An" Otol 88 :1979
FOREIGN BODY AND CAUSTIC INGESTION: MANAGEMENT 1979 ROBERT W. CANTRELL, MD
MICHAEL E. JOHNS, MD
ROBERT A. JAHRSDOERFER, MD
W. COPLEY McLEAN, MD
CHARLO'TI'ESVILLE, VIRGINIA
Most physicians involved in the diagnosis and management of foreign body aspiration and caustic ingestion assume that the numbers of these cases are decreasing. A sizeable number of patients die of caustic ingestion and poisoning annually, and deaths from foreign body ingestion have more than doubled since 1950. Increasing the significance of these needless tragedies is the fact that the most frequent victim is a young, healthy child. Physicians should encourage educational campaigns to alert parents to the dangers of caustic agents and small items capable of being aspirated. They should be conversant with the treatment of both. This paper reviews current opinions regarding management.
Caustic ingestion of foreign bodies in the air or food passages causing obstruction or suffocation have always been dramatic and unnecessary ways to die. Generally the event is accidental and, with the exception of suicides and food aspiration leading to the "cafe coronary," the victim is usually a young, healthy child. The American Broncho-Esophagological Association (ABEA) has pioneered efforts in identifying and treating these problems and in educating the medical profession and the public to their occurrence and prevention. This Association and its members have been instrumental in urging the enactment of laws which require the labelling of poisons, identification of toys capable of being aspirated, reduction of the concentration of caustic alkalis in drain cleaners, and the development of childproof containers. This report discusses the mortality trends for foreign body and caustic ingestion, reviews efforts to reduce the incidence, and lists current treatment recommendations. INCIDENCE
Available data refer to mortality only. The actual incidence is many times higher than the figures listed here since most victims are rescued by prompt medical intervention.
Table 1 lists mortality for poisonings and foreign body aspirations for the years 1940 to 1976. Accidental poisonings include mortality from alcohol, cleansing and polishing agents, disinfectants, paints and varnishes, petroleum and solvents, pesticides and fertilizers, heavy metals and their fumes, corrosives and caustics, noxious foods and poisonous plants and unspecified solid and liquid poisons. These poisonings accounted for about 1,000 deaths annually from 1940 to 1976, the last year for which statistics are available.' The mortality rate (deaths /100,000 population) from accidental poisonings for this period was 1.0 in 1940, 0.6 in 1950, and 0.5 in 1960. Since 1970 the rate has remained stable at 0.6 (Table 1). Further trends can be observed. The number of corrosives and caustics accidentally ingested has decreased, as have most other categories except acute alcohol poisoning, which has risen 38% since 1970, and the unspecified category which includes alcohol and drugs. Prior to 1960 cleansing and polishing agents, disinfectants, paints and varnishes, and pesticides and fertilizers were not part of the index of accidental poisonings. Apparently attempts to prevent acute poisonings have been successful except for those caused by alcohol and drugs, which appear to be increasing.
From the Denartment of Otolaryngology and MaxlIIofaclal Surgery. University of Virginia. CharlottesvlIIe. Virginia. Presented at the meeting of the American Broncho-Esophagologlcal Association. Los Angeles. California, April 2-3. 1979.
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TABLE 1. MORTALITY FROM FOREIGN BODIES AND OAUSTIC AGENTS, 1940-1976
Total U.S. population (millions) Accidental poisoning Alcohol Cleansing and polishing agents Disinfectants Paints and varnishes Petroleum and solvents Pesticides and fertilizers Heavy metals and their fumes Corrosives and caustics, n.e.c. Noxious foods and poisonous plants Unspecified solids and liquids Total Death rate" Inhalation and ingestion of substances causing obstruction or suffocation Food Death rate" Other substances Death rate" Suicides Corrosive aromatics Caustic alkali
1940
1950
1960
131.6
151.1
179.3
246
357
146
78
1970
1973
1976
203.2
209.9
214.6
333 10 2 1 41 32 21 15 3 781 1,239 0.6
337 14 6 0 45 31 15 22 6 846 1,322 0.6
151 78 18 204 842 0.6
145 56 7 200 836 0.5
208 29 4 1 64 44 50 25 6 743 1,174 0.6
1,088 9310 0.7 0.70 262 0.2
1,949 1.1 448 0.2
2,059 1.0 694 0.3
2,210 1.1 803 0.4
2,144 1.0 889 0.4
39
12 43
15 23
4 33
1,324 1.0
70
'Death rate - Deaths/100,OOO population. "Mortality from inhalation and ingestion of all substances causing obstruction or suffocation. For 1940. aggregate data only are available.
