Battery ingestion in children

Complications of button battery ingestion or insertion in children: a systematic review and pooled analysis of individual patient-level data

BACKGROUND

Button battery (BB) exposures are common in children and can have devastating consequences. We reviewed current evidence on the complications associated with BB exposure and identified predictors of outcomes using individual patient-level data.

DATA SOURCES

We carried out a systematic review and pooled analysis by searching MEDLINE, Embase, and Scopus up to May 19, 2023. Included studies describe complications following BB exposures in children (aged < 18 years). Odds ratios (ORs) were calculated using binary logistic regression to measure associations between predictive factors and different outcomes.

RESULTS

Two-hundred seventeen studies (439 children) were included. The median age at presentation was 1.75 [interquartile range (IQR) 1.00-3.00] years and 399 (90.9%) exposures were ingestions. Of the 380 cases reporting sex, 162 (42.6%) were female. Feeding (192, 48.1%) and respiratory difficulties (138, 34.6%) were common presenting features for ingestions, while symptomatology was site-specific for insertions. Common complications included oesophageal mucosal damage alone (105, 26.3%) and tracheooesophageal fistula (93, 23.3%) for ingestions, and nasal septal perforation (22, 55.0%) and mucosal damage alone (13, 32.5%) for insertions. Intestinal perforation occurred in 2.5% of ingestion cases, including perforation of Meckel's diverticulum, peritonitis, and jejunocolic fistula. Vascular complications were common among children who died. Age (≤ 2 years), battery exposure duration (> 6 hours), and battery diameter (≥ 20 mm) were associated with common and severe complications of ingestions.

CONCLUSION

BB injuries are time-critical, with severe sequelae predominantly affecting young children. Diagnosis is challenging. Preventative work through regulation and safer battery design are required to eliminate this problem.

Accidental ingestion of foreign bodies/harmful materials in children from Bahrain: A retrospective cohort study

BACKGROUND

Children like to discover their environment by putting substances in their mouths. This behavior puts them at risk of accidentally ingesting foreign bodies (FBs) or harmful materials, which can cause serious morbidities.

AIM

To study the clinical characteristics, diagnosis, complications, management, and outcomes of accidental ingestion of FBs, caustics, and medications in children.

METHODS

We conducted a retrospective cohort study of all children admitted for accidental ingestion to the Department of Pediatrics, Salmaniya Medical Complex, Bahrain, between 2011 and 2021. Demographic data, type of FB/harmful material ingested, and investigations used for diagnosis and management were recorded. The patients were divided into three groups based on the type of ingested material (FBs, caustics, and medications). The three groups were compared based on patient demographics, socioeconomic status (SES), symptoms, ingestion scenario, endoscopic and surgical complications, management, and outcomes. The FB anatomical location was categorized as the esophagus, stomach, and bowel and compared with respect to symptoms. The Fisher's exact, Pearson's χ2, Mann-Whitney U, and Kruskal-Wallis tests were used for comparison.

