Button Battery Ingestion

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

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

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:

• National Capital Poison Center: NBIH Button Battery Ingestion Triage and Treatment Guideline
• Pediatric EM Morsels: Button Battery Ingestion
• St. Emlyn’s: Button Batteries – Hide and Seek in the Emergency Department
• ENT Blog: Lithium Disc Battery Danger for Kids

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