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Dysphagia and Food Bolus Impaction
Resuscitation and Universal Approaches
Approach to Unresponsive Patient
Approach to Airway Obstruction And Stridor
Approach to Acute Respiratory Distress With Impending Failure
Approach to Peri-arrest Hypotension
Approach to Post Resuscitation Care After Rosc
Approach to Cardiac Arrest Rhythms, Pea, Asystole
Approach to Cardiac Arrest Rhythms, Vf, Pulseless Vt
Approach to Severe Agitation With Safety Risk
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Chest and Cardiovascular
Approach to Pacemaker And Icd Related Presentations
Approach to Acute Limb Ischemia And Leg Pain
Approach to Suspected Deep Vein Thrombosis Symptoms
Approach to Hypertension
Approach to Chest Pain
Approach to Palpitations And Tachyarrhythmia Symptoms
Approach to Bradycardia Symptoms
Approach to Syncope And Presyncope
Approach to Syncope With Neurologic Concern
Approach to Unilateral Leg Swelling
Approach to Bilateral Leg Swelling
Approach to Calf Pain And Swelling
Respiratory
Approach to Wheezing, Undifferentiated
Approach to Wheezing In Infants
Approach to Stridor And Upper Airway Symptoms
Approach to Dyspnea
Approach to Aspiration Event
Approach to Cough
Approach to Hemoptysis
Approach to Upper Respiratory Infection Symptoms
Approach to Suspected Pulmonary Embolism Presentation
Approach to Smoke Inhalation Concern
Approach to Smoke Exposure And Inhalational Injury
Abdominal and Gastrointestinal
Approach to Abdominal Distension
Approach to Abdominal Pain, Undifferentiated
Approach to Acute Abdominal Pain (general)
Approach to Suspected Incarcerated Or Strangulated Hernia
Approach to Pancreatitis Concern
Approach to Biliary Colic And Cholecystitis Concern
Approach to Appendicitis Concern
Approach to Diverticulitis Concern
Approach to Rectal Pain And Anorectal Complaints
Approach to Dysphagia And Food Bolus Impaction
Approach to Foreign Body Ingestion
Approach to Refractory Vomiting And Recurrent Vomiting Syndromes
Approach to Cannabis Associated Hyperemesis
Approach to Upper Gastrointestinal Bleeding Symptoms (melena)
Approach to Lower Gastrointestinal Bleeding And Hematochezia
Approach to Constipation And Obstipation
Approach to Diarrhea
Approach to Acute Hepatitis And Jaundice Concern
Approach to Right Upper Quadrant Pain
Approach to Epigastric Pain
Approach to Left Upper Quadrant Pain
Approach to Right Lower Quadrant Pain
Approach to Left Lower Quadrant Pain
Approach to Suprapubic Pain
Renal and Urinary
Approach to Oliguria And Anuria
Approach to Catheter Related Urinary Complaints
Approach to Dialysis Patient Presentations
Approach to Flank Pain And Renal Colic Concern
Approach to Urinary Retention
Approach to Hematuria
Approach to Scrotal Pain
Neurologic
Approach to Transient Neurologic Deficits
Approach to Acute Aphasia And Speech Disturbance
Approach to Acute Confusion And Delirium
Approach to Postictal State And Seizure Recurrence Concern
Approach to Seizure
Approach to Acute Vision Loss
Approach to New Tremor And Involuntary Movements
Approach to Headache
Approach to Vertigo
Approach to Acute Weakness Or Numbness
Approach to Gait Instability And Ataxia
Back and Neck
Approach to Atraumatic Back Pain
Approach to Sciatica And Radicular Back Pain
Approach to Back Pain With Neurologic Deficit, Cauda Equina Concern
Approach to Back Pain With Fever Or Immunosuppression, Spinal Infection Concern
Approach to Atraumatic Neck Pain
Approach to Neck Pain After Trauma
Approach to Neck Pain With Meningismus Concern
Approach to Acute Torticollis
Women's Health, Pregnancy, and GU
Approach to Vaginal Discharge
Approach to Hyperemesis Gravidarum Concern
Approach to Hypertensive Disorders Of Pregnancy Symptoms
Approach to Postpartum Hemorrhage Concern
