›Expectant passage with stool monitoring and outpatient follow-up imaging if not passed in the expected timeframe
›Multiple magnets or magnet plus metal
›Categorically different management from a single magnet
›Attraction across bowel loops causes pressure necrosis, fistula, volvulus, and perforation
›Count and interval since ingestion determine urgency
›Exact count established by history, imaging, or caregiver inventory of a magnet set
›A longer interval between separate ingestion episodes raises concern the objects settled in separate, non-adjacent bowel loops before attraction
›Endoscopically reachable: endoscopic removal within 24 hours if accessible (Class I)
›Beyond endoscopic reach and asymptomatic: surgical consultation and serial imaging at a defined interval to track position
›Symptomatic at any location: surgical evaluation without delay
›Peritonitis
›Obstruction
›Non-progression on serial imaging
Nasal and aural battery removal
›Nasal battery
›Emergency removal to prevent septal necrosis and perforation
›ENT consultation without delay
›Aural battery
›Emergency removal to prevent tympanic membrane perforation and ossicular injury
›ENT consultation without delay
Post-removal surveillance and delayed-complication management
›Surveillance period
›Extended surveillance for at least 2 to 4 weeks after removal of a battery with documented deep mucosal injury
›Activity restriction to reduce hemorrhage risk during the surveillance period
›Delayed complications that can occur after apparently successful removal
›Aorto-esophageal fistula
›Sentinel minor hematemesis before catastrophic hemorrhage
›Emergent vascular surgery and massive transfusion activation for any sentinel bleed in this window
›Tracheo-esophageal fistula
›Mediastinitis
›Vocal cord paralysis from recurrent laryngeal nerve injury
›Esophageal stricture over subsequent weeks to months
›Negative pole orientation and injury side
›Negative pole generates the hydroxide injury and causes the deeper tissue damage
›Orientation assessed at endoscopy predicts the anatomic structure at greatest injury risk
›Anterior negative pole orientation threatens the trachea and tracheo-esophageal fistula
›Posterior negative pole orientation threatens the aorta and aorto-esophageal fistula
›Orientation informs the intensity of post-removal surveillance and imaging follow-up
Iatrogenic harms of routine ED interventions in this population
›Intubation
›Not contraindicated, but anticipate a difficult airway from mucosal edema over an esophageal battery
›Coordinate with anesthesia for a controlled airway during endoscopic removal
›Sedation
›Aspiration risk elevated from pooled secretions over an obstructing object
›Strict NPO status and suction readiness before any procedural sedation
›Fluid loading
›Standard resuscitation is not restricted, but avoid over-resuscitation that masks evolving mediastinitis physiology
›Oxygen
›No disease-specific target modification; treat to standard age-based targets
›Vasopressors
›Inadequate as sole therapy for aorto-esophageal fistula hemorrhage
›Definitive surgical or endovascular hemorrhage control required; do not delay for pressor titration alone
›Mechanical circulatory support, including intra-aortic balloon pump
›Relatively contraindicated in known or suspected aorto-esophageal fistula
›Balloon inflation across a compromised aortic wall risks catastrophic rupture
›Use only as a bridge in a controlled surgical setting with vascular surgery immediately available
›Anticoagulation
›Hold and reverse in known or suspected esophageal battery injury given delayed hemorrhage risk
›Fibrinolysis
›Contraindicated for an unrelated indication during the post-removal surveillance window given fistula and hemorrhage risk
›Analgesia
›Opioids acceptable with monitoring; avoid oversedation that masks evolving airway compromise
›NSAIDs relative caution with documented mucosal injury given GI bleeding risk
Procedural sedation and airway planning
›Sedation medication dosing
›Fentanyl IV 1 mcg/kg
›Titrate 0.5 to 1 mcg/kg every 5 to 10 minutes to effect
›Maximum single bolus 100 mcg
›Verify against current pediatric guideline before use
›Ketamine IV 1 to 1.5 mg/kg for induction if RSI required
›Repeat half the induction dose for prolonged procedures
›Maximum single dose per local protocol
›Verify against current pediatric guideline before use
›Monitoring cadence during titration
›Continuous pulse oximetry and capnography throughout sedation
›Blood pressure and heart rate reassessment with every titration step
›Reassess airway patency and secretion burden before each dose escalation
Antibiotics and complication management
›Suspected mediastinitis or perforation
›Piperacillin-tazobactam IV 100 mg/kg (piperacillin component) every 6 hours, maximum 4 g per dose
›Adult dosing 3.375 to 4.5 g IV every 6 hours
›Renal adjustment as indicated
›Alternative for beta-lactam allergy: ceftriaxone IV 50 mg/kg daily (maximum 2 g) plus metronidazole IV 10 mg/kg every 8 hours (maximum 500 mg per dose)
›Post-removal mucosal injury
›Pantoprazole IV 1 mg/kg daily, maximum 40 mg per dose
›Transition to oral when tolerating intake
›Duration guided by endoscopic mucosal injury grade
›ECG surveillance during massive transfusion
›ECG monitoring for hyperkalemia and hypocalcemia from citrate load during massive transfusion for aorto-esophageal fistula hemorrhage
›Correlate ECG changes with ionized calcium and potassium trends during transfusion