Tricks of the Trade: Low tech solutions to esophageal foreign bodies

Patients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline (pills shown on right) is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis.

She presents to your ED.

What do you do?

With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes and nasopharyngoscopes, you might be tempted to take a look. However, you can first take a low-tech approach to propel the pill into the stomach. Each of these options has its unique risks and complications, and the risks/benefits should be weighed appropriately.

Glucagon IV – relaxes lower esophageal sphincter (LES)
Nitroglycerin SL – relaxes LES – beware of acute hypotension
Nifedifine SL – relaxes LES – beware of acute hypotension
Carbonated beverage PO- gas forming agent to increase intraesophageal pressure

Instead of pharmacologically moving the pill into the stomach, you can also consider mechanically pushing the pill down using an orogastric tube or blindly pulling it out through the mouth using a foley catheter.

Trick of the Trade: What did we do?

Before we entertained the pharmacologic options, we gave the patient a can of Ensure, because it has a higher viscosity than water. Fifteen minutes later, the pill was pushed into the stomach and the patient’s foreign-body symptoms resolved. A simple $1.50 solution.

Teaching point

Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.

Caveat

These low-tech solutions are only appropriate for pill foreign bodies and impacted food boluses in the esophagus, which are at low risk for esophageal perforation. These are NOT applicable to special situations such as button batteries, sharp objects, fish/chicken bones, and coins.

By Michelle Lin, MD|2016-11-11T19:01:54-08:00Oct 21, 2009|Gastrointestinal, Tricks of the Trade|

Trick of the Trade: Style points in pediatric orthopedics

With this hot summer season in California, kids have been running around and getting into all sorts of orthopedic troubles. Monkey bars are a common culprit. In treating pediatric patients in the ED, it’s worth spending an extra few minutes on the subtle style points.

Trick of the Trade:

Splint the buddy bear

You should consider keeping a stash of stuffed teddy bears in the ED for those patients, whom you splint or cast. It is a nice touch to have the patient go home with a teddy bear with the same “injury” and splint/cast.

It’s the little touches that will make your patient’s day a little less sucky.

By Michelle Lin, MD|2019-02-04T03:00:51-08:00Sep 23, 2009|Orthopedic, Pediatrics, Tricks of the Trade|

Must-know toxicology website for emergency physicians

With recent discussion about the potential closing of California Poison Control Centers due to budget cuts, I suddenly became shockingly aware of how much Emergency Departments depend on these centers for assistance. They are always so knowledgeable and helpful in managing various ingestions and poisonings.

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By Michelle Lin, MD|2016-11-11T19:01:57-08:00Sep 10, 2009|Tox & Medications|

Trick of the Trade: Peritonsillar abscess needle aspiration

peritonsillar abscess

How do you drain a peritonsillar abscess?

When evaluating a patient with a sore throat and “hot potato voice,” peritonsillar abscess (PTA) is at the top of the differential diagnosis list. As with all abscesses, the definitive treatment involves drainage of pus. This can be done either by incision and drainage or, more commonly, by needle aspiration.

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By Michelle Lin, MD|2019-07-02T20:50:17-07:00Sep 9, 2009|ENT, Tricks of the Trade|

Article review: CT irradiation exposure and risk

I’m still working on my 2009 ACEP Scientific Assembly handout for the LLSA exam test prep session (which were actually due yesterday!). Even though the conference isn’t until mid-October, the handouts are always due a few months earlier. And every year, it sneaks up on me! One of the articles I’m reviewing is about the risks of CT irradiation, published in the New England Journal of Medicine in 2007.

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By Michelle Lin, MD|2016-11-11T19:01:58-08:00Aug 4, 2009|Radiology|

Article review: Propofol (2007 ACEP Guideline)

Given all the recent brouhaha around propofol and Michael Jackson, I thought I would review the 2007 Annals of EM Clinical Practice Advisory paper on the use of propofol in the Emergency Department for procedural sedation. This is one of the 2009 Lifelong Learning Self-Assessment (LLSA) articles. Each year EM-board certified physicians are tested on 20 pre-selected LLSA articles to maintain eligibility for re-certification.

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By Michelle Lin, MD|2019-09-05T20:30:32-07:00Aug 3, 2009|Guideline Review, Tox & Medications|

Top 10 list: Pearls in wound closure

This is a list of pearls and pitfalls that I share with the medical students and interns to whom I teach suturing and wound closure techniques. I can’t tell you how many pigs feet I have seen in my lifetime. Feel free to use and add to the list.

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By Michelle Lin, MD|2019-09-10T14:07:29-07:00Jun 11, 2009|Trauma|

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