C A S E R E V I E W

Matt LutheDepartmentJohn VinenHealth Care

For correspoAustralia, 26

J Emerg Nu

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January 2

A 12-YEAR-OLD BOY WITH UNUSUAL

NECK ADORNMENTS

Authors: Matt Luther, MPH, MNur(NP), GardDipMid, GradCert Emergency Nursing, BNur, andJohn Vinen, MBBS, MPH, Canberra, Australia

Section Editor: Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN

I t was a normal chaotic day in the emergencydepartment until early afternoon when an otherwisehealthy 12-year-old boy with an unusual neck

adornment walked into the triage area. While playingat home with a friend, the boy had placed strongmagnets on either side of his neck, pinching the skintogether (Figure 1). The child’s mother was unable todislodge the magnets and brought her son to the emergencydepartment for removal of the magnets and evaluation ofthe underlying tissue. By the time the patient arrived, themagnets had been compressing his skin for approximately1.5 hours. The boy reported increasing pain at the magnetsite and was assigned an Australasian Triage Score of 3,which meant he was to be seen within 30 minutes.

Rare-earth magnets are small, powerful magnets foundin many modern devices, including toys. Widespreadavailability of these magnets has led to an increase inmagnet-related injuries, especially among inquisitive chil-dren. Rare-earth magnets, which are composed of neodym-ium iron boron and samarium cobalt, entered the marketbetween 1970 and 1983. (Neodymium and samarium arereferred to as rare-earth magnets because these elements arefound in the rare-earth section of the periodic table, notbecause of scarcity of the metals themselves.) These magnetsare superior in remanence (magnetic attraction) whencompared with traditional ferrite magnets.1 As such, rare-earth magnets are increasingly replacing other magnet types.Neodymiummagnets are inexpensive to produce, which hascontributed to their popularity. Rare-earth magnets can befound in medical equipment such as magnetic resonance

r is Co-Director, Nurse Practitioner, and Midwife, Emergency, Calvary Health Care ACT, Canberra, Australia.is Emergency Consultant, Emergency Department, CalvaryACT, Canberra, Australia.

ndence, write: Matt Luther, PO Box 254, Jamison Centre ACT,14; E-mail: matt.luther@calvary-act.com.au.

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line 22 November 2013.$36.00

2014 Emergency Nurses Association. Published by Elsevier Inc.served.

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imaging scanners.2 They are also used for securingtranscutaneous devices, including cochlear implants.

Health care professionals are cognizant of the risksassociated with magnets, especially around sensitive equip-ment such as pacemakers and infusion pumps. However,until the development of these powerful, rare-earthmagnets, skin entrapment with crushing of tissue has notbeen a common magnet-related problem. Although fewcases of magnet entrapment have been reported in themedical literature, health care professionals, especially thoseworking in emergency departments, should be aware ofthese magnets, their associated complications, and themanagement options available to minimize injury.3

When tissue is entrapped between strong opposingmagnets, the magnets need to be separated as soon aspossible to avoid permanent damage. The processescommonly used for demagnetizing ferrite (magnetic) metalsare heating, hammering, and exposure to a greater magneticfield of opposite polarity.2 However, in many cases thesemethods are not acceptable for a patient with entrappedtissue who is already in pain and distress. Shearing theopposing magnets out of polar alignment will, in manyinstances, lead to secondary tissue damage. Thus use ofdistracting (rather than shearing) forces should be consid-ered when strong magnets are pinching soft tissue.

Initial assessment of the child’s neck revealed twoneodymium magnet discs stacked together just to the rightof midline, with a single opposing magnet on the left, atapproximately the level of the cricoid ring. The magnetswere all of the same size and construction: 10 mm indiameter and 5 mm in depth (Figure 2).

The boy reported pain with swallowing and wheneverthe magnets were touched. A small amount of a localanesthetic agent was injected subcutaneously, superior andinferior to the pinched tissue. This procedure improved thechild’s comfort level but was insufficient to prevent patientmovement during subsequent removal attempts. Pain wasalleviated with administration of nitrous oxide.

