Choking!? Oh No!

Case:

You are working a busy peds shift and are nearing the end of your shift when EMS brings in this adorable 12-month-old girl with her mother. Mom says her child’s only medical history is eczema, and an hour prior to arrival, the child had been crying with a couple episodes of gagging followed by 1 episode of vomiting. Mom was in a different room and ran over when she heard crying, only to find her child gagging and then rubbing her nose. The girl calmed down after a few minutes. She was fed without difficulty, but then a few minutes later she started gagging again. Mom was concerned and rushed her to the Emergency Department.

 

By the time the child arrives to the ED, she is back to her normal self: happy, playful, with seemingly no other complaints. Vitals and exam are unremarkable: seems completely appropriate, no drooling or stridor, lungs are clear, belly is soft…

 

Great, can we discharge them yet?? No, not quite yet!

 

Whenever we hear about an unsupervised child with reported coughing, gagging, and vomiting, one thing should come to mind: FOREIGN BODY!

 

But wouldn’t the patient be symptomatic if they had ingested or aspirated a foreign body?

No. Surprisingly it is very common for the children to be asymptomatic. The most sensitive tool in these cases is the history obtained by the parents or caregiver.3,4 Most of the time, the ingestion of a foreign body (FB) is witnessed, but when it’s not and the parent reports some acute onset of respiratory symptoms or gagging/vomiting, a FB must be seriously considered. The peak incidence is in children less than 3 years of age, because at this age they love putting toys and other items in their mouth.

 

When patients ARE symptomatic, it makes things easier because you will do some sort of intervention like laryngoscopy or endoscopy to see why the patient is having difficulty breathing. The trouble occurs when the patient is asymptomatic like our child above.

 

Foreign body Aspiration vs. Ingestion can be difficult to distinguish from one another, because they can present in the same way!

 

Presentation:

With either ingestion or aspiration, children can present with any of the following: choking/gagging, coughing, vomiting, respiratory distress, stridor, drooling, odyno-/dysphagia.

 

In the past, we have been taught that a patient with acute-onset, paroxysmal coughing, wheezing, and unilaterally decreased breath sounds means a FB aspiration. While careful auscultation of the chest is the most critical part of the physical exam, when there is concern for aspiration, a normal exam does not rule out the presence of an aspirated FB.4 Surprisingly, this frequently taught presentation is not as common in reality as originally presumed. Linegar, et al reported that in children with a positive history but negative exam & CXR, there was a 45% incidence of FB on airway endoscopy, highlighting once again, the importance of obtaining a good history in these patients.7

 

So, if our exam is not reliable and patients are frequently asymptomatic, are there any noninvasive tests to guide whether or not we have to do endoscopy or laryngoscopy?

 

Yes. Although it’s not perfect and does not rule out the possibility of a FB, the next diagnostic tool would be a chest X-ray.

 

In aspiration, CXR is less helpful because most of the aspirated objects tend to be radiolucent (approximately 80% of cases).4 The most commonly aspirated objects are peanuts, seeds, and beans.4 Sometimes, the aspirated material can cause significant tissue reaction with granulation tissue and can absorb water and worsen the obstruction. You may notice subtle findings such as hyperinflation of one lung.4,5 You can also try lateral decubitus films, which may demonstrate subtle air trapping, and at times, the patient may be positioned in such a way that you may see the semblance of the FB itself.

 

Decubitus view with visible air trapping in the left lung:

Left

 

In ingestion, CXR may be more helpful, as the majority of foreign body ingestions are radiopaque and therefore more likely to be seen on imaging. Typically, if you are concerned about ingestion, the recommendation is to include neck X-rays as well or attempt to include the neck in the CXR if the child is small enough to obtain both areas in one film. Some also recommend abdominal X-ray. The most commonly ingested FB in the United States is a coin followed by button batteries, which are among the most harmful.2 X-ray can help distinguish between button battery & coin ingestions, which is important because the management is different depending on the object ingested. A coin on plain film will appear like a homogenous, circular object, whereas a button battery will have a “double halo sign” or a second ring visible on the outer area as seen below.2

 

Button Battery

Coin

Films are less helpful for smaller items or sharp objects like a needle or toothpick. These are not likely to be seen on plain film and may require a CT. Sharp objects can also be dangerous due to the high risk of perforation.

 

There has been some recent discussion about using hand held metal detectors instead of X-rays, Metal detectors may be useful in the setting of coins but may miss other FBs. This approach is also controversial because you want to make sure you are not missing a button battery and confusing it for a coin.

 

Foreign body ingestions tend to become lodged in the esophagus, most commonly in 3 specific anatomic locations: the upper esophageal sphincter / thoracic inlet, mid-esophagus/ aortic arch, and above the lower esophageal sphincter.2,11 Typically, the main groups of objects that are ingested are coins, button batteries, sharp objects, and magnets. If the FB remains in the esophagus, it can cause complications, and there are different approaches to management depending on the type of FB.

 

Complications of Ingested FB:

Usually, complications only arise when the FB remains in the esophagus, unless it is a sharp object which should continue to cause concern after clearing the esophagus. Complications include strictures, perforation, obstruction, and fistula formation. The most feared complication that may arise is the creation of an aortoesophageal fistula, as this can lead to severe hemorrhage and death. Other complications that are seen with the button batteries include mucosal burns, and these may lead to perforations & fistulas.

 

Management/Treatment of Ingested FBs:2,11

In general, if a child is symptomatic from a FB, it is an emergency and he/she must be taken for endoscopy or another procedure for removal. The main invasive interventions include:

  • Removal with a balloon tipped catheter (usually done under fluoroscopy). The catheter is advanced past the coin, inflated, and pulled back. Complications include aspiration, vomiting, and perforation.
  • Esophageal Bougie – A semirigid bougie is used to push the object into the stomach. This may be used with coin management.
  • Endoscopy* (mainstay of treatment) can be done with a rigid or flexible endoscope.

 

The management of ASYMPTOMATIC patients differs amongst the different groups of ingested objects and is discussed below:

 

Coins:

In this group, it is reasonable to recommend a period of observation to see if they have spontaneous passage from esophagus to stomach. Retrospective study of the spontaneous passage rates of the coins have found variable rates.11 A prospective study found no difference in passage rate between coin type or size but did find differences depending on location in the esophagus. The passage rate of proximal objects was 14%, whereas middle was 43%, and distal was 67%.12 Those which were going to pass spontaneously occurred within 6-19 hours, so the recommendation is to observe for a maximum of 24 hours before attempting more invasive methods.11,12

 

Once in the stomach, coins are not considered problematic. The patient may be re-evaluated in 2-3 weeks, UNLESS they become symptomatic with abdominal pain, bloody bowel movements, vomiting, and/or poor feeding. There is a small possibility of obstruction at the pylorus, but this tends to be rare. If patients are found to have coins in the stomach or duodenum, then they can be safely discharged and do not need repeat imaging. Instead, they need good return precautions and can be seen by PMD in 2-3 weeks. Whether or not parents need to check the stool for coin passage seems to be controversial. Kramer, et al recommend checking the stool, and if there is no passage after 4 weeks, then they recommend endoscopy.6

 

What about medications like glucagon to help promote passage from the esophagus?

Glucagon has been tried in the past due to clinical experience in adults with food bolus impaction. It was thought that medications such as glucagon and benzodiazepines may induce relaxation and increase the spontaneous passage into the stomach, thus reducing the need for invasive retrieval. Glucagon is not recommended for the use of esophageal FB in pediatric patients at this time. The few, very small studies of the utility of glucagon have failed to show a benefit.1,9 Instead, side effects were reported, including vomiting, which may increase the risk of aspiration.1,9,13

 

Button Batteries:

If a button battery is in the esophagus – regardless of location – it is an emergency and must be taken out as soon as possible. Button batteries cause much more morbidity mainly due to either leakage of battery contents, direct pressure, or electrical discharge with hydrolysis that in turn creates hydroxide ions to lead to mucosal burns. Burns can begin to occur as early as 2 hours post-ingestion with reported cases of perforation within 5 hours.2 The most feared complication of FB ingestions, aortoesophageal fistula, is predominately due to button battery ingestions. It is important to NOT induce vomiting in these cases.

 

If the button battery has passed into the stomach, then management is more controversial. Generally, you can observe as long as they are asymptomatic:

– If child is < 5 years of age –> observe in the hospital, assess for esophageal injury, and remove within 48 hours.

