Kate Parkins Lead Consultant NWTS Referral line: 08000 84 83 82 - PowerPoint PPT Presentation

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

NWTS www.nwts.nhs.uk  Consultant advice 24/7 – 08000 84 83 82  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

Case 1  3 ½ year old – ex-prem 28/40 – fit & well Cap gas  Haematemesis at nursery – bright red blood pH 7.33 pCO2 3.7 pO2  Referred to NWTS after 3 rd episode HCO3 16.4  Very pale; lethargic BE -10.2  HR 190/min; BP 77/49; RR 30-45/min Lactate 5.1

Case 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 Hb 88 AST 13  Further haematemesis + melaena WCC 41.9 ALT 15  Shock – HR 180/min; mBP ↓ Plts 1166 ALP 197 APTT 28 CRP 15  I&V – ketamine/suxamethonium INR 1.1  Further packed cells & FFP  Dopamine infusion

Case 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 2  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 Wt = 10 kg  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

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

Case 3  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 115-130/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

Case 4  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

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

USA Algorithm www.poison.org/battery/guideline.asp.  Australia  Research into safety measures  Food dye coating to stain the mouth  Bitex coating?  USA  Compulsory lockable battery compartments

Know your enemy……  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

How?  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

Size Matters!  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

Suspicious if…..  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

Ticking time bomb…..  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

Removal…. Upper airway or Oesophageal Stomach & beyond  Remove ASAP  Asymptomatic, repeat X- ray …….  Do NOT wait until fasted  Within 4 days for < 6 years of age or  At removal - note direction of button batteries > 15 mm negative pole  Repeat in 10 – 14 days for older  Remove endoscopically ASAP children if not large battery  If battery remains in stomach,  Check site for any evidence endoscopic removal recommended mucosal injury  Watch for: abdominal pain, fever,  NB 2 nd look if any signs of vomiting, haematemesis, melaena injury NB remove ASAP if co-ingested with magnet

After removal….  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

Future….  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?

Extent of problem in North West? Case 5 Case 6  2 year old referred to paeds  4 year old presents to ED  Poor appetite, abdo pain &  c/o back pain weight loss for 6 weeks  Vomited once in ED, metallic  AXR: ‘ coin ’ shaped object in object in vomit, size of a 10p lower oesophagus piece  Removal: very difficult,  What are you going to do mucosal injury now............................?  Oesophageal stricture requiring regular dilatation More cases?

Stop press!  ‘ 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 

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