You respond lights and sirens to a popular lunch spot near the provincial legislature for a man choking. You find 56-year-old Jeff clutching at his chest, struggling to breathe and looking very panicked. Around him are dozens of other patrons looking equally panicked, uncertain of what to do. After performing a primary survey on Jeff and assisting him to your stretcher, your partner, who had been at the table talking to Jeff’s wife, comes over to tell you that he’d learned that Jeff had been eating a steak dinner and there are large pieces still on the plate.
[bg_faq_start]About Sirens to Scrubs
Sirens to Scrubs was created with the goal of helping to bridge the disconnect between pre-hospital and in-hospital care of emergency patients. The series offers in-hospital providers a glimpse into the challenges and scope of practice of out-of-hospital care while providing pre-hospital providers with an opportunity to learn about the diagnostic pathways and ED management of common (or not-so-common) clinical presentations. By opening this dialogue, we hope that these new perspectives will be translated into practice to create a smoother, more efficient, and overall positive transition for patients as they pass through the ED doors.
[bg_faq_end]Objectives
- What are signs of a life-threatening esophageal foreign body obstruction (FBO)?
- How can emergency providers manage esophageal FBOs, both in the field and in the ED?
What are signs of life-threatening injuries of an esophageal foreign body obstruction?
Our steak-eater is suffering from a “café coronary” where the meat bolus has gotten stuck in the proximal esophagus and occluded the posterior trachea, which can ultimately lead to loss of vital signs. In this situation, a history will often suggest the pathology. In the case of a complete, or near-complete proximal obstruction, the patient can become hypoxic and collapse quickly. If the proximal obstruction is partial, the patient may present with retrosternal pain that causes shortness of breath, cough (there may be hemoptysis), aphonia, stridor, diaphoresis and anxiety (you can see how history becomes so important here, as these symptoms can easily suggest other pathologies, such as cardiac ischemia or pulmonary embolism).1
When the food bolus becomes lodged in the distal esophagus, below the carina, this is sometimes called “steakhouse syndrome”.1 Although these obstructions don’t directly occlude the airway, a complete esophageal obstruction, marked by drooling or a complete inability to manage secretions, is still an airway threat and should be approached as such.
It’s easy for us to describe esophageal FBOs when it is a clear-cut presentation, but it can actually be challenging to distinguish between esophageal and airway FBOs, especially in children. Always be suspicious that this may be choking directly due to airway obstruction.1
What tools do we have to manage esophageal FBOs in the field?
Remove the object
If the patient is unresponsive, see if the object is visible in the oropharynx and, if it is, attempt to remove it with the Magill forceps. If you cannot see it, do not go digging around.
Suction
In the patient that is having trouble clearing their secretions, oropharyngeal suction with a Yankauer type tip can provide relief to the awake patient and help protect the airway.
Intubation
In a case series, it was found to be difficult to advance the tube beyond the obstruction. If the cuff is below the cords, and you cannot advance, see if you can ventilate in that position. Be careful to make sure the tube does not become dislodged if it is inserted shallowly; reassess often and use your ETCO2 to re-confirm tube placement.2
Glucagon
We all carry glucagon in our kits. In the past, glucagon has been suggested as a possible medical intervention for a food bolus stuck in the lower two-thirds of the esophagus. The muscle layers here contain smooth muscle (while the upper third is only striated, voluntary muscle), and glucagon relaxes smooth muscle. However, the evidence for this is weak while glucagon’s known side effect (vomiting) can be very serious. Vomiting is a common side effect of glucagon, which creates an airway that is difficult to manage and may lead to aspiration or esophageal perforation.1 For paramedics, the risks of glucagon likely outweighs the potential benefits (remember, if it’s in the lower esophagus, it has likely passed the carina and is thus not an emergent airway threat).
Transport
Transport the patient upright to allow them to clear their oral secretions – you do not want to complicate any esophageal injury with aspiration. If there are signs of esophageal perforation, including severe, sudden chest pain that radiates to the back or left shoulder, epigastric pain, subcutaneous emphysema (either palpable or audible, which is called Hamman’s sign), vomiting, fever, or airway compromise, then a prudent emergent return is necessary.3
Having been notified by the paramedics of their imminent arrival, you review where foreign bodies get caught in the esophagus and why
Where?4
Robert and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care (p808)
Who?