Data for the inhalation or ingestion of food causing obstruction or suffocation indicate that the rate has remained constant or increased slightly since 1940, as has the rate for inhalation or ingestions of true foreign bodies. Another trend is the decrease in suicides by corrosive aromatics or caustic alkalis. Presumably the population bent on suicide has learned that there are many quicker, less painful ways to exit this world than through the ingestion of these devastating substances. Table 1 indicates that overall rates are either stable or increasing. Have attempts at education and regulation of these substances been less than optimum? One can only surmise what the rate would be if some corrective actions and educational measures had not been taken. As stated previously, members of this society have assisted in endeavors to prevent poisonings. Chevalier Jackson, MD, was instrumental in having legislation passed which required that poisonous substances be labelled with the skull
and crossbones. More recently, Frank Ritter, MD, as chairman of the Foreign Body Committee assisted in securing the reduction of caustics in liquid drain cleaners. Not all new laws, rules or regulations are greeted with enthusiasm. The Poison Prevention Packaging Acts of 1970 and 1972 mandated the use of child-resistant containers for nearly all prescription medications. Some wags have suggested that only a child can open these containers. This is only partially funny since elderly people, especially those with arthritis or other diseases diminishing dexterity, may have great difficulty opening their medications. Sherman et al" recently reported 33% of elderly patients who were given drugs in childresistant packages admitted improper use of the drug due to difficulty in opening the container. These containers have undoubtedly saved children's lives since aspirin poisoning in children dropped from 11,000 in 1966 to 3,600 in 1976. Is it necessary to do away with childproof containers to enable the elderly to open their drugs? The law al-
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lows the physician to order containers that are not child-resistant for his patients. It further allows the patient to specify a noncompliant container to the pharmacist, and finally, the pharmacist may inform the patient of the availability of such containers. These facts point out that education of patients and physicians alike can do much to gain acceptance for rules and regulations designed to reduce the accidents which are the subject of this paper. Another factor in reducing the number of dangerous objects and substances easily aspirated or ingested is consumerism. Any physician who has been sued for malpractice need not be reminded of the demands consumers place on goods and services today. The business community feels this even more acutely than the medical community. Any company marketing a faulty product which causes an injury need only be sued successfully to unleash a flood of similar suits. Consequently, they are keenly aware of these possibilities and, in most cases, try to market safe products. The federal government through the Consumer Products Safety Commission and the Environmental Protection Agency (EPA) can exert much pressure to bring civil and criminal lawsuits against errant manufacturers. One company recalled 900,000 games after two children choked to death on rubber rivets. Another company was forced to place a warning not to fire its missiles toward the face after several aspirations occurred. EPA has required recently childproof packaging of 14 pesticides used in approximately 1,000 agricultural products. Protection of the environment can cause problems. As reported before the ABEA by Morioka et al," the pull-tab openers on beer cans are one cause of environmental pollution. Ecology-minded beer drinkers thought that rather than throw these tops away, a good place for them was in the full beer can. Several accidental ingestions were enough to urge discontinuance of this practice. Aspiration of pull-tabs has resulted in a death and two esophageal perforations.' Particularly distressing is the difficulty in visualizing these aluminum tabs on x-ray.
New products are marketed and later may be found to be dangerous, such as the toys mentioned. Even seemingly innocuous materials must be scrutinized. Abramson" reported that such ubiquitous compounds as denture cleansers, not considered dangerous by many, are capable of causing severe focal to diffuse caustic bums of the esophagus if aspirated. Likewise many bleaching agents used in home laundries can cause mild to moderate esophageal burns," and the corrosive effects of caustic cleaning compounds containing lye are well known. TREATMENT
Prevention is always better than treatment. Education of the public to avoid storing lye in soft drink bottles where children can find them, not allowing toddlers to eat nuts or seeds, placing prominent warnings on dangerous toys, drugs and pesticides, and mandating child-proof containers for items with poisonous potential are effective ways to prevent some accidents. It is clear from the statistics presented that accidental poisonings are increasing numerically. All endoscopists must be familiar with treatment of these problems. Foreign Bodies. The treatment for aspirated foreign bodies is to remove them, and there are several ways of doing this. Choking on food is the one area of aspiration more common in adults than in children. Heavy ingestion of alcohol predisposes to this accident. Typically the victim is dining in a restaurant, chokes, cannot say anything and tries to reach the restroom to dislodge the food, usually a piece of meat. If he is unsuccessful, he may be found dead at the toilet, or if he falls at the tables ide, may be erroneously diagnosed as having a myocardial infarction (hence the name "cafe coronary") by his fellow diners, although the symptoms of a heart attack and choking on food are not similar. While the population rose five million from 1973 to 1976, the overall number of deaths from choking on food dropped by 66 and the rate dropped from 1.1 to 1.0/100,000. The reasons for this may be many, but it is at least in part due to the technique described by Heimlich, a member of this society. This maneuver,
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FOREIGN BODIES AND CAUSTIC AGENTS