Approach to Postpartum Infection Concern
Approach to Sexual Assault Medical Evaluation Overview
Approach to Pelvic Pain
Approach to Vaginal Bleeding, Nonpregnant
Approach to Vaginal Bleeding In Pregnancy
Approach to Pelvic Pain In Pregnancy
Approach to Post Procedure Or Post Abortion Complications Concern
Infectious Disease and Fever Syndromes
Approach to Fever In The Immunocompromised Patient
Approach to Fever With Rash
Approach to Animal Bites And Rabies Risk Assessment
Approach to Tick Exposure And Tick Borne Illness Concern
Approach to Sepsis Concern Without Clear Source
Approach to Soft Tissue Infection Concern
Approach to Abscess And Skin Infection Concern
Approach to Sore Throat
Approach to Sore Throat And Pharyngitis Symptoms
Approach to Meningitis
Approach to Envenomation And Bites
Allergy and Dermatology
Approach to Pruritus Without Rash
Approach to Contact Dermatitis And Eczema Flare
Approach to Herpes Zoster Concern
Approach to Drug Eruption Concern And Severe Cutaneous Reaction Red Flags
Approach to Urticaria
Approach to Angioedema Concern
Approach to Unexplained Bruising Or Bleeding Symptoms
Musculoskeletal and Extremities
Approach to Shoulder Pain
Approach to Elbow Pain
Approach to Wrist Pain
Approach to Hand Pain
Approach to Hip Pain
Approach to Knee Pain
Approach to Ankle Pain
Approach to Foot Pain
Approach to Cast Or Splint Complication Symptoms
Approach to Wound Check And Suture Related Visits
Approach to Joint Swelling And Monoarthritis
Approach to Suspected Septic Joint Presentation
Approach to Suspected Tendon Rupture Presentation
Approach to Limp Or Refusal To Bear Weight
Trauma and Wounds
Approach to Motor Vehicle Collision Evaluation
Approach to Chest Wall Trauma And Rib Injury
Approach to Blunt Abdominal Trauma Evaluation
Approach to Penetrating Trauma Evaluation
Approach to Pediatric Minor Head Trauma
Approach to Pediatric Head Trauma
Approach to Facial Lacerations And Dental Trauma
Approach to Hand Lacerations With Tendon Injury Concern
Approach to Puncture Wounds And Retained Foreign Body Concern
Approach to Electrical Injury
Approach to Burn Injury
Approach to Fall Evaluation
Approach to Assault And Interpersonal Violence Evaluation
Approach to Eye Trauma And Hyphema Concern
ENT, Eye, Dental
Approach to Dysphagia And Odynophagia
Approach to Throat Pain
Approach to Ear Pain
Approach to Foreign Body In Ear Or Nose
Approach to Vision Loss Complaint
Approach to Flashes And Floaters
Approach to Atraumatic Eye Pain
Approach to Red Eye
Approach to Dental Abscess Concern
Approach to Post Extraction Pain And Complications
Endocrine, Metabolic, and Abnormal Labs
Approach to Hyperglycemia
Approach to Hypoglycemia
Approach to Hyponatremia Symptoms
Approach to Hyperkalemia Symptoms
Approach to Hypokalemia Symptoms
Approach to Rhabdomyolysis Concern
Approach to Anticoagulation Related Abnormal Coagulation Studies
Approach to Acute Kidney Injury And Elevated Creatinine Referral
Approach to Symptomatic Anemia Concern
Toxicology and Behavioral
Approach to Undifferentiated Overdose
Approach to Opioid Toxicity
Approach to Opioid Withdrawal
Approach to Alcohol Intoxication
Approach to Alcohol Withdrawal
Approach to Stimulant Toxicity
Approach to Pediatric Ingestion
Approach to Carbon Monoxide Exposure
Approach to Inhalational Or Chemical Exposure
Approach to Suicidal Ideation And Self Harm Risk Assessment
Approach to Acute Psychosis And Mania Symptoms
Approach to Anxiety And Panic Symptoms
Approach to Capacity Assessment And Safe Disposition
Approach to Behavioral Escalation And Restraint Considerations
Pediatrics
Approach to Fever In The Neonate And Young Infant
Approach to Pediatric Fever By Age 0 To 28 Days
Approach to Pediatric Fever By Age 29 To 60 Days
