Inhalation or ingestion of a foreign body (suspected)

Any person, 4 weeks to 15 years, presenting with a suspected inhaled or ingested foreign body.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Maintain patient’s preferred position

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency
Unconscious and/or total airway obstruction	Escalate immediately as per local CERS protocol to assist with securing airway (anaesthetist or ENT if available) Position patient supine with head-tilt, chin-lift or jaw thrust Open the mouth and carefully remove any visible object if possible Commence CPR starting with compressions Before each attempt at ventilation reassess the airway for the presence of foreign body Attempt careful removal with Magill forceps Continue CPR until assistance arrives Switch to cardiorespiratory arrest protocol

Assessment	Intervention
Conscious with partial airway obstruction: Marked tachypnoea or bradypnea Sniffing or tripod position Severe work of breathing Silent gagging or coughing Agitated or drowsy conscious state Markedly reduced air movement Stridor	Escalate immediately as per local CERS protocol to assist with securing airway (anaesthetist or ENT if available) If the patient is calm and conscious, maintain the preferred position until medical assistance is available If signs of distress or deterioration occur: Perform 5 back blows to the interscapular region Turn the patient face up If obstruction is not relieved perform 5 chest thrusts Inspect airway for foreign body dislodgement Reassess and repeat until breathing and/or coughing effectively If unconscious, switch to cardiorespiratory arrest protocol
Effective cough	Encourage coughing Observe closely for deterioration Escalate care as required

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Do not disturb the patient unnecessarily Observe for respiratory distress Assist ventilation if required Unilateral or decreased breath sounds or wheeze may be an indication for CXR Do not upset the patient unnecessarily Hypoxia in the context of airway obstruction is a late sign

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor if clinically indicated. Consider distress to patient
IVC and/or pathology	Where possible, cannulation should be avoided to minimise distress and threatening airway

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If there is pain present, escalate as per local CERS protocol

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
NBM	Keep NBM. The exception is the use of honey for button battery ingestion

Focused assessment

If there is any suspicion of moderate or severe upper airway obstruction, exercise caution with any physical assessment.

Complete a respiratory focused assessment.

Complete an abdominal focused assessment for suspected ingested foreign body.

Precautions and notes

Inhaled foreign body

• Signs and symptoms of foreign body inhalation will depend on the site of impaction, degree of blockage and type of object.
• Children under 4 years are at most risk for inhalation injuries from objects such as nuts, raw apples and carrots, seeds, popcorn, coins, balloons and pieces of toys.
• Inhalation of foreign bodies is often unwitnessed and so a high degree of suspicion is required in young children with respiratory symptoms.
• A normal respiratory examination or chest x-ray does not exclude an inhaled foreign body.

Ingested foreign body

• Most ingested foreign bodies are low risk and can be conservatively managed.
• Button batteries and magnets are high risk objects and require immediate imaging.
• Button batteries can erode mucosal surfaces in less than two hours.
• Ingestion of multiple magnets requires urgent removal.

Interventions and diagnostics

Specific treatment

Inhaled foreign body

• Stabilise the airway by either safe removal of the foreign body (see A-G) or positioning of the patient until specialist review.
• A chest x-ray, including upper airway (inspiratory/expiratory films or lateral decubitus views) is required in suspected or known inhaled foreign body.

Ingested foreign body

• Suspected or known button battery ingestion: give honey at regular intervals (patients over 12 months only).

High risk objects

• Button battery in the oesophagus
• Object over 6 cm long and 2.5 cm wide
• Two or more magnets
• A magnet and metal
• Sharp object in the oesophagus
• Toxic objects, e.g. lead based.

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Radiology

• Suspected or known inhaled foreign body: CXR and neck x-ray (inspiratory/expiratory films or lateral decubitus view)
• Ingestion of a radio-opaque foreign body: abdominal x-ray
• Button battery or magnet ingestion: urgent CXR, neck and abdominal x-ray
• Ingestion of high risk or unknown object or symptomatic and/or unwell patient: urgent CXR, neck and abdominal x-ray
• Low risk object (asymptomatic): imaging is generally not required

A normal film does not exclude an inhaled foreign body.

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au