EM Quick Hits 54 Button Battery Ingestion, C. difficile, ECG in Tox, Bed Bugs, Fibrinogen in Trauma, Cold Air for Croup

Topics in this EM Quick Hits podcast Olivia Ostrow on the management of pediatric button battery ingestions and impaction (1:15) Brit Long on c. difficile infection (19:15) Jesse McLaren on an approach to ECGs in the poisoned patient (26:34) Joe Mullally on the identification and treatment of bed bug bites (31:50) Andrew Petrosoniak on fibrinogen replacement in bleeding trauma patients (38:30) Justin Morganstern on cold air for management of croup  (48:35) Podcast production, editing and sound design by Anton Helman Written summary & blog post by Shaila Gunn and Brit Long, edited by Anton Helman Cite this podcast as: Helman, A. Ostrow, O. Long, B. McLaren, J. Mullally, J.  Petrosoniak, A. Morgenstern J. EM Quick Hits 54 - Button Battery Ingestion, C. difficile, ECG in Tox, Bed Bugs, Fibrinogen in Trauma, Cold Air for Croup. Emergency Medicine Cases. January, 2024. https://emergencymedicinecases.com/em-quick-hits-january-2024/. Accessed September 17, 2024. Button battery ingestion and impaction Button battery ingestion with esophageal impaction is a potentially life-threatening emergency with damage to tissues typically starting within minutes-hours, but may be delayed by weeks-months. More than 50% of serious outcomes due to button battery ingestion occur after unwitnessed ingestions, in which case there is likely a delay in recognition and management.  * How is the tissue damaged? The tissue injury is a caustic chemical reaction (rather than thermal) – this leads to an alkaline burn and liquefactive necrosis through the esophagus, trachea, and major blood vessels which may lead to  severe complications including tracheoesophageal and aortoesophageal fistulas. * Location of impaction matters: Impactions in the proximal and mid esophagus are most dangerous. The risk of injury decreases if it is lodged in the stomach or duodenum. * Timing of tissue damage/symptoms/complications: Coagulative necrosis has been shown to start within 15 minutes of contact but complications may be delayed up to 2 months. Symptoms may take hours to days to develop but the damage to tissues occurs within 2 hours making suspicion for button battery ingestion and prompt recognition important. If the button battery is removed within a 2 hour time frame, the risk of severe and fatal injury decreases significantly. The risk of perforation increases dramatically after 12 hours. Parents must continue to monitor for symptoms of tissue damage even if the button battery was removed. * What type of battery? Serious complications and death from button battery ingestion are associated most frequently with 3V lithium batteries ≥20mm. * If a parent thinks the child swallowed a coin – assume button battery ingestion until proven otherwise. * Presenting symptoms may be subtle and nonspecific: classic findings of foreign body ingestion (i.e. cough, chest pain, wheeze), vomiting, hematemesis, poor feeding/food refusal or fever. ED management of button battery ingestion * Administer a neutralizing agent * Sucralfate, (or pasteurized honey if sucralfate is unavailable), should be given immediately, so long as it does not cause a delay in removal of the battery, it is given within 12 hours of ingestion and there are no airway concerns. Both work by reducing pH and coating the battery to delay alkaline burns to tissue. * Dosing honey for management of button battery ...