Attempts to manually grasp the opposing magnets wereunsuccessful because of their rounded shape. Staff membersconsidered the use of clinical instruments, such as needleholders or artery forceps, but two pairs of large “bull nose”pliers were eventually requested from the maintenance

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FIGURE 1

Powerful rare-earth magnets compressing tissue in the patient’s neck.

FIGURE 2

The magnets that were attached to the patient’s neck.

IGURE 3

xtensive bruising and pressure-related indentations were present after the magnetsere removed.

CASE REVIEW/Luther and Vinen

department. The plan was to remove the magnets bygrasping each side with pliers. However, when one of themagnets was approached with the pliers, the magnetic fieldproved too strong to align the ferrous pliers and create anappropriate grip. It was then that the idea of usingdistracting forces was considered. In retrospect, this processshould have been considered initially, as soon as theattached objects were identified as rare-earth magnets.

The principle behind applying distracting forces toseparate magnets relies on the premise that a magnet willhave a greater attraction to a large mass of ferrous materialthan to the opposing magnet. In this instance, the two large

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pairs of pliers were used as the ferrous mass. In otherdocumented cases, large steel mallets have been used withsuccess.3 The broad side of a pair of pliers was attached toeach of the patient’s opposing magnets. The pliers werethen pulled apart, slowly and at equal speed, so as not toshear the entrapped tissue. This technique proved to beboth simple and effective. Once the magnets were removed,inspection of the underlying tissue revealed extensivebruising and pressure-related indentations, but the skinwas intact (Figure 3).

As requested, the child and his mother returned to theemergency department 24 hours after discharge for follow-up. Upon examination, isolated significant anterior neckbruising was noted where the compressive force had beenapplied by the magnets, but no signs of tissue necrosis wereobserved. Upon re-evaluation 7 days after the incident, thewounds were noted to have healed without complication.The only residual finding was slight darkening of the affectedareas due to resolving bruising. No further care was required.

The medical literature pertaining to magnet-relatedemergencies predominantly addresses magnet ingestion.4–6

Because of the thin tissue density of the gastrointestinaltract, multiple magnets located in adjacent areas of bowelcan entrap tissue and lead to life-threatening necrosis.4,5

Other magnet-related emergency cases reported in theliterature involve injuries to the nose as a result of magnet-induced tissue entrapment.5 Foreign body ingestion ischiefly a problem found in young children, but tissueentrapment caused by the strong magnetic attraction ofrare-metal magnets can occur in any age group and may bean increasingly important issue in occupational medicine.5,6

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REFERENCES1. Cullity B, Graham C. Introduction to Magnetic Materials. 2nd ed.

Hoboken, NJ: John Wiley & Sons; 2009.

2. Gupta CK, Krishnamurthy N. Extractive Metallurgy of Rare Earths. BocaRaton, FL: CRC Press; 2005.

3. Rice S, Rajan P, Hansen R, Munro F. Painful attraction: a magneticpenile injury. J R Soc Med. 2005;98(3):122-3.

4. U.S Consumer Product Safety Commission. Safety alert—ingestedmagnets can cause serious intestinal injuries. http://www.cpsc.gov/PageFiles/112864/5221.pdf. Accessed October 11, 2013.

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5. Swaminathan M, Baker R, Scott D. Injuries due to magnets in children:an emerging hazard. Queensland Injury Surveillance Unit. Inj Bull.March 2010;(109):1-10.

6. Midgett J, Inkster S, Rauchschwalbe R, Gillice M, Gilchrist J. Gastro-intestinal injuries from magnet ingestion in children—United States, 2003–2006. MMWR Morb Mortal Wkly Rep. 2006;55(48):1296-300.

Submissions to this column are encouraged and may be sent toLaura M. Criddle, PhD, RN, CEN, CCNS, FAENhttp://ees.elsevier.com/jen

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