RESULTS

A total of 161 accidental ingestion episodes were documented in 153 children. Most children were boys (n = 85, 55.6%), with a median age of 2.8 (interquartile range: 1.8-4.4) years. Most participants ingested FBs (n = 108, 70.6%), 31 (20.3%) ingested caustics, and the remaining 14 (9.2%) ingested medications. Patients with caustic ingestion were younger at the time of presentation (P < 0.001) and were more symptomatic (n = 26/31, 89.7%) than those who ingested medications (n = 8/14, 57.1%) or FBs (n = 52/108, 48.6%) (P < 0.001). The caustic group had more vomiting (P < 0.001) and coughing (P = 0.029) than the other groups. Most FB ingestions were asymptomatic (n = 55/108, 51.4%). In terms of FB location, most esophageal FBs were symptomatic (n = 14/16, 87.5%), whereas most gastric (n = 34/56, 60.7%) and intestinal FBs (n = 19/32, 59.4%) were asymptomatic (P = 0.002). Battery ingestion was the most common (n = 49, 32%). Unsafe toys were the main source of batteries (n = 22/43, 51.2%). Most episodes occurred while playing (n = 49/131, 37.4%) or when they were unwitnessed (n = 78, 57.4%). FBs were ingested more while playing (P < 0.001), caustic ingestion was mainly due to unsafe storage (P < 0.001), and medication ingestion was mostly due to a missing object (P < 0.001). Girls ingested more jewelry items than boys (P = 0.006). The stomach was the common location of FB lodgment, both radiologically (n = 54/123, 43.9%) and endoscopically (n = 31/91, 34%). Of 107/108 (99.1%) patients with FB ingestion, spontaneous passage was noted in 54 (35.5%), endoscopic removal in 46 (30.3%), laparotomy in 5 (3.3%) after magnet ingestion, and direct laryngoscopy in 2 (1.3%). Pharmacological therapy was required for 105 (70.9%) patients; 79/105 (75.2%) in the FB group, 22/29 (75.9%) in the caustic group, and 4/14 (28.8%) in the medication group (P = 0.001). Omeprazole was the commonly used (n = 58; 37.9%) and was used more in the caustic group (n = 19/28, 67.9%) than in the other groups (P = 0.001). Endoscopic and surgical complications were detected in 39/148 (26.4%) patients. The caustic group had more complications than the other groups (P = 0.036). Gastrointestinal perforation developed in the FB group only (n = 5, 3.4%) and was more with magnet ingestion (n = 4) than with other FBs (P < 0.001). In patients with FB ingestion, patients aged < 1 year (P = 0.042), those with middle or low SES (P = 0.028), and those with more symptoms at presentation (P = 0.027) had more complications. Patients with complications had longer hospital stays (P < 0.001) than those without.

CONCLUSION

Accidental ingestion in children is a serious condition. Symptomatic infants from middle or low SES families have the highest morbidity. Prevention through parental education and government legislation is crucial.

Button battery ingestion: A serious pitfall of diagnosis of ingested foreign bodies in children from resource-limited settings - A case report

INTRODUCTION AND IMPORTANCE

Button battery ingestion and impaction in the oesophagus can result in severe morbidity and even fatality if not diagnosed and managed urgently. Delayed or missed diagnosis due to the sometimes-vague symptomatology and limited investigations in resource-limited settings further increases the complications rate.

CASE PRESENTATION

Case 1: A 2 years old male child presented with a nine months history of recurrent respiratory tract infections not responding well to medical treatment. A radio-opaque round foreign body (FB) was incidentally seen in the chest. Rigid esophagoscopy and removal were done, but the child had developed a trachea oesophagal fistula. The fistula was managed conservatively by retaining a nasogastric tube until spontaneous fistula closure happened. Case 2: A 2 years old female child presented with a one-year history of poor feeding, vomiting, difficulty in breathing and persistent wet cough, and fever. He underwent tonsillectomy with no improvement. A radio-opaque round FB was incidentally seen in the oesophagus near the carina by a chest x-ray. A thoracotomy had to be done after two failed removal attempts by rigid esophagoscopy.

CLINICAL DISCUSSION

The similarity in the symptomatology of common aerodigestive conditions with FB ingestion compounded with low chances of witnessing the ingestion creates a possible pitfall for clinicians when resulting in a missed or a delayed diagnosis, further raising the complications rate of FB impaction in the oesophagus, such as tracheoesophageal fistula formation or the need for a massive surgery such as thoracotomy to remove the button battery.

CONCLUSION

Complications of foreign body ingestion in the paediatric population can have serious complications. High morbidity and mortality may be attributed to delayed diagnosis and intervention.

Pediatric Battery-Related Emergency Department Visits in the United States: 2010-2019

OBJECTIVES

To describe the epidemiology of battery-related emergency department (ED) visits among children aged <18 years in the United States from 2010 to 2019 and compare with previous study findings.

METHODS

Data on ED visits were obtained from the National Electronic Injury Surveillance System. Using narrative descriptions and diagnosis codes, battery-related cases were coded into four exposure routes: (1) ingestion, (2) mouth exposure, (3) ear insertion, and (4) nasal insertion.

