Button Battery Ingestion

Button Batteries

We all know that kids love to put odd objects in their mouths (and ears, and nostrils, and other interesting places).  We also know that this can cause significant problems and lead to true emergencies.  The location of the object (ie, airway) may lead to the emergency, but don’t forget that the object itself may lead to problems and severe tissue destruction!  Button batteries are one of these unique objects that warrant our specific concern and respect!  We have discussed previously the problems that a button battery in the nostril can cause, now let us turn our attention to a potentially even more devastating problem: Button Battery Ingestion.

Button Battery – Easy Access

  • With our ever increasing number small electronic devices, button batteries are becoming more prevalent.
    • Toys & Electronic Games
    • TV Remote Controls & Key Fobs
    • Flashlights & Calculators
    • Watches & Hearing Aids
  • They come in a variety of sizes, some that are rather large (>20mm).
    • A Button Battery that is smaller generally is able to pass uneventfully.
    • A Button Battery that is large (>20mm) is more likely to get stuck and lead to worse outcomes.

 

Button Battery – Scope of the Issue

  • During a 20 year period in the US, it was found that there was a significant increase in battery-related ED visits!
    • During this time, 65,788 patients <18 years visited EDs for battery-related issues equating to an average of 3,289 visits annually!
    • That works out to be 1 patient almost every 3 hours!
  • Unfortunately, in 2009, this number had increased (~6,000 children seen in US EDs for battery-related complaints).
  • Worse outcomes associated with larger Lithium button batteries and younger children (< 4 years).

 

Button Battery Ingestion – Presentation

  • Most often will present as other Foreign Bodies.
    • Cough & Gagging
    • Drooling & Dysphagia
    • Increased Work of Breathing & Stridor
  • But don’t forget kids can be tricky (and not tell you that they swallowed a FB).
    • Croup-like
      • Acute stridor without associated viral symptoms warrants concern.
      • Recurrent stridor warrants consideration for airway FB.
    • Wheeze
      • One great reason to check CXR in young child with first time episode of wheezing.
  • May have symptoms that initially don’t seem related to a FB ingestion, but are related to the evolution of tissue damage.
    • Vomiting
    • Fever
    • Irritability
    • Listless

 

Button Battery Ingestion – The Science

  • Tissue damage from Button Battery is due to alkaline caustic exposure.
    • Recall, aLkaLine caustics lead to Liquefaction necrosis.
    • When the battery is placed in a moist environment (ex, mucous membranes, saliva), an electrical charge is generated.
      • The Lithium Button Batteries have twice the capacitance of other button batteries (3 volts vs 1.5 volts).
      • Lithium Button Batteries can generate more current and have been associated with worse outcomes.
      • Even used (spent) Lithium Button Batteries can still generate enough current to damage tissue!
    • The discharged current hydrolyzes water, generating Hydoxide ions — leading to alkaline injury.
  • Negative-Narrow-Necrotic” Mneumonic
    • The current generates the hydroxide at the negative terminal of the battery.
    • The negative terminal is the more narrow side of the button battery when viewed laterally.
    • The anatomic orientation of the battery can predict where the necrosis will be and the subsequent injury.
  • The Esophagus (and nostril) are highly susceptible to this injury.
    • A button battery moving freely does not generate enough hydroxide ions in one location to produce focal damage.
    • The button battery lodged in the esophagus or nostril generates a focal collection of alkaline caustic material in a confined region that can cause tissue necrosis.
  • Serious damage can occur within 2 hours!
  • Damage can also occur from:
    • Leakage of alkaline material from the battery (usually, not the cause of the tissue damage that is seen to occur within 2 hours).
      • This is more of a problem with the non-lithium batteries.
    • Compression of local structures.

