Esophageal foreign body extraction

CORRESPONDENCE

References 1.

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3. 4. 5. 6. 7. 8. 9. 10.

References

Duckman S, Chen W, Spitaleri J, et al. Comparison

of paired midstream voided and catheterized urine samples from the postpartum clinic population. Amer J Obstet Gynecol 1970;106:1184-1186. Barnes W, Albers D. Comparison of paired midstream voided and catheterized urine samples from female patients in a general hospital. Oklahoma State Med Assoc J 1978;71:82-84. Wallach J. Interpretation of Diagnostic Tests. Boston: Little, Brown, and Company, 1978:18. Rocom Reference Series. Urine Under the Microscope. Nutley, New Jersey: Rocom Press, 1973:56. Ravel R. Clinical Laboratory Medicine. Chicago: Year Book Medical Publishers, 1978:lll. Fass R, Klainer A, Perkins R. et al. Urinary tract infection. JAMA 1973;225:1509-1513. Farrar W. Infections of the urinary tract. Med Clin North Am 1983;67:187-199. McGuckin M, Cohen L, MacGregor R. Significance of pyuria in urinary sediment. J Urol 1978;120:452-454. lmmergut MA, Gilbert EC, Frensilli F, et al. The myth of the clean-catch urine specimen. Urology 1981;17:339-340. Fisher L, Johnson T, Porter D, et al. Collection of a clean voided urine specimen: A comparison among spoken, written and computer-based instructions. Am J Public Health 1977;67:640-644.

REWARMING WITH HOT PACKS To the Editor:-It was with great interest that I read the article “Thermal injury caused by hot pack application in hypothermic children” by Feldman et al in the January issue of AJEM.’ The authors certainly make a very important point about the amount of heat that is generated by instant hot packs, especially as applied to children. Exposure of adult skin to water at 52.8”C for 60 seconds will cause a fullthickness burn.* The damage caused by hot packs is obvious in light of this. However, an equally important but missed concept is that of the problems with external active rewarming of the severely hypothermic patient (<32.2”C).3 Peripheral or skin rewarming will cause warmed blood to perfuse the central circulatory system causing alternately warm and cold blood to pass through the heart, thus increasing the risk of lethal dysrhythmias. Furthermore, this warmed blood will have a significantly lower pH and higher potassium level because of anaerobic metabolism and cellular breakdown (with resultant cell death), factors that further predispose the patient to lethal dysrhythmias. Finally, hypothermic patients with frostbite should not have the frostbitten area rewarmed until core rewarming has begun to take effect3 for the same reason as stated previously. Preservation of life obviously takes precedence over that of local tissue. Consequently, the skin should not be actively rewarmed in the field. Proper measures include removal of wet clothing, wrapping in dry blankets, and protection of frostbitten areas from friction. DONALD N. COHEN,

Armonk,

New York

MD

1. Feldman KW, Morray JP, Schaller RT. Thermal injury caused by hot pack application in hypothermic children. Am J Emerg Med 1985;3:38-41. 2. Katcher ML. Scald burns from hot tap water. JAMA 1981;246:1219-1222. 3. Rueler JB. Hypothermia: Pathophysiology, clinical settings, and management. Ann Intern Med 1978;89:519-527.

ESOPHAGEAL FOREIGN BODY EXTRACTION To the EditorzRegarding Ginaldi’s article “Removal of esophageal foreign bodies using a Foley catheter in adults” in the January issue of AJEM,’ I agree that “a safe, quick method of removal [of esophageal foreign bodies] that would not necessitate hospitalization is desirable,” provided that such a method is not associated with increased morbidity or mortality as compared with endoscopic removal. However, I do not feel that there are sufficient data on Foley-catheter extraction in the literature to warrant such an emphatic endorsement of its efftcacy and safety. Several objections to the Foley-catheter technique include: 1) an inability to appreciate small esophageal lesions or granulation (which may be clinically important) and certain foreign bodies2.3 on barium swallow or fluoroscopy; 2) an inability to determine the extent of antecedent and/or iatrogenic esophageal injury1,3 with this technique; and 3) an inability to protect against airway aspiration of the foreign body upon withdrawal of the catheter. In addition, I take issue with the implications made that 1) previous esophageal pathology will usually be apparent from the history, and 2) the “shape, number, and location” of potential esophageal foreign bodies can always be ascertained with a preliminary barium swallow. No large, prospective study of a series of patients with esophageal foreign bodies managed with Foley-catheter extraction or a comparative study with endoscopic removal has yet been undertaken. Thus, the true nature and incidence of complications with this technique have not been defined. In contrast, endoscopic removal has been shown to be a safe and effective technique with low morbidity and mortality for esophageal foreign body removal in several large series.4-8 Until such a series is published regarding the use of the Foley catheter, I do not think that this method should be recommended as “the first line of treatment” or as necessarily safe or effective. LOUIS S. BINDER, MD Texas Tech University El Paso, Texas

References 1. Ginaldi S. Removal of esophageal foreign bodies using a Foley catheter in adults. Am J Emerg Med 1985;3:64-66. 2. Ritter FN. Questionable method of foreign body treatment. Ann Otolaryngol 1974;83:729-733. 3. Stool SE, Deitsch M. Potential danger of catheter removal of foreign bodies. Pediatrics 1973;51:313-314. 4. Clerf LH. Foreign bodies in the air and food passages. Surg Gynecol Obstet 1940;70:328-329. 5. Holinger PH, Johnston NC. Foreign bodies in the air and food passages. Pediatr Clin North Am 1954;1:827-843.