RESULTS

An estimated 70 322 (95% confidence interval: 51 275-89 369) battery-related ED visits among children aged <18 years occurred during the study period, or 9.5 per 100 000 children annually. Button batteries were implicated in 84.7% of visits where battery type was described. A statistically significant increase in the ED visit rate occurred from 2010 to 2017 (P = .03), followed by a nonstatistically significant decrease from 2017 to 2019. The ED visit rate was highest among children aged ≤5 years compared with those 6 to 17 years (24.5 and 2.2 per 100 000 children, respectively). The mean patient age was 3.2 years (95% confidence interval: 2.9-3.4). Ingestions accounted for 90.0% of ED visits, followed by nasal insertions (5.7%), ear insertions (2.5%), and mouth exposures (1.8%).

CONCLUSIONS

Pediatric battery-related ED visit rates continued to significantly increase from 2010 to 2017, with children aged ≤5 years having the highest rates. Prevention efforts have not significantly reduced injury rates; therefore, regulatory efforts are needed. Ultimately, hazard reduction or elimination through safer button battery design is critical and should be adopted by the battery industry.

Foreign Body in the Cervical Oesophagus: A Case Report

BACKGROUND

Foreign bodies in the upper aerodigestive tract represent an uncommon cause of visits to emergency departments. In the majority of cases, foreign bodies do not go beyond the pharynx. They cause dyspnoea or pneumonia if they reach the tracheo-bronchial tree. If ingested, they will pass spontaneously through the gastrointestinal canal in the majority of cases. Nevertheless, especially in case of sharp-pointed or large objects, the foreign bodies can stop in the oesophagus. In case of dysphagia, stinging sensation and/or odynophagia occurring after eating a meal, a foreign body in the upper aerodigestive tract should be suspected. If not clinically visible, imaging is required.

CASE PRESENTATION

A 72-year-old woman presented to the Emergency Department with pharyngodynia, odynophagia, stinging, dysphagia, and sialorrhea for 12 hours. Her symptoms started after eating a meal with meat. The patient underwent a standard two-projection radiogram of the neck. The antero-posterior projection radiogram was unremarkable. The lateral projection radiogram showed 16 millimetres in maximum length radiopaque foreign body within the cervical oesophagus. The patient underwent transoral flexible oesophagoscopy under general anaesthesia, with successful removal of the foreign body (bony fragment). Her symptoms improved rapidly after the procedure, and the patient was discharged after 48 hours in good health.

CONCLUSION

A foreign body in the cervical oesophagus may lead to visceral perforation. Once suspected, every effort should be made to identify and remove the foreign body to avoid potentially catastrophic consequences. In some cases, imaging could be necessary to detect the foreign body.

Association between the corrosion of ingested lithium button battery in the esophagus and its complications in pediatric patients

PURPOSE

The incidence of lithium button battery ingestion has been increasing recently, which results in severe complications. We aimed to demonstrate the association between the corrosion of lithium button batteries in the esophagus on radiographs and their complications.

METHODS

The nine pediatric patients included in this study were classified into two groups based on the presence of severe complications. The presence and degree of corrosion on plain radiographs were evaluated. The degree of corrosion was classified into the following three grades; none: 0%; moderate: 1-50%; severe: 51-100%. Fisher's exact test was used for statistical analyses.

RESULTS

Of the nine patients, five showed complications. The number of patients who had grade none, moderate, and severe degrees of corrosion was three, four, and two, respectively. The incidence of severe complications differed significantly between the incidence of lithium button batteries' contour (without vs. with severe complications [presence/absence of corrosion] = 1/3 vs. 5/0, respectively; P = 0.0476). In cases with "none" degree of corrosion, all three cases had no complication, and in cases with a "severe" degree of corrosion, all two cases had complications.

CONCLUSION

The cases with the presence of corrosion of lithium button batteries had a higher tendency to have severe complications. Therefore, physicians should anticipate the presence of severe complications in pediatric patients with corrosion more than those without corrosion.

What's Inside of a AA Battery? An Unusual Caustic Ingestion in an Infant

Current guidelines for the management of battery ingestions in children focus on button batteries due to the risk of morbidity and mortality. In our review of the literature, there is little information on the ingestion of cylindrical AA or AAA battery contents. We report a case of an 11-month-old female who ingested the internal alkaline contents of a AA battery. The ingestion resulted in oropharyngeal and esophageal caustic injuries visualized on upper endoscopy. Imaging has long been used for localizing ingested whole batteries. In our case, standard radiograph confirmed that internal battery contents were ingested. Advanced imaging modalities, including computed tomography, have been suggested as methods to investigate the degree of caustic injury and were utilized in this case. Our case is one of the few reported cases of the ingestion of alkaline battery contents alone.

