title: [No Blister-Wrapped Pills: Perforation after Ingestion a Blister-Pack].
abstract: BACKGROUND
  Pills in sharp packaging that are accidentally swallowed (blisters) can cause perforations in the gastrointestinal tract, which are only clinically apparent after the emergence of mediastinitis or peritonitis. Mortality is high.
  
  
  METHODS
  We have seen two cases in cognitively limited patients, one with oesophageal and one with ileal perforation.
  
  
  RESULTS
  Despite surgery, the patient with oesophageal perforation died 3 weeks later of multi-organ failure. The patient with ileal perforation survived sepsis after multiple procedures.
  
  
  CONCLUSIONS
  As a consequence, a hospital-wide policy was implemented prohibiting the issue of tablets in blister packaging at the bedside. No more cases have emerged since that time.
authors.affiliation: Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Kliniken Sindelfingen, Klinikverbund Südwest.
authors.forename: A
authors.initials: A
authors.lastname: Prokop
authors.affiliation: Apotheke, Kliniken Sindelfingen, Klinikverbund Südwest.
authors.forename: H
authors.initials: H
authors.lastname: Stepper
authors.affiliation: Radiologie, Kliniken Sindelfingen, Klinikverbund Südwest.
authors.forename: S
authors.initials: S
authors.lastname: Koll
authors.affiliation: Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Kliniken Sindelfingen, Klinikverbund Südwest.
authors.forename: M
authors.initials: M
authors.lastname: Chmielnicki
mesh_terms: D000368:Aged; D001630:Bezoars / Q000175:diagnosis* / Q000209:etiology* / Q000628:therapy; D004349:Drug Packaging; D004939:Esophageal Perforation / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D017809:Fatal Outcome; D005260:Female; D005549:Foreign-Body Reaction / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D007416:Intestinal Perforation / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D008297:Male; D008875:Middle Aged