Guilty as charged: be careful of the
negative effects of button batteries!
Kate Parkins
Lead Consultant NWTS
Referral line: 08000 84 83 82
NWTS
www.nwts.nhs.uk
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Consultant advice 24/7 – 08000 84 83 82
Co-ordinate conference calls with relevant specialists
Team mobile within 20mins of referral acceptance if at base
At patient bedside within 2-3 hours of referral
Case 1
 3 ½ year old – ex-prem 28/40 – fit & well
Cap gas
 Haematemesis at nursery – bright red blood
 Referred to NWTS after
3rd
episode
 Very pale; lethargic
 HR 190/min; BP 77/49; RR 30-45/min
pH
7.33
pCO2
3.7
pO2
HCO3
16.4
BE
-10.2
Lactate
5.1
Case 1
 No known accidental ingestion
 Eg paracetamol, iron, other
 Initially improved with fluid resuscitation
 30 mL/kg 0.9% NaCl
 20 mL/kg Packed Cells
 Further haematemesis + melaena
 Shock – HR 180/min; mBP↓
 I&V – ketamine/suxamethonium
 Further packed cells & FFP
 Dopamine infusion
Hb
88
AST
13
WCC
41.9
ALT
15
Plts
1166
ALP
197
APTT
28
CRP
15
INR
1.1
Case 1
 Omeprazole + ranitidine
 Octreotide infusion (on advice of gastroenterology)
 Massive haemorrhage – blood via mouth & nose
 Cardiac arrest
 Blood products given
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Packed cells 1,800 mLs
FFP 900 mLs
Cryoprecipitate 100 mLs
Gelofusine 750 mLs
Case 1
 Tranexamic acid bolus & infusion
 Calcium gluconate
 Inotrope infusions
 Dopamine
 Adrenaline + boluses
 Sodium bicarbonate bolus x2
 Foley catheter placed in oesophagus – attempt to tamponade
 Adrenaline via short NGT
Case 1
 D/W paediatric haematologist, gastroenterologist & surgeon
 + local consultant surgeon/adult intensivist/paediatrician
 “You are already doing everything I can suggest”
 Little other options
 Consider OGD – but on-going major haemorrhage/cardiac arrest!
 Local surgeons & paeds surgeons discussed options
 Surgery not an option
 Resus attempt: 70 mins - unsuccessful
Case 2
 Fit & healthy 12 month old
 Attended A&E: swallowed a watch battery previous day
 Difficulty swallowing
 Had not passed battery in stool
 Removed by paediatric surgical team (rigid gastroscope)
 Approx 24 hrs after ingestion
 Mucosal burn noted at removal site
 Discharged home 36 hrs later: eating/drinking normally
Case 2
 Presented to DGH 7 days post ingestion
 Haematemesis at home + active bleeding via mouth & nose
 Cardiac arrest soon after presentation
 CPR started: drugs (APLS) + blood products
 Intermittent cardiac output & respiratory effort
 Consultant surgeon called
 NWTS team mobilised + consultant paediatric surgeon
Case 2
Wt = 10 kg
 Laporotomy + thoracotomy
 Initially bleeding ‘tamponaded’:
 Using foley catheter + clamp across stomach
 BUT continued to ooze
 Higher thoracotomy – unable to gain control bleeding point
 Massive blood loss
 Cardiac arrest – despite rapid volume transfusion
 Unsuccessful resuscitation
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Packed cells: 3,ooo mL
FFP: 1, 000 mL
Platelets: 500 mL
Adrenaline infusion + boluses + Calcium boluses
Post-mortem findings
 Case 1
 Isolated oesophageal ulcer with oesophageal-aortic fistula
 Case 2
 Oesophageal perforation into aberrant origin of right
subclavian artery
Case 3
 Fit & healthy 12 month old
 Vomited after a feed at approx 23:00
 Parents concerned: noisy breathing
 O/A: stridor, not drooling
 Increased WOB: tracheal tug, subcostal recession
 HR 115-130/min; RR 30/min; SpO2 96% in air
 Treatment: oral dexamethasone, nebulised adrenaline
Case 3
 CXR: button battery seen in cervical region
 Approx 2cm
 ENT conferenced into initial referral
 Agreed: NWTS urgent transfer to tertiary centre
 Theatre ASAP: battery removed from upper oesophagus
 Oesophageal mucosal ulceration noted at removal
 Difficult removal
 Rantidine/Co-amoxiclav/Oral dexamethasone
Case 3
 Review – further MLTB/OGD
 Vocal cord palsy
 Kept intubated & ventilated for 7 days
 Resolving – avoided tracheostomy
 OGD: oesophageal stricture
 No fistula
 Dilated
 Gastrostomy inserted
Case 4
 4 year old – fit & healthy
 Presented to A&E with battery stuck up nostril
 Removed approximately 4 hours after insertion
 Inferior septum blackened on left & right side
 but not perforated initially
 Review at 2 weeks: perforated septum
 Likely permanent defect
Situation elsewhere……
USA national database: over 20 years
Significant ↑ in battery-related ED visits!
