What is the appropriate emergency management for a toddler who has ingested a button (disc) battery?

Emergency Management of Button Battery Ingestion in Children

Immediately obtain a chest/abdominal X-ray to locate the battery position, and if lodged in the esophagus, perform emergent endoscopic removal within 2 hours (no later than 6 hours) due to the high risk of catastrophic tissue damage including pressure necrosis, electrical burns, and chemical injury. 1, 2

Immediate Actions Upon Presentation

Initial Assessment and Imaging

• Obtain plain radiographs (chest and abdomen) immediately to confirm presence and location of the battery—do not delay imaging even with vague or nonspecific symptoms 1, 2, 3
• Biplanar radiography helps differentiate esophageal from tracheal location 1
• Children may present with nonspecific symptoms including fussiness, decreased appetite, refusal to eat/drink, drooling, difficulty swallowing, hematemesis, or abdominal pain 3
• Maintain high index of suspicion as many cases involve unwitnessed ingestion with delayed presentation 4

Critical Time-Dependent Management Based on Location

Esophageal Impaction (EMERGENCY)

• Perform emergent flexible endoscopy preferably within 2 hours, absolutely no later than 6 hours 1, 2, 5
• Tissue damage can occur rapidly—serious injury may develop in as little as 2 hours 6, 3
• Activate emergency medical services immediately 2
• Do NOT induce vomiting or administer activated charcoal 2

Temporizing Measures While Awaiting Endoscopy (Esophageal Location Only)

• In children >1 year old: Consider administering honey (10 mL every 10 minutes, maximum 6 doses) if ingestion occurred ≤12 hours ago and removal will be delayed 2, 5
• Alternative: Sucralfate may be considered under same conditions 2, 5
• These measures should NEVER delay endoscopic removal 2, 5
• Do not administer water or milk 2

Battery Beyond the Esophagus (Stomach/Intestines)

• Asymptomatic patients with early diagnosis (≤12 hours): Monitor conservatively with repeat X-ray in 7-14 days to confirm passage in stool 5
• Delayed diagnosis (>12 hours after ingestion) even if battery has passed esophagus: Consider endoscopy to screen for esophageal damage and CT scan to rule out vascular injury, even in asymptomatic children 5
• Consider abdominal radiography for children with history of pica or excessive mouthing behaviors to assess for additional foreign bodies 1

Post-Removal Evaluation and Complications

Immediate Post-Endoscopy Assessment

• Grade the depth of esophageal injury during battery removal using established classification systems 7, 8
• Obtain tissue biopsies if concerns exist about depth of injury or infection 7, 8
• Document extent of burns, ulceration, or necrosis 1

Advanced Imaging for Severe Injuries

• Obtain CT scan with contrast if clinical suspicion exists for:
  • Transmural necrosis or perforation 7, 8
  • Mediastinitis 1, 7
  • Vascular injury (aorto-esophageal fistula risk) 7, 9, 4
  • Clinical indicators: fever, sepsis, subcutaneous emphysema, severe chest pain, respiratory distress 8
• Absence of post-contrast wall enhancement indicates transmural necrosis and mandates emergency surgery 7, 8

Delayed Diagnosis Protocol (>12 Hours)

• Even if battery has passed the esophagus, perform CT scan before removal to evaluate for vascular injury 5
• Lithium batteries ≥16mm diameter (3V) carry highest risk of severe complications in children <6 years 9, 5
• Fatal aorto-esophageal fistula can occur days after removal 9, 4

Surgical Intervention

Indications for Emergency Surgery

• Confirmed or suspected perforation 7
• Transmural necrosis on CT (absent wall enhancement) 7, 8
• Tracheo-esophageal fistula 4
• Aorto-esophageal fistula 9, 4

Surgical Approach

• Preferred technique: Esophagotomy with minimal resection of necrotic tissue and primary repair over feeding tube 7
• External drainage, esophageal exclusion, or resection may be necessary if primary repair not feasible 7
• Do NOT use hemoclipping for battery-induced esophageal injuries—these involve deep transmural necrosis, electrical burns, and chemical damage requiring more definitive intervention 7

Critical Pitfalls to Avoid

• Never delay endoscopic removal for esophageal batteries—tissue damage progresses rapidly 1, 2, 3
• Do not use oral contrast studies (barium or gastrografin) as they may coat the battery/mucosa and impair endoscopic visualization 1
• Do not assume asymptomatic presentation means low risk—severe injuries including TEF and AEF can develop with minimal initial symptoms 4
• Lithium batteries (3V, ≥16mm) pose exponentially higher risk than smaller alkaline batteries, particularly in children <6 years 9, 5
• Even after successful removal, monitor for delayed complications including stricture formation, fistula development, and vascular erosion 6, 4