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

 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

www.nwts.nhs.uk

 3 ½ year old – ex-prem 28/40 – fit & well  Haematemesis at nursery – bright red blood  Referred to NWTS after 3rd episode

 Very pale; lethargic  HR 190/min; BP 77/49; RR 30-45/min

Case 1

Cap gas pH 7.33 pCO2 3.7 pO2 HCO3 16.4 BE

• 10.2

Lactate 5.1

 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

Hb 88 AST 13 WCC 41.9 ALT 15 Plts 1166 ALP 197 APTT 28 CRP 15 INR 1.1

 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 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

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

www.poison.org/battery/guideline.asp.

 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?

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

• f 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 2nd look if any signs of injury

Stomach & beyond

 Asymptomatic, repeat X-ray …….

 Within 4 days for < 6 years of age or button batteries > 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

• bject 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