Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Foreign Bodies
 



SPECIFIC FOREIGN BODY LOCATIONS


Eye
Conjunctiva


Use sterile saline to wash out a foreign body embedded in the conjunctiva or, after administering a topical anaesthetic, wipe it away with a sterile, cotton tipped applicator. Eversion of the lid may be necessary to expose the foreign body.

Cornea

If the patient complains of the feeling of a foreign body but none is seen, instil two drops of 2% sodium fluorescein. A corneal abrasion, which the patient cannot distinguish from a foreign body, will be confirmed by the retention of green pigment in the abrasion. To remove a superficial corneal foreign body, use a 27-gauge needle. Apply antibiotic eye ointment and an eye patch for 24 hours. Refer patients with corneal foreign bodies that cannot be removed and ones that have corneal inflammation that persists more than 3 days.

Intraocular foreign body

An intraocular foreign body is determined by X-ray or clinical examination. Apply atropine 1%, dress the eye with a sterile pad and shield and refer the patient to an ophthalmologist. Immunize all patients with injuries to the globe for tetanus.

Ear

Children often insert foreign bodies, such as beans, peas, rice, beads, fruit seeds or small stones into their ears. Accumulated ear wax is often confused with foreign bodies. Visualize both the symptomatic and asymptomatic auditory canal to confirm the presence of a foreign body.

Use a syringe to wash the ear; this will remove most foreign bodies, but is contraindicated if the foreign body absorbs water: for example, grain or seeds. If needed, use gentle suction through a soft rubber tube. Rest the suction tip against the object (Figure 5.25).

Figure 5.25
Figure 5.25

As an alternative, pass an aural curette or hook beyond the foreign body and then turn so that the foreign body is withdrawn by the hook (Figures 5.26, 5.27). This requires gentle technique and a quiet patient; children may require a general anaesthetic. To remove a mobile insect from the ear, immobilize it with glycerol irrigation followed by a wash with a syringe.

Figure 5.26
Figure 5.26


Figure 5.26
Figure 5.27

To remove accumulated ear wax, syringe the ear with warm water. If the wax remains, instruct the patient to instil glycerol or vegetable oil drops twice daily for 2 days then repeat the syringe wash.

Nose

Visualize nasal foreign bodies to determine their nature and position. Remove a foreign body with rough surfaces with angled forceps or pass a hook beyond it, rotate the hook, and pull the object out. Alternatively, use rubber tube suction.

Airway

Airway foreign bodies are common in children; peanuts are the most frequent object. They usually lodge in the right main stem bronchus and follow an episode of choking while eating. The post aspiration wheeze may be misdiagnosed as asthma and cause a delay in diagnosis. Bronchoscopic removal is indicated.

Obstruction of the upper airway with a bolus of food occurs from improper chewing. It may be associated with poor dentition. Patients present with a sudden onset of respiratory distress while eating. Treatment is the Heimlich manoeuvre (see Unit 13: Resuscitation and Preparation for Anaesthesia and Surgery).

Gastrointestinal tract

Oesophageal and stomach foreign bodies in children usually are coins, while bones and boluses of meat are more common in adults. Objects lodge at the cricopharyngeus in the upper oesophagus, the aortic arch in the mid-oesophagus and the gastro-oesophageal junction in the distal oesophagus.

Remove objects in the upper oesophagus with a laryngoscope and Magill forceps. A rigid or flexible oesophagoscope is needed for mid and lower oesophageal objects and the patient should be referred for this treatment.

Superficial lacerations at the oesophageal entrance by fish bones result in a foreign body sensation to the patient. This will resolve in 24 hours, but may need endoscopic examination to rule out the presence of a bone.

Smooth objects that reach the stomach will generally pass through the entire gastrointestinal tract and do not require retrieval. Instruct patients or parents to check the bowel contents to confirm passage of the object. Consider removal of sharp objects by endoscopy. Adults with mental disorders may ingest large objects requiring laparotomy for removal. Treat bezoars (conglomerates of vegetable matter) by dissolving them with proteolytic enzymes (meat tenderizer).

Blunt foreign bodies in the small intestine usually pass and exit the gastrointestinal tract without difficulty. Sharp objects require careful observation with serial X-rays and operative removal if the clinical signs of intestinal perforation present. Catharsis is contraindicated.

Colon and rectum

Sharp foreign bodies may perforate the colon during transit. Remove foreign bodies placed in the rectum using general anaesthesia with muscle relaxation.

Soft tissue

Confirm foreign bodies are present (often pins or needles) in the foot or knee by X-ray. Make one attempt to remove them under local anaesthesia. If that fails, perform the procedure with ketamine or regional anaesthesia with radiological assistance, preferably fluoroscopy.
Remove bullets in subcutaneous tissue or muscle if they are grossly contaminated or if the wound requires exploration for other reasons. Leave deep seated bullets or fragments if vital structures are not in danger. Remove bullets from joint cavities.

Body cavities

Remove foreign bodies that penetrate the head, chest or abdomen in the operating room after the patient’s airway has been secured and preparations are made for the consequences of removal, which could include severe haemorrhage.



Top of Page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
  Kep Points  
The removal of a foreign body may be urgent, as in the case of airway compromise or unnecessary, as in the case of some deep metal fragments


Foreign body removal may be difficult or time-consuming; the patient should therefore be anaesthetized


 
X-ray or fluoroscopy is recommended for the removal of radiopaque objects

 
Foreign bodies in the cranium, chest or abdomen or in close proximity to vital structures must be removed in an operating room with a team prepared to manage possible complications.