Approach to Pediatric Fever By Age 2 To 24 Months
Approach to Pediatric Respiratory Distress
Approach to Croup And Stridor In Children
Approach to Pediatric Dehydration
Approach to Pediatric Abdominal Pain
Approach to Febrile Seizure
Approach to Rash In The Child
Approach to Poor Feeding And Lethargy In The Infant
Approach to Vomiting In The Child
Approach to Diarrhea In The Child
Approach to Pediatric Trauma Evaluation
Approach to Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern
Approach to Lethargy And Altered Mental Status In The Child
Environmental and Exposure
Approach to Heat Illness
Approach to Hypothermia And Cold Exposure
Approach to Frostbite Concern
Approach to Drowning And Submersion Injury
Dysphagia and Food Bolus Impaction
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Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting pattern
Dysphagia history
▶
Solids only
Solids and liquids
Liquids only
Odynophagia
Globus sensation
Food bolus impaction episode
Complete obstruction
Partial obstruction
Inability to tolerate secretions
Drooling
Regurgitation
Vomiting
Aspiration event
OPQRST
OPQRST
▶
Onset
▶
Sudden onset during meal
Gradual onset over days to weeks
Chronic progressive over months
Provocation/Palliation
▶
Worse with solids
Worse with liquids
Worse with large bites
Worse with dry foods
Relief with sips of water
Relief after regurgitation
Quality
▶
Sticking sensation
Choking sensation
Burning retrosternal pain
Sharp chest pain
Region/Radiation
▶
Cervical
Retrosternal
Epigastric
Severity
▶
Unable to swallow saliva
Able to swallow liquids only
Able to swallow solids with difficulty
Timing
▶
Intermittent
Progressive
Recurrent similar episodes
Associated symptoms
Associated symptoms
▶
Chest pain
Shortness of breath
Fever
Neck pain
Voice change
Hematemesis
Melena
Weight loss
Neurologic symptoms
Heartburn
Food allergies
Atopy history
Exposures and precipitating events
Exposures and events
▶
Meat impaction
Pills
Sharp foreign body
Denture ingestion
Fish bone
Button battery
Caustic ingestion
Recent endoscopy
Recent esophageal dilation
Recent vomiting retching
Alarm Features
Airway and breathing threats
Airway risk features
▶
Stridor
Respiratory distress
Hypoxia
Inability to handle secretions
Persistent drooling
Suspected aspiration
Hemodynamic and systemic danger thresholds
High risk vitals
▶
Hypotension
Tachycardia out of proportion
Fever
Altered mental status
Perforation and mediastinal infection
Perforation concern
▶
Severe chest pain
Severe neck pain
Subcutaneous emphysema
Crepitus
Hamman sign
Persistent tachycardia
Leukocytosis with toxicity
High risk ingestion categories
High risk foreign body
▶
Button battery in esophagus
Magnets
Sharp pointed object
Large object
Denture with metal hooks
Caustic ingestion
Immediate escalation triggers
Escalation triggers
▶
Complete obstruction with drooling
Any airway compromise
Suspected perforation
Button battery suspicion
Multiple magnet ingestion
Hemodynamic instability
Medications
Current therapies and recent changes
Medication history
▶
Anticoagulants
Antiplatelets
Diabetes therapies
Opioids
Anticholinergics
Sedatives
Recent antibiotic exposure
Recent corticosteroid exposure
Impaction and symptom directed medications
Pharmacologic options
▶
Glucagon IV
▶
Adult dose 1 mg IV once
Repeat 1 mg IV once after 10 to 15 minutes if no response
Nausea and vomiting risk
Antiemetic
▶
Ondansetron IV 4 mg once
QT prolongation risk
Analgesia
▶
Fentanyl IV 25 mcg increments
Titration every 5 minutes to comfort
Acid suppression when mucosal injury suspected
▶
Pantoprazole IV 40 mg once
Local protocol dependent
Contraindications and traps
Medication cautions
▶
Avoid oral intake in complete obstruction
Avoid effervescent agents
Avoid blind instrumentation
