6. Clorhexidina
6.15 Prescripción
Clinical presentation may be only a history of ingestion. One third of patients may be asymptomatic. It cannot be overstated that a positive history of foreign body ingestion in a child should not be dismissed (6). Symptoms may include choking, gagging, or vomiting at the time of ingestion, refusal to take foods, drooling, respiratory stridor, or wheezing, and complaint of pain with localization in older children. Less than 20% have an abnormal physical examination ( 2,6). The
examination should include palpation for subcutaneous emphysema in addition to scrutiny of the head, neck, chest, and abdomen. Direct and indirect laryngoscopy may help to locate the foreign body. Diagnostic studies include chest radiograph in posterior-anterior and lateral views that give adequate visualization of the neck soft tissues, the esophagus, and the stomach bubble. See Table 9–5.1 for indications for radiographs (8,9). If the object is suspected to be sharp or large, stool should be checked for blood. It may be necessary to locate an area of impaction with water-soluble contrast media or a barium-soaked pledget, but there is a risk in using these procedures in the presence of perforation or obstruction.
Table 9–5.1. Indications for Radiographic Evaluationa
Management
Eighty percent of foreign bodies pass uneventfully into the gastrointestinal (GI) tract ( 1,10). Management of an obstructed airway is discussed elsewhere in the text and represents an extreme emergency (see Aspirated Foreign Bodies, Chapter 9–6). If the child is breathing comfortably and able to talk without difficulty and the suspected object is smooth rather than sharp, the child can be observed for several hours after ingestion. A soft catheter may be used to suction oral secretions, minimizing the risk of aspiration. The ED need at this point is for diagnosis and a decision as to whether a consultant is required ( 11).
Major complications may ensue after 24 hours, making endoscopic removal much more difficult. These include erosion of the mucosa so that the foreign body must be dissected from the esophageal wall. The erosion can lead to perforation with resulting mediastinitis, tracheoesophageal fistula, or a potentially fatal aortoesophageal fistula. Tracheal compression, aspiration of secretions, atelectasis from airway obstruction, pleural effusion, pneumothorax, lung abscess, and sepsis are additional complications of retained foreign bodies.
FOREIGN BODY REMOVAL
Removal of the esophageal foreign body has been controversial. Currently, many authors do not recommend removal with a Fogarty or Foley catheter under fluoroscopy because the airway cannot be adequately safeguarded in a child (1,2,6,12). Friedman categorically states that “esophageal foreign bodies should be removed under general anesthesia with a secured airway” (6). This is because the dislodged foreign body can possibly obstruct the laryngeal outlet. On the other hand, a recent report puts a success rate of 86% with balloon extraction and, if unsuccessful, the patient went to the operating room ( 3). Catheter removal is contraindicated in cases of anatomic abnormality; a retained foreign body; a sharp, radiolucent, or unknown foreign body; or an uncooperative patient. Endoscopic removal provides the advantage of an assessment of mucosal injury and the presence of another foreign body. The drawback of endoscopy, however, is that it has required general anesthesia in children. With the advent of shorter-acting anesthetics, however, this risk may be substantially less.
The foreign body should not be pushed into the stomach because this may cause compression of the trachea or perforation. Agents such as diazepam (Valium) and meperidine must be avoided because of their sedative effect, which compromises the airway and the handling of secretions. Anticholinergics decrease secretions but increase the risk of gastric outlet obstruction. Proteolytic enzymatic degradation of a meat bolus has been complicated by degradation of the partially eroded mucosal wall. Administration of glucagon to relax esophageal smooth muscle, although it is often effective, has been complicated by vomiting, which further compromises the airway. Both sublingual nitroglycerine and nifedipine have been used alone or with glucagon in a similar manner to glucagon to relieve esophageal smooth muscle spasm (6A). Effectiveness is variable, but use is warranted if surgery is avoided. If the foreign body is passed into the stomach, an abdominal film can be obtained at 3- to 4-day intervals until the object passes the pylorus. If it does not pass the gastric outlet in 7 days, or if symptoms arise, endoscopic removal may be considered. Although it usually takes a benign course thereafter, the foreign body may yet lodge in the lower gut because of anatomic configurations as illustrated in Figure 9–5.1. Perforation may manifest as an acute abdomen with pain and fever or as an obstructed bowel with vomiting and distention. Stools should be followed for occult blood in all ingestions of sharp objects.
