Foreign Bodies
GENERAL CONSIDERATIONS
Patients frequently present to the emergency department complaining of a foreign body or a foreign body sensation. Several general guidelines should be noted before discussing particular areas of involvement and the various methods of removal.
Impaled foreign bodies, most often knives or other tools, that may have penetrated the chest or abdominal cavity, the eye, or the skull and are in place on initial evaluation of the patient should be removed only in the operating room. This recommendation is based on the probable tamponade or compression of severed vessels by the impaled object and associated hemorrhage upon removal.
A foreign body incorporated into a laceration or puncture wound can be a vexing problem for the emergency physician. If undetected, such a foreign body can cause local infectious complications within 24 to 72 hours. Wood and glass are typical foreign bodies. Glass generally can be detected by radiography, but wood, unless it is painted with leaded paint, cannot. Ultrasound will frequently detect wood-based foreign bodies.
Most patients who report a foreign body sensation localized to the soft tissues of the foot, hand, or fingers are correct in their suspicion; this is true even when the physical examination and radiographic studies fail to reveal a specific agent. In this setting, the physician should explain to such patients that blind dissection of the area without the ability to localize the foreign body accurately is rarely successful and may produce complications. These foreign bodies may require surgical extraction. Tetanus prophylaxis, if needed, a prophylactic antibiotic, crutches if a weightbearing portion of the foot is involved, and consultation with general surgical or surgical subspecialty are all appropriate.
In contrast, foreign body sensations involving the cornea or throat are often misleading or inaccurate. Minor scratches or abrasions involving these areas are frequently responsible for the symptom, rather than a retained foreign body. After a simple corneal abrasion is demonstrated by fluorescein staining and any airway
foreign body ruled out by radiologic and physical examination, reassurance and follow-up in 24 hours may be recommended.
Occult foreign bodies must always be considered in patients presenting with unusual or infectious complications related to previous trauma. Children presenting with a foul-smelling discharge from the nose or the external auditory canal or with a recurrent or refractory pneumonia in the same anatomic location are prime suspects for an occult foreign body. Vaginal or urethral discharge or bleeding in the child should also suggest this possibility.
Similarly, patients presenting with local infection several days after suturing must always be questioned as to the nature of the original injury. If an occult foreign body is possible based on the history or if fluctuance is present, partial or complete suture removal, drainage, radiologic evaluation, and manual inspection of the wound may be indicated. Oral trauma with occult dental fractures may result in embedded dental fragments that may be diagnosed by lateral lip radiographs.
The actual removal of foreign bodies that have penetrated the skin surface may require subspecialty consultation. What often appears to be a simple procedure, such as removing an embedded pin from the sole of the foot, may be both extremely difficult and time consuming. When removal is not straightforward or easily accomplished, early referral is appropriate.
Importantly, when infection is not present, removal is not urgently necessary. Consultation with the general surgeon and clear instructions for follow-up in 12 to 24 hours are recommended. If infection is suspected, however, removal should be undertaken as soon as possible.
When foreign material is suspected, AP and lateral, soft-tissue films should be requested. Additional imaging with CT or US may be indicated.
SPECIFIC DISORDERS
Airway Foreign Bodies
History
Patients with a foreign body sensation in the airway may report cough, pleuritic chest pain, dyspnea, or stridor or may be frankly moribund with severe hypoxia, cyanosis, and reduced or absent ventilatory efforts. Most alert adult patients who are able to speak will report that “something is caught” in the throat. Persons who are unable to speak will usually point to or grasp their throats. Airway aspiration is particularly common in children. This diagnosis must be considered in all children presenting with respiratory insufficiency or respiratory or cardiac arrest.
Physical Examination
In comparison to patients with esophageal foreign bodies, those with airway obstruction present with predominant respiratory symptoms and are able to swallow normally. Some diagnostic confusion may arise in children in whom relatively large esophageal foreign bodies may become impacted, producing tracheal compression and a presentation that often includes prominent respiratory symptoms, such as stridor, which typically began suddenly.
Diagnostic Tests
A lateral roentgenogram of the neck in such patients, if time permits, should demonstrate the foreign body lodged posteriorly in the neck. Compression of the tracheal air
shadow posteriorly is noted and is an important diagnostic finding. Fluoroscopy, if available and if time permits, is similarly useful.
shadow posteriorly is noted and is an important diagnostic finding. Fluoroscopy, if available and if time permits, is similarly useful.
Treatment
Patients with suspected foreign bodies of the airway must be quickly triaged into either those with incomplete obstruction and adequate ventilatory function, or those without adequate ventilatory function. This latter group must be rapidly evaluated and managed in the following manner:
A rapid Heimlich maneuver (abdominothoracic thrust) should be attempted and repeated once if unsuccessful; this may also be accomplished with the patient supine by exerting a similar abdominothoracic thrust. The pharynx should then be quickly visualized, and any foreign material that is freely movable should be manually extracted.
The posterior pharynx should then be “swept” with the examining finger; material palpated deep in the posterior pharynx should not be removed without direct visualization unless its expulsion appears imminent. It is generally much wiser to use the laryngoscope gently, visualize the foreign body, and then proceed with forcepsaided removal. This approach will limit the tendency of such material to fragment or become further impacted in the airway. When foreign material is noted below the level of the cords, it may be possible, using forceps, to grasp and remove the material during expiration or cough, if the patient is alert, or during abdominal chest compression.
If a foreign body is successfully removed, the upper airway should be inspected quickly unless normal and spontaneous respirations have been immediately and completely restored.
When removal of a foreign body does not immediately restore normal ventilatory function, further resuscitative measures must be immediately undertaken.
Material that completely occludes the airway, is distal to the level of the cricothyroid membrane, and is not accessible despite attempts to remove it must be displaced distally so that oxygenation may proceed; this is accomplished by placement of the endotracheal tube. In this uncommon setting, it is necessary in patients with lifethreatening hypoxia to impact the material forcibly into one bronchus to the extent that the other lung may be ventilated; patients with more proximal obstructions that remain refractory to removal or displacement should undergo immediate cricothyrotomy by either needle or incision. In children younger than 12 years of age, needle cricothyrotomy is the treatment of choice and may be performed with a 14-gauge needle followed by pressure insufflation.
In adults, when cricothyrotomy is unsuccessful, a 14-gauge angiocath may be rapidly inserted through the cricothyroid membrane and may provide adequate ventilation by pressure insufflation until a definitive airway is established. Patients without inspiratory effort obviously require mechanical ventilation. Surgical or incision cricothyrotomy is relatively contraindicated in children younger than 12 years of age, and needle cricothyrotomy should be undertaken when an airway is otherwise unavailable.
In patients with adequate ventilatory function, oxygen should be administered, and the mouth, posterior pharynx, and chest quickly examined and radiologic assessment of the neck and chest undertaken. Foreign material identified by one of these maneuvers that does not significantly compromise ventilatory function may be removed laryngoscopically if present in the proximal airway. If the foreign material is localized more distally, subspecialty consultation is required for removal.
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