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

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

NBIH Button Battery Ingestion Algorithm

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

Read More

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