Why do emergency physicians need to know about the recognition and management of button battery ingestion? Button batteries are ubiquitous in the United States. They have been used in car keys, flashlights, and children’s toys. It can take only two hours for potentially life-threatening tissue damage to develop, and more than 50 percent of serious outcomes due to button battery ingestion occur after unwitnessed ingestions, when there is often a delay in recognition and management.^1,2 Annual button battery ingestions increased by 66.7 percent in the United States from 1999–2019, accompanied by a 10-fold increase in complications.³ The emergency medicine community has a responsibility to educate ourselves, our patients, and the public on this mostly preventable illness.

To understand why button battery ingestion can be rapidly fatal, it is important to realize that the tissue injury these batteries cause results from a caustic chemical reaction that leads to coagulative necrosis, alkaline burns, and liquefaction necrosis. Typically, this occurs in the proximal and mid-esophagus where the battery is impacted, and esophageal perforation may occur, or a fistula into the trachea and/or aorta may ensue, leading to life-threatening bleeding, respiratory failure, and/or sepsis. Three-volt lithium batteries ≥ 20 mm in diameter are most frequently associated with serious complications.⁴ The rate of necrosis is variable, with perforation typically occurring after 12 hours. Complications may be delayed up to two months, however, making the diagnosis even more challenging.⁵ Even if the button battery has been removed or expelled from the GI tract, delayed complications are possible, and parents should be counseled to monitor for symptoms of complications.

One of the common pitfalls in the recognition of button battery ingestion cases is assuming that a history of coin ingestion was, in fact, an ingestion of a coin, and not a button battery.⁶ Parents may mistakenly report a coin ingestion, which typically does not require immediate treatment. A report of coin ingestion should be assumed to be a button battery ingestion until proven otherwise. To differentiate a coin impaction from a button battery impaction, use two radiographic findings: the halo sign, seen on the anteroposterior view as a ring within a ring only with button batteries, and the step-off sign, seen on the lateral view as a 90-degree step at the edge of the button battery that is not present with coin impaction.⁶ Adding to the diagnostic challenge are the poor specificity and the sometime subtlety of presenting symptoms, which may or may not include wheeze, chest pain, cough, vomiting, hematemesis, shortness of breath, poor feeding, unexplained food refusal, or fever.⁷