POTD: The Ingested Coin

This POTD is inspired by a common occurrence in the pediatric ED and a question that routinely shows up on board questions.

History: Mom and Dad are spring cleaning the apartment when 1 year old Freddy Boy starts having sporadic episodes of gagging or choking, and has vomited once. Parents report an episode where he looked like he was breathing faster and almost looked like he was struggling to catch his breath, which has since resolved. Mom and Dad panic and bring F.B. to your ED. Physical exam reveals a happy looking kid, vitals WNL, and a benign exam. Nothing in the back of the throat. Normal breath sounds BL. 

As their provider, high on your differential is foreign body ingestion, and you begin your workup.

Background: Children frequently swallow foreign bodies, with coins being the most common. Other objects, such as fish or chicken bones, buttons, marbles, and the dreaded button battery are common (for adults, food boluses are most common, followed by fish bones, coins, fruit pits, pins, and dentures). A patient who has ingested a FB raises the concern- where is the coin? Is it in the esophagus, or the trachea? Has it already been swallowed and now in the stomach? What was the FB? Oftentimes the history can be suspicious for FB ingestion but the point (or object) of ingestion is often not witnessed. 

Whether the coin/FB be in the esophagus or the airway can produce similar symptoms. Patients can be vomiting, have episodes of gagging and choking, stridor, complaining of chest pain, pain in the neck, throat, or upper back, drooling, and an inability to eat.

A lot of those symptoms are fighting words- they're usually how you describe a patient in danger of respiratory distress, and thus the patient with FB ingestion must be assessed with ABCs in mind on initial and repeat assessments.

Imaging:

The most important next step on evaluation for ingestion of moderate to high risk ingestion is to obtain imaging. Obtain a CXR AP and lateral; additionally, a babygram xray can include the chest and abdomen, which can pick up a coin that may have already passed through the esophageal sphincter and is likely on it's way out.

Back to our case. The child has an xray depicting:

https://prod-images-static.radiopaedia.org/images/219249/4b44984b51f84022153d6f2572b60f_jumbo.jpg

This is an example of the coin being in the esophagus. On AP imaging, coins in the esophagus show their face, while objects stuck in the trachea will usually be visible only by its edge. Obtaining a lateral view can often times help you visualize the trachea; a coin stuck in the trachea on lateral view will show you its face.

https://img.grepmed.com/uploads/5385/peds-trachea-coins-esophagus-chestxray-original.jpeg

In the esophagus, objects are most likely to get stuck at the cricopharyngeus muscle (about 75% of the time), at the level of the aortic arch, and the lower esophageal sphincter.

What to do depends on the object swallowed and where it is located. For esophageal FB, if the object is sharp, a single high powered magnet or several magnets, a disk battery stuck in the esophagus, if airway compromise is present or imminent due to mass effect on the trachea, evidence of perforation, unable to manage secretions, or if the point of ingestion is possible to be >24 hours, emergent/urgent endoscopy is needed.

For esophageal objects that don't have these characteristics, definitive intervention such as endoscopy can be delayed up tot 24 hours to allow a chance for the object to pass spontaneously. If past the lower esophageal junction, objects are very likely to pass through the GI tract on their own. If warranted, objects can be be monitored with serial xrays to follow the object on its way out. These benign objects can be expectantly managed, and the asymptomatic patient can be sent with follow up with PMD/GI.

For tracheal objects, such as this coin, in a patient without complete airway obstruction/on the verge of airway compromise, you can provide supplemental O2 if needed, have the parents calm the child if possible, and allow the patient to assume a position of comfort. These patients are likely to need bronchoscopy to remove, and it is important to get your ENT and possibly anesthesia friends involved in the case.