Increased bleeding risk with anticoagulation for endoscopy
Aspiration risk with sedatives
Diet
Recent intake and triggers
Diet context
▶
Last oral intake timing
Trigger food type
Meat
Bread
Dry rice
Hot dog
Poor dentition or ill fitting dentures
Hydration and swallowing capacity
Hydration and tolerance
▶
Able to tolerate liquids
Unable to tolerate liquids
Unable to tolerate saliva
Dehydration indicators
Review of Systems
Gastrointestinal
GI
▶
Dysphagia
Odynophagia
Heartburn
Regurgitation
Nausea
Vomiting
Hematemesis
Melena
Abdominal pain
Respiratory and ENT
Respiratory and ENT
▶
Cough
Wheeze
Dyspnea
Stridor
Voice change
Sore throat
Drooling
Constitutional and neuro
Constitutional and neuro
▶
Fever
Weight loss
Night sweats
Weakness
Focal neurologic deficit
Dysarthria
Collateral History and Family History
Collateral sources
Collateral
▶
Witnessed choking event
Caregiver report for baseline swallowing
EMS report of secretions and airway status
Family history and atopy
Family and atopy history
▶
Esophageal cancer family history
Atopy
Asthma
Eczema
Food allergy
Eosinophilic esophagitis family history
Risk Factors
Structural and inflammatory esophageal disease
Esophageal risk factors
▶
Gastroesophageal reflux disease
Prior esophagitis
Prior stricture
Schatzki ring
Eosinophilic esophagitis
Prior radiation
Caustic injury history
Malignancy risk
Malignancy risk
▶
Progressive dysphagia
Weight loss
Tobacco use
Heavy alcohol exposure
Barrett esophagus history
Neuromuscular and stroke risk
Oropharyngeal dysphagia risk
▶
Prior stroke
Parkinson disease (G20)
ALS
Myasthenia gravis (G70.00)
Dementia
Frailty
Sedative use
Procedure and device related
Iatrogenic and device risks
▶
Recent endoscopy
Recent dilation
Nasogastric tube placement
Esophageal stent
Differential Diagnosis
Life threatening
Life threatening causes
▶
Esophageal perforation (K22.3)
▶
Severe chest pain
Subcutaneous emphysema
Button battery in esophagus
▶
Drooling
Chest discomfort
Sharp foreign body with perforation risk
▶
Odynophagia
Focal neck pain
Mediastinitis (J98.51)
▶
Fever
Toxic appearance
Airway compromise from proximal obstruction
▶
Stridor
Hypoxia
Common
Common causes
▶
Food bolus impaction (T18.128A)
▶
Sudden onset with meal
Prior intermittent solid dysphagia
Peptic stricture from GERD (K21.9)
▶
Longstanding heartburn
Progressive solids then liquids
Schatzki ring (K22.2)
▶
Intermittent solid dysphagia
Meat impaction history
Eosinophilic esophagitis (K20.0)
▶
Atopy
Recurrent impactions
Less common
Less common causes
▶
Esophageal malignancy (C15.9)
▶
Progressive dysphagia
Weight loss
Achalasia (K22.0)
▶
Dysphagia to solids and liquids
Regurgitation
Pill esophagitis (K20.8)
▶
Recent doxycycline
Recent bisphosphonate
Infectious esophagitis
▶
Candida esophagitis (B37.81)
HSV esophagitis
CMV esophagitis
Zenker diverticulum (K22.5)
▶
Regurgitation of undigested food
Halitosis
Mimics and alternative diagnoses
Mimics
▶
ACS (I21.9)
▶
Exertional chest pressure
ECG changes
Aortic dissection (I71.00)
▶
Sudden tearing pain
Pulse deficit
Foreign body sensation without obstruction
▶
Globus
Anxiety
Past Medical History
Relevant chronic conditions
Comorbidities
▶
GERD (K21.9)
Barrett esophagus (K22.70)
Prior esophageal stricture (K22.2)
Eosinophilic esophagitis (K20.0)
Esophageal cancer (C15.9)
Prior stroke (I63.9)
Parkinson disease (G20)
Diabetes mellitus (E11.9)
Prior episodes and procedures
Prior episodes and procedures
▶
Prior food impaction
Prior endoscopic removal
Prior dilation
Prior barium swallow
Prior aspiration pneumonia (J69.0)
Physical Exam
General and airway
General and airway
▶
Toxic appearance
Work of breathing
Stridor
Voice quality
Drooling
Handling secretions
Vitals pattern interpretation
Vitals patterns
▶
Fever pattern