Fifty percent of children are seen within 3 days of an ingestion, but as many as 20% may not come to medical attention for more than 1 month (6). They may present with chronic respiratory symptoms, recurrent or migrating pneumonia, or failure to thrive. They may be worked up for cystic fibrosis, allergy, asthma, immunodeficiency syndromes, or mucociliary dysfunction. The long-term complications are related to poor nutritional intake, formation of granulation tissue, and chronic infection.
Perforation
Less than 1% of all foreign bodies cause perforation, but for sharp objects the incidence is 15 to 35% ( 1). Common sites of impaction or perforation are illustrated in
Figure 9–5.1. The flow of the object is influenced by its size and shape as well as any gut pathology such as Meckel's diverticulum or hernia. Objects usually pass in 48 to 72 hours; the range is up to 14 days. Surgery is indicated for symptoms or if the object fails to progress.
Body Packings
A relatively recent phenomenon is the “body packer” or “mule” who transports cocaine by ingesting grape-sized packets containing 3 to 7 g each. Caruana et al. ( 13) studied 50 patients imprisoned for this offense and reported ingestions of 54 to 182 packets. Because 1 to 3 g of cocaine can be fatal, with seizures, delirium, and cardiovascular collapse, surgical removal of packets has been the treatment of choice. The above series, however, documented conservative management with the patient receiving nothing by mouth except mineral oil. Venous access was maintained at all times. Packets were passed in an average of 28 hours. Emergency surgery was required in three cases for bowel obstruction. There were no ruptured packets in this series. The authors speculate that this is because the packages appeared to be a manufactured product and not the finger cots or condoms frequently used in the past, which were more subject to rupture (13). With danger of rupture, obstruction, and rapid death, surgical removal offers the safest choice of treatment. However, whole bowel irrigation has also been used in this situation with success (13A).
References
1. Webb W: Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988;94:204. 2. Taylor RB: Esophageal foreign bodies. Emerg Med Clin North Am 1987;5:301.
3. Dokler ML, Bradshaw J, Mollitt DL, et al: Selective management of pediatric esophageal foreign bodies. Am Surg 1995;61(2):132–134. 4. Perry PA, Dean BS, Krenzelok EP: Drug induced esophageal injury. Clin Toxicol 1989;27:281.
5. Litovic TL: Battery ingestions: product accessibility and clinical course. Pediatrics 1985;75:469. 6. Friedman EM: Foreign bodies in the pediatric aerodigestive tract. Ped Ann 1988;17:642.
6A. Pace SA, Young GP. Esophageal foreign bodies. In: Roberts JR, Hedges JR. Clinical Progress in Emergency Medicine. Philadelphia: WB Saunders, 1985;679–691. 7. Roach J: Anhydrous pill ingestion: a new cause of esophageal obstruction. Ann Emerg Med 1987;16:913.
8. Savitt DL, Wason S: Delayed diagnosis of coin ingestion in children. Ann Emerg Med 1988;6:378. 9. Hodge D, III: Coin ingestion: does every child need a radiograph? Ann Emerg Med 1985;14: 443.
10. Stevens C, Ardagh M, Abbott GD: Aerodigestive tract foreign bodies in children: one year's experience at Christchurch Hospital emergency department. N Z Med J 1996;109(1024):232–233. 11. Stack LB, Munter DW: Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am 1996;14(3):493–521.
12. Krome RL: Swallowed foreign bodies. In: Tintinalli JE, Krome RI, Ruiz E, eds. Emergency medicine, a comprehensive study guide. New York: McGraw-Hill, 1988. 13. Caruana D, Weinbach B, Goerg D, et al: Cocaine-packet ingestion. Ann Emerg Med 1984;100:73.
Chapter 9.6 Food and Foreign Body Asphyxiation
Principles and Practice of Emergency Medicine