first reported in 1974,8 consists of wrapping the arms around the standing, choking victim from behind, and grabbing one fist with the other hand. The thumb side of the fist is placed against the midriff just below the rib cage. Then, with a sudden upward thrust the fist is pressed into the victim's abdomen, several times if necessary. This forces air out of the lungs rapidly and expels the obstructing bolus. It can be accomplished with the victim lying supine as well, by kneeling over the victim and pressing into the same area of the midriff with the heel of the hand. Anyone can be taught this technique in a few minutes. Food aspiration can also occur in hospitalized patients, and in one recent series," food asphyxiation caused 1.3% of all deaths of patients who came to autopsy at a hospital for chronic disease. The patients usually died during or shortly after meals and were mistakenly diagnosed as having myocardial infarctions (8 of 14 patients). Sedation, old age and poor dentition predisposed to aspiration. Food which lodges in the esophagus is another problem, and although some local anesthetic agents may be given by mouth in an effort to relax esophageal sphincters and let the food pass, the former practice of giving meat digestants (especially when meat is obstructing) is condemned. The concept was to partially "digest" the meat in the esophagus and allow it to pass. Sometimes the esophagus itself was "digested," as suggested by reports of death from perforation and mediastinitis following the ingestion of caroid." Food lodged in the esophagus should be removed endoscopically if it does not pass in a relatively short time (approximately 12 hours) and should not be pushed into the stomach. Bones, coins or other unyielding objects should be removed as soon as possible, especially if they have sharp edges. If they enter the stomach, they may be allowed to progress through the gastrointestinal tract and most will pass. The patient must be followed carefuIlIy, however. An extensive perirectal abscess from an aspirated chicken bone has been reported." A method of identifying fish bones or
875
other small radiolucent obstructions is to fluoroscope the patient swallowing a small wisp of cotton soaked in a radiopaque material. This will frequently reveal the foreign body when the cotton is stopped by the obstruction. All foreign bodies aspirated into the tracheobronchial tree must be removed. Radiopaque items are not difficult to diagnose and locate radiographically, but plastic and rubber items, and particularly vegetable matter such as peanuts, seeds or nut shells are difficult to detect. Aspiration of foreign bodies into the tracheobronchial tree occurs most often in children aged one to three years. The aspirated items can be any item small enough to pass the glottis. Candy, which will dissolve in the tracheobronchial secretions, can cause severe respiratory obstruction." Apparently the sticky secretions cannot be cleared by coughing. Most adults can usually tell when they have aspirated a foreign body, but children, particularly toddlers who aspirate most often, usually cannot. Any child playing with, or eating, small objects who develops severe coughing or dyspnea may have aspirated. If the parents relate that kind of history to the physician, bronchoscopy is indicated even with a negative chest x-ray. Law and Kosloske-" reported success using postural drainage in dislodging foreign bodies from the tracheobronchial tree in 12 of 49 patients. Many skilled endoscopists question this, and even these authors agree that waiting beyond 24 hours is not a good idea. Since the efficacy of bronchoscopy exceeds 90% and the morbidity is low, it is accepted treatment today. Morbidity from bronchoscopy performed by a properly trained endoscopist working closely with an anesthesiologist is much less than from atelectasis that develops distal to a foreign body. Postendoscopic treatment with antibiotics and!or steroids lowers the morbidity further. Recurrent pulmonary infections, "asthma," and lung abscess are some of the complications of untreated foreign bodies in the tracheobronchial tree. If bronchoscopy is unsuccessful, thoracotomy and bronchotomy to remove the foreign body are required,
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and the parents of the patient should be appraised of this fact before bronchoscopy. The term "properly trained endoscopist" raises the question of who should remove aspirated foreign bodies, and what constitutes proper training. Some years ago, people like the Jaeksons, Norris, Holinger, Maloney, and the Tuckers removed many aspirated foreign bodies annually. Their patients were referred from hundreds of miles away. Today endoscopists see only a handful of these cases annually. Yet the total number of deaths has increased from 262 in 1950 to 889 in 1976 and the rate has doubled from 0.2 in 1950 to 0.4 in 1976. The decrease in numbers of patients with aspirated foreign bodies seen by anyone endoscopist can prevent him from developing the skills to become proficient in this field. Caseloads have been diluted by increased numbers of otolaryngologists, thoracic surgeons, pulmonary medicine specialists, gastroenterologists, general surgeons and pediatricians performing endoscopic procedures. The availability and ease of passing a fiberoptic endoscope has tempted many physicians with inadequate training to attempt removal of aspirated foreign bodies. Here, as in other aspects of medicine, the first person to attempt the treatment usually has the best chance of success provided he has two prerequisites: skill and proper equipment. A case report serves to point out some of the problems. A 47-year-old female was accompanying her politician husband on a political campaign when,
while eating some chicken, she choked. She was taken to the local hospital where a physician with a fiberoptic gastroscope was called. After a delay, alleged to be several hours, the physician arrived and passed the gastroscope without sedation, local or general anesthesia. The patient later described the experience as the worst in her life. The piece of chicken, with a bone attached, was pushed into the stomach. The next morning, the patient was transferred to a medical center and the care of a thoracic surgeon. Her white blood count was 15,000 and her temperature was 39C. Repeat esophagoscopy revealed no esophageal lacerations, but a barium swallow did show slight extravasation of radiopaque material. A nasogastric tube, nothing by mouth and massive antibiotics resulted in resolution of her symptoms. She was most fortunate since mortality from esophageal perforation is high. The Education Committee of the ABEA has attempted to establish guidelines for adequate training for an endoscopist, but there is no means of forcing compliance of these principles. Responsible physicians would not perform procedures unless they were qualified to do so, and irresponsible persons would probably ignore guidelines. As with other surgical procedures, it falls to hospital credential committees to require proof of training and experience for staff members performing endoscopy. As a minimum, any endoscopist attempting to remove a foreign body should be familiar with rigid tube endoscopy and have adequate numbers and
