Rapid Sequence Intubation for Esophageal Coin Removal in Kids
Rapid sequence intubation by emergency physicians resulted in coin removal in 95% of patients, but 10% of procedures lasted more than 30 minutes and half the patients had complications.
Esophageal coins pass spontaneously in children about 25% of the time, but most coins must be actively removed. Methods of removal in the emergency department (ED) include bougienage, Foley catheter, and Magill forceps. Endoscopy under general anesthesia typically is not performed in stable patients and, in stable patients, is delayed until patients have fasted and intubation can be performed in a more controlled setting than the ED. These authors report a 4-year retrospective review of 101 children (age range, 4 months–13 years) who underwent rapid sequence intubation (RSI; usually with succinylcholine and etomidate) for coin removal by emergency physicians at a pediatric ED in California.
Median time from ingestion to presentation was 5 hours. Coins were successfully retrieved in 96 patients, with Magill forceps alone (56 patients) or Magill forceps plus a Foley catheter (40 patients). Complications occurred in 46 patients and included minor bleeding (13 patients), lip lacerations (7), multiple attempts (5), hypoxia (2), accidental extubation (3), dental injuries (3), and bradycardia (2) despite pretreatment with atropine in 84 cases. Median ED length of stay was 5 hours (range, 1.5–45 hours), and median time from intubation to extubation was 15 minutes (range, 2–93 minutes); nine procedures lasted more than 30 minutes.
Even at this tertiary referral center, almost 10% of procedures lasted longer than 30 minutes and nearly half the patients had complications. Faster, safer, simpler, less-expensive, and less resource-intensive techniques are more appropriate for removal of esophageal coins in most children. Why this aggressive RSI approach was used in the children in the study is unclear; however, it should be reserved for difficult cases and performed in an area of the hospital with dedicated resources.
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 1, 2011
CITATION(S): Bhargava R and Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM 2011 Jan; 13:28.