Posted: July 1st, 2024

A 12-month-old male presents to your emergency department after ingesting a watch battery

History: A 12-month-old male presents to your emergency department after
ingesting a watch battery, which was left out on the counter. He has been
drooling since the incident and refusing his bottle.
PMH: None.
Physical Examination:
T: 98.6°F HR: 137 bpm RR: 32 breaths per minute BP: 100/62 mm Hg
General: He is awake, alert and calm in appearance.
HEENT: Drooling from mouth.
Pulmonary: Clear to auscultation.
CV: Regular rate and rhythm without murmur, normal perfusion.
Extremities: Normal.
QUESTIONS CASE STUDY #1
1. What is the initial approach to this patient?
2. What complications may be associated with these types of batteries?
3. On x-ray, the battery is located in the esophagus at the level of the aortic arch.
What therapy is indicated?

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Battery Ingestion in Pediatric Patients: Review of Management and Outcomes

Button battery ingestion represents a significant pediatric emergency that demands prompt recognition and intervention. This paper examines the current best practices for managing such cases, with a focus on the initial approach, potential complications, and appropriate therapeutic interventions.

Initial Approach

The initial management of a child presenting with suspected button battery ingestion involves a rapid assessment and stabilization of the patient’s condition. A thorough history should be obtained, including the time of ingestion, size and type of battery if known, and any observed symptoms (Litovitz et al., 2020). In the case presented, the 12-month-old male exhibits drooling and feeding refusal, which are concerning symptoms that may indicate esophageal injury.

The physical examination should focus on vital signs, hydration status, and signs of respiratory distress or shock. Immediate medical imaging is crucial, with a two-view chest radiograph being the standard initial study. This allows for confirmation of the battery’s presence, its location, and potential signs of complications such as pneumomediastinum or pneumothorax (Jatana et al., 2019).

Complications Associated with Button Battery Ingestion

Button batteries can cause severe tissue damage through several mechanisms. The primary concern is the generation of an electrical current when the battery comes into contact with tissue fluids, leading to hydroxide ion production and subsequent liquefactive necrosis. This process can occur rapidly, with significant esophageal injury possible within two hours of ingestion (Ing et al., 2018).

Potential complications include:

1. Esophageal perforation
2. Tracheoesophageal fistula formation
3. Aortoesophageal fistula (potentially fatal)
4. Vocal cord paralysis due to recurrent laryngeal nerve injury
5. Esophageal stricture formation
6. Mediastinitis

The severity of these complications underscores the urgency of proper management and the need for long-term follow-up in affected patients.

Therapeutic Intervention for Esophageal Battery Impaction

When a button battery is identified in the esophagus, as in this case where it is located at the level of the aortic arch, immediate removal is indicated. The current standard of care involves emergent endoscopic removal under general anesthesia (Zhu et al., 2021). The procedure should be performed by an experienced endoscopist, typically a pediatric gastroenterologist or surgeon, in a facility equipped to manage potential airway or vascular complications.

Prior to endoscopic removal, administration of honey or sucralfate may be considered if the ingestion occurred within 12 hours and there are no contraindications. These substances can potentially create a protective barrier and reduce the severity of injury, although this should not delay definitive management (Anfang et al., 2019).

Post-removal care is critical and may include:

1. Esophageal assessment for injury severity
2. Antibiotic prophylaxis if mucosal injury is present
3. Proton pump inhibitor therapy to promote healing
4. Serial imaging to monitor for delayed complications
5. Coordination with otolaryngology for airway evaluation if indicated

Conclusion

Button battery ingestion in pediatric patients represents a time-sensitive emergency requiring a multidisciplinary approach. Prompt recognition, appropriate imaging, and timely intervention are crucial to preventing severe complications. Ongoing research continues to refine management strategies, emphasizing the importance of prevention through public education and improved product safety measures.

References

Anfang, R.R., Jatana, K.R., Linn, R.L., Rhoades, K., Fry, J. and Jacobs, I.N., 2019. pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. The Laryngoscope, 129(1), pp.49-57.

Ing, R.J., Hoagland, M., Mayes, L., Twite, M. and Kurth, C.D., 2018. The anesthetic management of button battery ingestion in children. Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 65(3), pp.309-318.

Jatana, K.R., Rhoades, K., Milkovich, S. and Jacobs, I.N., 2019. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. The Laryngoscope, 129(6), pp.1428-1433.

Litovitz, T., Whitaker, N. and Clark, L., 2020. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics, 125(6), pp.1178-1183.

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Tags: A 12-month-old male presents to your emergency department after ingesting a watch battery, Battery Ingestion in Pediatric Patients: Review of Management and Outcomes, Toxicology case study analysis