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6. Spitz L. Management of ingested foreign bodies in childhood. Br Med J 1971;4:469-472. 7. Baraka A, Bitchazi G. Oesophageal foreign bodies. Br Med J 1975;1:561-563. 8. Nandi P, Ong GB. Foreign bodies in the esophagus: Review of 2,394 cases. Br J Surg 1978;65:5-9. The author replies:I appreciate the interest and comments of Dr. Binder concerning the treatment of acute impaction of esophageal foreign bodies in adults. However, I differ with my colleague on both the principle and the facts of his criticism. I believe that the role of the radiologist should not be limited to confirming the clinical diagnosis, but when feasible, should help with the treatment of obstruction. First, Dr. Binder is skeptical about the accuracy of radiological investigations in ascertaining esophageal abnormalities. The literature is replete with material showing a high degree of accuracy in diagnosing esophagitis, peptic strictures, and malignancy using radiographic evaluation of the esophagus, especially by means of double-contrast techniques.‘-’ Adult patients will easily disclose what was swallowed, and the radiologist can therefore carefully ascertain whether the impacted foreign body, most often impacted food, is abrasive or sharp. A detailed clinical history is mandatory to be certain that the proposed treatment will not harm the patient. No studies comparing the method illustrated in my article with endoscopic removal exist, but they will probably never exist because of the situation. The same foreign body, once extracted, will probably never be put back in the same location for a direct comparison with the other method. Several articles in the literature illustrate the merit of the procedure using Foley catheters in children.8-‘2 No complications have been reported in many hundreds of pediatric patients. I have had the opportunity to perform the procedure to date in 18 patients without complications, but with failure in two patients. In both cases the swallowed foreign body was present for over 24 hours. If, as Dr. Binder suggests, esophagoscopy is preferable he should compare the substantially increased cost and risks of complications from endoscopy, with associated sedation and trauma, with the theoretical or potential complication of retrieval of smoothly defined foreign bodies. The treatment of this condition endoscopically may not be available in some centers, whereas radiographic and fluoroscopic procedures can be readily performed without delay. Familiarity in interventional procedures, though not mandatory, will further facilitate the approach to the situation. Although some patients will still require endoscopy, especially if a long time has passed since the moment of impaction (and, of course, if we are dealing with sharp and abrasive materials), I feel that the “Foley catheter technique” is safe, cost-effective, and, in the proper clinical setting, the procedure of choice for the removal of blunt impacted foreign bodies from the esophagus in adults. SERGIO GINALDI, MD

Tallahassee, Florida

References 1. Feczko PJ, Simms SM, lorio J, et al. Gastroduodenal sponse to low-dose glucagon. AJR 1983;140:935-940. 372

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2. Creteur V, Thoeni

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RF, Federle MP, et al. The role of single and double contrast radiography in the diagnosis of reflux esophagitis. Radiology 1983;147:71-75. Kressel HY, Glick SN, Laufer I, et al. Radiologic features of esophagitis. Gastrointest Radio1 1981;6:103-108. Ott DJ, Gelfand DW, Lane TG, Wu WC. Radiologic detection and spectrum of appearances of peptic esophageal strictures. J Clin Gastroenterol 1982;4:11-15. Koehler RE, Moss AA, Margulis AR. Early radiographic manifestation of carcinoma of the esophagus. Radiology 1976;119:1-5. Moss AA, Koehler RE, Margulis AR. Initial accuracy of esophagrams in detection of small esophageal carcinomas AJR 1976;127:909-913. Zornoza J, Lindell MM Jr. Radiologic evaluation of small esophageal carcinoma. Gastrointest Radio1 1980;5:107111. Shackelford GD, McAlister WH, Robertson CL. The use of a Foley catheter for removal of blunt esophageal foreign bodies from children. Radiology 1972;105:455-456. Henry LN, Chamberlain JW. Removal of foreign bodies from esophagus and nose with the use of a Foley catheter. Surgery 1972;71:918-921. Growe JE. Removal of blunt esophageal foreign bodies: Foley catheter technique. NC Med J 1976;37:431-432. Campbell JB, Anattomeni FL, Foley LC. Foley catheter removal of blunt esophageal foreign bodies-Experience with 100 consecutive children. Pediatr Radio1 1983;13:116-119. Nixon GW. Foley catheter method of esophageal foreign body removal. AJR 1979;132:441-442.

PHYSICIAN-ATTENDED MlCUs To the Editor:-In the January 1985 issue of AJEM, Applebaum’ reports that Jerusalem’s physician-attended mobile intensive care unit (MICU) saved the city’s “backlogged” emergency departments (EDs) 1,200 visits over the course of a year, or about 1% of the city’s annual ED volume. In an accompanying editorial, Thompson’ suggests taking the emergency physician off the MICU so that he can augment ED staffing and provide greater relief for crowded waiting rooms. As Dr. Applebaum points out, the main reasons for physician staffing of the MICU are not economic and never have been. They are based on the assumption that emergency physicians can provide a very high level of pre-hospital treatment, better even than remote-controlled paramedics. Until this assumption is disproven, there is no reason to take the emergency physician off the MICU. A recent study3 showed that 62% of Jerusalem’s ED patients are discharged from the ED within four hours of arrival. Backlogs exist at times, but they are not backlogs of emergency patients. The latter are evaluated and treated expeditiously by emergency physicians who are backed up, when necessary, by on-duty hospital residents and senior staff. Emergency department waiting rooms here, as elsewhere, are crowded with patients who have routine medical complaints. The solution to ED crowding in Jerusalem includes 1) adequate community primary-care coverage (Kupat Holim Sick Fund clinics are open, on the average, only four hours a day); 2) education of the public to the appropriate use of the ED; 3) non-reimbursement by Kupat Holim of non-urgent ED visits: and 4) effective triage before