01Approach to the Critical Patient/attcp56

Immediate priorities

›Airway and hemodynamic stabilization

›Immediate high-acuity location triggers

›Stridor

›Respiratory distress

›Inability to handle secretions

›Cyanosis

›Shock

›Airway protection

›If persistent drooling with declining respiratory status, intubate

›If impending obstruction, consult anesthesia and ENT for advanced airway backup

›Aspiration risk mitigation

›Upright positioning if tolerated

›Continuous suction setup

›NPO status

›Access and monitoring

›Cardiac monitor

›Pulse oximetry

›Blood pressure cycling

›Two large-bore IV lines if unstable or high-risk object

High-risk object recognition

›Object-risk stratification

›Emergent removal triggers

›Button battery in esophagus

›Multiple magnets or magnet with metal object

›Sharp or pointed object in esophagus

›Complete obstruction

›Inability to swallow saliva

02History/hx42

Focused history

›Symptom pattern

›Dysphagia

›Odynophagia

›Drooling

›Chest pain

›Globus sensation

›Regurgitation

›Cough

›Wheeze

›Stridor

›Timeline

›Time of ingestion or onset

›Duration of impaction symptoms

›Interval since last normal swallow

›Object characteristics

›Button battery possibility

›Magnet possibility

›Sharpness

›Size estimate

›Food bolus type

›Meat bolus

›Pill impaction

›High-risk background

›Known esophageal disease

›Eosinophilic esophagitis

›Stricture

›Schatzki ring

03Physical Exam/exam32

Targeted exam

›Airway and breathing

›Work of breathing

›Stridor

›Voice quality

›Wheeze

›Oxygen saturation trend

›Oropharynx and neck

›Drooling

›Trismus

›Oropharyngeal pooling

›Neck tenderness

›Subcutaneous emphysema

›Cardiovascular and perfusion

›Heart rate

›Blood pressure

›Capillary refill

›Shock index trend

›Chest and abdomen

›Chest wall tenderness

›Mediastinal crunch

›Abdominal tenderness

›Peritoneal signs

›Red-flag findings

›Toxic appearance

›Altered mental status

›Hematemesis

›Hypotension

04Differential Diagnosis/ddx21

Life-threatening and mimics

›Obstructive and airway

›Epiglottitis

›Retropharyngeal abscess

›Anaphylaxis

›Angioedema

›Esophageal emergencies

›Esophageal perforation

›Boerhaave syndrome

›Caustic ingestion injury

›Esophageal malignancy obstruction

›Cardiac and thoracic

›Acute coronary syndrome

›Aortic dissection

›Pulmonary embolism

›Functional and inflammatory

›Esophageal spasm

›GERD with severe esophagitis

›Eosinophilic esophagitis flare

Coding considerations

›ICD-10 and SNOMED CT alignment

›ICD-10 T18.1XXA foreign body in esophagus, initial encounter

›SNOMED CT foreign body in esophagus

05Laboratory Tests/lt21

Labs for complications and procedural readiness

›Targeted laboratory evaluation

›Complete blood count for fever, toxicity, or bleeding

›Leukocytosis as supportive of mediastinitis or aspiration pneumonia

›C-reactive protein for suspected deep infection

›Rising trend as supportive of complication

›Basic metabolic panel for dehydration and pre-sedation status

›Potassium and bicarbonate abnormalities with poor intake and vomiting

›Serum glucose in altered mental status

›Hypoglycemia as alternate cause of symptoms

›Coagulation studies if anticoagulated or planned high-risk endoscopy

›INR for warfarin exposure

›Anti-Xa level availability dependent for factor Xa inhibitors

›Type and screen for suspected perforation or significant bleeding

›Crossmatch if hemodynamic instability or GI hemorrhage

›Venous blood gas for respiratory distress or impending airway intervention

›pH

›pCO2 mmHg

›Lactate mmol/l for shock or sepsis concern

PITFALLS

›Limitations

›Normal labs do not exclude perforation early

›Lactate can be normal early in contained perforation

06Diagnostic Tests/dt59

Scoring Systems

›Urgency stratification framework

›Emergent endoscopy pathway

›Button battery in esophagus

›Multiple magnets

›Sharp or pointed object in esophagus

›Complete esophageal obstruction

›Urgent endoscopy pathway

›Esophageal foreign body without complete obstruction

›Food bolus with persistent symptoms

›Non-urgent pathway

›Small blunt object beyond esophagus with no symptoms

›Known passage of foreign body with reassuring exam

MRI

›MRI role and contraindications

›Limited role in acute evaluation

›Time delay compared with CT and endoscopy

›Contraindications

›Suspected metallic foreign body

›Uncertain object composition

›Potential indications

›Selected radiolucent foreign bodies with stable patient and no endoscopy access

CT

›CT indications and interpretation

›Indications

›Suspected perforation

›Severe pain with systemic toxicity

›Radiolucent foreign body with persistent symptoms and negative radiographs

07Disposition/dispo31

Level of care and follow-up

›Admission and monitored care

›ICU or step-down triggers

›Airway intervention

›Hemodynamic instability

›Significant aspiration

›Perforation or mediastinitis

›Inpatient admission triggers

›Button battery ingestion with esophageal involvement

›Multiple magnets ingestion

›Sharp object injury with mucosal damage

›Deep ulceration or necrosis on endoscopy

›Persistent dysphagia after removal

›Transfer criteria

›No urgent endoscopy capability with high-risk object

›Button battery

›Multiple magnets

›Sharp object

›Complete obstruction

›Airway risk requiring higher-level anesthesia support

›Discharge criteria

›Complete symptom resolution

›Tolerating oral intake

›No red-flag exam findings

›Reliable return precautions and follow-up

›Follow-up planning

›Gastroenterology follow-up for suspected underlying pathology

›Recurrent food bolus

08Treatment/t81

Initial management

›Supportive care

›NPO status

›No oral trials in ongoing impaction symptoms

›Suction and secretion control

›Yankauer suction at bedside

›Oxygen and ventilation support

›Supplemental oxygen for hypoxemia

›If respiratory fatigue, intubate

›Antiemetic therapy

›Ondansetron IV 4 mg

›Repeat dosing per local protocol

›Analgesia

›Fentanyl IV 25 to 50 micrograms

›Titration every 5 to 10 minutes to comfort and respiratory safety

Definitive removal

›Endoscopic removal strategy

›Timing targets

›Emergent endoscopy within 2 hours for button battery in esophagus

›Emergent endoscopy within 2 hours for complete obstruction

›Emergent endoscopy within 2 hours for sharp object in esophagus

›Urgent endoscopy within 24 hours for non-sharp esophageal foreign body

›Urgent endoscopy within 24 hours for persistent food bolus

›Technique considerations

›Overtube use for multiple passes and aspiration reduction

›Particularly for sharp objects and large bolus extraction

›Distal advancement of food bolus

›Only if no bone and low perforation risk

›Retrieval devices

›Rat-tooth forceps

›Retrieval net

›Snare

›Basket

›Protective accessories

›Transparent distal cap

›Overtube

›Hood for sharp object shielding

Pharmacologic temporization for food bolus

›Non-endoscopic options with limited evidence

›Glucagon IV 1 mg

›If partial obstruction and stable airway

›Lower success rates with structural esophageal disease

›If no response, proceed to endoscopy without delay

›Avoided therapies

›Carbonated beverages for impaction

›Aspiration risk

›Perforation risk with forceful emesis

›Proteolytic enzymes

›Mucosal injury risk

Button battery specific measures

›Pre-endoscopy mitigation

›Honey by mouth in children older than 12 months

›If able to swallow

›10 ml every 10 minutes while awaiting endoscopy

›If symptoms of complete obstruction, no oral intake

›Sucralfate suspension by mouth as alternative when available

›If able to swallow

›Post-removal injury management

›High-dose proton pump inhibitor for mucosal injury

›Pantoprazole IV 40 mg daily

›Transition to oral when tolerating intake

›Broad-spectrum antibiotics if deep ulceration or perforation concern