Cylindrical and button battery ingestion in children: a single-center experience

PURPOSE

The purpose of our study was to perform a comparative analysis of the examination and treatment outcomes of children with cylindrical and button batteries (BB) ingestion depending on their size and anatomical locations.

METHODS

This study was a retrospective analysis of 124 children aged from 1 month to 18 years who ingested batteries and were treated in a tertiary care center from January 1, 2014 to March 31, 2019. The data studied included age, sex, presenting symptoms at the time of evaluation, type and size of battery and modality of management.

RESULTS

Twenty-three (18.5%) patients ingested cylindrical batteries (CBs), and 101 (81.5%) ingested BBs. The duration of hospital stay was significantly longer (p = 0.004) in the group of children who ingested BBs larger than 20 mm. Endoscopic removal was performed in 75 (60.5%) children, 46 (37.1%) were followed up and three (2.4%) underwent open surgeries. Children with CBs ingestion, in 55% of cases, had gastric mucosal injuries. Children with BBs impacted in the esophagus in 96% cases had visible severe mucosal damage, whereas patients with gastric BB ingestion 19.5% had superficial gastric mucosal damage.

CONCLUSION

Performing timely endoscopic retrieval in children who are admitted early to the hospital will reduce the risk of damage to the gastrointestinal mucosa, especially in the stomach. Unlike BBs, CBs, despite their large size, have advantageous shapes, uneventfully pass the esophagus and are more often retained in the stomach; thus, mucosal injuries are more often observed in the stomach. Consequently, endoscopic extraction is the treatment of choice for children with BB ingestion.

Systematic review of rigid and flexible esophagoscopy for pediatric esophageal foreign bodies

BACKGROUND

Esophageal foreign body (EFB) is a common presentation in pediatric hospitals. Rigid and flexible esophagoscopy are both primary modalities used for EFB removal. By systematically reviewing the literature, we sought to assess success and complication rates of both rigid and flexible esophagoscopy in pediatric EFB retrieval.

METHODS

A systematic search of the literature was performed in MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, CINAHL. Two authors independently reviewed 74 abstracts and included studies that documented success rates of flexible and rigid esophagoscopy for EFB retrieval. The certainty and quality of the overall body of evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

Five retrospective chart reviews published between 1993 and 2016 identified 955 patients with a mean age of 4.2 (range 3.2-5.3 years). Foreign bodies were localized to the upper esophagus in 69.6%, middle esophagus in 13.0% and lower esophagus in 11.5%. Coins (82.1%) and food boluses (8.5%) comprised the majority of EFB. The success rate of foreign body retrieval was 95.4% with rigid esophagoscopy and 97.4% with flexible esophagoscopy. Complication rates were 2.4% for rigid esophagoscopy and 3.4% for flexible esophagoscopy. Rates of successful foreign body retrieval (odds ratio [OR] = 1.9 [95% CI 0.9-3.8; p = 0.07]) and complications (OR = 0.9 [95% CI 0.3-2.3; p = 0.79]) were not significantly different across modalities. There were no mortalities in any of the studies analyzed.

CONCLUSION

Flexible and rigid esophagoscopy are equally safe and effective for the retrieval of EFB in children. Otolaryngologists, gastroenterologists, and pediatric general surgeons can be consulted for foreign body retrieval depending on institutional policies and resource availability.

