I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

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Wednesday, 3 June 2015

Foreign Bodies

Children often swallow things. The management pretty much depends on what they have swallowed, and whether they have symptoms or not. If the child is coughing, consider that they may have inhaled the foreign body instead - the inhaled FB can act as a ball-valve and air can enter but not leave.

The Object
Button batteries, objects >5mm and sharp, and razor blades are considered dangerous. Button batteries are toxic, and have a slow but deep action, and can also cause direct pressure necrosis. Their effects may be seen after they have been removed. Open safety pins might be dangerous - sharp objects have a 15 - 35% risk of perforation.

1. X-ray if likely to be radio-opaque or "dangerous".  Request a neck and chest x-ray- an abdomen is not needed, and irradiates the gonads un-necessarily.
Look at the x-ray carefully- common points that get stuck are:
- C6 is cricopharyngeal sling and upper oesophageal sphincter
- 15% get stuck in the midoesophagus where the aortic arch and carina push on the oesophagus.
- 15% get stuck in the lower oesophageal sphincter / oesophagogastric junction
Check carefully it is a coin and not a button battery. If you are not sure if the coin is in the oesophagus or not, do a lateral film. If the coin is in the oesophagus, it appears coronal. Tracheal objects appear in a sagittal orientation.

2. Dangerous Object - refer to surgeons where ever the object is. There is some debate about button batteries if they are below the diaphragm. Above the diaphragm - in the oesophagus, nose or throat, they need to come out ASAP.

3. Above diaphragm, symptomatic, - refer to the surgeons. Most (75%) objects impact in the upper oesophagus.
b. Mild or no symptoms - home, repeat x-ray 24 hours.

4. Below diaphragm
Reassure, return if symptoms develop

5. Asymptomatic, not seen - reassure and return if symptoms develop.
b. Symptomatic - refer to surgeons

There is no need to search the poo. It might take six weeks for the foreign body to come out.

Metal Detector
The metal detector can help prove whether a FB is above the diaphragm or not. They can confirm whether the coin has reached the stomach.

(flowchart from the amazing and well worth buying http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X



  1. Airway Obstruction and foreign Bodies – Dr Stephanie Bew (Leeds)

    Hungry Hippo Foreign body
    2 year old, mum tries to remove but pushed back
    presented like epiglottitis, sat forwards, drooling
    mum very pregnant → moved to dad's knee, very upset
    Crying, partial/complete obstruction – gas induction
    ball removed with magill forceps

    FETO balloon – in utro sited balloon in trachea at 29 weeks – removal at 34 weeks
    for congenital diaghramatic hernia – complete airway obstruction unless removed

    Who - Children under age of 3 60% boys
    What - over 80% organic material depends on age
    Where - >80% in bronchial tree R>L don't forget laryngeal, tracheal, oesphageal

    Oesphageal – often at level of crycophanegeous muscle

    history – witnessed choking event, cough, dyspnoea, wheeze, stridor
    persistent cough

    only 10-20% visible on x-ray

    urgency depends on symptoms
    most UK surgeons with rigid bronchoscope
    flexible bronchoscopy if diagnostic doubt

    Traditional way, atropine, gas induction, airway local

    suggested max 4mg/kg for airway topicalisation

    start with 1% then increase concentration

    IV vs gas – IV in longer history
    controlled vs spontaneous, → need deep plane if spontaneous to avoid cough
    paralysis? → prevents laryngospasm
    TIVA? → tricky to maintain spontaneous ventilation but no theatre pollution

    immediate – hypoxia, laryngospasm, cough, oedema, bleeding, pneumothorax, lacerations, tracheostomy, cardiac arrest

    mortality 0.4% (worldwide case series)

    most bronchial FB's can be removed semi electively when starved, right kit etc
    occcassional emergency delt with as best as possible

  2. Surgical Perspective Mr David Crabb (Leeds)

    3000 hospital admissions PA in UK
    24 deaths 2003-4 all <5years old
    most commonly 1-3years old
    Food, nuts, sweets in toddlers
    small objects and balloons in older children

    BS – small parts cylinder to restrict toy parts size to reduce risk of aspiration

    CXR, lateral neck
    medistenal shift – ball valve effect of FB

    definitive management
    100% O2
    attemps to force FB into main bronchus by intubation is futile – just impacts FB

    Rigid bronchoscopy
    team discussion, correct equipment, warm equipment, slow inhalational induction maintaing spontanous ventilation, preliminary inspection, remove FB, confirmatory bronchoscopy
    if topicalised airway – distal to FB is not anaesthetised so may cough if not very deep and FB lost elsewhere in the airway

    Ventilating bronchoscope
    15mm connecting port for anaesthetic circuit
    -small size → big leak
    side ports to ventilate other lung when tip down one brochus but when in trachea may be out of larynx → leak
    smallest scope 4.5 – 5mm external diameter which will take an optical biopsy forceps

    Helpful things
    place rigid bronchoscope in trachea for surgeons – risk of dental and lip trauma

    peanut oil very irritating and can cause grannulation tissue rapidly, also can become soggy and fragment

    Button batteries – halo on CXR around dense circle
    2cm round batteries – will get lodge in oesphagus and burn rapidly

    half button battery ingestion not witnessed
    bradford case – in situ 2hrs → bilateral cord palsy and oesophageal stricture

  3. http://www.poison.org/battery/guideline

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