›Piperacillin-tazobactam IV 4.5 g every 6 hours

›Renal dosing adjustments as indicated

Antibiotics and perforation management

›Suspected perforation pathway

›Broad-spectrum IV antibiotics

›Piperacillin-tazobactam IV 4.5 g every 6 hours

›Alternative for severe penicillin allergy

›Ceftriaxone IV 2 g daily

›Plus metronidazole IV 500 mg every 8 hours

›Antifungal therapy considerations

›Immunocompromised host with mediastinitis

›Surgical consultation

›Immediate for free perforation or unstable patient

›Imaging reassessment

›CT with IV contrast for mediastinal contamination extent

Post-removal and prevention

›Underlying disease evaluation

›Eosinophilic esophagitis evaluation planning

›Biopsy strategy per gastroenterology

›Stricture evaluation planning

›Dilation timing individualized based on mucosal injury

›Acid suppression

›Proton pump inhibitor for esophagitis or mucosal injury

›Pantoprazole PO 40 mg daily

›Duration per endoscopic findings

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Imaging selection

›Plain radiographs with shielding when indicated

›CT use for suspected perforation or life-threatening complication

›Sedation considerations

›Obstetric consultation for viable gestation when procedural sedation planned

›Left lateral tilt positioning if supine intolerance

›Medication considerations

›Avoid hypotension during sedation

›Antiemetic selection with pregnancy safety in mind

Geriatric

›Geriatric considerations

›Higher prevalence of dentures related impaction

›Airway aspiration risk with poor gag reflex

›Comorbidity and anticoagulation

›Bleeding risk with mucosal trauma

›Coagulation assessment when high-risk removal anticipated

›Atypical presentation

›Minimal pain despite significant injury

Pediatrics

›Pediatric considerations

›High-risk ingestion patterns

›Button battery common in toddlers

›Magnet ingestion with bowel injury risk even after esophageal passage

›Emergent management emphasis

›Button battery in esophagus as immediate removal indication

›Honey mitigation only if age appropriate and able to swallow

10Background/b44

Epidemiology

›Epidemiologic features

›Common objects by age group

›Children

›Coins

›Button batteries

›Small toys

›Magnets

›Adults

›Food bolus

›Dentures

›Pills in blister packs

›Common impaction sites

›Upper esophageal sphincter

›Aortic arch level

›Lower esophageal sphincter

Pathophysiology

›Mechanisms of injury

›Obstruction physiology

›Salivary pooling

›Aspiration risk

›Mucosal injury patterns by object

›Button battery

›Local alkaline generation

›Rapid liquefaction necrosis

›Sharp object

›Laceration

›Perforation

11Patient Discharge Instructions/pdi19

Copy discharge instructions

›Discharge counseling

›Expected course

›Mild throat discomfort for 24 to 48 hours possible

›Soft diet progression as tolerated if advised

›Medications

›Proton pump inhibitor as prescribed

›Avoid NSAIDs if mucosal injury documented

›Return to ED immediately

›Trouble breathing

›Drooling or inability to swallow liquids

›Worsening chest pain

›Fever

›Vomiting blood

›Black stools

›Severe neck pain

›Fainting

›Follow-up

›Gastroenterology appointment if dysphagia history or recurrent impactions

›Primary care follow-up for risk factor evaluation

12References/r10

Guidelines and key sources

›Professional society guidance

›ASGE guideline on management of ingested foreign bodies and food impactions

›Endoscopic timing stratified by battery, magnets, sharp objects, and obstruction severity

›ESGE guideline on removal of foreign bodies in the upper gastrointestinal tract

›Timing and device selection recommendations

›NASPGHAN guidance on button battery ingestion in children

›Honey and sucralfate mitigation guidance while awaiting removal

›Clinical review topics

›Esophageal perforation recognition and management reviews

›Imaging findings and antibiotic strategies

Evidence & Review

Evidence & Review