We see lots of kids presenting to the ED with “things” where they shouldn’t be (we see adults too, sometimes – but that’s a whole set of different stories). Foreign bodies show up in all sorts of forms in all sorts of places, typically in the preschool and early school age kids who display a potentially deadly combination of curiosity and dexterity with a magpie-like obsession; they just can’t keep away from shiny things. And what could be better than a tiny shiny thing that fits easily into your ear, or your nostril – or your mouth?
I’ve removed all sorts of things from ears and noses (memorably a HUGE kidney bean, bits of Lego, a nosepad from a pair of glasses – apparently that’s what these things are called) and seen kids where there’s no clear history of foreign body insertion or ingestion but one is suspected. I’m not proud of making a mum vomit encouraging her to attempt the mother’s kiss to dislodge a piece of chicken which had been up a nostril for around three weeks… The smell was NOT pleasant (and the chicken didn’t budge). I’ve lost count of the number of coin ingestions I’ve seen (and if you want to know whether we can use handheld metal detectors instead of x-rays to exclude their presence, I could talk for hours…).
But there’s one particular foreign body we need to think carefully about: the potentially deadly button battery.
What are Button / Coin / Disc Batteries (Cells)?
Button batteries are small, disc shaped single cells designed for use in small, portable electronic devices such as watches, calculators, hearing aids and the like. They come in a variety of shapes and sizes typically with a cathode of zinc or lithium. There’s a nice description of how they work over at Medscape.
The batteries have a code printed on them which tells you their type and constituents; if you have the packaging or an identical battery (they are sometimes sold in multi-packs) you can check this table on the wikipedia page to find out what kind of battery it is.
Why Are They Dangerous?
Common belief is that when the battery comes into contact with a mucosal surface the lithium leaks out but actually this is not the case. In fact the contact permits transmission of a small amount of current which burns the surrounding tissues as sodium hydroxide is produced at the anode.
Make no mistake – these seemingly innocuous items can be utterly devastating. Tissue damage is visible at endoscopy within as little as two hours, potentially with devastating consequences – perforation and fistulation, including into major blood vessels, can occur within hours (or weeks after removal) with damage occurring more quickly for lithium batteries.
This blog shows what happened to a frankfurter (hotdog) sausage as a lithium battery was left in it over just three hours.
Button Batteries in the ED – Do They All Require Removal?
The short answer? No.
Deaths and major complications from ingestion are rare. Most button batteries, like other ingested foreign bodies, will pass entirely through the digestive tract as long as they make it out of the oesophagus – beyond the lower oesophageal sphincter the risk of perforation is substantially lower although it is advisable to ensure that these children have some sort of surveillance (many departments x-ray children with batteries in the stomach again 8 hours later; toxbase advises repeat x-ray two days later for batteries not beyond the pylorus on initial radiograph).
Parents of discharged children must have robust safety netting (there is a graphic at the end of this post with suggested advice). Parents need to know exactly what to look out for. If the battery is in the oesophagus then it is a surgical emergency and should be removed as soon as possible. Similarly complications are more likely with larger batteries (specifically those more than 20mm in diameter, as this open access paper from Pediatrics suggests).
Button batteries in ears and noses should also be removed as soon as possible; don’t leave these kids to wait 4 hours in the waiting room!
Management in the ED
Many ingestions/insertions are unwitnessed; the child reports that they have eaten something or put something in their ear. Parents may have reason to suspect that there is a button battery – an analysis of a database held in the US suggested the majority of button batteries ingested were removed directly from products – but as healthcare professionals we must consider whether an unknown foreign body might be a button battery and investigate as such.
For ingestions, plain radiographs can reveal a radio-opaque foreign body with a “double shoulder” appearance (shown nicely in these images from Radiopedia) which is not seen in coin ingestion and should raise suspicion that the foreign body is a button battery.
Further management depends on the location of the battery and there are several pathways available online to guide this process; generally, if the battery is beyond the oesophagus the asymptomatic child can be observed at home with careful safety netting and potentially regular review to ensure the battery passes. Do NOT induce vomiting – this can cause retrograde movement of the battery from the stomach into the oesophagus. Co-ingestion of a magnet also necessitates removal, irrespective of the location of the battery.
Most US guidelines (and toxbase) advise checking stools for passage of the battery; I am a little wary of this advice for a few reasons. Firstly, it’s unpleasant, unhygienic and technically rather difficult in children who are not wearing nappies. Secondly, passage invariably occurs in the one stool the parents don’t check (the one they do at school or at Grandma’s) and thus there is a persisting and heightened anxiety if the battery’s passage is not observed. Passage usually occurs within two weeks but can take longer and that’s a LOT of poo. It is probably wiser to consider regular ED review with imaging (single image fluoroscopy would be sufficient after the first imaging studies and carries lower radiation exposure). Endoscopic removal is usually indicated if the battery remains in the stomach for four days or more. It’s worth thinking about how you would want to manage these patients in your ED.
If the battery is in the oesophagus, ear or nose then urgent referral is required for removal and assessment (surgery or ENT as appropriate). Oesophageal batteries are almost always removed endoscopically.
Of course, it’s possible that the first time the patient sees a healthcare professional is when things have already gone badly wrong.
When the battery is lodged in the gastrointestinal tract the patient may present with vomiting (including haematemesis), abdominal pain, altered bowel habit, respiratory symptoms, reduced feeding, fever or potentially in extremis with circulatory shock due to massive haemorrhage. Button battery ingestion should be considered in children presenting with upper GI bleeding as per this safety alert from the College of Emergency Medicine, even if there is no history of witnessed or suspected ingestion before that point.
In these circumstances resuscitation may be necessary, including activating the major haemorrhage pathway with immediate surgical consultation.
Again, imaging can be used to confirm the location of the battery but surgical exploration and repair is likely to be necessary.
Pitfalls – the Stuff You REALLY Need to Know
THERE MAY BE NO HISTORY OF INGESTION/INSERTION
So just like the kids with persisting cough, we have to think about whether there may be a foreign body involved – and investigate appropriately.
COIN INGESTION IS MORE COMMON AND COINS LOOK SIMILAR ON RADIOGRAPH
Make sure you look for the “double shoulder” appearance.
EVEN AFTER REMOVAL, PERFORATION CAN OCCUR – MUCH LATER
In Manchester this recent tragedy has added to our collective awareness of the dangers of button battery ingestion. Frighteningly, even weeks after removal potentially fatal complications can occur. The challenge is to educate ourselves and remain vigilant to the possibility of button battery ingestion or complications even after removal.
There are a number of global awareness campaigns about button batteries – Emmett’s Fight and The Battery Controlled are two good US examples. Hopefully recent UK cases will prompt a similar awareness campaign.
GIVE GOOD SAFETY NET ADVICE
Since many of these patients will be going home, it is essential to give clear advice to parents about when to return and, if they do return, not to dismiss their concerns. There is further advice available through the National Poisons Information Service (Toxbase) – login required.
Many thanks to the fabulous Rachel Rowlands for her pre-publication peer review of this post.