Tachycardia pattern
Hypoxia pattern
Hypotension pattern
Head and neck
Head and neck
▶
Oropharynx foreign body
Tonsillar swelling
Uvular edema
Trismus
Neck tenderness
Subcutaneous emphysema
Chest and cardiovascular
Chest and cardiovascular
▶
Chest wall tenderness
Hamman sign
Breath sounds asymmetry
Wheeze
Crackles
Murmur
Abdomen
Abdomen
▶
Epigastric tenderness
Peritoneal signs
Distension
Neuro and swallowing mechanics
Neuro
▶
Cranial nerve deficits
Dysarthria
Facial droop
Gait instability
Lab Studies
Baseline labs when escalation likely
Core labs
▶
CBC for infection and anemia
Electrolytes for dehydration
Creatinine for contrast planning
Glucose for diabetes management
Infection and perforation support
Inflammation and sepsis support
▶
Lactate for sepsis physiology
Blood cultures if febrile and toxic
Bleeding and procedure readiness
Hemostasis and procedure considerations
▶
INR if on warfarin
Platelets if thrombocytopenia concern
Imaging
Scoring Systems
Decision and timing logic
▶
Button battery
▶
Immediate endoscopic removal when in esophagus
Imaging to localize when uncertain
Sharp object
▶
Urgent endoscopy when in esophagus
Surgical consultation triggers when perforation concern
MRI
MRI considerations
▶
Limited role in acute food bolus impaction
Avoid delays in unstable patients
Consider for neuro etiologies of dysphagia when stable
Contraindications
▶
Ferromagnetic implants
Unstable airway
CT
CT indications
▶
Suspected perforation
Severe chest pain out of proportion
Fever with toxicity
Subcutaneous emphysema
Suspected deep neck space infection
CT protocol pearls
▶
CT neck and chest with IV contrast if perforation concern
Water soluble oral contrast if esophageal leak evaluation and safe to administer
Avoid barium when perforation suspected
CT findings
▶
Pneumomediastinum
Mediastinal fluid
Pleural effusion
Esophageal wall thickening
Foreign body localization
Ultrasound
Ultrasound role
▶
Limited for esophageal obstruction diagnosis
Lung ultrasound for aspiration patterns
POCUS for pleural effusion if perforation concern
POCUS for volume status in dehydration
Special Tests
Endoscopic evaluation
Endoscopy
▶
Diagnostic and therapeutic for food bolus
Removal techniques per GI
Biopsies when eosinophilic esophagitis suspected after clearance
Contraindications and precautions
▶
Unsecured airway with copious secretions
Suspected perforation requires careful planning
Radiographic contrast swallow studies
Contrast esophagram
▶
Water soluble contrast when perforation suspected
Barium reserved when perforation excluded
Aspiration risk considerations
Oropharyngeal assessment
Swallow safety screening
▶
Bedside swallow screen in stable patients with neuro concern
Speech language pathology evaluation when available
ECG
Indications
ECG indications
▶
Chest pain
Dyspnea
Syncope
Significant risk factors for ACS
High risk findings
High risk patterns
▶
ST elevation
Dynamic ischemic changes
New bundle branch block with symptoms
Significant QT prolongation before antiemetics
Assessment
Problem representation
Working problem
▶
Suspected esophageal food bolus impaction (T18.128A)
Oropharyngeal dysphagia concern
Complicated course concern
▶
Aspiration
Perforation
Sepsis physiology
Severity and risk stratification
High risk features present
▶
Unable to manage secretions
Airway compromise features
High risk foreign body category
Signs of perforation
Lower risk features
▶
Partial obstruction
Able to swallow secretions
No systemic toxicity
Key alternative diagnoses
Alternate diagnoses to address
▶
Achalasia (K22.0)
Esophageal malignancy (C15.9)
Pill esophagitis (K20.8)
Infectious esophagitis
ACS (I21.9)
Plan
First 5 minutes
Immediate stabilization
▶
Airway risk stratification
Suction setup at bedside
Oxygen if hypoxic