Fully Passive Flexible Wireless Neural Recorder for the Acquisition of Neuropotentials from a Rat Model

Wireless implantable neural interfaces can record high-resolution neuropotentials without constraining patient movement. Existing wireless systems often require intracranial wires to connect implanted electrodes to an external head stage or/and deploy an application-specific integrated circuit (ASIC), which is battery-powered or externally power-transferred, raising safety concerns such as infection, electronics failure, or heat-induced tissue damage. This work presents a biocompatible, flexible, implantable neural recorder capable of wireless acquisition of neuropotentials without wires, batteries, energy harvesting units, or active electronics. The recorder, fabricated on a thin polyimide substrate, features a small footprint of 9 mm × 8 mm × 0.3 mm and is composed of passive electronic components. The absence of active electronics on the device leads to near zero power consumption, inherently avoiding the catastrophic failure of active electronics. We performed both in vitro validation in a tissue-simulating phantom and in vivo validation in an epileptic rat. The fully passive wireless recorder was implanted under rat scalp to measure neuropotentials from its contact electrodes. The implanted wireless recorder demonstrated its capability to capture low voltage neuropotentials, including somatosensory evoked potentials (SSEPs), and interictal epileptiform discharges (IEDs). Wirelessly recorded SSEP and IED signals were directly compared to those from wired electrodes to demonstrate the efficacy of the wireless data. In addition, a convoluted neural network-based machine learning algorithm successfully achieved IED signal recognition accuracy as high as 100 and 91% in wired and wireless IED data, respectively. These results strongly support the fully passive wireless neural recorder's capability to measure neuropotentials as low as tens of microvolts. With further improvement, the recorder system presented in this work may find wide applications in future brain machine interface systems.

Clinical Profile and Outcome of Esophageal Button Battery Ingestion in Children: An 8-Year Retrospective Case Series

Objective

To present the clinical profile and outcomes of esophageal button battery ingestion cases treated at our institution over an 8-year period.

Methods

A total of 17 children who presented after ingesting a button battery and were treated at a tertiary care clinic over an 8-year period were included in this retrospective case series study. Data on patient demographics and esophageal location of the battery, time from ingestion to admission, symptoms, grade of mucosal injury, size of the battery, management, complications, and follow-up outcome were recorded.

Results

Median age was 29 months (range, 2–99 months). Boys comprised (n=11, 64.7%) of the study population. The most common location was the proximal esophagus (n=10, 58.8%). The median time from ingestion to admission was 6 h (range, 3–24 h). Hypersalivation alone (n=6, 35.3%) or together with vomiting (n=5, 29.4%) was the most common symptom. Grade IIA mucosal injury was noted in six (n=6, 35.3%) patients. The diameter of the battery was a median of 18.0 mm (range, 14–22 mm). We did not observe any correlation between the size of the battery and the grade of the injury. Early postoperative complications were encountered in one patient (n=1, 5.8%) and late postoperative complications were noted in eight patients (n=8, 47.1%) which required further esophageal dilatations, and follow-up revealed normal findings in eight patients (n=8, 47.1%) and mortality occurred in one patient.

Conclusion

The current case series study describing the clinical profiles and outcomes of 17 children who had ingested an esophageal button battery revealed male predominance, young patient age, and admission after a median of 6 h (3–24 h) of ingestion with nonspecific symptoms. Our findings confirm the success of rigid endoscopy to remove esophageal button batteries and indicate the likelihood of severe complications after removal.

Foreign object ingestion and esophageal food impaction: An update and review on endoscopic management

Foreign body ingestion encompasses both foreign object ingestion (FOI) and esophageal food impaction (EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance, its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.

Button battery removed from the stomach resulting in a missed aortoesophageal fistula - a multidisciplinary approach to rescuing a very young patient: a case report

Background

While coins are still the most common foreign bodies swallowed by children, ingestion of batteries has become more frequent among children due to the increasing access to electronic toys and devices.

Coin battery ingestion is potentially life threatening for children. Aortoesophageal fistula is the most common cause of death in children who have swallowed coin batteries, and there have not been any reported survivors.

Case presentation

A 3-year-old Caucasian girl presented to the emergency room of a community hospital complaining of abdominal pain. An abdominal X-ray showed a coin lithium battery located in the fundus of her stomach, and she was transferred to a referral pediatric hospital. In the following hours she developed massive hematemesis and severe hypovolemic shock. An emergency laparotomy was attempted, and the coin battery was removed. The initial surgery and multiple blood transfusions did not, however, improve the clinical situation.

She was then referred to our tertiary referral center, where a multidisciplinary team decided to attempt a combined angiographic and endoscopic approach to resolve a life-threatening aortoesophageal fistula. A 3-year follow-up was uneventful.

