Clinical Opal - Isaac presents with drooling and stridor
Isaac has re-presented today to the GP with his mother, he is a 2 year old boy with no past medical history. He was a vaginal birth with no complications at 40 weeks gestation. His immunisations are up to date.
Isaac’s mother expresses that she is really concerned and feels that this is not a viral illness. It has been going on now for 4 weeks and he is just not getting better. Today he coughed up some blood and now seems to have a sound when he is breathing in.
Assessment
Weight: 17kg
Height: 105cm
Airway: Audible mild inspiratory stridor, not swallowing his saliva. You cannot see any redness in the back of his throat on inspection
Breathing: RR 20, subcostal recession noted, upper airway noises on inspiration
Circulation: HR 170, will not tolerate BP, capillary refill 3-4 seconds centrally
Disability: Irritable and crying
Exposure: No deformities or rash noted
Question
Would you consider Isaac's presentation an emergency?
Yes or No
Answer -Yes
Isaac presents to the local emergency department where they obtain a chest x ray:
Park & Burns (2022) Button Battery Injury; An Update. Australian Journal of General Practice. 51, 7
The chest x-ray shows that the child has a halo or double ring appearance indicating he has swallowed a button battery at some point.
Oesophageal button battery injury should always be included as a differential with a low threshold for imaging particularly in children under 5 years of age due to its non-specific nature of presentation.
Unknown ingestion of a button battery can present with symptoms including:
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dysphagia
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nausea & vomiting
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drooling
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fever
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cough
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irritability
Other less common symptoms include dyspnoea, dysphonia, anorexia and chest pain. If the child is experiencing haematemesis, epistaxis, melaena or altered consciousness, gastrointestinal bleeding from an aorto-oesophageal fistula should be suspected.
The longer a button battery remains in place, the worse the damage becomes.
Park & Burns (2022) Button Battery Injury; An Update. Australian Journal of General Practice. 51, 7
In the prehospital stage, the severity of injury may be reduced by administering honey or sucralfate. If button battery ingestion is suspected and it has been less than 12 hours since the ingestion, administer two teaspoons of honey at 10-minute intervals (up to six doses). Sucralfate is preferred to honey in children under 1 year due to the risk of botulism. In Australia, Sucralfate is only available as a tablet so it needs to be crushed and mixed with a small amount of water prior to administration.
Issac went in for emergency removal of the button battery with an ENT surgeon and required intubation and ventilation in PICU for 7 days following. The button battery was found to be almost flat which contributed to less acid leaking into the oesophagus, but some mucosal injury had occurred and Isaac will likely need ongoing monitoring by ENT for scar tissue.
Further Learning and Courses
- Emergencies in General Practice course
- Can’t Intubate, Can’t Oxygenate (CICO) course
- PACED: Paediatric Assessment of Clinical Emergencies & Deterioration course
- Paediatric Advanced Life Support (PALS) course
- Lunch & Learn: Paediatric Ingestions and Poisoning
References
https://www1.racgp.org.au/ajgp/2022/july/button-battery-injury
https://www.rch.org.au/kidsinfo/fact_sheets/Safety_Button_batteries/
Grace Larson, RN, BN, CertIV(TAE), GradDipClinNurs(PaedCritCare), MAdNursPrac(PaedCritCare), has extensive experience in paediatric nursing, with 13 years in Paediatric Intensive Care Units (PICU). She’s published journal articles in the specialty area of pain and sedation in PICU, and has presented at national and international conferences on the area of pain and sedation in paediatrics. Grace has previously worked with the ACCCN delivering Paediatric Advanced Life Support in Victoria, bringing a wealth of experience into her clinical teaching on paediatric resuscitation. She has also consulted with NSW Health on quality and safety delivering within PICU, and has been contracted with the ANMF to develop nursing programs for nurses who require additional education as part of their practice requirements.
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