Kids put things in the craziest places... 2 year old observed to - - PDF document

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Kids put things in the craziest places...

Judith Klein, MD FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Medicine

You can’t make me eat my dinner!

2 year old observed to stuff corn up right nostril PE: vs wnl, playing, comfortable, corn visible What now?

Objectives

“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

Nasal foreign bodies

Most common place kids put stuff Where?

• nasal floor
• in front of middle

turbinate Most can be visualized When to worry: button batteries, > 1 magnet

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A few words about button batteries...

Electrical conduction across tissue: liquefaction necrosis Leakage of caustic material (acidic environment) Esophagus:

• ulceration within 2 hrs
• perforation within 8 hrs

should i be worried?

Most objects: Go for it! 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

• xymetolazone/4%

lidocaine 1:1 Soft: resp suction catheter, alligator forceps Hard: balloon cath, right angle hook, q tip and glue

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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

Insects: mineral oil or lidocaine first Contraindications: battery, organic, perforation/tubes

Well that didn’t work...

Sedation: ketamine.... Headlight/oto-microscope Soft/insects: alligator forceps, suction catheter Hard: q tip/glue

• hold 30 seconds
• glue the ear? acetone/3%

H2O2 soaked cotton in ear Topical abx gtt (e.g oflox)

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Who’s got the money?

3 year old observed to swallow disk battery from brother’s microscope PE: playful, no resp distress, no drooling, no vomiting Worried?

Foreign bodies in the GI tract

100K/yr: 80% kids (6m-3yr) 10-20% require intervention Culprits: coins, toys, ?? Sx: usually only if >72 hours

Workup

X rays: AP/lateral neck, chest, abdomen Sx or high suspicion of unvisualized bad guy: CT or MR (non-metallic) Repeat x ray in 24 hours If in stomach by 24 hrs: most pass 1-2 wks

Esophagus Trachea Trachea

When to worry?

Perforation: neck swelling, crepitus, fever, ill appearing Obstruction Aspiration: wheezing, resp distress (bronchoscopy) Nasty objects:

• >5 cm and/or sharp
• disk battery, magnets, lead

>24 hrs: still in esophagus

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GI Foreign Bodies

Sharp and/or >5cm? button battery? >1 magnet? lead? perforation? obstruction? X-rays: neck, chest, abdomen Stomach or beyond? Immediate flex endoscopy (Surgery if beyond prox duodenum and sharp, long, magnet) Repeat x ray 24 hours Stomach or beyond? Observe Repeat x ray 2-4 wks YES NO YES NO YES NO

the toy in the Box

2 1/2 year old eating cereal Sudden choking-resolved In ED: playful, VS wnl, no stridor, hoarseness, cough, lungs clear What next?

Airway Foreign Bodies

3500 deaths/yr; peak < 3 yrs Anatomy: conical airway Objects:

• peanuts, popcorn, grapes
• round=obstruction

Most in bronchi

Adult Infant/toddler

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Diagnosis

Hx:

• choking? (76-92% sensitive)

Sx/PE:

• larynx: stridor, hoarse
• bronchi: focal wheeze, cough, BS,
• r nothing!

X ray: (AP/lateral/exp or lat decub)

• only 10% objects visualized
• 2/3 normal

Trust a choking history!

Symptomatic?

Life threatening?

• Back blow/chest

compression (infant) or Heimlich (child)

• Intubation/Macgill forceps

Immediate rigid bronchoscopy

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