Button Battery Ingestion

Author: Jacob Stelter, MD (EM Resident Physician, PGY-1, NUEM) // Edited by: Colin McCloskey, MD (EM Resident Physician, PGY-4, NUEM)

Citation: [Peer-Reviewed, Web Publication] Stelter J, McCloskey C (2016, January 5). Button Battery Ingestion. [NUEM Blog. Expert Peer Review by Lank P]. Retrieved from http://www.nuemblog.com/blog/button-battery-ingestion/

The Case

Chief Complaint: “I think my son ate a watch battery.”

History of Present Illness: An 18 month old male patient presents to the pediatric emergency department with his mother for concern of possible battery ingestion.  Per mother, patient was in the kitchen with her as she was washing dishes and ended up getting into her purse which was on the floor.  By the time she realized it, the patient had gotten a small battery-powered flashlight out of her purse and had opened it up. Per the mother, the flashlight had two button-sized batteries inside it, of which there was only one left. On presentation, the child is asymptomatic, no vomiting, no coughing, no choking since the episode.  Patient is behaving normally per mother.

Exam: Afebrile, vitals normal for an 18 month old (Pulse 122, respirations 28, saturation 99%), physical exam is unremarkable, no signs of respiratory distress, no stridor, no accessory muscle use or retractions.

 

You decide to obtain an initial x-ray:

 

Discussion

Epidemiology:

According to Poison Control, about 3,300 button battery ingestions occur each year in the United States, with about two thirds of those cases occurring in patients younger than 6 years old [4].  These are especially dangerous. 12.6% of children under the age of 6 that ingested a battery that was 20-25mm experienced either a major complication or death[5].

Pathophysiology:

Button batteries, due to their small size and shape, can easily become lodged in the esophagus and cause caustic burns due to their adherence to the esophageal mucosa.  There are three primary ways that batteries cause damage.  The first is that they develop a current that subsequently produces hydroxide at the negative pole, causing tissue damage.  Second, they cause damage by leaking alkaline electrolytes from the battery.  Third, the batteries can cause pressure on intestinal mucosa [5].

Management:

When evaluating a patient that has potentially ingested a battery, the first and most important step is to evaluate their airway to make sure it is patent and that they have not aspirated the battery into the trachea.  If the airway is stabilized and the patient is not displaying any signs or symptoms that would indicate immediate surgical or GI intervention, an X-ray should be performed to localize the battery.  Ideally, in the pediatric population, this is a “baby-gram” or an x-ray from head to rump [6].  If a battery is localized, such as in the X-ray shown previously, in the esophagus, the next step is an emergent GI consult to have the battery endoscopically removed and to have the GI tract and surrounding mucosa evaluated for tissue damage.  If the patient is symptomatic, such as complaining of chest pain, difficulty swallowing, vomiting, abdominal pain, the battery needs to be emergently removed, regardless of where the battery is located [7].

Batteries, if located in the stomach, can be observed for passage if the patient is asymptomatic.  The patient should be closely observed for battery passage and can be followed with serial x-rays to ensure passage [5].  Any symptomatic patient needs immediate evaluation and potential surgical removal regardless of where the battery is located in the gastrointestinal tract.  A treatment algorithm such as this can be used to guide evaluation and management [7]:

 

Click image to enlarge

 

Educational Points for Parents

  • Keep all batteries out of reach of young children. Ingestion of batteries can have life-threatening consequences.
  • Keep devices that use button batteries for power out of the reach of small children, as children can remove these batteries from the devices and ingest them.
  • Use child-proofing mechanisms or tape to keep batteries secured within devices and make them more difficult for children to access.
  • If you think your child swallowed a battery, even if you did not observe it, call the National Battery Hotline at 202-625-3333 and bring your child to the nearest emergency department immediately.

Expert Commentary

Hi Jacob:

Thank you for this excellent post on disc/button battery ingestions in pediatric patients. In contrast to the many benign things children swallow, these types of ingestions should strike fear into the hearts of parents and clinicians alike. Here are some things that run through my head when I hear of a case of button battery ingestion either in the ED or through the poison center:

    + The tox history in these cases should focus on a few things:

a) Is the time of ingestion known, or can it be approximated? Some numbers commonly thrown out are that significant injury can happen as quickly as 2-2.5 hours after ingestion, and perforation has happened 6 hours after ingestion. The faster you facilitate intervention, the better the outcome will be.

b) Does the child have a history of ingestions? Does the parent describe their child as one who “puts everything in his mouth?” These kinds of behaviors are seen more commonly in children with developmental disorders and are associated with increased risk of all types of ingestions. In particular, I worry about co-ingestants in these children – additional batteries and magnets mentioned below.

c) Are there other batteries around? The chart you included mentions taking at most 5 minutes to find companion or replacement batteries. That’s a great recommendation, since it reminds people to take no longer than a brief period of time to try to collect this information.

