Descripción del Estudio

Management

INTRODUCTION

The widespread use of coins has seen a concomitant increase of coin ingestions (usually pennies), mostly in the pediatric age group. Occasionally an adult will present as well, but in most cases adults do not seek medical care for this condition. Conners et al. (1) discovered through a survey that most coin ingestions are managed at home, without calling a physician or poison center (85% of the returned sample). This study demonstrated an average age of about 3 years old. There was no incidence of removal procedures in their study. Coin ingestions seen in the emergency department tend to be more serious, more worrisome to the parents, or more symptomatic as demonstrated by the studies of Paul et al. (2).

Pediatric coin ingestion can result in aspiration either directly or through a caregiver's well-meaning efforts to induce vomiting. Other life-threatening consequences are discussed in this chapter.

RESPIRATORY TRACT

Any coin that enters the respiratory tract (usually the bronchi on the right) can lead to total respiratory obstruction and must be considered an extreme emergency requiring admission and, usually, bronchoscopy. When complete obstruction is present, intubation is needed and if unsuccessful should be followed by cricothyrotomy or tracheostomy. In dire straits, large needles in the trachea can provide respiratory relief because the level of obstruction usually is above this level. Attempts to remove foreign bodies in the bronchi by Heimlich maneuver or holding a child upside down can lead to complete obstruction. However, such maneuvers should be attempted in cases of respiration obstruction.

ESOPHAGEAL COINS

Occasionally, a coin will lodge in the esophagus and can result in persistent irritation. Usually, in normal children, such coins eventually reach the stomach. However, esophageal coins have resulted in esophagitis, tears, tracheal-esophageal fistulas, perforation through to the aortic arch, mediastinitis, and death.

MANAGEMENT

Routine radiographs are indicated to locate the coin. In cases where esophageal symptoms or respiratory symptoms are present, there is strong indication to localize the foreign bodies. Particularly when the coin is larger (quarters, half dollars) concerns regarding symptoms and passage through the intestines are increasingly warranted.

There has been some interest in using metal detectors to follow the passage of coins and avoid radiographs. While this is novel, most emergency departments do not have such equipment and proper localization to avoid complications is preferable.

Patients (mostly children) who present to the emergency department tend to have more severe conditions and complications. Concomitantly, a child can be having gastrointestinal symptoms, but there may be no foreign body to account for the symptoms.

The following are recommendations for emergency department management: 1. Radiograph all children who present with a history of coin ingestion.

2. If a coin ingestion history is obtained, further history is necessary as to why the parent is potentially concerned. There may be other symptoms necessitating radiographic evaluation. Evaluation is undertaken (and is recommended in almost all emergency department patients). Ensure that the esophagus is shown. 3. If coin ingestion is in doubt, a radiograph will settle the issue and allow a baseline or require another explanation if there are symptoms. Once a single

radiograph is done that demonstrates a coin, the parents should be advised that almost all coins pass uneventfully and there is no need for vomiting or

laxatives. Repeat radiograph is needed only if there are ongoing symptoms or the coin is lodged at a point that creates the potential for complications (e.g., the upper mid or lower esophagus or the gastric outlet). Figure 9–7.1 indicates a radiograph of a penny lodged in the esophagus of a 10-month-old infant.

Endoscopy was required to remove the coin.

Figure 9–7.1. Ten-month-old infant with persistent lodged coin in the esophagus (AP and lateral radiograph). Endoscopy was required to remove the coin.

4. Metal detectors are a novel way of following the course of a metallic coin, but are usually not available and are inaccurate.

5. Most coins are detected in the stool within three days. The larger the coin, the more concern about passage. Pennies and dimes are almost always easily passed, except in infants (Fig. 9–7.1).

References

1. Conners GP, Chamberlain JM, Paul RW: Pediatric coin ingestion: a home-based survey. Am J Emerg Med 1995;13:638–639.

2. Paul RI, Christoffel KK, Binns HJ, et al: Foreign body ingestions in children: risk of complication varies with site of initial health care contact. Pediatrics 1993;91:121–127.

Suggested Readings

Byard RW, Moore L, Bourne AJ: Sudden and unexpected death: a late effect of occult intraesophageal foreign body. Pediatr Patho 1990;10:837–841. Conners GP, Chamberlain JM, Ochsenschlager DW: Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med 1995;149:36–39. Crysdale WS, Sendi KS, Yoo J: Esophageal foreign bodies in children: 15-year review of 484 cases. Ann Otol Rhinol Laryngol 1991;100:320–324.

Hodge D, III, Tecklenburg F, Fleisher G: Coin ingestion: does every child need a radiograph? Ann Emerg Med 1985;14:443–446. Joseph PR: Management of coin ingestion. Am J Dis Child 1990;144:449–450 (letter).

Remsen K, Lawson W, Biller HF, et al: Unusual presentations of penetrating foreign bodies of the upper aerodigestive tract. Ann Otol Rhinol Laryngol 1983;92:32–44. Schunk JE, Corneli H, Bolte R: Pediatric coin ingestions: a prospective study of coin location and symptoms. Am J Dis Child 1989;143:546–548.

CHAPTER 10 ROUTES FOR DRUGS AND FLUIDS

Principles and Practice of Emergency Medicine

CHAPTER 10 ROUTES FOR DRUGS AND FLUIDS

James S. Cohen*