Complete obstruction of esophagus (pooling, risk of aspiration)
Ingestion of button batteries
Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
Ingestion of multiple foreign bodies
Evidence of perforation
Coin at the level of the cricopharyngeus muscle (C6)in a child (Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation)
Airway compromise
Presence of foreign body for >24hr
Multiple magnets (can trap bowel)
Objects >6cm in length
Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly but do not allow food bolus to remain impacted for >12-24hr.  It is reasonable to consider therapies such as glucagon or a carbonated beverage
Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
Only one RCT of glucagon with 24 patients compared glucagon to diazepam and found no difference in the need for endoscopy
The major side effect of glucagon is vomiting and can increase the risk for esophageal perforation or aspiration. Consider pretreatment with an antiemetic
Rate of success increases with soft foods and lack of anatomic pathology, though in majority of presentations this information, particularly anatomic defects, is unknown
Carbonated beverage (effervescents) may be effective for small impactions (carbonation dilates esophagus)
Calcium channel blockers (nifedipine) / Benzos / Nitrates / papain (meat tenderizer) no longer recommended given low success and higher side effect profile
Only one RCT of glucagon with 24 patients compared glucagon to diazepam and found no difference in the need for endoscopy
The major side effect of glucagon is vomiting and can increase the risk for esophageal perforation or aspiration. Consider pretreatment with an antiemetic
Rate of success increases with soft foods and lack of anatomic pathology, though in majority of presentations this information, particularly anatomic defects, is unknown
If attempting to avoid endoscopy, there are non-endoscopic management options
Foley Catheter removal
Traditionally was done with fluoroscopy, but has been demonstrated to be safe without it. First described by Bigler et. al. in 1966 
Does not require subspecialist
Cheap, can save 300-800% on the total Emergency Department bill by avoiding endoscopy   
The diameter of the foley balloon should be decided based on the diameter measured on radiograph or with twin object brought in by a family member. This procedure can be done with or without sedation depending on the patient age and clinical comfortability but has been demonstrated to be equally effective without sedation. The catheter is then inserted into the esophagus passed the foreign body, inflated with either air or normal saline, and slowly retracted  
Gold standard is still endoscopy, but consider if endoscopy not available or after shared decision-making conversation with patient and family
Foley Catheter removal
Traditionally was done with fluoroscopy, but has been demonstrated to be safe without it. First described by Bigler et. al. in 1966 
Does not require subspecialist
Cheap, can save 300-800% on the total Emergency Department bill by avoiding endoscopy   
The diameter of the foley balloon should be decided based on the diameter measured on radiograph or with twin object brought in by a family member. This procedure can be done with or without sedation depending on the patient age and clinical comfortability but has been demonstrated to be equally effective without sedation. The catheter is then inserted into the esophagus passed the foreign body, inflated with either air or normal saline, and slowly retracted  
Gold standard is still endoscopy, but consider if endoscopy not available or after shared decision-making conversation with patient and family
Traditionally was done with fluoroscopy, but has been demonstrated to be safe without it. First described by Bigler et. al. in 1966 
Does not require subspecialist
Cheap, can save 300-800% on the total Emergency Department bill by avoiding endoscopy   
The diameter of the foley balloon should be decided based on the diameter measured on radiograph or with twin object brought in by a family member. This procedure can be done with or without sedation depending on the patient age and clinical comfortability but has been demonstrated to be equally effective without sedation. The catheter is then inserted into the esophagus passed the foreign body, inflated with either air or normal saline, and slowly retracted  
Gold standard is still endoscopy, but consider if endoscopy not available or after shared decision-making conversation with patient and family
Bougienage
The basis of this technique involves purposefully passing the object into the stomach to help facilitate spontaneous passage thereafter and ensure no esophageal impaction
Has also been described as safe (<1% complication rate), effective (>95% effective), and cheap (similar cost benefit as detailed above)   
This involves using a thin, flexible esophageal dilator and passing it from the oral cavity into the esophagus. One can measure the needed depth by measuring a Hurst dilator from the tip of the nose to the epigastrium, then a quick insertion with the child restrained can yield forced passage of the object passed the lower esophageal sphincter.
Bougienage
The basis of this technique involves purposefully passing the object into the stomach to help facilitate spontaneous passage thereafter and ensure no esophageal impaction
Has also been described as safe (<1% complication rate), effective (>95% effective), and cheap (similar cost benefit as detailed above)   
This involves using a thin, flexible esophageal dilator and passing it from the oral cavity into the esophagus. One can measure the needed depth by measuring a Hurst dilator from the tip of the nose to the epigastrium, then a quick insertion with the child restrained can yield forced passage of the object passed the lower esophageal sphincter.
The basis of this technique involves purposefully passing the object into the stomach to help facilitate spontaneous passage thereafter and ensure no esophageal impaction
Has also been described as safe (<1% complication rate), effective (>95% effective), and cheap (similar cost benefit as detailed above)   
This involves using a thin, flexible esophageal dilator and passing it from the oral cavity into the esophagus. One can measure the needed depth by measuring a Hurst dilator from the tip of the nose to the epigastrium, then a quick insertion with the child restrained can yield forced passage of the object passed the lower esophageal sphincter.
Administer 10mL of honey every 10min if child is > 12 months old and ingestion < 12 hours old 
Call the National Button Battery Ingestion Hotline: 800-498-8666 (24/7) 
True emergency if located in esophagus
Perforation can occur within 6hr of ingestion
via direct pressure or electrical conduction leading to liquefactive necrosis
Mercury toxicity
Obtain urgent endoscopic removal
Batteries past the esophagus can be managed expectantly with 24hr follow up
Perforation can occur within 6hr of ingestion
via direct pressure or electrical conduction leading to liquefactive necrosis
Mercury toxicity
Obtain urgent endoscopic removal
via direct pressure or electrical conduction leading to liquefactive necrosis
Intestinal perforation from objects distal to stomach is common (up to 35%)
Require immediate removal (even if located in stomach or duodenum)
If object is distal to duodenum and patient is asymptomatic document passage with daily films
If object is distal to duodenum and patient symptomatic obtain immediate surgery consult
If object is distal to duodenum and patient is asymptomatic document passage with daily films
If object is distal to duodenum and patient symptomatic obtain immediate surgery consult
*plastic bread clips are invisible on radiographs and CT
Multiple packets inserted in latex bags,<unk>  to cross borders
Each packet potentially toxic if bag bursts
Consider whole-bowel irrigation
Endoscopy contraindicated (high % leakage/rupture of packets)
Surgical removal indicated if evidence of systemic toxicity
Do not discharge until all packets removed or 3 packet-free stools
Each packet potentially toxic if bag bursts
Ingested foreign body
Consider tracheal/lung aspiration  of foreign body
Aspirated foreign body
Oropharyngeal dysphagia
Soft tissue foreign body
CVA
Infected G-tube
Parkinson's disease