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P2) Sudden onset chest pain and drooling in an unattended child
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with drooling and chest pain.
- Review the DDx considerations in a pediatric patient with drooling and chest pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with drooling and chest pain.
History
A 4-year-old boy presents to the emergency department with drooling and central chest pain. The parents reveal that symptoms started abruptly about two hours ago when they noticed the child was briefly choking after playing with his father’s watch.
Physical Exam
BP: 105/60, HR 96, RR 34, Temp 36.7, O2 saturation 100 %.
Pulmonary: Breath sounds present bilaterally. No stridor. Abdomen: Soft, tender, nondistended.
Labs
None.
Provisional Diagnosis
Select the Dx you believe is most appropriate
A foreign body ingestion is likely considering the acute onset of chest pain and drooling. Given the sudden onset of the symptoms and lack of fever, a pneumonia is unlikely. A pneumothorax would present with low oxygen saturation, tachycardia, and decreased breath sounds on one side.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient requires urgent workup for his condition.
First Imaging Study
What is the first imaging study you will order?
A chest X-Ray is the first test to evaluate for the presence of foreign bodies due to its decreased cost, low radiation exposure, and timeliness. Further imaging may be needed if a radiolucent foreign body such as wooden, plastic, glass or fish bones was ingested.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Two view chest X-ray
The foreign body is located in the trachea.
The frontal view shows that the object is located below the carina. Therefore, it is not in the trachea and likely in the esophagus. Its location within the esophagus is confirmed on the lateral view.
The foreign body is a:
Upon closer examination, the object has a peripheral double rim. This is known as the halo sign and indicates the object is likely a battery instead of a coin, which would appear solid. There is also the stepoff sign on the lateral view.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
The Chest X-Ray confirmed the presence of a foreign body, so no further imaging study is needed. A negative X-ray would probably warrant a CT to evaluate for possible radiolucent structures.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
Given the halo and step off sign present in radiography, we can deduce this is an ingestion of a button battery due to its location in the esophagus.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
Given that this is likely a button battery ingestion, emergent care is required to prevent caustic injury to the esophagus and adjacent structures like the trachea and aortic arch. An electrolysis reaction from the battery may also lead to formation of hydroxide radicals causing tissue necrosis. Potential complications include tracheoesophageal fistula, aortoesophageal fistula, and esophageal perforation.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is a 4-year-old male presenting with a foreign body ingestion of a button battery. They will require immediate endoscopic removal to prevent injury. Endoscopic removal can also allow for direct visualization of mucosal injury. We can also perform another endoscopy 2-3 weeks after the procedure to evaluate for delayed perforations or fistulas. Lastly, we can advise the parents of preventative safety measures to avoid another similar incident.
Lessons Learned:
- Foreign body ingestion is a common injury in pediatric patients between 3 months of age and 4 years.
- Foreign bodies ingestion or aspiration may be asymptomatic but can present with symptoms like tachypnea, drooling, dysphagia, gagging, wheezing, and stridor.
- Radiograph of the chest, neck, and upper abdomen is the first test of choice and it’s important to determine if the object is ingested or aspirated.
- The Halo Sign and Step Off Sign are good indicators that the foreign object is likely a button battery
Treatment for ingestion of a button battery involves emergent endoscopy to prevent tissue necrosis.
Socioeconomic Factors: Swallowing of a foreign object more commonly occurs in males less than five years old.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Contributors:
Jay Talati, MS2 - Content Contributor
Eva Merlob - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator
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