+ +Good not to leave these batteries just lying around.
Battery Ingestion Triage and Treatment Guideline (text version) (2022, poison.org)Klicke zum Öffnen/Schließen
Suspect the diagnosis:
Most serious battery ingestions are not witnessed. Consider the possibility of a battery ingestion in every patient with acute airway obstruction; wheezing or other noisy breathing; drooling; vomiting; chest pain or discomfort; abdominal pain; difficulty swallowing; decreased appetite or refusal to eat; or coughing, choking or gagging with eating or drinking. Suspect a button battery ingestion in every presumed "coin" or other foreign body ingestion. Carefully observe (zoom in on x-ray imaging) for the button battery’s double-rim or halo-effect on AP radiograph and step-off on the lateral view. Beware that the step-off may not be discernible if the battery is unusually thin or if the lateral film is not precisely perpendicular to the plane of the battery.
If battery ingestion is suspected:
- Do not induce vomiting.
- Administer honey immediately and while en route to the ER, if:
A lithium coin cell may have been ingested (if you don’t know what kind of button battery was swallowed, assume it is a lithium coin cell unless it is a hearing aid battery);
The child is 12 months of age or older (because honey is not safe in children younger than one year);
The battery was swallowed within the prior 12 hours (because the risk that esophageal perforation is already present increases after 12 hours);
The child is able to swallow; and
Honey is immediately available.
How to dose honey:
Give 10 mL (2 teaspoons) of honey by mouth every 10 minutes for up to 6 doses. Do not worry about the exact dose or timing.
Use commercial honey if available, rather than specialized or artisanal honey (to avoid inadvertent use of large amounts of honey produced from potentially toxic flowers).
Honey is NOT a substitute for immediate removal of a battery lodged in the esophagus. Honey slows the development of battery injury but won’t stop it from occurring. Do not delay going to an ER.
Why give honey?
Honey is administered to coat the battery and prevent local generation of hydroxide, thereby delaying alkaline burns to adjacent tissue. Efficacy is based on a 2018 study (Anfang et al) assessing the in vitro protective effects of various liquids in the cadaveric porcine esophagus and in vivo protective effects of honey and sucralfate (Carafate®) compared to saline irrigations of batteries placed in the esophagus of live piglets. Both honey and sucralfate (Carafate®) effectively prevented the expected battery-induced pH increase and decreased the depth of the resulting esophageal injury. - Other than giving honey, keep the patient NPO until an esophageal battery position is ruled out by x-ray.
- If the patient is asymptomatic, take up to 5 minutes to determine the imprint code from a companion or replacement battery, battery packaging, or product instructions. If no imprint code is available, measure or estimate the diameter based on the size of the slot the battery fits in or the size of a comparable battery. To estimate the battery diameter, compare the battery with a U.S. penny (19 mm) and nickel (21 mm).
- Consult the National Battery Ingestion Hotline at 800-498-8666 for assistance in battery identification and patient management.
- If the patient is ≤ 12 years, immediately obtain an x-ray to locate the battery. Batteries lodged in the esophagus may cause serious burns in as little as 2 hours. Do not wait for symptoms to develop. Patients with a battery in the esophagus may be asymptomatic initially. The 20 mm diameter lithium coin cell, with a diameter intermediate between a U.S. penny and nickel, is most frequently involved in esophageal injuries. Smaller cells lodge less frequently, but may also cause serious injury or death, especially in children younger than 1 year.
- If the patient is > 12 years and the battery diameter is > 12 mm or unknown, immediately obtain an x-ray to locate the battery.
- If the patient is > 12 years and the ingested battery is ≤ 12 mm, no x-ray to locate the battery is required if all of the following conditions are met:
The patient is entirely asymptomatic and has been asymptomatic since the battery was ingested.
Only one battery was ingested
A magnet was not also ingested.
The battery has been reliably identified based on imprint code or measurement of an identical cell, and the diameter is < 12 mm. Definitive determination of the battery diameter prior to passage is unlikely in at least 40% of ingestions. Assume hearing aid batteries are less than 12 mm.
There is no history of prior esophageal surgery, esophageal stricture/narrowing, motility disorders, or other esophageal disease.
The patient (or caregiver) is reliable, mentally competent, and agrees to report symptoms that develop prior to battery passage, or over the subsequent month if passage is not documented, and understands the importance of promptly seeking evaluation for symptoms possibly related to the ingested battery. - X-rays obtained to locate the battery should include the entire neck, esophagus, and abdomen. Batteries located above the range of the x-ray have been missed, as have batteries assumed to be coins or cardiac monitor electrodes. On physical exam, check both ear canals and the nasal cavity to exclude battery insertion. Obtain both AP and lateral x-rays for batteries in the esophagus to determine orientation of the positive and negative poles. On the lateral film, the step-off is on the negative side of the battery. (The negative pole has a slightly smaller diameter, fitting within the battery can which forms the positive pole.) Anticipate complications based on battery position and orientation. Damage will be more severe in tissue adjacent to the negative pole.
- Immediately remove batteries lodged in the esophagus. Serious burns can occur in 2 hours.
- If possible, and if the child is able to swallow, administer sucralfate (Carafate® suspension, 1 g/10 mL). Give 10 mL PO every 10 minutes, up to 3 doses, from the time of x-ray determination that a battery is lodged in the esophagus until sedation is given for endoscopy. Honey has comparable efficacy (Anfang, 2018) and may be substituted for sucralfate suspension in children 12 months of age or older, dosed as outlined in #2, above. Do not give sucralfate or honey if the battery was possibly in the esophagus for more than 12 hours. Sucralfate or honey administration is not a substitute for emergent battery removal as these agents slow but do not eliminate tissue damage.
- Do not delay battery removal because a patient has eaten recently or because a patient was given honey or sucralfate (Carafate®) by mouth.
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Mechanism of Battery-Induced Injury (2022, poison.org) Neutralize Button Battery in the Esophagus (2020, pedemmorsels.com) Button Battery Nasal Foreign Body (2013, pedemmorsels.com) Paediatric Foreign Body Ingestion (piernetwork.org) The 'parent's kiss': an effective way to remove paediatric nasal foreign bodies (2008, Ann R Coll Surg Engl)
