Medical Emergencies · patient case question
The patient who swallowed the crown has NO signs of respiratory distress. What is the appropriate action?
Patient case: Three Emergencies in One Afternoon
Patient: Three separate patients seen the same afternoon
Chief Complaint: (1) A crown slipped from the forceps and the patient swallowed it. (2) A patient's blood pressure reads 180/120 mmHg at screening. (3) A patient has a generalised seizure lasting seven minutes.
Background: Patient 1: routine crown cementation, coughed once then settled. Patient 2: known hypertensive, took no medication this morning, asymptomatic. Patient 3: known epilepsy, missed his medication.
Medications: Patient 2: amlodipine. Patient 3: levetiracetam.
Vital Signs: Patient 1: SpO₂ 99%, RR 16, speaking in full sentences. Patient 2: BP 180/120 mmHg confirmed on repeat, HR 88. Patient 3: post-ictal, then becomes cyanotic.
Findings: Patient 1: no stridor, no wheeze, no distress. Patient 2: no chest pain, no headache, no visual change, no neurological deficit. Patient 3: recovered consciousness briefly, then developed central cyanosis.
Show answer and explanation
Correct answer: A. Refer for a chest and abdominal radiograph to confirm the object is in the GI tract
- A. CORRECT. The patient is speaking normally with a normal oxygen saturation and no stridor — the object has been SWALLOWED (into the oesophagus and GI tract), not ASPIRATED. But you cannot tell radiographically-blind which it was, and an aspirated object may be initially silent. The standard of care is to refer for RADIOGRAPHS of the chest and abdomen to locate it. If it is in the GI tract, it will almost always pass spontaneously and is managed expectantly with dietary advice and follow-up.
- B. The Heimlich manoeuvre is for a patient who is CHOKING — unable to speak, cough effectively or breathe. Performing abdominal thrusts on a patient with a patent airway achieves nothing and can cause injury.
- C. Doing nothing is unacceptable because aspiration cannot be excluded clinically, and a retained aspirated object causes pneumonia, abscess or bronchiectasis.
- D. Oxygen and EMS activation are for a compromised airway. This patient's airway is intact.
Note: The prevention is the point: a rubber dam, a gauze throat screen, or floss tied to small objects prevents essentially all of these events. Note also that this exact scenario appeared twice in the recall, once phrased around the Heimlich manoeuvre for an OBSTRUCTED airway — read the stem carefully for whether respiratory signs are present.
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