Update on Critical I have no financial relationships with Foreign - PDF document

12/11/2012 Update on Critical I have no financial relationships with Foreign Body Ingestions any commercial entity to disclose Petar Mamula, M.D. The Children’s Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA Learning objectives Background • Be familiar with critical issues with foreign body • The challenge for the clinician is to predict which ingestions objects will not pass, or pose risk of a serious complication that would warrant removal • Understand evaluation and management of these • Understand evaluation and management of these ingestions • American Association of Poison Control Centers - 116,000 cases of foreign body ingestion in 2010 • Learn about NASPGHAN’s efforts highlighting (86,426 ≤ 5 year old) these public health issues Risks Factors for Complications Background • Most pass spontaneously- 80-90% • Size – Endoscopic removal - 10-20% – Greater than 2 cm diameter or 5 cm long unlikely to pass spontaneously – Surgical removal rare - ~1% • Location • Perforation rate <1% – Esophagus – Increased in symptomatic patients 5% • Type • Accounts for ~1500 deaths/year in US – Sharp objects, magnets, batteries 1

12/11/2012 “Stuck in a cage: Hamster swallows magnet from a toy Magnet ingestion chronology and hangs from bars by its cheek for hours” • 2002 - isolated case reports • 2006 - 20 cases of magnet ingestion and injury in children were reported in the Center for Disease Control’s Morbidity & Mortality Weekly Report y y p • 2007 - The U.S Consumer Products Safety Commission (USCPSC) issued the first warning after the death of a 20-month-old-child, as well as 33 other cases of ingestion • 2008 - USCPSC had documented more than 200 reports Neodymium Magnetic Ingestion Magnets Cases and intervention per time period • 2012 - 39 pediatric gastroenterologists responding to 120 an informal survey reported 93 cases of magnet 100 ingestion (age 1-13 years, at least 372 magnets ingested) cases 80 Number of c All ingestion cases All ingestion cases 60 Endoscopy cases – 46 (49%) endoscopies (37 or 83% successful intervention), Surgery cases 38 EGD and 8 colonoscopies Observation or lavage cases 40 – 30 (32%) patients requiring surgery (30 bowel perforations 20 or fistulas, 11 reported near perforations or areas of 0 pressure necrosis, 5 bowel resections) prior to 2009 2009-2010 2011-2012 Time period Clinical management of magnet ingestions Management of Magnet Ingestions Lavage no endoscopy Surgery Observation only Endoscopy 7% only 6% and surgery 14% 21% Endoscopy 52% Liu, S. et al. JPGN, 2005. 2

12/11/2012 NASPGHAN efforts NASPGHAN efforts • Professional education – Action Alert • Patient education – Podcast – Patient brochure – Survey – Letter to the Editor L tt t th Edit (Chandra, S. et al., JPGN 2012) (Ch d S l JPGN 2012) – Management of Ingested Magnets in Children (Hussain, S. et al., 2012 JPGN) – AAP Newsletter – To report a magnet ingestion using the Commission’s online submission form, go to http://www.cpsc.gov/ NASPGHAN efforts Magnet Algorithm • Advocacy – Meeting with the U.S. Consumer Product Safety Commission (USCPSC) – Outreach to other societies (AAP, AGA, ACG, ASGE, etc.) – Media alert (spokespersons) – July 2012- USCPSC came to an agreement with most manufacturers regarding voluntary recall except for Maxfield & Oberton, which resulted in legal action 3