Cardiac monitor if unstable or chest pain
IV access criteria
▶
Two large bore IV if unstable
One IV if stable
NPO
Aspiration precautions
Immediate consult triggers
▶
GI emergent endoscopy for complete obstruction
ENT for suspected proximal oropharyngeal foreign body
Surgery for perforation concern
Reassessment loop
Reassessment loop
▶
Vitals every 15 to 30 minutes until stable
Airway and secretion tolerance trend
Chest pain trend
Vomiting and aspiration events
Escalate if new fever or worsening pain
Diagnostic sequencing
Diagnostic sequence
▶
Plain radiographs when foreign body possible
▶
Neck soft tissue radiograph
Chest radiograph
CT neck and chest when perforation concern
Endoscopy pathway when food bolus likely and no perforation signs
Therapeutics
Symptom and definitive management
▶
Antiemetic if nausea
Analgesia titration
Glucagon trial in selected stable patients
Avoid oral liquids challenge in complete obstruction
Antibiotics if perforation or mediastinitis suspected
▶
Piperacillin tazobactam IV 4.5 g every 6 hours
Ceftriaxone IV 2 g daily
Metronidazole IV 500 mg every 8 hours
Local protocol dependent
Acid suppression when esophagitis suspected
Steroids not routine for acute impaction
Sedation and airway planning for endoscopy
Procedure readiness
▶
NPO status documentation
Airway protection planning when drooling or aspiration risk
Anesthesia involvement criteria
▶
High aspiration risk
Anticipated difficult airway
Significant comorbidity
Anticoagulation considerations for endoscopic intervention
Disposition
ICU and high acuity
ICU or high acuity criteria
▶
Airway compromise risk
Requiring intubation
Hemodynamic instability
Sepsis physiology
Suspected perforation with deterioration
Inpatient admission
Admission criteria
▶
Post endoscopy complications
Aspiration pneumonia concern
Inability to tolerate oral intake after clearance
Significant dehydration requiring IV fluids
Need for urgent inpatient diagnostic workup
▶
Suspected malignancy
Severe esophagitis
Observation pathway
Observation criteria
▶
Symptoms improving
Able to tolerate oral liquids after intervention
No systemic toxicity
Reliable follow up
Discharge criteria and follow up
Copy
Discharge criteria
▶
Complete symptom resolution
Tolerating oral intake
No perforation or aspiration concern
Stable vitals
Reliable supervision
Follow up timing
▶
GI follow up within 1 to 2 weeks after impaction
Earlier follow up when recurrent impactions
Speech language pathology follow up when neuro concern
Discharge Instructions
Copy discharge instructions
Copy
Patient instructions
▶
Diagnosis
Symptoms improved after treatment in the emergency department
Diet plan
▶
Soft foods for 24 to 48 hours
Small bites
Chew thoroughly
Medications
▶
Take prescribed acid suppression if provided
Avoid pills that previously caused pain when swallowing
Follow up
▶
Gastroenterology appointment within 1 to 2 weeks
Further testing may be needed to find the cause of the blockage
Return to emergency department now for
▶
Trouble breathing
Unable to swallow saliva
New or worsening chest pain
Fever
Vomiting blood
Severe neck pain
Fainting
References
Guidelines and key sources
Evidence sources
▶
American Society for Gastrointestinal Endoscopy guideline on ingested foreign bodies and food impactions
European Society of Gastrointestinal Endoscopy guideline on management of ingested foreign bodies
North American Society for Pediatric Gastroenterology Hepatology and Nutrition guidance for pediatric foreign body ingestion
American College of Radiology appropriateness criteria for dysphagia and suspected esophageal perforation imaging
National Capital Poison Center guidance for button battery ingestion
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Dysphagia and Food Bolus Impaction