Button Battery Ingestion

04 Sep
September 4, 2017

Button Batteries: Small, disc shaped battery cells which are designed for use in small electronic devices. Common sources are kids toys, watches, calculators and hearing aids. Most batteries use lithium as a power source

Button Battery Ingestion Danger:

  • Contact with mucosal surfaces (oropharynx, esophagus, nasal passage) results in transmission of current
  • Current transmission causes chemical burns and necrosis via alkaline injury (sodium hydroxide)
  • Tissue damage can progress rapidly and result in devastating injuries
  • Nasal passage and esophagus are most susceptible to injury (narrow places for battery to become lodged)
  • Injury Patterns
    • Viscous perforation
    • Fistula formation
    • Erosion into blood vessels and resultant bleeding and possible catastrophic bleeding with erosion into aorta

When to Suspect Ingestion:

  • Reported pediatric ingestion of unknown substance
    • Parent may report seeing “shiny” object being placed in mouth
    • Parent may report missing battery from open electronic device
  • Typical foreign body ingestion symptoms
    • Coughing
    • Gagging
    • Drooling
    • Dysphagia
    • Increased work of breathing or stridor
  • Symptoms consistent with tissue damage
    • Vomiting
    • Chest discomfort
    • Fever
    • Hematemesis

Button Battery XR (scielo.br)

Imaging:

  • Batteries are radio-opaque and will appear on plain X-rays
  • Views: At least 2 (PA and lateral)
  • Nasal placement: Obtain skull X-ray
  • Swallowed battery: Chest X-ray
  • Battery vs. Coin
    • Battery can often be mistake for the more benign coin ingestion on X-ray
    • En face view: may see a ring of radiolucency inside outer edge of object (“halo rim”)
    • On edge view: may see a central bulge with a battery

X-ray – Radiographic Appearance of Coings and Disk Batteries (www.hawaii.edu)

ED Management:

  • Supportive Care
    • Aggressively resuscitate patients with hematemesis and/or signs of shock
    • Look for signs/symptoms of airway obstruction and control airway if necessary
    • Keep patient NPO
  • Obtain X-ray for localization of button battery
  • Nasal and Esophageal batteries should be removed within 2 hours of presentation to avoid significant necrosis. Do Not Wait for Symptoms to Develop!
  • Nasal battery
    • If battery can be visualized, can attempt removal with forceps, suction, skin glue on cotton swab or any other standard approach
    • If cannot visualize battery, obtain ENT consultation for direct visualization and removal with fiberoptics
  • GI Tract Battery
    • X-ray localizes to esophagus
      • Emergency consultation (Institution dependent – GI, Peds surgery) for direct visualization and removal
      • Removal without direct visualization (i.e. foley catheter removal) sub-optimal
        • Does not allow for visualization of mucosal injury
        • May result in translocation of of the battery from the esophagus to the trachea
      • If patient exhibits any evidence of mucosal damage, admit for observation
    • X-ray localizes distal to esophagus (i.e. stomach, small intestine)
      • Symptomatic or magnet co-ingestion
        • Emergency consultation (Institution dependent – GI, Peds surgery) for direct visualization and removal
        • Battery and magnet can cause problems even after passage into stomach via attraction of geographically distinct parts of bowel leading to obstruction or mucosal necrosis
      • Asymptomatic
        • If battery > 15 mm in child < 6 years of age
          • Lower risk of spontaneous passage
          • Repeat X-ray in 4 days. If battery still in stomach, remove under endoscopy
        • Expectant Management
          • Discharge home
          • Regular diet
          • Confirm passage by stool inspection or repeat X-ray in 10-14 days (if no passage, consider removal)
    • Continued Management
      • Development of any symptoms in a patient with battery beyond esophagus should prompt removal
      • Delayed perforation possible up to 28 days out of ingestion
      • Some gastroenterologists recommend routine repeat endoscopy

Take Home Points:

  1. Button battery ingestions are extremely dangerous. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours
  2. ALL esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage
  3. Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis
  4. Co-ingestion of a button battery with a magnet requires emergency removal regardless of where it is in the GI system

For More on This Topic Checkout:

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)

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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at Bellvue/NYU
REBEL EM Associate Editor and Author

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