Presentation on theme: "Guilty as charged: be careful of the negative effects of button batteries! Kate Parkins Lead Consultant NWTS Referral line: 08000 84 83 82."— Presentation transcript:
Guilty as charged: be careful of the negative effects of button batteries! Kate Parkins Lead Consultant NWTS Referral line:
NWTS Consultant advice 24/7 – Co-ordinate conference calls with relevant specialists Team mobile within 20mins of referral acceptance if at base At patient bedside within 2-3 hours of referral
3 ½ year old – ex-prem 28/40 – fit & well Haematemesis at nursery – bright red blood Referred to NWTS after 3 rd episode Very pale; lethargic HR 190/min; BP 77/49; RR 30-45/min Case 1 Cap gas pH7.33 pCO23.7 pO2 HCO316.4 BE-10.2 Lactate5.1
No known accidental ingestion Eg paracetamol, iron, other Initially improved with fluid resuscitation 30 mL/kg 0.9% NaCl 20 mL/kg Packed Cells Further haematemesis + melaena Shock – HR 180/min; mBP ↓ I&V – ketamine/suxamethonium Further packed cells & FFP Dopamine infusion Case 1 Hb88AST13 WCC41.9ALT15 Plts1166ALP197 APTT28CRP15 INR1.1
Omeprazole + ranitidine Octreotide infusion (on advice of gastroenterology) Massive haemorrhage – blood via mouth & nose Cardiac arrest Blood products given Packed cells 1,800 mLs FFP 900 mLs Cryoprecipitate 100 mLs Gelofusine 750 mLs Case 1
Tranexamic acid bolus & infusion Calcium gluconate Inotrope infusions Dopamine Adrenaline + boluses Sodium bicarbonate bolus x2 Foley catheter placed in oesophagus – attempt to tamponade Adrenaline via short NGT Case 1
D/W paediatric haematologist, gastroenterologist & surgeon + local consultant surgeon/adult intensivist/paediatrician “You are already doing everything I can suggest” Little other options Consider OGD – but on-going major haemorrhage/cardiac arrest! Local surgeons & paeds surgeons discussed options Surgery not an option Resus attempt: 70 mins - unsuccessful Case 1
Fit & healthy 12 month old Attended A&E: swallowed a watch battery previous day Difficulty swallowing Had not passed battery in stool Removed by paediatric surgical team (rigid gastroscope) Approx 24 hrs after ingestion Mucosal burn noted at removal site Discharged home 36 hrs later: eating/drinking normally Case 2
Presented to DGH 7 days post ingestion Haematemesis at home + active bleeding via mouth & nose Cardiac arrest soon after presentation CPR started: drugs (APLS) + blood products Intermittent cardiac output & respiratory effort Consultant surgeon called NWTS team mobilised + consultant paediatric surgeon Case 2
Laporotomy + thoracotomy Initially bleeding ‘tamponaded’: Using foley catheter + clamp across stomach BUT continued to ooze Higher thoracotomy – unable to gain control bleeding point Massive blood loss Cardiac arrest – despite rapid volume transfusion Unsuccessful resuscitation Packed cells: 3,ooo mL FFP: 1, 000 mL Platelets: 500 mL Adrenaline infusion + boluses + Calcium boluses Case 2 Wt = 10 kg
Case 1 Isolated oesophageal ulcer with oesophageal-aortic fistula Case 2 Oesophageal perforation into aberrant origin of right subclavian artery Post-mortem findings
Fit & healthy 12 month old Vomited after a feed at approx 23:00 Parents concerned: noisy breathing O/A: stridor, not drooling Increased WOB: tracheal tug, subcostal recession HR /min; RR 30/min; SpO2 96% in air Treatment: oral dexamethasone, nebulised adrenaline Case 3
CXR: button battery seen in cervical region Approx 2cm ENT conferenced into initial referral Agreed: NWTS urgent transfer to tertiary centre Theatre ASAP: battery removed from upper oesophagus Oesophageal mucosal ulceration noted at removal Difficult removal Rantidine/Co-amoxiclav/Oral dexamethasone Case 3
Review – further MLTB/OGD Vocal cord palsy Kept intubated & ventilated for 7 days Resolving – avoided tracheostomy OGD: oesophageal stricture No fistula Dilated Gastrostomy inserted
4 year old – fit & healthy Presented to A&E with battery stuck up nostril Removed approximately 4 hours after insertion Inferior septum blackened on left & right side but not perforated initially Review at 2 weeks: perforated septum Likely permanent defect Case 4
Situation elsewhere…… USA national database: over 20 years Significant ↑ in battery-related ED visits!