Four types of patients are at the highest risk for having an esophageal FBO:1
- Pediatric patients, especially between the ages of 18mos and 48mos (75% of presentations)
- Psychiatric patients and prisoners
- Patients without teeth (they have impaired sensation within their mouth)
- Patients with underlying esophageal disease (i.e. strictures from chronic acid reflux, mucosal rings, such as a Schatzki ring, eosinophilic esophagitis, related to food allergies and atopic disorders, malignancy, diverticula) or other conditions that can impede passage through the esophagus (i.e. enlarged left atrium, motor neuron disorders, large goiter, mediastinal tumour
Jeff has arrived awake but in distress and having difficulty clearing his secretions – what options do you have in the ED to manage the obstruction?
Upper esophageal FBOs:1
If accessible in the oropharynx, Magill forceps or Kelly clamps can be used under procedural sedation to remove the object via direct visualization.
In less severe upper esophageal FBOs (i.e. the patient is stable, in no respiratory distress, and is able to clear their secretions), other procedures that may be attempted are Foley catheter removal or Bougienage. Beyond the oropharynx, there has been significant success reported in the use of Foley catheters in cooperative patients to remove smooth foreign bodies, especially coins, that have been trapped for a short period of time (24 to 48 hours) in a structurally normal esophagus. With this technique, the uninflated Foley catheter is passed beyond the obstruction, inflated, and slowly withdrawn, pulling the esophageal foreign body with it. Bougienage is another technique that can be used in a structurally normal esophagus when the foreign body, usually a coin, has been trapped for less than 24 hours; with this technique, an esophageal dilator is entered into the esophagus where it is used to push the object through to the stomach.
Lower esophageal FBOs:1
As we discussed earlier, glucagon relaxes smooth muscle and can facilitate enough distal esophageal relaxation to allow an impacted food bolus to proceed through the esophagus to the stomach. On this topic, a consensus hasn’t been reached yet as to the balance of benefits versus risks in its use. The American Society for Gastrointestinal Endoscopy (ASGE) supports a trial of glucagon (1mg IV) in an attempt to allow spontaneous passage of the bolus in severe obstructions while endoscopic interventions are being arranged.5 Rosen’s Emergency Medicine, however, while acknowledging that glucagon may be successful in allowing passage, doesn’t recommend its use in this setting due to the risks discussed earlier.1 Thus, depending on clinician experience, available resources, and availability of rapid endoscopy, glucagon may be administered as an initial trial to encourage passage of the bolus.
Effervescent agents, such as cola, have also been used to treat new-onset food boluses. Much like glucagon, the evidence for their effectiveness is weak, and there is a risk of esophageal perforation through an ischemic esophageal wall with their use.
What are the indications for emergent/urgent endoscopic removal of an esophageal FBO?
Button batteries are an important indication for emergent consultation with the GI service, as they can cause severe tissue damage within just two hours (a result of leakage of alkaline agents, pressure necrosis, and formation of hydroxide at the negative pole of the battery from the generation of a current).1 When endoscopy is performed for an esophageal FBO, the gastroenterologist may attempt to clear it either by removing it (whole or in pieces) or by gently pushing it through to the stomach.
Other indications for urgent GI consult for consideration of endoscopy include:1,5
- Sharp objects
- Magnets
- Coins lodged in the proximal esophagus
- Inability to manage secretions
Generally speaking, the ASGE recommends removal of all esophageal FBOs within 24 hours to minimize the risk of complications, such as perforation, aortoenteric fistula (a communication between the esophagus and aorta, which can lead to life-threatening hemorrhage), or abscess formation.5
That’s it! If you have any questions, thoughts, alternative perspectives, or requests for future topics, feel free to comments below or send me an email at [email protected]. Please keep in mind that, although I will do my best to publish information that is accurate across Canada, there will inevitably be some regional differences in both pre-hospital and in-hospital management of emergency patients. As a paramedic and Emergency Medicine resident in Ontario, some posts may wind-up being somewhat Ontario-centric, hence, I encourage anyone whose experiences differ from mine to contribute to the conversation by commenting below.
Click here for more articles in the Sirens to Scrubs series!
This article was reviewed and edited by Richard Armour, BParamedPrac, MCPara, MCANZCP and Ivan McCann, BA, ACP
Paula Sneath
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Michael Kruse
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