Foreign Body Ingestion Clinical Pathway — Emergency Department, ICU, and Inpatient

FLOC/RN Team Assessment

If the ingestion is suspected to be intentional with the goal of self-harm (e.g., child had suicidal ideation before swallowing object), activate ED Behavioral Health Pathway. Initiate consults with Social Work and Psychiatry.

History, Physical and Imaging

History	Details of Ingestion Suspected FB Witnessed by caretaker Choking episode Time of ingestion Size, configuration Sharp end Width > 2 cm, length > 5 cm (less likely to pass pylorus/duodenum) Did family bring similar object with them NPO time Hx of GI anomaly, surgery or disease (especially esophageal) Symptoms (related to age, location, size, duration of FB) FB sensation Refusing oral intake Drooling, dysphagia, gagging Choking, coughing with po intake Respiratory symptoms Stridor Hoarseness Chest pain Abdominal pain, vomiting (signs of perforation, obstruction) GI Bleeding
Physical Exam	VS, pulse ox, presence of fever Drooling, oral lesions Tripod position Neck crepitus, stridor Wheeze, unequal breath sounds Check ears and nose, especially if FB not confirmed on X-ray Signs suggesting acute abdomen

History

Details of Ingestion
- Suspected FB
  - Witnessed by caretaker
  - Choking episode
- Time of ingestion
- Size, configuration
  - Sharp end
  - Width > 2 cm, length > 5 cm (less likely to pass pylorus/duodenum)
  - Did family bring similar object with them
- NPO time
- Hx of GI anomaly, surgery or disease (especially esophageal)

Symptoms (related to age, location, size, duration of FB)
- FB sensation
- Refusing oral intake
- Drooling, dysphagia, gagging
- Choking, coughing with po intake
- Respiratory symptoms
  - Stridor
  - Hoarseness
- Chest pain
- Abdominal pain, vomiting (signs of perforation, obstruction)
- GI Bleeding

Physical Exam

VS, pulse ox, presence of fever
Drooling, oral lesions
Tripod position
Neck crepitus, stridor
Wheeze, unequal breath sounds
Check ears and nose, especially if FB not confirmed on X-ray
Signs suggesting acute abdomen

Imaging

Imaging	Imaging Triage: AP chest Additional Imaging Neck, abdomen as indicated Lateral if: Battery/magnet suspected Esophageal location FB location uncertain All coins
Imaging Tips	Flat object location on AP Esophagus: Orient in the coronal plane (e.g., coin is circular) Trachea: Orient in the sagittal plane Batteries AP: Look for double ring on AP, suggests bilaminar structure Lateral: Step-off between the anode and cathode Magnets Difficult to reliably distinguish single from multiple magnets Non-radiopaque FB Avoid GI contrast studies for suspected esophageal FBs Discuss need with GI May obscure visualization on endoscopy Increases the risk of aspiration if there is an esophageal FB Endoscopy favored CT scan may be considered in special circumstances

Imaging
- Triage: AP chest
Additional Imaging
- Neck, abdomen as indicated
- Lateral if:
  - Battery/magnet suspected
  - Esophageal location
  - FB location uncertain
  - All coins

Imaging Tips

Flat object location on AP
- Esophagus: Orient in the coronal plane (e.g., coin is circular)
- Trachea: Orient in the sagittal plane
Batteries
- AP: Look for double ring on AP, suggests bilaminar structure
- Lateral: Step-off between the anode and cathode
Magnets
- Difficult to reliably distinguish single from multiple magnets
Non-radiopaque FB
- Avoid GI contrast studies for suspected esophageal FBs
  - Discuss need with GI
  - May obscure visualization on endoscopy
  - Increases the risk of aspiration if there is an esophageal FB
- Endoscopy favored
- CT scan may be considered in special circumstances

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Foreign Body Ingestion Clinical Pathway — Emergency Department, ICU, and Inpatient

FLOC/RN Team Assessment

History, Physical and Imaging

Imaging

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Foreign Body Ingestion — Team Assessment — Clinical Pathway: Emergency, ICU and Inpatient

Foreign Body Ingestion Clinical Pathway — Emergency Department, ICU, and Inpatient

FLOC/RN Team Assessment

History, Physical and Imaging

Imaging