    + These batteries wreak havoc when they are stuck somewhere:

As long as they are distal to the esophagus in an asymptomatic child, they usually move along just fine. HOWEVER:

a) This is not an argument to skip the x-ray. In children with endoscopy-proven esophageal injury from a button battery, 35-40% of them were asymptomatic at time of presentation to the ED.

b) Don’t forget about other places where kids stick things. These batteries can cause extensive tissue damage in head and neck cavities such as the ear canal or nares. One rule in these exposures is to never use drops prior to removal. Drops can be electrolyte rich and may increase local electrically induced injury.

c) Radiographic evidence of ingestion of more than one battery is very concerning. Evidence of or suspicion for ingestion with a magnet must prompt more thorough evaluation, even if the button battery has moved distal to the esophagus. There are multiple published reports of magnets “attaching” to a battery located in a different gastrointestinal lumen, causing interruption of battery passage, more extensive local injury, and perforation.

    + Not all disc/button batteries are the same:

a) If you look at a button battery, you will notice a series of letters and numbers. These tell you the battery make-up, their height (in tenths of millimeters), and their diameter (in millimeters). They will also frequently mention the battery’s voltage in the etching.

b) As you mention, the larger (≥ 20mm) lithium batteries are the most concerning as they are more likely to become lodged in the esophagus. In the 2000s, we saw an increase in the frequency of reported ingestions of this size battery. This was associated with a concurrent increase in major or fatal outcomes from button battery ingestion. However, smaller button batteries can still cause severe damage, with higher risk patients being younger patients, symptomatic patients, and those who had co-ingestants.

My final thought to you is that these ingestions are in a list of the most dangerous diagnoses that are very easy to miss. The majority of these ingestions are not witnessed, and these pediatric patients may develop only very nonspecific symptoms when medical attention is first sought. In the paper you cited by Litovitz T, et al. in Pediatrics, this reality is highlighted in statistics – “Clinicians missed the diagnosis of a battery lodged in the esophagus in at least 27% of major outcome and 54% of fatal cases…” So, be vigilant and fear the double rim/halo.

Patrick M. Lank, MD, MS

Assistant Residency Program Director; Assistant Professor of Emergency Medicine; Attending Medical Toxicologist, Toxikon Consortium; Department of Emergency Medicine Northwestern University, Feinberg School of Medicine [Pubmed]

References:

  1. Image from: “Button batteries imperil bambinos.” Natural Awakenings Central Ohio Edition. 2013. http://www.nacentralohio.com/button-batteries-imperil-bambinos/
  2. Image from: “Lithium disc battery danger for kids (and hot dogs).” ENT Blog. 2012. http://fauquierent.blogspot.com/2012/07/lithium-disc-battery-danger-for-kids.html
  3. Image from: “Staying safe during the holidays.” 2014. http://srxawordonhealth.com/tag/button-battery-ingestion/
  4. “Button battery ingestion statistics.” Poison Control: National Capitol Poison Center. 2014. http://www.poison.org/battery/stats.
  5. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery ingestion hazard: clinical implications. Pediatrics 2010: 125(6): 1168-77. Epub 24 May 2010.
  6. Neilson, IR. “Consultation with the Specialist: Ingestion of coins and batteries.” Pediatrics in Review,1995, Vol 16.1; 35-6. http://pedsinreview.aappublications.org/content/16/1/35.abstract.
  7. “NBIH button battery ingestion triage and treatment guideline.” Poison Control: National Capitol Poison Center. 2012. http://www.poison.org/battery/guideline.
  8. “Safety tips for button batteries.” Poison Control: National Capitol Poison Center. 2012. http://www.poison.org/battery/tips.
Posted on January 4, 2016 by Michael Macias and filed under Toxicology and tagged Button Battery Ingestion Pediatrics.