TABLE 2. CAUSTIC SUBSTANCES CAUSING OROPHARYNGEAL AND ESOPHAGEAL BURNS Agent Sodium hydroxide (lye, Dranow, Easy-Off®, Clinitest® tabs, Liquid plumr®) Sodium hypochlorite (Purex®, Cloroxe ) Ammonia Carbolic acid (phenol) (Lysolw) Sodium bisulfate (Sani-Flush®) Hydrochloric acid Hydrofluoric acid Sulfuric acid Acetic acid
Use Detergent washing powder, paint remover, drain pipe and toilet bowl cleaner, oven cleaner Bleach Cleaning agent, jewelry and metal polish, hair dye Antiseptic, disinfectant Toilet bowl cleaner Swimming pool acidifier, metal cleaner Rust remover Metal cleaner Permanent wave neutralizer
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When a child accidentally ingests a types of grasping forceps. Most of all, experience in using the equipment is caustic, he spits it out and hopefully only oropharyngeal bums result. An necessary. Caustic Ingestion. One of the most adult bent on suicide will continue to difficult problems facing any physician swallow. is the diagnosis and management of Upon ingesting a caustic, the patient caustic ingestion. It is a controversial experiences intense pain, esophageal subject and much has been written spasm and vomiting. The mother usabout it. The following summarizes cur- ually brings the child to the emergency rent thinking. room, and parental knowledge of first As with foreign body aspiration, the aid measures is surprisingly good. In toddler between the ages of one and 85 cases reported by Feldman et aJ15 three makes up the majority of patients 50% were given milk, water, vinegar or in all series. When the victim is an adult, citrus juice immediately following iningestion is usually a suicide attempt. gestion, and 60% of the mothers followed Table 2 lists the substances commonly the instructions on the American Medseen which can cause oropharyngeal and ical Association's "poison chart" in that esophageal burns. Alkali burns are ap- they did not try to induce vomiting or proximately ten times as common as give emetics. This contrasts with preacid burns, probably because alkalis vious statements that the parents of chilare more ubiquitous in the home. High- dren ingesting caustics were ignorant of ly alkaline drain and pipe cleaners avail- their dangerous potential; ie, high socioable in liquid or solid form are found economic status is no protection against routinely in homes, as are laundry de- caustic ingestion. tergents, bleaches or other cleansing Emergency management previously agents which can cause serious injury. consisted of attempting to neutralize Caustic soda (NaOH) or caustic potash the agent, ie, alkalis for acid and acids (KOH) can be highly destructive of for alkali ingestion. Recent work'" has mucosal tissue in seconds in concentra- shown that the recommendation to use tions under 5%. acid neutralizers results in additional The tissue damage is referred to as heat being produced by exothermic reburns, but in reality, alkalis cause liqui- action and possibly increased tissue factive necrosis which extends deeply damage. Although caustics yroduced into tissue, whereas acid burns cause heat with all diluents including milk coagulation necrosis which tends to pre- a?d water, acid antidotes prolonged the vent further damage. high temperature. The ready availability In general, acids cause less damage in of milk or water and their acceptance the esophagus due to its slightly alkaline by the child make them the diluents of nature, and more damage in the stomach choice. Milk, egg whites or any comand duodenum. Alkalis damage the monly available antacids are recommouth, oropharynx, esophagus and stom- mended for acid ingestion. ach, but tend to be neutralized by gasEmetics are contraindicated in all castric acid. es, but gastric lavage through a nasoIn a review of 105 cases by Bikhazi et gastric tube has been recommended by al,14 lye and lye products caused oro- some as a means of removing excess pharyngeal burns in 54 of 60 patients, caustic. Most authors do not recommend esophageal burns in 34 and esophageal this. stricture or death in 17 (28.3%). TwenAn attempt to identify the caustic ty-six patients ingested CloroX®, result- ingested is important, as well as a careing in nine oroyharyngeal bums and ful history. Physical examination may seven esophagea burns with no stric- show burns of the lips, mouth or tures or deaths. This illustrates that the pharynx, and respiratory symptoms may extent and severity of the chemical be present if the larynx is burned. Orodamage is due to 1) the concentration pharyngeal burns do not invariably of the ingested caustic, 2) the amount mean the esophagus is burned. Of all of the caustic ingested, and 3) the dura- patients ingesting caustics, 60-80% will tion of tissue contact. have oropharyngeal bums, but only 50Downloaded from aor.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on July 15, 2015
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60% will have esophageal burnS.14, 15, 1 1 Oropharyngeal burns usually indicate esophageal burns, but esophageal bums can be present without oropharyngeal invclvement.v-" Holinger'" and Borja et a}19 advised against esophagoscopy because of the danger of perforation, but most authors now feel that early esophagoscopy (within 12 hours of ingestion) is indicated. Most advise stopping at any circumferential bum. If no burns are seen, early discharge with follow-up can be accomplished, or if burns are present, an assessment of degree can be made with a more reasoned approach to therapy. Burns are characterized as first degree (erythema and edema), second degree (erythema, blisters and superficial ulceration), and third degree (erythema, deep ulceration and eschar formation). Most authors recommend antibiotics and steroids, but several studles'
FOREIGN BODY AND CAUSTIC INGESTION: MANAGEMENT 1979 ROBERT W. CANTRELL, MD
MICHAEL E. JOHNS, MD
ROBERT A. JAHRSDOERFER, MD
W. COPLEY McLEAN, MD
CHARLO'TI'ESVILLE, VIRGINIA
Most physicians involved in the diagnosis and management of foreign body aspiration and caustic ingestion assume that the numbers of these cases are decreasing. A sizeable number of patients die of caustic ingestion and poisoning annually, and deaths from foreign body ingestion have more than doubled since 1950. Increasing the significance of these needless tragedies is the fact that the most frequent victim is a young, healthy child. Physicians should encourage educational campaigns to alert parents to the dangers of caustic agents and small items capable of being aspirated. They should be conversant with the treatment of both. This paper reviews current opinions regarding management.
