnest in yunger children, the histry may be vague and smetimes the cause fr presentatin is simply parental suspicin which shuld always be taken seriusly. PARAMETERS Target audience Health-care prfessinals wrking in the ED. Patient ppulatin Children aged 6 mnths t 15 years inclusive, wh present t the ED after inhaling a FB (freign bdy) r inserting a FB int their ear r nse. Exclusin criteria It des nt deal with children belw the age f 6 mnth nr des it deal with patients in respiratry/cardiac arrest after a chking episde. AIMS T prvide a guideline t assist in the ED management f children with ear, nse r upper airway freign bdies 3 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
INHALED FOREIGN BODY Presentatin Histry may be unclear as the event may have been unwitnessed. The symptms may have started while playing, particularly if the child was unsupervised. Children may present with cughing, chking, wheeze, drling, chest pain r sensatin f a freign bdy stuck in the thrat. After the initial event they may be asymptmatic and may remain undiagnsed, presenting at a later date with recurrent pneumnia. Impactin f a FB in the larynx can result in ttal airway bstructin causing rapid prgressin t uncnsciusness and respiratry arrest. This shuld always be cnsidered in the differential fr any child brught t ED in cardirespiratry arrest wh cannt be ventilated. Impactin f a FB in the larynx r main brnchus resulting in a partial bstructin is a sudden catastrphic event presenting with cughing, chking and stridr. Examinatin May be nrmal OR Unilateral wheeze Unilateral decreased breath sunds Asymmetrical chest mvement Tracheal deviatin 4 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
Investigatins 1. Chest radigraph Generally wd, plastic and rganic FBs are nt visible n radigraph, while stne and metal FBs are visible. Glass may r may nt be visible depending n the bject. In additin t certain FBs, a chest radigraph may shw: A unilateral hyper-lucent lung in the early stages. Pst-bstructive lbar r segmental infiltrates r cllapse later n. An expiratin film can help accentuate air trapping distal t the FB. In the case f yung children with suspected air trapping but where expiratry films are difficult t perfrm, a lateral decubitus film can take its place. Patients with negative radigraph but a strng histry suggestive f freign bdy inhalatin shuld be referred t ENT (ear, nse and thrat) fr rigid brnchscpy. 2. Sft tissue neck radigraph Sme FBs will be impacted abve the thracic inlet and may be t superir t be seen n chest radigraph. 5 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
Management 1. Ttal airway bstructin Fllw APLS (Advanced paediatric life supprt) Guidance Inspect the rpharynx, if the FB can be seen remve with magil s frceps under direct visualisatin - senir ED staff nly. SpR (specialist registrar) / Cnsultant shuld be present and ENT infrmed as sn as the prblem is identified. 2. Partial airway bstructin and FB impacted belw the level f the larynx Allw the child t remain upright in a cmfrtable psitin with minimal interventin and an emphasis n keeping calm. Imaging shuld nt delay definitive treatment in a life threatening aspiratin. Refer all suspected FBs t ENT as per lcal prcedures fr remval by laryngscpy and/r rigid brnchscpy. If ENT suspect there is a FB beynd the level f the primary brnchi (right and left main brnchi) which cannt be reached with rigid brnchscpy, please refer t the respiratry/ paediatric respiratry cnsultant n call as per lcal prtcls fr remval by flexible brnchscpy. All children wh have had a FB remved frm their lwer airways shuld have a respiratry review prir t discharge given the pssibility f shrt-term and lngterm sequelae ccurring in sme children wh have experienced a FB inhalatin. In reginal units withut paediatric respiratry services, this review and fllw up may be best facilitated thrugh general paediatric r adult respiratry services depending n age f child and lcal prtcls. 6 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
FOREIGN BODY IN THE EAR Presentatin Histry f recent witnessed r reprted FB insertin r may simply present with symptms f a FB. Symptms include ear pain, itch, reduced hearing r a feeling f fullness in the ear. Examinatin: The FB is usually seen by direct visualisatin with tscpy. Smetimes an area f lcal inflammatin can be seen arund the FB. It is imprtant t nte whether the tympanic membrane is visualised and if it is perfrated r nt as this determines the management plan. Management Freign bdies shuld nly be remved in ED by experienced medical staff. Cmplicatins include canal abrasin, laceratin, bleeding, tympanic membrane perfratin and hearing lss. It is imprtant that the child is held securely prir t any attempted remval f FB. Techniques include the Superman Pillwcase technique (see belw fr instructins) r wrapping the child in a blanket. Lighting is als very imprtant and a head trch can be useful. Prcedural sedatin may be required. A number f different instruments can be used t remve the FB frm the ear canal. These include frceps, cerumen lp, suctin catheter and katz extractr. 7 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
The Superman Pillwcase Technique: Place the child s arms behind their bdy; carefully pull a pillw case up ver their arms s that it sits against their back; lay the child dwn s that their arms are by their sides and they are lying n the pillw case Indicatins fr Urgent Referral t ENT Perfrated tympanic membrane. FB tuching the tympanic membrane. Nn-graspable r tightly wedged FB. Sharp FB. ED attempt t remve the FB unsuccessful. 8 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
NASAL FOREIGN BODY Presentatin Symptms include pain, unilateral ful smelling nasal discharge and epistaxis. FB shuld be visible, ften at level f inferir turbinate. Management The mther s kiss is a safe first line treatment t attempt remval f a freign bdy. The parent ccludes the unaffected nstril, cvers the child s pen muth with their muth and blws until they feel the resistance f the glttis. When this resistance is met the parent gives a puff f air which enters the naspharynx and hpefully disldges the freign bdy. A similar technique can be used in lder children by ccluding ne nstril and asking them t blw their nse. If this is unsuccessful and the bject is visible, ED staff may attempt t remve the bject. See abve fr recmmended hlding and instruments. Indicatins fr Urgent Referral t ENT Unsuccessful attempt at remval in ED. Septum r bny destructin frm chrnic freign bdy. 9 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled
Buttn batteries - shuld be remved immediately due t the risk f necrsis f surrunding tissues. Bleeding disrder. 10 IAEM CG 12: Freign Bdies: The Emergency Department Management f Inhaled