Foreign body ingestion

Question 1

A 27 year old man presents to the ED concerned that he swallowed a fish-bone. He felt a sharp pain in the region of the suprasternal notch after swallowing a piece of fish. Despite trying to dislodge the bone with frequent drinks and coughing, he still feels pain in the area. How would you assess and manage him?

Answer 1

Impression
Likely foreign body ingestion, am most notably concerned about potential for oesophageal/gastric perforation. Pain at suprasternal notch could be referred, and foreign body could be in different level of upper GI.

Goals

• ensure HD stability and assess for signs of perf
• appropriate dispositioning for removal of FB

Question 2

FBI - Assessment

Answer 2

Assessment
assume HD stable, but main consideration is airway depending on location of FB, and can have hypersalivation so would want to ensure airway is secure before proceeding with rest of assessment

Question 3

FBI - History

Answer 3

History

• PC: timing, pain (SOCRATES), is pain changing at all? assoc sx: haematemesis, dysphagia, odynophagia, Resp distress or otherwise
• chest pain, abdominal pain of sudden nature
• underlying psychiatric illness or alcohol intoxication
• last meal, meds, allergies,
• SNAP

Question 4

FBI - Examination

Answer 4

Examination

• Vitals
• General appearance
• ENT: Inspection for site of FB (if very high up), could use nasendoscopy for visualisation above vocal cords or upper oesophagus. Also looking for mucosal trauma.
• Resp exam: ensure no stridor or other abnormalities

Question 5

FBI - Investigations

Answer 5

Investigations
Diagnostic
- CT/MRI neck/chest (X-Ray unlikely to pick up fishbone even if large)
- Upper endoscopy (also therapeutic)

• Labs: pre-operative bloods

Question 6

FBI - Management

Answer 6

Management
Key
- referral to upper GI surgeon/ gastro/ENT for retrieval of FB (depending on its location)

Supportive

• analgesia
• NBM

ED management

• Trial of Coke
• This is non-urgent case and can wait till next day if need be

Definitive

• endoscopy for removal
• expectant management, particularly if passed to stomach/further with regular radiological monitoring.
• expectantly manage any complications (perforation, fistula, obstruction)