Caustic ingestion of foreign bodies in the air or food passages causing obstruction or suffocation have always been dramatic and unnecessary ways to die. Generally the event is accidental and, with the exception of suicides and food aspiration leading to the "cafe coronary," the victim is usually a young, healthy child. The American Broncho-Esophagological Association (ABEA) has pioneered efforts in identifying and treating these problems and in educating the medical profession and the public to their occurrence and prevention. This Association and its members have been instrumental in urging the enactment of laws which require the labelling of poisons, identification of toys capable of being aspirated, reduction of the concentration of caustic alkalis in drain cleaners, and the development of childproof containers. This report discusses the mortality trends for foreign body and caustic ingestion, reviews efforts to reduce the incidence, and lists current treatment recommendations. INCIDENCE
Available data refer to mortality only. The actual incidence is many times higher than the figures listed here since most victims are rescued by prompt medical intervention.
Table 1 lists mortality for poisonings and foreign body aspirations for the years 1940 to 1976. Accidental poisonings include mortality from alcohol, cleansing and polishing agents, disinfectants, paints and varnishes, petroleum and solvents, pesticides and fertilizers, heavy metals and their fumes, corrosives and caustics, noxious foods and poisonous plants and unspecified solid and liquid poisons. These poisonings accounted for about 1,000 deaths annually from 1940 to 1976, the last year for which statistics are available.' The mortality rate (deaths /100,000 population) from accidental poisonings for this period was 1.0 in 1940, 0.6 in 1950, and 0.5 in 1960. Since 1970 the rate has remained stable at 0.6 (Table 1). Further trends can be observed. The number of corrosives and caustics accidentally ingested has decreased, as have most other categories except acute alcohol poisoning, which has risen 38% since 1970, and the unspecified category which includes alcohol and drugs. Prior to 1960 cleansing and polishing agents, disinfectants, paints and varnishes, and pesticides and fertilizers were not part of the index of accidental poisonings. Apparently attempts to prevent acute poisonings have been successful except for those caused by alcohol and drugs, which appear to be increasing.
From the Denartment of Otolaryngology and MaxlIIofaclal Surgery. University of Virginia. CharlottesvlIIe. Virginia. Presented at the meeting of the American Broncho-Esophagologlcal Association. Los Angeles. California, April 2-3. 1979.
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TABLE 1. MORTALITY FROM FOREIGN BODIES AND OAUSTIC AGENTS, 1940-1976
Total U.S. population (millions) Accidental poisoning Alcohol Cleansing and polishing agents Disinfectants Paints and varnishes Petroleum and solvents Pesticides and fertilizers Heavy metals and their fumes Corrosives and caustics, n.e.c. Noxious foods and poisonous plants Unspecified solids and liquids Total Death rate" Inhalation and ingestion of substances causing obstruction or suffocation Food Death rate" Other substances Death rate" Suicides Corrosive aromatics Caustic alkali
1940
1950
1960
131.6
151.1
179.3
246
357
146
78
1970
1973
1976
203.2
209.9
214.6
333 10 2 1 41 32 21 15 3 781 1,239 0.6
337 14 6 0 45 31 15 22 6 846 1,322 0.6
151 78 18 204 842 0.6
145 56 7 200 836 0.5
208 29 4 1 64 44 50 25 6 743 1,174 0.6
1,088 9310 0.7 0.70 262 0.2
1,949 1.1 448 0.2
2,059 1.0 694 0.3
2,210 1.1 803 0.4
2,144 1.0 889 0.4
39
12 43
15 23
4 33
1,324 1.0
70
'Death rate - Deaths/100,OOO population. "Mortality from inhalation and ingestion of all substances causing obstruction or suffocation. For 1940. aggregate data only are available.