 

Button Battery Ingestion – Imaging

  • Fortunately, we are looking for a radio-opaque coin-like object!
    • Plain films should be sufficient.
  • Unfortunately, we can get fooled if we are not vigilant (common theme of the PedEM Morsels)!
    • 54% of fatalities due to a Button Battery FBs were misdiagnosed.
      • Most of these had non-specific presentations.
      • Additionally, a large, round, coin-like object in the esophagus, may be easily misinterpreted as a coin which would be appropriate to initially observe and repeat film to see if it passes…
      • If damage can occur within 2 hours, that period of observation can be very critical for your patient!!
    • Look carefully at the foreign body.
      • Viewed “en face,” a button battery will have a “halo rim” – ring of radiolucency just inside the outer edge of the object.
      • Viewed on edge, a button battery may have a central bulge or “step-off, although this can be difficult to appreciate if oblique or with newer, thinner Lithium batteries.

 

Button Battery Ingestion – The Problem

  • Any button battery ingestion should be treated promptly as if a emergent condition is developing before your eyes!
  • The button battery induced caustic tissue damage can lead to significant destruction of local structures:
    • Perforations
    • Fistulas
      • Tracheoesophageal Fistula
      • Fistulation of major blood vessels
    • Vocal cord damage and paralysis
    • Strictures
    • Spondylodiscitis
    • Massive Hemorrhage
    • Death
  • Removal can be difficult.
    • The local tissue damage can lead to friable structures that can be further damaged by instrumentation.
    • Should be removed under direct visualization.

 

Button Battery Ingestion – Management

  • Vigilance is required as the presentation may be non-specific and the outcomes severe!
  • Button Batteries that are in the Esophagus need to be removed promptly – within 2 hours!
  • Button Batteries that are in the stomach or beyond, in an asymptomatic patient, can be monitored and allowed to pass.
    • Repeat radiographs are reasonable.
      • Repeat in 4 days for < 6 years of age or for larger button batteries (> 15 mm).
      • Repeat in 10 – 14 days for older children if not large battery.
      • After that time, if battery still in stomach, endoscopic removal recommended.
    • Strict anticipatory guidance and return precautions should be given – emphasizing need to be evaluated for any abdominal pain, fever, or vomiting.
  • Co-ingestion of a magnet with the Button Battery necessitates removal.
  • After removal, some advocate for a delayed 2nd look endoscopy to ensure no damage occurred.
    • Perforations and fistulas may develop up to 18 days after removal.
    • Strictures can develop weeks and months after removal.
  • See nice algorithm.
  • Button Battery Task Force

 

References

Gohil R1, Culshaw J2, Jackson P3, Singh S3. Accidental button battery ingestion presenting as croup. J Laryngol Otol. 2014 Mar;128(3):292-5. PMID: 24555666. [PubMed] [Read by QxMD]

Jatana KR1, Litovitz T, Reilly JS, Koltai PJ, Rider G, Jacobs IN. Pediatric button battery injuries: 2013 task force update. Int J Pediatr Otorhinolaryngol. 2013 Sep;77(9):1392-9. PMID: 23896385. [PubMed] [Read by QxMD]

Jayachandra S1, Eslick GD. A systematic review of paediatric foreign body ingestion: presentation, complications, and management. Int J Pediatr Otorhinolaryngol. 2013 Mar;77(3):311-7. PMID: 23261258. [PubMed] [Read by QxMD]

Sharpe SJ1, Rochette LM, Smith GA. Pediatric battery-related emergency department visits in the United States, 1990-2009. Pediatrics. 2012 Jun;129(6):1111-7. PMID: 22585763. [PubMed] [Read by QxMD]

Centers for Disease Control and Prevention (CDC). Injuries from batteries among children aged <13 years–United States, 1995-2010. MMWR Morb Mortal Wkly Rep. 2012 Aug 31;61(34):661-6. PMID: 22932299. [PubMed] [Read by QxMD]

Litovitz T1, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010 Jun;125(6):1168-77. PMID: 20498173. [PubMed] [Read by QxMD]

Sharma A, Chauhan N, Alexander A, Campisi P, Forte V. The risks and the identification of ingested button batteries in the esophagus: a child safety issue. Pediatr Emerg Care. 2009 Mar;25(3):196-9. PMID: 19287282. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. August 10, 2014

    […] EM Morsels takes on button battery ingestion – they can start to cause damage within 2 hours of ingestion, so we need to be vigilant. […]

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