Magnets in the ED:
A cautionary tale

A mother and her 11-year-old daughter arrived at the emergency department visibly upset. The girl had inserted magnetic earrings in her nostrils, and when she removed them, the magnets remained behind and attached across her septum. The emergency physician tried to remove the magnets first by having the girl forcefully blow her nose and then by applying other magnets outside and inside the nasal cavity. Having failed at these initial attempts, he tried direct removal, but it caused trauma to the nasal mucosa and made both mother and daughter even more anxious. The girl refused benzodiazepine sedation, saying she felt she would vomit if she tried to swallow medication and did not want a shot. Finally, the physician instilled topical tetracaine hydrochloride 2% and epinephrine 1:1,000 into the nose, which facilitated the direct visualization and removal of one of the magnets while the patient was sitting upright. When the first magnet was removed, however, the second no longer adhered to the septum; it became loose in the nostril, fell into the pharynx, and was swallowed by the patient. She said she could not feel the magnet until it was in her throat and had swallowed reflexively. An abdominal film disclosed the magnet in the stomach. The patient had no further complications and was discharged home.

Comment. Because the magnets were attracted to each other, they could not be removed separately using a grasping instrument, suction, or a Foley catheter. Instead of trying to remove each one individually, the physician should have grasped both simultaneously and moved them slowly forward into the nasal vestibule; a surgical lubricant would facilitate that movement. He appropriately anesthetized the nasal septum before attempting to retrieve the object. Another option would be the combination topical anesthetic-vasoconstrictor spray consisting of benzocaine 14%, butyl aminobenzoate 2%, and tetracaine HCl 2%.

The other important error in this case was the removal of the nasal foreign body while the patient remained seated. To reduce the potential for airway obstruction, nasal foreign bodies should be removed with the patient prone and the head flexed. If the object can't be grasped firmly with an instrument, the safer approach is to secure the airway with an endotracheal tube and then either reach the object anteriorly or posteriorly using the appropriate endoscopic technique or retrieve it with a catheter. Removal under conscious sedation may provide an alternative to endotracheal intubation, although conscious sedation is a mixed blessing in a situation like this. It may make the patient more cooperative, but it also may blunt the protective airway reflex and thereby increase the risk of aspiration. In addition to airway obstruction, other disorders caused by nasal foreign bodies include infection of the obstructed nasal canal and sinus and erosion of the nasal septum. Alnico magnets contain a cobalt alloy, and there has been at least one reported case of dilated cardiomyopathy and erythrocytosis in a patient who swallowed a large number of refrigerator magnets.

Source: Reprinted with permission from "Avoidable Errors in Emergency Practice," edited by Sheldon Jacobson, MD, Emergency Medicine, September 1999, p 68.

 

Cathy Brown. Magnets in the ED. Contemporary Pediatrics 2000;2:145.