Data for the inhalation or ingestion of food causing obstruction or suffocation indicate that the rate has remained constant or increased slightly since 1940, as has the rate for inhalation or ingestions of true foreign bodies. Another trend is the decrease in suicides by corrosive aromatics or caustic alkalis. Presumably the population bent on suicide has learned that there are many quicker, less painful ways to exit this world than through the ingestion of these devastating substances. Table 1 indicates that overall rates are either stable or increasing. Have attempts at education and regulation of these substances been less than optimum? One can only surmise what the rate would be if some corrective actions and educational measures had not been taken. As stated previously, members of this society have assisted in endeavors to prevent poisonings. Chevalier Jackson, MD, was instrumental in having legislation passed which required that poisonous substances be labelled with the skull
and crossbones. More recently, Frank Ritter, MD, as chairman of the Foreign Body Committee assisted in securing the reduction of caustics in liquid drain cleaners. Not all new laws, rules or regulations are greeted with enthusiasm. The Poison Prevention Packaging Acts of 1970 and 1972 mandated the use of child-resistant containers for nearly all prescription medications. Some wags have suggested that only a child can open these containers. This is only partially funny since elderly people, especially those with arthritis or other diseases diminishing dexterity, may have great difficulty opening their medications. Sherman et al" recently reported 33% of elderly patients who were given drugs in childresistant packages admitted improper use of the drug due to difficulty in opening the container. These containers have undoubtedly saved children's lives since aspirin poisoning in children dropped from 11,000 in 1966 to 3,600 in 1976. Is it necessary to do away with childproof containers to enable the elderly to open their drugs? The law al-
Downloaded from aor.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on July 15, 2015
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CANTRELL ET AL
lows the physician to order containers that are not child-resistant for his patients. It further allows the patient to specify a noncompliant container to the pharmacist, and finally, the pharmacist may inform the patient of the availability of such containers. These facts point out that education of patients and physicians alike can do much to gain acceptance for rules and regulations designed to reduce the accidents which are the subject of this paper. Another factor in reducing the number of dangerous objects and substances easily aspirated or ingested is consumerism. Any physician who has been sued for malpractice need not be reminded of the demands consumers place on goods and services today. The business community feels this even more acutely than the medical community. Any company marketing a faulty product which causes an injury need only be sued successfully to unleash a flood of similar suits. Consequently, they are keenly aware of these possibilities and, in most cases, try to market safe products. The federal government through the Consumer Products Safety Commission and the Environmental Protection Agency (EPA) can exert much pressure to bring civil and criminal lawsuits against errant manufacturers. One company recalled 900,000 games after two children choked to death on rubber rivets. Another company was forced to place a warning not to fire its missiles toward the face after several aspirations occurred. EPA has required recently childproof packaging of 14 pesticides used in approximately 1,000 agricultural products. Protection of the environment can cause problems. As reported before the ABEA by Morioka et al," the pull-tab openers on beer cans are one cause of environmental pollution. Ecology-minded beer drinkers thought that rather than throw these tops away, a good place for them was in the full beer can. Several accidental ingestions were enough to urge discontinuance of this practice. Aspiration of pull-tabs has resulted in a death and two esophageal perforations.' Particularly distressing is the difficulty in visualizing these aluminum tabs on x-ray.
New products are marketed and later may be found to be dangerous, such as the toys mentioned. Even seemingly innocuous materials must be scrutinized. Abramson" reported that such ubiquitous compounds as denture cleansers, not considered dangerous by many, are capable of causing severe focal to diffuse caustic bums of the esophagus if aspirated. Likewise many bleaching agents used in home laundries can cause mild to moderate esophageal burns," and the corrosive effects of caustic cleaning compounds containing lye are well known. TREATMENT
Prevention is always better than treatment. Education of the public to avoid storing lye in soft drink bottles where children can find them, not allowing toddlers to eat nuts or seeds, placing prominent warnings on dangerous toys, drugs and pesticides, and mandating child-proof containers for items with poisonous potential are effective ways to prevent some accidents. It is clear from the statistics presented that accidental poisonings are increasing numerically. All endoscopists must be familiar with treatment of these problems. Foreign Bodies. The treatment for aspirated foreign bodies is to remove them, and there are several ways of doing this. Choking on food is the one area of aspiration more common in adults than in children. Heavy ingestion of alcohol predisposes to this accident. Typically the victim is dining in a restaurant, chokes, cannot say anything and tries to reach the restroom to dislodge the food, usually a piece of meat. If he is unsuccessful, he may be found dead at the toilet, or if he falls at the tables ide, may be erroneously diagnosed as having a myocardial infarction (hence the name "cafe coronary") by his fellow diners, although the symptoms of a heart attack and choking on food are not similar. While the population rose five million from 1973 to 1976, the overall number of deaths from choking on food dropped by 66 and the rate dropped from 1.1 to 1.0/100,000. The reasons for this may be many, but it is at least in part due to the technique described by Heimlich, a member of this society. This maneuver,