12/11/2012 Initial Presentation Multiple Magnets  Obtain History All within the stomach or Beyond the stomach o Known magnet ingestion esophagus  Consult pediatric gastroenterologist and pediatric surgery, if available o Unexplained GI symptoms with rare earth magnets in the child’s environment  If pediatric gastroenterologist if  If pediatric gastroenterologist and pediatric surgeon are not available , send to ref. center  Obtain an abdominal x-ray. If magnets are present on flat plate of abdomen, obtain lateral x-ray of available, notify for removal and less abdomen  Management depends whether symptomatic or asymptomatic than 12 hours since ingestion  Determine single versus multiple magnet ingestion  If no Pediatric Gastroenterologist is available, transfer to center where Asymptomatic pediatric endoscopy is available Symptomatic Single Magnet  May remove by enteroscopy or colonoscopy if Refer to Pediatric surgery for  If ingestion is greater than 12 hours available and no signs of obstruction or perforation on removal prior to the time of procedure to x ‐ ray remove magnets and consult surgery Within the stomach, or esophagus , p g Beyond the stomach y  Consult pediatric surgery prior to endoscopic removal Consult pediatric surgery prior to endoscopic removal prior to endoscopic removal prior to endoscopic removal  Option 1: Consult pediatric gastroenterologist if  Consult pediatric gastroenterologist if available.  May follow serial x ‐ rays for progression if no signs of available. Consider removal, if accessible bowel obstruction, partial bowel obstruction or Successful removal Unsuccessful removal perforation on x ‐ ray. Note: symptoms may be subtle  Follow with serial x ‐ rays as outpatient o Consider removal especially if patient is at  Discharge home with  Refer to pediatric surgery increase risk for further ingestion.  Educate parents : appropriate follow ‐ up and for removal education  Option2: Follow with serial x ‐ rays as outpatient and No Endoscopic Removal Successful removal o Remove any magnetic objects nearby educate parents:  Refer to Pediatric surgery  Discharge home after hospital observation to ensure tolerance of o Avoid clothes with metallic buttons and belts o Remove any magnetic objects nearby  May do serial x ‐ rays in ER to check feeds with appropriate follow ‐ up with buckles for progression by checking films 4 to and education o Avoid clothes with metallic buttons and belts 6 hours apart o Ensure no other metal objects or magnets are with buckles in the child environment for accidental ingestion Progression of magnets on serial x ‐ rays No progression of magnets on serial x ‐ rays o Ensure no other metal objects or magnets are  Confirm passage with serial x ‐ rays  Educated parents on precautions and discharge with close follow ‐ up  Admit to hospital (may use PEG 3350 solution or other laxative prep solution to in the child environment for accidental ingestion aid in passage and to help prep for colonoscopy)  Confirm passage with serial x ‐ rays  Continue serial x ‐ ray every 8 to 12 hours. If no movement in 24 hours or if  If at any time magnets do not progress or patient becomes symptomatic, admit patient becomes symptomatic , proceed with surgical or endoscopic removal Battery ingestion major outcomes Battery ingestion . Litovitz et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics . Jun 2010;125(6):1168-77. Batteries • Esophageal damage can occur in a relatively short period of time- 2-3 hours when a disk battery is lodged in the esophagus Courtesy of Adele Evans M.D., Assistant Professor of Otolaryngology, Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, NC 4

12/11/2012 Mechanism of injury • Generation of an external electrolytic current that hydrolyzes tissue fluids which produces hydroxide at the battery’s negative pole Geddes LA et al. J Clin Monit 2004. • Leakage of alkaline electrolyte Negative Pole Positive Pole • Physical pressure on adjacent tissue Courtesy of Robert Kramer M.D., Co-Medical Director DHI/Director of Endoscopy and Endoscopic Training • Heat production Section of Pediatric Gastroenterology and Nutrition Childrens Hospital Colorado/University of Colorado Denver Complications of battery ingestion Complications of battery ingestion • Vocal Cord Paralysis • Esophageal Perforation • Esophageal Stricture • Tracheal Stenosis • Tracheomalacia • Tracheo-Esophageal Fistula • Hemorrhage from Arterial Fistula • Infection • Death MRI- Fluid collection measuring 1.0 x 2.0 cm in para-esophageal soft tissues Stricture Complications of battery ingestion Complications of battery ingestion • Vocal Cord Paralysis • Esophageal Perforation • Esophageal Stricture • Tracheal Stenosis • Tracheomalacia • Tracheo-Esophageal Fistula • Hemorrhage from Arterial Fistula • Infection • Death National Button Battery Association Hotline: (202) 625-3333 5