Best,

SD

Sources:

https://www.grepmed.com/images/5385/peds-trachea-coins-esophagus-chestxray

https://radiopaedia.org/cases/ingested-foreign-body-coin-in-oesophagus-3

https://learningradiology.com/archives2008/COW%20313-Coin%20in%20esophagus/coinesophcorrect.htm

https://www.ncbi.nlm.nih.gov/books/NBK430915/

https://www.uptodate.com/contents/foreign-bodies-of-the-esophagus-and-gastrointestinal-tract-in-children

EMS Protocol of the Week - Pediatric Asthma/Wheezing

Last week, we went over the REMAC protocol for asthma, but in a cliffhanger not seen sinceAvengers: Infinity War, we were all left wondering what NYC EMS does with asthmatic/wheezing kids. Well worry not, faithful readers, because this week we’re taking a look at Protocol 554 – Pediatric Asthma/Wheezing!

There are a bunch of pediatric-specific protocols (remember that for the NYC REMAC, pediatric means up to 15 years of age), each with certain differences from its adult counterpart. Some differences are subtle, some not, so it’s worthwhile to at least have some awareness that these peds protocols exist in case the OLMC phone rings for a kid.

Protocol 554 is a good place to start with pediatric protocols since it’s not hugely different from 507, which we discussed last week. Albuterol and ipratropium are still being utilized as Standing Order, although a half dose of ipratropium is instructed for kids less than 6 years old. Further, while the adult protocol permits for continuous albuterol to be used, the pediatric protocol only allows for 3 doses as Standing Order. For children older than one year in severe distress, medics will also give epinephrine as Standing Order at a weight based dose (up to 0.3mg IM, the adult dose). After this point, OLMC may be utilized to request additional albuterol nebs and repeat doses of epi.

At this point, the only other significant difference in management is that the pediatric protocol does not include steroids or magnesium as adjuncts to treatment, either as SO or MCO, so just be aware that these kids will likely not have received any of those meds by the time they reach the ED (as opposed to adult patients).

That’s pretty much it for pediatric wheezers. Similar to the adult protocol, this one will generally leave most kids (and their parents) feeling much better by the time you see them, but just be aware of what may or may not have been done for them before immediately sending them out the door.

We’ll revisit other pediatric-specific protocols in the future, so be sure to keep an eye out! In the meantime, here’s your weekly plug forwww.nycremsco.org and the protocols binder by the OLMC phone.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

POTD: Retropharyngeal Abscess

Retropharyngeal Abscess

What is it?

• Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia

• Adults: Usually due to direct extension of local infection (ex. ludwig's angina, pharyngitis, dental abscess etc.)

• Peds: Usually due to suppurative changes in local lymph nodes from an infection in the head or neck

• Can also be caused from trauma- falling with pencil in mouth

Presentation:

• Patients may prefer to lay down to prevent abscess from collapsing the airway. If your suspicion is high enough, don't sit these patients up!

• Patients will complain most commonly of: sore throat, fever, torticollis, dysphagia

• In late stages will develop airway involvement (looks for stritor, change in phonation, drooling, neck stiffness, tripoding, SOB)

Diagnosis:

• CT Neck with IV contrast

• On CT you will see loss of definition between the anatomic spaces in the neck, stranding in the subcutaneous tissues, tissue enhancement, and frank abscess formation, the location of the findings indicates whether it is a parapharyngeal or retropharyngeal space infection

• You can get a soft tissue neck x-ray, but if your suspicion is still high and the x-rays are equivocal, you should still get a CT

• MRI is useful for assessing the extent of soft tissue involvement and for delineating vascular complications

Management:

• Get Anesthesia/ ENT involved early if there is any degree of upper airway obstruction!

• These signs include: neck extension/head in sniffing position, stritor, change in phonation, drooling, neck stiffness, tripoding, SOB,  retractions

• Coordinate with Anesthesia/ ENT to secure an airway (Tracheostomy in the OR or fiberoptic intubation should be considered)

• If there is no airway compromise, consult ENT because many of these patients require I&D/ needle aspiration in the OR

• Retropharyngeal abscess <2.5cm without airway compromise can potentially receive a trial of empiric IV abx for 24-48 hours without drainage  

•  Antibiotics (Covering: GAS, Staph aureus, respiratory anaerobes, +/-MRSA)  options include: Ampicillin/Sulbactam 3g IV  or Clindamycin 600-900mg IV or Cefoxitin 2gm IV  

• Admit