– If child is > 5 years of age, and the button battery is > 20 mm –> observe outpatient with return for repeat X-ray in 48 hours.

– If child is > 5 years of age, and the battery is < 20 mm –> return in 10-14 days if it has not passed in the stool.6

 

Since button battery ingestions are common and can have severe complications, there is a 24-hr National Button Battery Ingestion Hotline: +1-(202)-625-3333.

 

Sharp Objects:

These objects typically include items like fish bones, chicken bones, pins, needles, toothpicks, nails, etc. These objects commonly get stuck in a tonsil and cause focal pain, odynophagia, or drooling. These items are harder to locate because they are not easily seen on X-rays. In order to locate these items, you may need to do a CT. These items must be removed emergently even if they reach the stomach and may have to be surgically removal due to the high perforation risk.

 

Magnets:

It is important to know if the ingestion involves a single magnet or multiple. In the case of a single magnet, the treatment guidelines are the same as the coin ingestion (see above). However, with multiple magnets there is an increased risk of complications due to magnetic attraction across the bowel walls. This may lead to tissue necrosis, obstruction, perforation, or fistula formation. Management of ingestions of multiple magnets is more controversial, but generally emergent removal is advised.

 

Now that we have reviewed FB ingestions, back to our case…

Our adorable 12-month-old girl is still asymptomatic and playful. A CXR is obtained and is below:

 

It appears she has ingested a coin and it is lodged in the upper esophagus! It does not seem to have the “double halo” sign or rim that we would expect to see with a button battery, so that is a relief!

 

As you now know, with coin ingestions we have some time before we need to perform an invasive intervention. She is admitted for observation to see if the coin will be able to pass on its own.

 

Unfortunately, repeat X-rays 12 hours later find the coin to be in the same position. GI and ENT consults are notified. As per institutional guidelines, due to the proximal location, ENT performs the endoscopy & successfully removes the coin! Hooray!

 

Written by: Dr. Juliana Jaramillo – PGY 3 Emergency Medicine SUNY Downstate/KCH

Edited by: Dr. Caitlin Feeks – PEM 3rd year Fellow (PGY 6)

 

References:

  1. Arora S, Galich P. Myth: glucagon is an effective first-line therapy for esophageal foreign body impaction. CJEM 2009;11(2):169–71
  2. Chung S, Forte V, Campisi A review of pediatric foreign body ingestion and management. 2010
  3. Ciftci AO, Bingol-Kololu M, Senocak ME, et al. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg 2003;38(8):1170–6
  4. Digoy GP. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin North Am 2008;41(3):485–96
  5. https://radiopaedia.org/cases/inhaled-foreign-body-2
  6. Kramer RE, Lerner DG, Lin T, Manfredi M, Shah M, Stephen TC, Gibbons TE, Pall H, Sahn B, McOmber M, Zacur G, Friedlander J, Quiros AJ, Fishman DS, Mamula P. Management of Ingested Foreign Bodies in Children: A clinical report of the NASPGHAN Endoscopy Committee. Journal of Pediatric Gastroenterology & Nutrition 2015;60(4):562–74.
  7. Linegar AG, von Oppell UO, Hegemann S, et al. Tracheobronchial foreign bodies. Experience at Red Cross Children’s Hospital, 1985–1990. S Afr Med J 1992;82(3):164–7
  8. Louie JP, Alpern ER, Windreich RN. Witnessed and unwitnessed esophageal foreign bodies in children. Pediatric Emergency Care. 2005; 22:9
  9. Mehta D, Attia M, Quintana E, et al. Glucagon use for esophageal coin dislodgment in children: a prospective, double-blind, placebo-controlled trial. Acad Emerg Med 2001;8:200-3
  10. Teisch LF, Tashiro J, Perez EA, Mendoza F, Sola JE. Resource utilization patterns of pediatric esophageal foreign bodies. Journal of Surgical Research. 2015;198:299-304.
  11. Waltzman, M. Management of Esophageal Coins. Pediatric Emergency Care. 2006; 22:5
  12. Waltzman M, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005; 116(3):614–619
  13. Wright CC, Closson FT. Updates in Pediatric Gastrointestinal Foreign Bodies. Pediatric Clin N Am. 2013

 

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JJaramillo

Emergency Medicine PGY-2

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