Keywords: pain management, ketamine (PubMed Search)
Silva LOJ, Lee JY, Bellolio F, Homme JL, Anderson JL. Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis. American Journal of Emergency Medicine. 2020 (38)1860-1866. doi: 10.1016/j.ajem.2020.05.094
Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)
Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.
Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.
Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.
Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.
Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.
Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.
Anfang RR, Jatana KR, Linn RL, et al. pH-Neutralizing Esophageal Irrigations as a Novel Mitigation Strategy for Button Battery Injury. The Laryngoscope. 2019; 129:49-57.