USA Algorithm
www.poison.org/battery/guideline.asp.
 Australia
 Research into safety
measures
 Food dye coating to stain
the mouth
 Bitex coating?
 USA
 Compulsory lockable
battery compartments
Know your enemy……
 Lithium Button Batteries vs others
 Generate more current: x2 capacitance (3 volts vs 1.5 volts)
 Associated with more severe complications
 New vs Old
 New more likely to cause severe injury
 Used/spent still generate enough current to damage tissue!
 Only 60-80% ingestions are witnessed
How?
 3 ‘N’s – Narrow, Negative, Necrotic
 -ve pole = narrowest side causes severe, necrotic injury
 Injury caused by external electrolytic current at negative pole
 Hydrolysis sodium hydroxide (aka caustic soda) within 1 min pH 11
 Causes liquefaction necrosis
 Leakage does NOT cause injury (mild irritant only – organic electrolyte)
 Damage can occur within 1-2 hours
 More severe injury after 8-12 hours
How?
3 hours later…………
ANATOMICAL RUSSIAN
ROULETTE
3 areas of physiological narrowing
Size Matters!
 AGE……..
 Under 6 years most at risk
 Up to 12 years vulnerable
 Battery……….
 Any > 12 mm
 20 mm more frequently get stuck in oesophagus
 Smaller can cause serious injury or death
Suspicious if…..
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Airway obstruction or wheeze
Drooling
Nausea or vomiting
Chest or epigastric pain
Difficulty swallowing, decreased appetite, refusal to eat
Coughing, choking or gagging with eating or drinking
 WARNING: may be asymptomatic
Ticking time bomb…..
 Locate: CXR, AXR, neck x-ray ASAP
 Lateral to confirm battery not coin
 5p = 18 mm; 10p = 24.5 mm
 AP view: “halo rim” = ring of radiolucency just inside outer edge
of the object
 Lateral view: central bulge or “step-off“, may be difficult to
appreciate if oblique or with newer, thinner Lithium batteries
Removal….
Upper airway or
Oesophageal
 Remove ASAP
 Do NOT wait until fasted
 At removal - note direction of
negative pole
 Remove endoscopically ASAP
 Check site for any evidence
mucosal injury
 NB 2nd look if any signs of
injury
Stomach & beyond
 Asymptomatic, repeat X-ray …….
 Within 4 days for < 6 years of age or
button batteries > 15 mm
 Repeat in 10 – 14 days for older
children if not large battery
 If battery remains in stomach,
endoscopic removal recommended
 Watch for: abdominal pain, fever,
vomiting, haematemesis, melaena
NB remove ASAP if co-ingested with magnet
After removal….
 Delayed complications……
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Trachoesophageal fistula
Oesophageal perforation, Pneumothorax, hydrothorax
Mediastinitis
Vocal cord paralysis, Tracheal stenosis or tracheomalacia
Aspiration pneumonia, empyema, lung abscess
Spondylodiscitis
Exsanguination due to perforation into major vessel
 Perforations/fistulas may be delayed up to 28 days!!
 Strictures = weeks-months
Future….
 Public awareness campaign
 Discussions with national child safety groups
 Safety measures – prevention better than cure!
 UK guideline
 TOXBASE
 National database
 What’s the extent of the problem in UK?
Extent of problem in North West?
Case 5
 2 year old referred to paeds
 Poor appetite, abdo pain &
weight loss for 6 weeks
 AXR: ‘coin’ shaped object in
lower oesophagus
 Removal: very difficult,
mucosal injury
 Oesophageal stricture
requiring regular dilatation
Case 6
 4 year old presents to ED
 c/o back pain
 Vomited once in ED, metallic
object in vomit, size of a 10p
piece
 What are you going to do
now............................?
More
cases?
Stop press!
 ‘Simple battery armor to protect against gastrointestinal injury
from accidental ingestion’
 B. Laulicht, G. Traverso, V. Deshpande, R. Langer, J. Karp
 Proceedings of National Academy of Sciences of USA, Nov 2014
 Waterproof, pressure-sensitive battery coatings; nonconductive in the
low-pressure gastrointestinal tract, yet conduct in higher-pressure
standard battery housings
 Quantum Tunnelling Composite QTC™
 = an "exciting possibility", if widespread adoption
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Courage is not the absence of
fear…….
But rather the judgement
that something else is more
important than fear
Ambrose Redmoon