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first reported in 1974,8 consists of wrapping the arms around the standing, choking victim from behind, and grabbing one fist with the other hand. The thumb side of the fist is placed against the midriff just below the rib cage. Then, with a sudden upward thrust the fist is pressed into the victim's abdomen, several times if necessary. This forces air out of the lungs rapidly and expels the obstructing bolus. It can be accomplished with the victim lying supine as well, by kneeling over the victim and pressing into the same area of the midriff with the heel of the hand. Anyone can be taught this technique in a few minutes. Food aspiration can also occur in hospitalized patients, and in one recent series," food asphyxiation caused 1.3% of all deaths of patients who came to autopsy at a hospital for chronic disease. The patients usually died during or shortly after meals and were mistakenly diagnosed as having myocardial infarctions (8 of 14 patients). Sedation, old age and poor dentition predisposed to aspiration. Food which lodges in the esophagus is another problem, and although some local anesthetic agents may be given by mouth in an effort to relax esophageal sphincters and let the food pass, the former practice of giving meat digestants (especially when meat is obstructing) is condemned. The concept was to partially "digest" the meat in the esophagus and allow it to pass. Sometimes the esophagus itself was "digested," as suggested by reports of death from perforation and mediastinitis following the ingestion of caroid." Food lodged in the esophagus should be removed endoscopically if it does not pass in a relatively short time (approximately 12 hours) and should not be pushed into the stomach. Bones, coins or other unyielding objects should be removed as soon as possible, especially if they have sharp edges. If they enter the stomach, they may be allowed to progress through the gastrointestinal tract and most will pass. The patient must be followed carefuIlIy, however. An extensive perirectal abscess from an aspirated chicken bone has been reported." A method of identifying fish bones or
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other small radiolucent obstructions is to fluoroscope the patient swallowing a small wisp of cotton soaked in a radiopaque material. This will frequently reveal the foreign body when the cotton is stopped by the obstruction. All foreign bodies aspirated into the tracheobronchial tree must be removed. Radiopaque items are not difficult to diagnose and locate radiographically, but plastic and rubber items, and particularly vegetable matter such as peanuts, seeds or nut shells are difficult to detect. Aspiration of foreign bodies into the tracheobronchial tree occurs most often in children aged one to three years. The aspirated items can be any item small enough to pass the glottis. Candy, which will dissolve in the tracheobronchial secretions, can cause severe respiratory obstruction." Apparently the sticky secretions cannot be cleared by coughing. Most adults can usually tell when they have aspirated a foreign body, but children, particularly toddlers who aspirate most often, usually cannot. Any child playing with, or eating, small objects who develops severe coughing or dyspnea may have aspirated. If the parents relate that kind of history to the physician, bronchoscopy is indicated even with a negative chest x-ray. Law and Kosloske-" reported success using postural drainage in dislodging foreign bodies from the tracheobronchial tree in 12 of 49 patients. Many skilled endoscopists question this, and even these authors agree that waiting beyond 24 hours is not a good idea. Since the efficacy of bronchoscopy exceeds 90% and the morbidity is low, it is accepted treatment today. Morbidity from bronchoscopy performed by a properly trained endoscopist working closely with an anesthesiologist is much less than from atelectasis that develops distal to a foreign body. Postendoscopic treatment with antibiotics and!or steroids lowers the morbidity further. Recurrent pulmonary infections, "asthma," and lung abscess are some of the complications of untreated foreign bodies in the tracheobronchial tree. If bronchoscopy is unsuccessful, thoracotomy and bronchotomy to remove the foreign body are required,
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and the parents of the patient should be appraised of this fact before bronchoscopy. The term "properly trained endoscopist" raises the question of who should remove aspirated foreign bodies, and what constitutes proper training. Some years ago, people like the Jaeksons, Norris, Holinger, Maloney, and the Tuckers removed many aspirated foreign bodies annually. Their patients were referred from hundreds of miles away. Today endoscopists see only a handful of these cases annually. Yet the total number of deaths has increased from 262 in 1950 to 889 in 1976 and the rate has doubled from 0.2 in 1950 to 0.4 in 1976. The decrease in numbers of patients with aspirated foreign bodies seen by anyone endoscopist can prevent him from developing the skills to become proficient in this field. Caseloads have been diluted by increased numbers of otolaryngologists, thoracic surgeons, pulmonary medicine specialists, gastroenterologists, general surgeons and pediatricians performing endoscopic procedures. The availability and ease of passing a fiberoptic endoscope has tempted many physicians with inadequate training to attempt removal of aspirated foreign bodies. Here, as in other aspects of medicine, the first person to attempt the treatment usually has the best chance of success provided he has two prerequisites: skill and proper equipment. A case report serves to point out some of the problems. A 47-year-old female was accompanying her politician husband on a political campaign when,
while eating some chicken, she choked. She was taken to the local hospital where a physician with a fiberoptic gastroscope was called. After a delay, alleged to be several hours, the physician arrived and passed the gastroscope without sedation, local or general anesthesia. The patient later described the experience as the worst in her life. The piece of chicken, with a bone attached, was pushed into the stomach. The next morning, the patient was transferred to a medical center and the care of a thoracic surgeon. Her white blood count was 15,000 and her temperature was 39C. Repeat esophagoscopy revealed no esophageal lacerations, but a barium swallow did show slight extravasation of radiopaque material. A nasogastric tube, nothing by mouth and massive antibiotics resulted in resolution of her symptoms. She was most fortunate since mortality from esophageal perforation is high. The Education Committee of the ABEA has attempted to establish guidelines for adequate training for an endoscopist, but there is no means of forcing compliance of these principles. Responsible physicians would not perform procedures unless they were qualified to do so, and irresponsible persons would probably ignore guidelines. As with other surgical procedures, it falls to hospital credential committees to require proof of training and experience for staff members performing endoscopy. As a minimum, any endoscopist attempting to remove a foreign body should be familiar with rigid tube endoscopy and have adequate numbers and
TABLE 2. CAUSTIC SUBSTANCES CAUSING OROPHARYNGEAL AND ESOPHAGEAL BURNS Agent Sodium hydroxide (lye, Dranow, Easy-Off®, Clinitest® tabs, Liquid plumr®) Sodium hypochlorite (Purex®, Cloroxe ) Ammonia Carbolic acid (phenol) (Lysolw) Sodium bisulfate (Sani-Flush®) Hydrochloric acid Hydrofluoric acid Sulfuric acid Acetic acid
Use Detergent washing powder, paint remover, drain pipe and toilet bowl cleaner, oven cleaner Bleach Cleaning agent, jewelry and metal polish, hair dye Antiseptic, disinfectant Toilet bowl cleaner Swimming pool acidifier, metal cleaner Rust remover Metal cleaner Permanent wave neutralizer
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When a child accidentally ingests a types of grasping forceps. Most of all, experience in using the equipment is caustic, he spits it out and hopefully only oropharyngeal bums result. An necessary. Caustic Ingestion. One of the most adult bent on suicide will continue to difficult problems facing any physician swallow. is the diagnosis and management of Upon ingesting a caustic, the patient caustic ingestion. It is a controversial experiences intense pain, esophageal subject and much has been written spasm and vomiting. The mother usabout it. The following summarizes cur- ually brings the child to the emergency rent thinking. room, and parental knowledge of first As with foreign body aspiration, the aid measures is surprisingly good. In toddler between the ages of one and 85 cases reported by Feldman et aJ15 three makes up the majority of patients 50% were given milk, water, vinegar or in all series. When the victim is an adult, citrus juice immediately following iningestion is usually a suicide attempt. gestion, and 60% of the mothers followed Table 2 lists the substances commonly the instructions on the American Medseen which can cause oropharyngeal and ical Association's "poison chart" in that esophageal burns. Alkali burns are ap- they did not try to induce vomiting or proximately ten times as common as give emetics. This contrasts with preacid burns, probably because alkalis vious statements that the parents of chilare more ubiquitous in the home. High- dren ingesting caustics were ignorant of ly alkaline drain and pipe cleaners avail- their dangerous potential; ie, high socioable in liquid or solid form are found economic status is no protection against routinely in homes, as are laundry de- caustic ingestion. tergents, bleaches or other cleansing Emergency management previously agents which can cause serious injury. consisted of attempting to neutralize Caustic soda (NaOH) or caustic potash the agent, ie, alkalis for acid and acids (KOH) can be highly destructive of for alkali ingestion. Recent work'" has mucosal tissue in seconds in concentra- shown that the recommendation to use tions under 5%. acid neutralizers results in additional The tissue damage is referred to as heat being produced by exothermic reburns, but in reality, alkalis cause liqui- action and possibly increased tissue factive necrosis which extends deeply damage. Although caustics yroduced into tissue, whereas acid burns cause heat with all diluents including milk coagulation necrosis which tends to pre- a?d water, acid antidotes prolonged the vent further damage. high temperature. The ready availability In general, acids cause less damage in of milk or water and their acceptance the esophagus due to its slightly alkaline by the child make them the diluents of nature, and more damage in the stomach choice. Milk, egg whites or any comand duodenum. Alkalis damage the monly available antacids are recommouth, oropharynx, esophagus and stom- mended for acid ingestion. ach, but tend to be neutralized by gasEmetics are contraindicated in all castric acid. es, but gastric lavage through a nasoIn a review of 105 cases by Bikhazi et gastric tube has been recommended by al,14 lye and lye products caused oro- some as a means of removing excess pharyngeal burns in 54 of 60 patients, caustic. Most authors do not recommend esophageal burns in 34 and esophageal this. stricture or death in 17 (28.3%). TwenAn attempt to identify the caustic ty-six patients ingested CloroX®, result- ingested is important, as well as a careing in nine oroyharyngeal bums and ful history. Physical examination may seven esophagea burns with no stric- show burns of the lips, mouth or tures or deaths. This illustrates that the pharynx, and respiratory symptoms may extent and severity of the chemical be present if the larynx is burned. Orodamage is due to 1) the concentration pharyngeal burns do not invariably of the ingested caustic, 2) the amount mean the esophagus is burned. Of all of the caustic ingested, and 3) the dura- patients ingesting caustics, 60-80% will tion of tissue contact. have oropharyngeal bums, but only 50Downloaded from aor.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on July 15, 2015
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60% will have esophageal burnS.14, 15, 1 1 Oropharyngeal burns usually indicate esophageal burns, but esophageal bums can be present without oropharyngeal invclvement.v-" Holinger'" and Borja et a}19 advised against esophagoscopy because of the danger of perforation, but most authors now feel that early esophagoscopy (within 12 hours of ingestion) is indicated. Most advise stopping at any circumferential bum. If no burns are seen, early discharge with follow-up can be accomplished, or if burns are present, an assessment of degree can be made with a more reasoned approach to therapy. Burns are characterized as first degree (erythema and edema), second degree (erythema, blisters and superficial ulceration), and third degree (erythema, deep ulceration and eschar formation). Most authors recommend antibiotics and steroids, but several studles'
