Lithium Disc Battery Danger for Kids (and Hot Dogs)

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which were due to disc batteries (20 millimeter lithium cells).

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

When swallowed, it can burn through the esophageal/intestinal lining causing a perforation which can lead to death if not promptly treated (or even in spite of it if too much time passes before treatment).

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

For illustrative purposes, lets see what happens to a hot dog when a lithium disc battery is placed inside it. This example was created by Dr. Stephen Marcus who is the director of the New Jersey Poison Information Center and published in the Pediatrics Blog here. You can also do this at home... give it a try (make a slit in the hot dog and push a lithium button battery into it... than watch).

Just 3 hours later, this is what you would see...

Keep disc batteries away from kids!!!

Please!!!

References:
A lithium battery in a hot dog is no picnic. Pediatrics Blog 7/2/2012


Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009. PEDIATRICS Vol. 129 No. 6 June 1, 2012 pp. 1111-1117

Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010 PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

12 Years Old Girl Dies After Tonsillectomy

Tampa Bay Times reported on June 10, 2012 a 12 years old girl died after a tonsillectomy performed on Aug 13, 2010 for chronic tonsillitis. From the details provided from the news report, it seems that several independent issues all contributed together that lead to this child's unfortunate and tragic death.

This case was also complicated by subsequent non-medically related actions taken by medical personnel which will not be discussed here.

Strictly medically speaking...

Local Anesthetic With Epinephrine

It is unclear exactly when the local anesthetic bupivacaine (Marcaine) with epinephrine was injected into the tonsil region which may help with post-tonsillectomy pain control in the pediatric population. Also unclear is what concentration and how much got injected.

However, it is far from common practice (though not rare) and it is not something I personally inject in the pediatric population for a few reasons in spite of its well-known suspicion to minimize a sore throat after surgery. (There are plenty of papers that report such injection offers NO additional pain control in children. See references below.)

1) The risk of bupivacaine is toxicity to the heart leading to arrhythmias that may ultimately lead to a heart attack.
2) Epinephrine can result in hypertension as well as further exacerbate cardiac problems

Given report of "bloody froth" in the endotracheal tube along with acute onset of tachycardia and hypertension, I suspect the child suffered from pulmonary edema, most likely secondary to accidental intra-vascular injection of the local anesthetic (causing cardiac failure) and epinephrine (causing tachycardia and hypertension).

Given these risks and fact that kids are so much smaller and more susceptible to medication risks, I personally never inject this medication during/after tonsillectomy. Even in adults, I never inject routinely, though I do offer to adults undergoing tonsillectomy (but than I use bupivacaine alone without epinephrine).

The hypertension itself led to problem #2...

Congenital Cerebellar Vascular Anomaly

The child had a congenital cerebellar vascular anomaly that ruptured leading to a life-threatening bleed in the brain.

In and of itself, this anomaly would not have been a problem, but given the reported sudden hypertension, the rupture is akin to inflating a tire with too much air causing it to pop.

Most likely, if the child's cardiovascular compromise never occurred, this bleed never would have happened in the first place.

It's also entirely possible if the local anesthetic was never used, this death would not have happened as well.


Source:
Lawsuit claims doctors' mistakes caused Palm Harbor girl to die after tonsillectomy. Tampa Bay Times 6/10/12.


References:
Comparison of clonidine, local anesthetics, and placebo for pain reduction in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg. 2011 Jun;137(6):591-7. Epub 2011 Mar 21.

Preincisional bupivacaine in posttonsillectomy pain relief: a randomized prospective study. Arch Otolaryngol Head Neck Surg. 2002 Feb;128(2):145-9.

Control of early postoperative pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J. 1993 Aug;72(8):560-3.

Head CT Scans Increase Risk of Cancer in Kids

By how much?

Brain tumor/cancer risk was 3X greater than the general population in children who received two to three CT scans of the head.

And the chance of developing leukemia was three times as great for children who received five to 10 CT scans of the head.

In the study published in Lancet, the researchers examined 176,587 children who had received a CT scan before age 22 and looked at their medical history for an average of 10 years afterward.

Though the risk sounds "high," the overall risk is still relatively small and CT scans should still be performed if medically warranted.

Phrased another way, the risk corresponds to one additional case of leukemia in the 10 years after the first scan for every 10,000 patients younger than 10 who were scanned or an extra case of brain cancer for every 30,000 children scanned.

Even so, the study does illustrate that CT scans should not be ordered unless there's a very good reason to do so, especially in children given they are more radiosensitive compared to adults.

In the ENT world, the most common reason to order a CT scan is to evaluate for sinusitis.

My own personal preference is to obtain one in children if and only if all other sinusitis interventions have already been performed.

Such "sinusitis" interventions include:

• Allergy intervention (steroid and/or anti-histamine nasal sprays)
• Failure to respond to antibiotics
• Adenoidectomy (if large adenoids present which can be determined on endoscopy)
• Turbinate Reduction (if turbinates are enlarged)
• Check for cystic fibrosis and primary ciliary dyskinesia

If above interventions have been performed, only than would I consider a CT scan of the sinuses.

Some (other ENTs) may argue that CT scan of the sinuses should be performed early as a more directed intervention can than be performed.

My argument against that is, EVEN if the CT sinus comes back abnormal, I STILL would perform the above interventions first because often the above interventions will clear up and sinus abnormality seen on a CT scan.

Only when everything else has been tried would I consider sinus surgery in a child and only than would a CT sinus be justified in my mind.

However, there are certain other situations I may consider getting a CT scan relatively quickly...

• If I find a sino-nasal mass on exam concerning for tumor or nasal polyps
• Congenital hearing loss
• Cholesteatoma (tumor of the ear)
• "Significant" Facial Trauma (ie, not just for a simple broken nose)


Reference:
Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 7 June 2012. doi:10.1016/S0140-6736(12)60815-0

Source:
Children's CT Scans Pose Cancer Risk. Wall Street Journal 6/6/12