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

The mainstay of treatment of esophageal battery button impaction is emergency endoscopic removal, ideally within two hours of ingestion.⁸ Sucralfate or pasteurized honey, 10 mL every 10 minutes, should be given as soon as possible—within 12 hours of ingestion barring any airway concerns.⁸ Honey should be given no more than six times

and sucralfate no more than three times. These coat the battery and reduce pH to delay alkaline burns to the surrounding tissues but should not be considered a replacement for emergency surgical removal. An emergency department (ED) button battery pathway, including who to call for emergency endoscopic removal, transport to a tertiary care center if necessary, and location and dosing of first-line treatments, should be available in all EDs to help facilitate rapid and efficient diagnosis and management.

A controversial area in the management of button battery ingestions is in the asymptomatic patient with a battery discovered distal to the esophagus in the GI tract. Recent expert opinion-based guidelines from the Endoscopy Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommended consideration of urgent endoscopic assessment and removal in patients older than five years or those in whom the battery is > 20 mm in diameter.⁸

The more we, as emergency physicians, understand about the recognition and management of button battery ingestions, the better equipped we are to educate the public about preventive measures such as counseling families with young children about how to safely use, store, and discard batteries, including taping over battery compartments and recycling used batteries. These are simple measures that can prevent this potentially catastrophic illness.

Many thanks to Dr. Olivia Ostrow for their expert contributions to the EM Cases podcast, which inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website.

References

1. Varga Á, Kovács T, Saxena AK. Analysis of complications after button battery ingestion in children. Pediatr Emerg Care. 2018;34(6):443-446.
2. Leinwand K, Brumbaugh DE, Kramer RE. Button battery ingestion in children: a paradigm for management of severe pediatric foreign body ingestions. Gastrointest Endosc Clin N Am. 2016;26(1):99-118.
3. National Capital Poison Center. Button Battery Ingestion Statistics. Accessed June 17, 2024.
4. Krom H, Visser M, Hulst JM, et al. Serious complications after button battery ingestion in children. Eur J Pediatr. 2018;177(7):1063-1070.
5. Soto PH, Reid NE, Litovitz TL. Time to perforation for button batteries lodged in the esophagus. Am J Emerg Med. 2019;37(5):805-809.
6. Baharudin N, Gendeh H, Teh HM. Neck radiograph halo sign: do not be fooled. Cureus. 2023;15(4):e38029.
7. Lorenzo C, Azevedo S, Lopes J, et al. Battery ingestion in children, an ongoing challenge: recent experience of a tertiary center. Front Pediatr. 2022;10:848092.
8. Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562–574.