Rosen & Barkin's 5-Minute Emergency Medicine Consult (257 page)

DIAGNOSIS

• Dysphagia: Difficulty swallowing
  
• Odynophagia: Pain with swallowing
  
• Chest pain: Angina like, often pleuritic, severe, and unrelenting
  
• Hoarseness
  
• Dyspnea
  
• Tears or perforations:
  
  • Bleeding
    
  • Hematemesis
    
• Ingestions/foreign bodies:
  
  • Drooling or excessive salivation
    
  • Choking, gagging, vomiting, stridor, or wheezing
    
  • Inability of food or liquid to pass
    
• Caustic ingestions:
  
  • Oral pain
    
  • Abdominal pain
    
  • Vomiting
    
  • Drooling
    

• History of ingestions (type, time, amount)
  
• History of protracted vomiting
  
• History of inability to swallow after eating, foreign body sensation in throat
  
• History of penetrating trauma
  
• History of cancer therapy
  

• Tears or perforations:
  
  • SubQ air at base of neck
    
  • Hamman crunch:
    
    • Systolic crunching sound secondary to air in mediastinum
      
  • Shock
    
  • Septicemia
    
  • Peritonitis
    
• Penetrating trauma:
  
  • Associated neck, chest, or abdominal injury with trauma:
    
    • Most commonly trachea
      
    • Associated with penetrating/blunt trauma
      
• Caustic ingestions:
  
  • Airway edema leading to stridor
    
  • Oral burns
    

High level of suspicion and early diagnosis are key:

• Mortality <5% for perforation if repaired within 24 hr; 75% if delayed
  
• Early endoscopy for caustic ingestions
  
• Chest/lateral neck radiograph
  

• CBC in cases of GI bleeding
  
• TXC for any extensive bleeding/OR candidate
  
• Coagulation studies
  
• Electrolytes for protracted vomiting or prolonged foreign body retention
  
• Arterial blood gas (ABG) for acid ingestions
  

• CXR for foreign body or perforation:
  
  • Pneumomediastinum
    
  • Widened mediastinum
    
  • Pneumothorax
    
  • Pleural effusion
    
• Lateral cervical spine films for foreign body or perforation:
  
  • Retropharyngeal air or fluid
    
  • Cervical emphysema
    
• Fiberoptic nasopharyngoscopy for foreign body removal
  
• Esophagram for foreign bodies or suspected perforation:
  
  • 10–25% false-negative rate
    
  • Current recommendations for water-soluble contrast (Gastrografin) 1st if perforation likely
    
  • Barium may limit visibility for later endoscopy:
    
    • More irritating if extravasates into mediastinum
      
  • Water-soluble contrast provides better visibility:
    
    • Less reaction if extravasates into mediastinum
      
    • May cause chemical pneumonitis if aspirated
      
  • Nonionic contrast may be safest but more expensive
    
• Endoscopy for suspected perforation, caustic ingestions, and esophageal foreign body removal
  
  • Severity of injury in caustic ingestions
    
    • 1st degree: Superficial mucosal damage, focal or diffuse, erythema, edema, mucosa sloughs without scar
      
    • 2nd degree: Mucosal and submucosal damage, ulcers and vesicles, granulation tissue and scar formation, stricture possible
      
    • 3rd degree: Transmural with deep ulcers, black discoloration, and wall perforation
      
• CT scanning with dilute oral contrast may be useful in diagnosis of perforations.
  

• Pulmonary:
  
  • Tracheal injury
    
  • Pneumothorax
    
• Cardiovascular:
  
  • Myocardial infarction
    
  • Aortic dissection
    
  • Spontaneous pneumomediastinum
    
• Other esophageal emergencies:
  
  • Peptic stricture
    
  • Esophageal neoplasm
    
  • Schatzki ring
    
  • Diverticula
    
  • Achalasia
    
  • Diffuse esophageal spasm
    
  • Nutcracker esophagus
    
  • Gastroesophageal reflux
    
  • Esophagitis
    
    • esophagitis esp. teracycline
      

TREATMENT

• Manage airway and resuscitate as needed
  
• Intravenous access, monitoring
  
• Early intubation for penetrating neck and chest wounds
  
• Frequent suctioning of copious secretions
  
• Fluid replacement
  

• Foreign bodies/food impaction:
  
  • 80% pass, 20% need endoscopy, <1% need surgery
    
  • Glucagon may be tried: 1 mg IV and repeated in 20 min. Carbonated beverage in combo may be more effective
    
  • Nitroglycerin or nifedipine may be tried.
    
  • Diazepam may be of benefit in the upper (striated muscle) esophagus.
    
  • GI consultation and endoscopic extraction if not relieved
    
• Caustic ingestions:
  
  • Emesis/lavage contraindicated
    
  • Immediate decontamination with milk
    
  • Avoid neutralizing agents as they may cause exothermic reaction.
    
  • GI consultation for early endoscopy to provide prognostic information
    
  • No role for corticosteroids and may be harmful
    
• Tears/perforations:
  
  • Partial-thickness tears usually heal spontaneously.
    
  • GI consultation may be needed for diagnosis (endoscopy).
    
  • Perforation requires surgical consultation for thoracotomy and primary repair; some patients may be managed nonoperatively.
    
  • Broad-spectrum parenteral antibiotics for perforation
    

• Certain swallowed foreign bodies require GI consultation and endoscopic removal:
  
  • Sharp objects: Fish bones, straight pins, razor blades, pencil
    
  • Caustic objects: Button batteries
    
• Objects may pass on their own:
  
  • Coins, buttons, marbles
    
  • Open safety pins may pass spontaneously if blunt end forward.
    
• Consult pediatric GI specialist.
  

• Foreign bodies/food impactions:
  
  • Glucagon: 1–2 mg (peds: 0.02–0.03 mg/kg) IV; may repeat once in 20 min
    
  • Nitroglycerin: 0.4 mg sublingually
    
  • Diazepam: 5–10 mg (peds: 1–2 mg) IV
    
• Perforation:
  
  • Cefoxitin: 1–2 g (peds: 100–160 mg/kg/24 h) IV q6–8h
    
  • Gentamicin: 1–1.7 mg/kg (peds: 1.5–2.5 mg/kg/24 h) IV q8h
    
  • Steroids not indicated in caustic ingestions
    

FOLLOW-UP

• Caustic ingestion
  
• Sharp foreign bodies
  
• Airway compromise
  
• Penetrating neck or chest trauma
  
• Evidence of sepsis, mediastinitis, or esophageal perforation
  
• Significant bleeding
  
• Inability to tolerate oral fluids
  

• Self-limited bleeding from partial-thickness tear
  
• Foreign body or food impaction that has passed lower esophageal sphincter
  

Factors to predict outcomes in esophageal injuries:

• Time to diagnosis and definitive therapy: 24 hr decreases mortality by half.
  
• Location of injury: Cervical less than thoracic or abdominal
  
• Mechanism of injury: Spontaneous perforation has highest mortality 30–40%; iatrogenic 15–20%, and direct trauma 5–10%.
  

• Abbas G, Schuchert MJ, Pettiford BL, et al. Contemporaneous management of esophageal perforation.
  Surgery
  . 2009;146(4):749–755.
  
• Gander JW, Berdon WE, Cowles RA. Iatrogenic esophageal perforation in children.
  Pediatr Surg Int
  . 2009;25(5):395–401.
  
• Plott E, Jones D, McDermott D, et al. A state-of-the-art review of esophageal trauma: Where do we stand?
  Dis Esophagus
  . 2007;20:279–289.
  

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