Investigate an inhaled FB with chest x-rays in inspiration and expiration.
Definite or probable inhaled FB in adults - refer Cardiothoracic surgery.
Possible inhaled FB - the patient must not be discharged until you are convinced that there is no FB present. If in doubt bring back to next ED Review Clinic for repeat CXR.
Swallowed fish bone/chicken bone
These may get stuck in the pharynx or they may just scratch it giving the feeling of something being stuck.
Examine oropharynx thoroughly, especially the tonsillar area and the back of the tongue.
Perform video laryngoscopy or direct laryngoscopy (local anaesthesia with amethocaine lozenges or lignocaine spray)
Consider lateral neck x-ray - look for pre-vertebral swelling, fluid level and/or FB (not all bones radio-opaque)
There is a spectrum of symptoms from the patient who is in severe pain who cannot even swallow his saliva, and who clearly has a foreign body, to the patient with symptoms for 4 - 5 days which are resolving and which do not stop him from eating a normal meal.
If you think there is a FB - refer to ENT.
If you think there is NO foreign body - patients can go home with instructions to return if symptoms do not improve or to return immediately if symptoms get worse.
Swallowed FB stuck in oesophagus
If there is a food bolus stuck, try giving a small quantity of a fizzy drink as the bubbles may dislodge it. If this fails refer patient to ENT for upper oesophagus and General Surgery for lower oesophagus.
Other swallowed FBs
- May break open and the patient may get local corrosion and mercury poisoning.
- Record time of ingestion
- Try and ascertain the type of battery and whether it was active or "dud" (Usually these facts are not available)
- X-ray chest and abdomen
If lodged in Oesophagus -- Refer to ENT or General Surgery for removal
If in stomach -- Arrange re-x-ray in approximately 48 hours at review clinic
If beyond pylorus -- Advise natural laxative
Arrange re-x-ray in approximately 48 hours
The x-rays are taken to assess the progress through the GI tract and look for signs of opening of the casing.
Patients should be advised to return if they become symptomatic.
All Patients should be discussed with a Senior ED Doctor at the Return Visit
Swallowed coins and similar large objects
Coins stuck in the pharynx or oesophagus may be asymptomatic.
Once a coin has entered the stomach it virtually never causes problems and can be left to pass.
Therefore in all cases xray the neck and chest.
If no FB seen on these x-rays the patient can be reassured and discharged.
Sharp objects - X-ray neck/chest/abdomen and ask advice.
Small objects which may be expected to pass through the GI tract. There is no indication to x-ray (Unless there is doubt as to whether object has been inhaled).
There is no point x-raying for plastic or other radiolucent objects.
- Adults - remove
- Children - may need EUA, so refer to Gynaecologists.
- Ask advice
- Frequently need a GA for removal
- refer to General Surgery
Foreign body in tissues e.g. needle in foot/airgun pellet
- See under wounds (page12).