Australia Research into safety measures Food dye coating to stain the mouth Bitex coating? USA Compulsory lockable battery compartments USA Algorithm
Lithium Button Batteries vs others Generate more current: x2 capacitance (3 volts vs 1.5 volts) Associated with more severe complications New vs Old New more likely to cause severe injury Used/spent still generate enough current to damage tissue! Only 60-80% ingestions are witnessed Know your enemy……
3 ‘N’s – Narrow, Negative, Necrotic -ve pole = narrowest side causes severe, necrotic injury Injury caused by external electrolytic current at negative pole Hydrolysis sodium hydroxide (aka caustic soda) within 1 min pH 11 Causes liquefaction necrosis Leakage does NOT cause injury (mild irritant only – organic electrolyte) Damage can occur within 1-2 hours More severe injury after 8-12 hours How?
3 hours later…………
ANATOMICAL RUSSIAN ROULETTE 3 areas of physiological narrowing
AGE…….. Under 6 years most at risk Up to 12 years vulnerable Battery………. Any > 12 mm 20 mm more frequently get stuck in oesophagus Smaller can cause serious injury or death Size Matters!
Airway obstruction or wheeze Drooling Nausea or vomiting Chest or epigastric pain Difficulty swallowing, decreased appetite, refusal to eat Coughing, choking or gagging with eating or drinking WARNING: may be asymptomatic Suspicious if…..
Locate: CXR, AXR, neck x-ray ASAP Lateral to confirm battery not coin 5p = 18 mm; 10p = 24.5 mm AP view: “halo rim” = ring of radiolucency just inside outer edge of the object Lateral view: central bulge or “step-off“, may be difficult to appreciate if oblique or with newer, thinner Lithium batteries Ticking time bomb…..
Removal…. Upper airway or Oesophageal Remove ASAP Do NOT wait until fasted At removal - note direction of negative pole Remove endoscopically ASAP Check site for any evidence mucosal injury NB 2 nd look if any signs of injury Stomach & beyond Asymptomatic, repeat X-ray ……. Within 4 days for 15 mm Repeat in 10 – 14 days for older children if not large battery If battery remains in stomach, endoscopic removal recommended Watch for: abdominal pain, fever, vomiting, haematemesis, melaena NB remove ASAP if co-ingested with magnet
Delayed complications…… Trachoesophageal fistula Oesophageal perforation, Pneumothorax, hydrothorax Mediastinitis Vocal cord paralysis, Tracheal stenosis or tracheomalacia Aspiration pneumonia, empyema, lung abscess Spondylodiscitis Exsanguination due to perforation into major vessel Perforations/fistulas may be delayed up to 28 days!! Strictures = weeks-months After removal….
Public awareness campaign Discussions with national child safety groups Safety measures – prevention better than cure! UK guideline TOXBASE National database What’s the extent of the problem in UK? Future….
Extent of problem in North West? Case 5 2 year old referred to paeds Poor appetite, abdo pain & weight loss for 6 weeks AXR: ‘coin’ shaped object in lower oesophagus Removal: very difficult, mucosal injury Oesophageal stricture requiring regular dilatation Case 6 4 year old presents to ED c/o back pain Vomited once in ED, metallic object in vomit, size of a 10p piece What are you going to do now ? More cases?
‘Simple battery armor to protect against gastrointestinal injury from accidental ingestion’ B. Laulicht, G. Traverso, V. Deshpande, R. Langer, J. Karp Proceedings of National Academy of Sciences of USA, Nov 2014 Waterproof, pressure-sensitive battery coatings; nonconductive in the low-pressure gastrointestinal tract, yet conduct in higher-pressure standard battery housings Quantum Tunnelling Composite QTC™ = an "exciting possibility", if widespread adoption Stop press!
Courage is not the absence of fear……. But rather the judgement that something else is more important than fear Ambrose Redmoon