The least considered…
As the seasons turn so do the types of calls the Missouri Poison Center receives on the hotline. From summer stings and sunscreen we now turn our attention to the winter’s mix of cold medicines, antifreeze, and one substance that often is not thought to be much trouble – button batteries.
The disc or button battery is one of the least considered hazards during the holidays. It is almost ubiquitous with gift giving. Not only are they found in toys, games, and musical greeting cards, but they are also found in hearing aids, watches, flashlights, remote control devices, keyless entry fobs, and key chains.
Button batteries are small cell-type, disc shaped batteries that differ in size, chemical composition, and voltage. They contain an anode and cathode. The anode is generally made of zinc or lithium; whereas the cathode is made of one of many chemicals such as manganese dioxide, silver oxide, oxygen, carbon monofluoride, copper oxide, or mercuric oxide.
Button batteries differ in diameter and thickness. Harmful outcomes are more common with ingestion of batteries with a diameter greater than or equal to 20 millimeters (mm); approximately the same size as an American quarter. National databases show that since 2008, 18% of ingested batteries with a known diameter of 20 mm all virtually were lithium cells. Not only the size, but the type of battery was more likely associated with clinically significant outcomes.1
Nationally, there are approximately 3500 cases of swallowing button batteries per year. The Missouri Poison Center reported 104 button battery ingestions in 2016 of which 36% of those exposed experienced no effects, 4% minor effects, 2% moderate effects, while the remainder of the cases were unrelated or the specialist was unable to follow to a known outcome. Most of these exposures occur in children. Last year, according to the AAPCC National Poison Data System, there were 5 deaths from button batteries in children < 5 years old.
A study published in Pediatrics reviewed available data from NPDS, National Battery Ingestion Hotline (NBIH), and the literature to identify outcome predictors and trends. A total of 13 fatalities from 1977 – 2009 from battery ingestion was reported; 9 fatalities in the most recent 6 years. All fatalities occurred in children under the age of 3 years. The diagnosis was missed by health care providers in 7 of the 13 deaths because of nonspecific presenting symptoms of vomiting, fever, lethargy, poor appetite, irritability, cough, wheezing, and/or dehydration. Batteries were lodged in the esophagus for 10 hours to 2 weeks before removal or death. Exsanguination as a result of esophageal fistulas into major arteries occurred in 9 patients, including 7 aortoesophageal fistulas. Delayed, unanticipated, and uncontrollable massive bleeding occurred up to 18 days after removal. Also occurring were esophageal perforation, tracheoesophageal fistulas, esophageal strictures, and vocal cord paralysis.
Mechanism of Toxicity
Earlier studies have shown 3 factors responsible for the injuries:
- Generation of an external electrolytic current that hydrolyzes tissue fluids and produces hydroxide at the battery’s negative pole.
- Leakage of battery content
- Physical pressure on adjacent tissue (this, alone, does not cause significant injury).2
Recent studies demonstrate the increased use of larger-diameter, more powerful 3-V lithium batteries in consumer electronics has resulted in a 6.7 fold increase in severity of injury.2 Unlike other disc or button batteries, lithium coin cells contain a mildly irritating organic electrolyte instead of an alkaline electrolyte; therefore, leakage does not cause local injury. Lithium cells have a higher capacitance, and generate more current. In most severe outcomes the generation of an external current, electrolysis of tissue of mucosal fluids and generation of hydroxide was the cause of injury.
Children always require an immediate localization x-ray to exclude an esophageal battery, even when asymptomatic. This is because 36% of patients with batteries lodged in the esophagus were initially asymptomatic.
1. ESTABLISH RESPIRATIONS:
Establish respirations and ensure adequate ventilation.
Keep patient NPO until the battery position is determined by radiograph.
2. RadiographiC imaging:
Obtain posterior, anterior, and lateral view radiographs of the head, neck, chest, and abdomen to confirm the exposure and determine location and size of the battery.
4. impacted batteries:
The disc battery should be removed IMMEDIATELY if it is impacted in the esophagus, ear, or nose or if the battery compresses other tissue.
5. battery identification:
Without delaying intervention, attempt to determine the diameter of the battery by measuring the diameter of the slot the battery fit into or measuring the diameter of a companion replacement battery
6. batteries in stomach or intestines:
Endoscopic or surgical removal from the stomach or intestines is indicated if the battery is impacted and/or causing peritoneal symptoms.
Additional indications for endoscopic or surgical removal:
- Child younger than 6 years of age ingests a battery 15 mm or more in diameter
- The battery remains in the stomach for 4 days or longer
- Disc battery ingestion in small infants, there has been severe gastric mucosa damage reported in this age group
- or if a magnet was also ingested
Consultation with GI or Surgery may be helpful in such cases.
If the battery is located in the stomach or intestines and the aforementioned circumstances are not applicable the patient may be discharged.
All stools should be examined for passage of the battery or until a repeat radiograph demonstrates that the battery is no longer in the GI tract.
7. Repeat Radiograph:
In asymptomatic patients, a repeat radiograph is recommended in 4 days if the battery has not passed in the stool.
Button battery ingestion can produce significant morbidity and mortality within a short period of time and can range from no effects to esophageal perforation and death. Battery ingestion needs to be identified as quickly as possible and the size of the battery should be noted.1
The Missouri Poison Center stands ready to consult on battery exposures. Specially-trained and experienced health care professionals are just a phone call away at 1-800-222-1222.
Shelton A, Toxicology Today. Utah Poison Control Center 2011, Vol 13:Issue 4.
Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168 –1177
Toby Litovitz, Nicole Whitaker and Lynn Clark Preventing Battery Ingestions: An Analysis of 8648 Cases. Pediatrics 2010;125;1178; originally published online May 24, 2010; DOI: 10.1542/peds.2009-3038
Tanaka J, Yamashita M, Yamashita M, Kajigaya H. Esophageal electrochemical burns due to button type lithium batteries in dogs. Vet Hum Toxicol. 1998;40(4):193–196.
Yamashita M, Saito S, Koyama K, Hattori H, Ogata T. Esophageal electrochemical burn by button-type alkaline batteries in dogs. Vet Hum Toxicol. 1987;29(3):226 –230.
Yamashita M, Saito S, Koyama K, Noyama M, Hattori H, Naito S. Chemical burns due to low voltage direct current button type battery [in Japanese]. Igaku no Ayumi. 1983; 126(12):957–959.
Yoshikawa T, Asai S, Takekawa Y, Kida A, Ishikawa K. Experimental investigation of battery-induced esophageal burn injury in rabbits. Crit Care Med. 1997;25(12): 2039 –2044.
Yasui T. Hazardous effects due to alkaline button battery ingestion: an experimental study. Ann Emerg Med. 1986;15(8):901–906.
Langkau JF, Noesges RA. Esophageal burns from battery ingestion. Am J Emerg Med. 1985;3(3):265.