fireEMS ❘ By MICK MESSOLINE
Throughout emergency medical services (EMS) schooling, there is talk about the “ABCs” (Airway, Breathing, and Circulation) and the disease processes to which they are directly related. Although not every response is for a condition with an immediate risk of death, it is important to recognize that there are many presentations still considered to be time-sensitive emergencies. One potentially serious issue that is an infrequent complaint is an esophageal blockage, which is seen infrequently and often overlooked.
RELATED
Esophageal blockage occurs when the esophagus is occluded and nothing is allowed to pass into the stomach. For the patient, this can be a very scary situation. In a complete blockage, not even liquids can be tolerated, and the patient will vomit up everything. This article will look at causes, presentation, and treatment of this rare occurrence.
Causes
Although the complaint will likely be that the patient cannot swallow, the actual condition may have a long buildup, with the blockage being the final piece of the puzzle. Many of these patients will have a history of progressive dysphagia (difficulty swallowing). Some of them may have an actual diagnosis, while others may not have a diagnosed cause of the dysphagia. In some patients, an esophageal blockage can occur suddenly with no prior warning. Some of the potential causes include the following:
- Previous injury to the esophagus.
- Foreign object restriction such as a coin or other swallowed object.
- Esophageal cancer.
- Gastro esophageal reflux disease.
- Eosinophilic esophagitis.
- A growth outside the esophagus, causing restriction.
- Achlasia (nerve issue resulting in the esophagus failing to open when swallowing).
- Abnormal or deformed esophagus.
- Esophageal stricture.
Each of these conditions creates a situation where the esophagus is either inflamed or restricted, limiting the passage of food to the stomach. Gathering a comprehensive history of events and diagnostic tests can be very valuable with these patients and can help significantly once the patient arrives at the emergency department.
Through the process of gathering history, be on the lookout for medications like omeprazole (Prilosec®) or corticosteroid inhalers. Do not overlook the inhalers; they are frequently prescribed to be used as a swallowed steroid to help reduce inflammation in the esophagus. If the patient has a treatment plan with his physician, it will also be important to know if he has had a recent endoscopy or has undergone esophageal stretching because both treatments may increase inflammation for a short time.
Presentation
Although it is great to know the cause of a condition, it is most important to be able to recognize the condition and create a treatment plan to address it. Presentation of esophageal blockage can vary greatly, but there are some constants that make forming a proper field impression much easier. As mentioned earlier, it is vital to have a complete medical history, which can be of great assistance in determining the level of the impaction.
Some of the more common signs and symptoms are the following:
- Difficulty swallowing.
- Pain in the center of the chest after swallowing.
- Sensation of stuck food.
- Vomiting soon after swallowing.
- Feeling of choking after eating or drinking.
- Persistent hiccups.
- Weight loss.
- Shortness of breath.
The most important thing to determine is whether the blockage is partial or complete. Although both can be very uncomfortable, the patient with a complete blockage will likely take more attention and should be treated as a true medical emergency. With a partial obstruction, normal body secretions may still pass through to the stomach. In the instance of a complete obstruction, normal body secretions will not pass through to the stomach and can create a period of time where the patient feels as though he cannot breathe. This sensation can result from two potential causes: (1) secretions temporarily blocking the upper airway, resulting in restricted breathing; and (2) a response to built-up secretions, resulting in the epiglottis closing to prevent secretions from entering the lungs. In either situation, the patient will likely become very anxious and panicked, as the sensation of not being able to breathe is very real.
In the setting of a complete blockage, you may see a patient sitting up or slightly slouched with a pronounced amount of drool coming from his mouth. Since the body usually absorbs these secretions through the stomach, when the esophagus is occluded, the secretions will naturally flow back out through the mouth.
Although most of these patients may not present with an esophageal complaint, they are at a very high risk for significant complications if they are ignored or mismanaged. In reality, few of these patients will complain of “esophageal” pain; more often, they present with chest pain, nausea or vomiting, epigastric pain, or difficulty breathing. It is our job to connect these complaints to their cause and associate them with the proper region of the body.
These patients can require constant reassurance and support. The sensation created by an esophageal blockage can be very similar to a choking event, resulting in high levels of anxiety and panic. This is a situation where constant support and focus can reduce the anxiety and help calm the patient. Although most EMS providers are very task oriented, it is important to remember that in some situations the most important intervention is compassion.
Treatment
Prehospital treatment of esophageal blockages is limited. In some cases, it may take a surgical intervention or direct visual removal under endoscopy. Although there are few prehospital treatments, one advanced life support (ALS) intervention may be the administration of Glucagon, one milligram IV. When given, IV Glucagon can act as a smooth muscle relaxant and decrease spasms. This may result in the impaction passing through to the stomach. In most EMS systems this would be a physician’s order only, so consult your local protocol before attempting it. If, in reviewing your local protocol, you find that there is no specific section for esophageal blockages, it may be worth visiting with your physician advisor to hear what his expectation is with these patients.
Always be prepared to support a patient with an esophageal obstruction. Have suction readily available, and be prepared for vomiting. With the impaction and the backup of secretions, it is common for patients to have nausea and violent dry heaving; this may result in an esophageal tear or rupture. A rupture could result in a significant internal hemorrhage and may require vascular support. Esophageal rupture is a true life-threatening emergency and carries a mortality rate of 10 percent to 40 percent. If you are in a system that does not have first line ALS, make sure to get them started as soon as possible to assist with any complications that may require intervention.
Many of the patients with a frequent occurrence of blockages will have already tried multiple things to clear the obstruction. Some of the things they may try have been mentioned above and may include forcefully swallowing water or self-induced vomiting. If they have tried and have been unsuccessful, believe them! Help them as you can, and find them the most prudent and safe mode of transportation to definitive care. If you are able to provide them an intervention during transport that relieves their blockage, great! If, on the other hand, you cannot, be supportive and prepared for any complications that may arise.
Reference
Vogel SB, WR Rout, TD Martin, et al. “Esophageal perforation in adults: Aggressive, conservative treatment lowers morbidity and mortality.” Ann Surg. 2005; 241(6): 1016–1023.
MICK MESSOLINE has been a firefighter/paramedic and emergency medical services educator with the Sacramento (CA) Fire Department since 1999. He began his fire service career in 1985 with the Fairmount Fire Protection District in Golden, Colorado, and spent several years with the Denver (CO) Paramedics.
