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Guilty as charged: be careful of the negative effects of button batteries! Kate Parkins Lead Consultant NWTS Referral line: 08000 84 83 82.

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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:

1 Guilty as charged: be careful of the negative effects of button batteries! Kate Parkins Lead Consultant NWTS Referral line:

2 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  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

4  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

5  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

6  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

7  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

8  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

9  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

10  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

11  Case 1  Isolated oesophageal ulcer with oesophageal-aortic fistula  Case 2  Oesophageal perforation into aberrant origin of right subclavian artery Post-mortem findings

12  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

13  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

14  Review – further MLTB/OGD  Vocal cord palsy  Kept intubated & ventilated for 7 days  Resolving – avoided tracheostomy  OGD: oesophageal stricture  No fistula  Dilated  Gastrostomy inserted

15  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

16 Situation elsewhere…… USA national database: over 20 years Significant ↑ in battery-related ED visits!

17  Australia  Research into safety measures  Food dye coating to stain the mouth  Bitex coating?  USA  Compulsory lockable battery compartments USA Algorithm

18  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……

19  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?

20 3 hours later…………

21 ANATOMICAL RUSSIAN ROULETTE 3 areas of physiological narrowing

22  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!

23  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…..

24  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…..

25 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

26  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….

27  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….

28

29 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?

30  ‘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!

31 Courage is not the absence of fear……. But rather the judgement that something else is more important than fear Ambrose Redmoon


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