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To understand the pathophysiology of button battery ingestion (BBI), it is important to understand the basic principles of batteries. Batteries produce electricity using two different metals in a chemical substance known as an “electrolyte”. An electrolyte simply means a substance that can be broken down by electrolysis. Each battery contains two different metals which create a chemical reaction. During this reaction, one metal will lose more electrons than the other.
When a button battery becomes impacted within the esophagus, or the digestive tract, the body's mucosa serves as a circuit between the two electrical terminals (+/-) of the battery. This circuit allows for the the electrons freed in the one metal to flow into the other metal, balancing the electrical charge.
The electrical current that is now flowing through the tissues results in the generation of hydroxide radicals in the body’s tissues. This presents a serious risk to patients as hydroxide radicals are associated with a rapid rise in pH far outside normal physiological parameters. The result is caustic injury and subsequent coagulative necrosis. This can weaken the esophageal wall in a short amount of time. As the injuries are caustic in nature, there is significant probability that they will not be isolated to the point of contact and can extend to adjacent tissue, such as the trachea or great vessels.
Risk Factors
First Responders, Emergency Medical Responders, and Paramedics should be aware of the risk of battery ingestion, the presentations, and subsequent management.
There has been an increase in battery ingestion incidents, specifically in children. Over the last 10 years, there has been a 10-fold increase in complications with the likelihood of rapid damage to the body being catastrophic, with 75% of all foreign body ingestions occurring in children, specifically between the ages of 6 months and 3 years of age. Approximately 90% of BBI occurrences resulted in adverse outcomes due to a BB size greater than 20mm in diameter.
A BB size of 20-25mm in diameter carries an increased risk of the BB becoming impacted in the pediatric esophagus compared to the previously standard 15mm and under alkaline BB. The increased voltage in newer lithium cells (3.0 V) is a major contributing factor in the type and degree of harm sustained from ingestion when compared to alkaline cells (1.5 V).
This guideline provides clinicians with the knowledge necessary to quickly recognize this specific emergency, identify environmental and population-based risk factors, and to perform necessary treatment. It is focused on BBI only. Paramedics and EMRs/FRs should refer to other guidelines for the management of airway obstruction, croup, epiglottitis, or anaphylaxis as required:
Warning
A battery lodged in the esophagus is a medical emergency even if asymptomatic.
Presentation can vary and be non-specific – from the completely asymptomatic patient to a clinically unstable patient.
Non-specific symptoms can include nausea, pain, coughing, fever, and tachycardia. Misdiagnosis and mistreatment can be high, therefore thorough history gathering is key.
Unconscious patients should have their breathing and circulation assessed concurrently. If the patient is found to be pulseless, there is no change in patient management – compressions and defibrillation continue to be prioritized above ventilations. In the event of a pediatric cardiac arrest, emphasis must be placed on early airway management and ventilatory support.
With the exception of honey, patients should be given nothing by mouth until the ingestion is confirmed through radiography. Honey is administered in an attempt to coat the battery poles and delay the progression of chemical burns to the adjacent tissues.
There is no current referral pathway for these patients. Conveyance to an Urgent and Primary Care Centre is not appropriate.
BBI can lead to significant morbidity and mortality in the pediatric population due to the creation of a local pH environment from 10-13 leading to liquefactive necrosis at the negative pole.
There is often little out-of-hospital treatment available beyond supportive care and conveyance to the nearest emergency department.
Patients who have ingested a button battery can present with vague symptoms similar to a viral illness. Any suspicion of ingestion needs to be investigated and clinicians must maintain a high index of suspicion.
General clinical features include:
Late Signs:
For stable witnessed or suspected unwitnessed ingestion within 12 hours, and if there are no airway concerns and the patient's ability to swallow is intact: