Death Metal: Pediatric Button Battery Ingestions

In a sudden moment of clarity, I realize I’ve made a huge mistake.

It is too late to do anything about it now; we are committed and past the point of no return. Dark thoughts come creeping into my head. I can envision a very long night ahead of us now, ending with us pulled over on the side of the road in this dark canyon, in a snowstorm, with a dead child in the back waiting for hours on the coroner to arrive.

*Fair warning--things are going to get a bit dark in this article. This is all real and is an intimate portrait of what went on in the back of the ambulance and in my head.*

This will be a controlled flight into terrain. Composure,(at least externally) will be maintained all the way to the end, but on the inside I know I might be screwed here. I'm past the point in my career where things can induce panic in me. A shrug of the shoulders and an acceptance of the facts, perhaps like a condemned prisoner feels after all their appeals have been exhausted--it is out of my hands now. No matter what, in a few long hours this will be over one way or another and I will go home. I will go on with my life. Make no mistake about it though, it would be perfectly acceptable to panic right now. In fact, that might be the more appropriate and healthier response.

An hour earlier, I bought an express ticket straight to system one thinking when the hospital called and told me “we have a one-year-old with a button battery in their esophagus, confirmed by x-ray, and flights are grounded, you need to come and take them to the big hospital.” Two and a half hours of winding roads and blowing snow lay between us and the people who can get the battery out of the child. I did not stop to consider the second-order effects, I did not look for other options, and there was no gathering of more information. I just told them l that we would be there in ten minutes.

In the emergency department, it was easy to be fooled and to get lulled into a false sense of security as I did. The patient looked okay. No one seemed concerned in the emergency department. In hindsight, the lack of concern was probably more due to ignorance of the issue at hand than a true predicted clinical course. They should have been horrified.

While I didn’t feed the child the button battery I sure as hell could have done a better job of preparing for the doomsday scenario that is about to unfold here in the back of the ambulance. The sending hospital didn’t start an IV, and to be honest, when I looked at her chubby arms and hands, I couldn’t find anything worth putting a needle in. Not wanting to make her cry for no real reason I said we could skip it.

My plan of “if she crashes, I can just start an IO” seems like a really bad plan right now. While I can give intra-nasal or even intra-muscular medications for analgesia they always take what feels like an eternity to kick in - if they work at all. I imagine it will feel especially long if there is a one-year-old screaming and exsanguinating in front of me while I wait for the meds to kick in, not that they would change the outcome but at least she might be more comfortable as she dies. Or maybe it just makes me more comfortable thinking that? Sometimes I think the line between analgesia and euthanasia gets a bit blurry. But that is another story for another blog post, or perhaps that one should stay locked away in the file or only told late at night in hotel bars to other drunk conference-goers in order to retain the notion of plausible deniability.

The first thirty minutes of the transport are easy, aside from the usual fighting to keep the pulse ox sticker on the patient’s foot it is "situation normal." Every ten minutes I hand the mother a syringe full of Carafate and she feeds it to her child. I am on the verge of convincing myself that this is no big deal and that maybe this whole button battery ingestion thing is overblown, and that those YouTube videos of a button battery in a hotdog are nonsense. I think about pulling my book out of my bag and doing some reading between glances at the monitor and filling syringes full of sticky Carafate.

And then it happens, the calm is shattered, things are not okay. The nightmare scenarios come flooding back to center stage, my outlook goes from complacent optimism to something much darker, to a land where there will be no happy endings, no sunshine, no rainbows and cute babies with big eyes die badly in the back of ambulances. “She’s vomiting,” the mother says in a panicked voice. Thick white chunks with some darker specks are coming out of the patient’s mouth.

I am filled with swirling doubts and unanswered questions, the unknowns present are near overwhelming. There is no pediatric RSI in my state without a waiver (and we don’t have one) and until this moment I never thought it sounded like a good idea anyway. In sixteen years of EMS, I have never intubated a child, and this does not seem like a good one to be my first. This seems like a terrible first pediatric intubation. There is no safety net here, I don’t think an i-gel is going to work if the esophagus has a hole in it or is blocked by a button battery and it is especially doubtful that it will work if the esophagus has become a geyser of blood. If the battery has fused to the tissues in the esophagus, shoving the i-gel in there might just rip it and part of the esophagus off.

I resist the urge to act. I force myself to move slowly and to try and think before acting, I force myself to sit on my hands and do nothing for a few seconds. Maybe this will pass.

Over the past few years in EMS, the paradigm has shifted to embrace the idea that kids are just little adults in order to prevent paramedics from being scared sh*tless of them. I try to tell myself that, but it seems like a load of bullsh*t right now. This is not just a little adult, this is an alien, this is foreign, this is the deep end of the pool and I am not a strong swimmer. I discretely set out the “purple” pouch from the Handtevy kit. I tell the mother that things are okay, that vital signs look great. Ignore the fact that there is a battery inside of her creating lye in there. Perhaps it is burning a hole through her esophagus at this very moment and then into, who knows? The carina? The aorta? I wonder how much blood is there going to be if this perforates, probably a lot. I picture her airway looking like the scene in The Shining when the elevator doors open, and a torrent of blood comes out. How much blood does a one-year-old have in their body, a liter? More? Looking at the mother again, I wonder just how good of a poker-face do I have?

The planning starts and I quickly realize there is no plan—does a Ducanto suction catheter fit in a one-year-old? Is pediatric SALAD a thing? Do I take her out of the car seat to intubate her? How the hell do you transfuse a one-year-old? Not that I could right now anyway because I never stopped to think about getting blood when leaving the hospital. Should I have grabbed all the ingredients for a massive transfusion protocol such as platelets and FFP before leaving? I make a mental note to look up information on pediatric blood transfusions for next time. How do I get the small ET tube to fit on the end of the suction tubing, is there an adapter I use? Could an ET tube in the esophagus be a makeshift Blakemore tube? Jesus, that is so far outside of my protocols, would I even attempt it if I thought the options were that or death?

A quick glance at my phone shows no service, not surprising and not that it matters—who would I call right now?

“Hey it’s me, so…I’ve got this one-year-old that melted a fistula between their esophagus and aorta…and maybe their trachea too, and they are bleeding out AND drowning on their own blood in front of me here…so I just wondered if, you know, you had any ideas?”

What could they tell me besides I should have anticipated things better, established an IV and brought blood products? I begin looking at this kid’s tiny tibial plateau. How long do I let this go on before I do something? it won’t be long until the bright lights come on and the sharp needles come out and the screaming starts.

Pediatric Button battery ingestions are the stuff of nightmares.

A child with a button battery in their esophagus is the kind of call that can make you rethink your career choices and perhaps your religious convictions - if you have them...

Button batteries are found in devices like watches, hearing aids, remote controls, calculators and toys. Round and shiny, they seem innocuous, but they can kill children in just a few hours if they are ingested and become lodged in the esophagus. It is not a pleasant death to picture, often it is the result of rapid exsanguination from an internal bleed.

The good news is that if caught early enough there are steps that can be taken to mitigate the damage.If an adult were to eat a button battery, aside from having to examine their own bowel movements for several days to see if the battery has passed, it is probably not going to be a big deal. Young children are different, these batteries can become lodged in the esophagus rather than passing through the GI system. Should this happen there are three proposed mechanisms of injury that result.

The main cause of injury when a button battery becomes lodged in the esophagus is from electrical discharge, at least, sort of. The other two proposed mechanisms of injury, pressure necrosis and leakage of the battery contents are relatively inconsequential, if at all contributory. When a button battery is trapped in the esophagus and both sides of the battery make contact with the moist, conductive tissue of the pediatric esophagus an electrical circuit can be completed. The electrical current is not in itself directly harmful, it is not going to electrocute anyone or cause an arrhythmia, the mechanism of damage is much more insidious than that.

The electrical current from a completed circuit inside the esophagus causes local hydrolysis, turning harmless hydrogen found in water molecules into caustic hydroxide. The hydroxide may then go on to combine with sodium, forming sodium hydroxide which is more commonly known as lye. In juvenile porcine models of button battery ingestion, the pH in the surrounding esophageal tissue can reach an astounding 12.8 within two hours.1 The accumulation of hydroxide and sodium hydroxide rapidly causes a caustic injury in the esophagus by two rather grim sounding processes: liquefactive necrosis and saponification of cell lipid membranes—turning the cells into the equivalent of soapy slime.

The extent of the caustic injury caused by button battery lodged in the esophagus depends on many variables—the voltage, with the 3V variety of batteries being far worse than the 1.5V batteries, the size of the battery, the orientation of the battery as the one side of the battery tends to produce worse injuries than the other, the charge left in the battery, and how long it has been in the esophagus.

A button battery can perforate an esophagus in just a few hours. Even worse, the erosion from a button battery can extend into deeper structures around the esophagus including the aortic arch or the distal thoracic aorta causing rapid exsanguination should these tissues fail and allow for massive hemorrhage.

If the battery passes through the esophagus to the stomach it can still cause injuries and may eventually need to be removed, but it is not an immediate life threat, especially if the patient is asymptomatic. However, it must be noted that in small children that are found to have a button battery in their stomach or beyond, one must consider the notion that the battery might have been lodged in the esophagus for some time before traveling to the stomach—the presence of the battery in the stomach does not guarantee there are not esophageal injuries present.

Small Child + Big Battery = Bad. The highest risk combination is when a child less than five-years-old ingests a button battery that is greater than 20mm in diameter. More than 90% of button battery ingestions resulting in fatalities or major outcomes over the last 15 years were from 20mm, 3V lithium cells becoming impacted in the esophagus of children aged four or younger.2

Many smaller batteries, such as those found in hearing aids, can pass through the GI tract without causing anything more than some anxiety in parents and healthcare providers. For the purpose of comparison and because the USA never adopted the metric system, a dime is 18 mm, a nickel is 21 mm, and a quarter 24 mm in diameter. If the battery can be confirmed to be in the stomach of an asymptomatic patient the size is still important; those with a battery of 20mm or greater should have repeated imaging in 48 hours provided the battery has not passed yet and if they are asymptomatic and the battery is less than 20mm they can be given 10-14 days to pass it before further imaging is needed.3

Learn to read the code on the battery. It may be possible to find the package the battery came in or identify the device the battery came out of and find out what kind of battery that device uses. If the package is available or it was a multi-pack of batteries, you may be able to read the code on it. The International Electrotechnical Commission Code is printed on most button batteries and if known it may help identify if this is a high-risk ingestion (although all button battery ingestions in children should be treated as such until proven otherwise).

• Voltage may or may not be listed on the battery. Most button batteries are 1.5V or 3V.

• The first letter in the code identifies the composition of the battery, commonly being lithium or zinc. The composition is not that important as much as other factors. It should be noted that if the voltage is not printed on the battery and it is a lithium battery, assume it is the 3V variety until proven otherwise.

• The second letter identifies the shape of the battery. “R” means it is round.

• The numbers that follow give the diameter in millimeters (on a round battery) and the height. The first two numbers are the diameter, the last two digits (if present) represent the height with a decimal point omitted.

Unrecognized button battery ingestions are a thing; a horrifying nightmarish thing. A high index of suspicion for button battery ingestion should be maintained for a young child with hematemesis or drooling of unknown etiology. In a case series of 13 deaths after button battery ingestion, misdiagnosis occurred in seven patients because of a lack of ingestion history combined with nonspecific presenting symptoms, such as fever, vomiting, lethargy, poor appetite, irritability, cough, wheezing, and/or dehydration.2

Not out of the woods yet

Getting an impacted button battery out of a pediatric patient’s esophagus is a crucial time-sensitive step, but it does not ensure a good clinical course. The injuries from button battery ingestion can leave tissue weakened and fragile, and this may extend to tissues deeper than the esophagus.

In a case series by Children’s Hospital Colorado, there were several reports of exsanguination occurring when friable tissues ruptured days to weeks after removal of an esophageal button battery. The injuries from a button battery ingestion may not be fatal but can result in lifelong sequelae including esophageal strictures, vocal cord dysfunction, esophageal perforation which may lead to sepsis and dysphagia.4

What can you do about this as an EMS provider: Try to confirm the size and type of battery before leaving the scene if it can be done quickly. Is there a package somewhere? Can the device it came out of be identified? If so, you may be able to have someone find a manual for it online that specifies what battery it takes.

If there are questions, call the national Consult the National Battery Ingestion Hotline at 800-498-8666 Go to a pediatric center if possible Many small hospitals are not equipped to perform endoscopy on young children. Even if the hospital has the right equipment this child is going to be better served at a pediatric facility as it is doubtful many small rural centers will be comfortable or skilled in pediatric endoscopy. Do not be lulled into a false sense of security if they are asymptomatic and plan ahead for the worst-case scenario.

Give honey if the child is one year or older, or Carafate to any age group if it is available.

Oral honey or Carafate administration is a potentially life-saving treatment with button battery ingestions. Both honey and Carafate will coat the battery, acting as an insulator and dramatically decreasing the amount of hydroxide produced.

If the child is over 1-year of age give 10ml of honey as soon as possible and take the honey with you. Repeat the dose of honey every ten minutes. Do not administer honey if the child is less than one-year-old due to the risk of botulism. If this is at a sending hospital, clinic, doctor’s office, etc. ask if they have Sucralfate/Carafate and administer 10ml of it every ten minutes. Do not worry about the exact dose or timing but get the first dose in as soon as possible. Aside from honey or Carafate, keep the patient NPO. How effective are honey and Carafate at mitigating injury? Both honey and Carafate are surprisingly effective at mitigating the damage caused by button battery ingestions. I wish I had known just how effective they are; it would have made me feel much better during the transfer of the one-year-old with the button battery ingestion. Then again, that thing had been in her for about three hours before she ended up at the emergency department.

In a 2019 study where 10-11kg piglets were anesthetized and had a button battery placed in their esophagus for one hour and received irrigation with either Carafate, honey or saline. The battery was then removed, and the piglets were kept alive for seven days and then euthanized and their esophagi examined.1*

When looking at the depth of the necrosis in the piglet's esophagi, both the Carafate and Honey treated piglets had a minimal depth of their esophageal injuries, whereas the saline-treated piglets had an extensive depth of injuries to their esophagus. Half of the saline-treated piglets in the 2019 study developed delayed esophageal perforations by day seven, and none of the Carafate or Honey treated piglets developed delayed esophageal perforations.1

And then, just as suddenly as it began, it’s over.

The one-year-old burps and she stops vomiting. The doomsday clock rolls back a few minutes, the crisis is averted for the moment. She looks at me and half-smiles, wanting to go back to playing with the roll of fluorescent Coban I had been distracting her with before this brief nightmarish interlude took place. I look at the mother and give her a reassuring nod as if to say, “See, I told you everything was fine. No big deal.” The patient soon drifts off to sleep and I feel bad about having to wake her up every ten minutes to get her mother to feed her more Carafate.

On arrival at the pediatric facility, she gets taken to the OR almost immediately. The battery was removed from her esophagus with some difficulty. No perforation was noted but there was some damage. Seven days later she was still in the PICU and being fed via a tube, but her prognosis was optimistic.

On the way home the exhaustion finally wins over. We decide to stop at a hotel halfway home and time-out for a few hours of sleep. As a lifelong insomniac, I often have trouble falling asleep, but that night unconsciousness quickly washes over me and I go deep for a few hours before getting up to finish the drive home with the rising sun. The continental breakfast that morning is disappointing but the breakfast lady there is attentive, and she seemed genuinely concerned about me, and I can’t say that I blame her, I look like crap.

I wander around the lobby in a daze—three and half hours of sleep was not enough. She asks me if I am okay. I reply, “I think so.” And ask, “is there any bacon?” There is no bacon. Within hours the whole experience begins to fade. I make a mental note to throw out any button batteries I find in my house and to stop and think before getting in too deep next time.

Lessons learned. 1 Carafate or honey works surprisingly well to mitigate the damage from a button battery in the esophagus. 2. I should have gotten an IV established before leaving the hospital. 3. I should have had a plan in place for bleeding/perforation. 4. I should have brought blood and blood products (although it is doubtful it would change the outcome in the worst-case scenario). 5. I should know about giving blood to pediatric patients (rate, how much, anything special?) I also need to learn about endpoints for resuscitation in trauma with peds – is permissive hypotension a thing, if so, what is that number?

6. Many people in healthcare do not know about the dangers of button battery ingestion in young children.

7. Less than 5 years of age and >20mm button battery equals badness

8. Sequalae can occur days to weeks after removal.

Notes/References: *Esophagi is the plural of esophagus

1. Anfang, R.R., Jatana, K.R., Linn, R.L., Rhoades, K., Fry, J. and Jacobs, I.N. (2019), pH‐neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. The Laryngoscope, 129: 49-57. doi:10.1002/lary.27312

2. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010;125:1168–1177

3. https://www.childrenscolorado.org/globalassets/healthcare-professionals/clinical-pathways/ingested-button-battery.pdf

4. 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. doi:10.1016/j.giec.2015.08.003