Conclusions

Coin batteries are designed for a wide variety of small appliances, such as hearing aids, watches, remote controls, and toys.

Although a change in the clinical approach to battery ingestion is needed to avoid misdiagnosis or delayed treatment, primary prevention of battery ingestion would be even more effective than an improved treatment.

Predictors of nature of ingested foreign bodies in children & assessment of operative outcomes

OBJECTIVE

To examine sensitivity/specificity of history & radiology to identify ingested foreign body (FB) and develop a protocol for management of ingested FBs in paediatric patients; to assess outcomes of removal of lithium button battery foreign body (LBBFB).

METHODS

Retrospective review. Children presenting to ENT emergency with suspected FB ingestion underwent rigid esophagoscopy and FB removal. Average age, number of attempts, duration of ingestion, success rate, and complications were analysed.

RESULTS

Cases of coin/LBBFB ingestion: 916/70. Mean age: 5.8/2.03 years (p < 0.001). Average duration of ingestion: 37/9.5 h (p < 0.001). Patients below 3: 31.3/62.8% (p < 0.001). Suggestive history/radiological signs: 100%/100%, 75.7%/98.6% (p < 0.0001). Site of impaction cricopharynx: 60.3%/74.3% (p = 0.02). LBBFB group: Successful removal in 1st attempt: 66 (94.3%). Cases requiring multiple attempts due to impaction: 4 (5.7%). Parenteral steroids were administered before successful reattempt. No relation was found between duration of ingestion/impaction. Five (7.1%) cases developed complications. Average follow-up duration: 13.59 months.

CONCLUSIONS

Children <3 years with vague history of FB ingestion and suggestive chest x-ray should be sent urgently for FB removal. Parenteral pre-and postoperative short course steroid use may be considered to improve outcomes.

Ileocolic Perforation Secondary to Disk Battery Ingestion in a Dog

A 7 yr old spayed female shih tzu was evaluated for anorexia of 4 days duration. Conservative treatment for gastroenteritis had been administered by another veterinarian 2 days before presentation. Abdominal radiography revealed two round, disk-shaped, metallic-opacity foreign objects within the bowel with loss of serosal detail. Exploratory laparotomy was performed and revealed circumferential full-thickness necrosis and perforation of the intestines at the ileocolic junction with a small amount of peritoneal effusion. Two disk batteries were palpated in the colon and milked out of the rectum. An ileocolic anastomosis was performed without complication. However, the dog died following cardiopulmonary arrest shortly after extubation. Disk batteries are capable of causing severe tissue necrosis due to the generation of electric current when prolonged contact with mucosal surfaces occurs. Immediate removal is recommended to prevent gastrointestinal perforation and potential fatalities.

Post-mortem computed tomography: Technical principles and recommended parameter settings for high-resolution imaging

Post-mortem computed tomography (PMCT) has become a standard procedure in many forensic institutes worldwide. However, the standard scan protocols offered by vendors are optimised for clinical radiology and its main considerations regarding computed tomography (CT), namely, radiation exposure and motion artefacts. Thus, these protocols aim at low-dose imaging and fast imaging techniques. However, these considerations are negligible in post-mortem imaging, which allows for significantly increased image quality. Therefore, the parameters have to be adjusted to achieve the best image quality. Several parameters affect the image quality differently and have to be weighed against each other to achieve the best image quality for different diagnostic interests. There are two main groups of parameters that are adjustable by the user: acquisition parameters and reconstruction parameters. Acquisition parameters have to be selected prior to scanning and affect the raw data composition. In contrast, reconstruction parameters affect the calculation of the slice stacks from the raw data. This article describes the CT principles from acquiring image data to post-processing and provides an overview of the significant parameters for increasing the image quality in PMCT. Based on the CT principles, the effects of these parameters on the contrast, noise, resolution and frequently occurring artefacts are described. This article provides a guide for the performance of PMCT in morgues, clinical facilities or private practices.

Disc battery ingestion; a single event with different outcomes

Foreign body (FB) ingestion is a common problem especially in children below the age of 5 years. This is fueled by their curiosity to explore their surroundings. The ingested foreign body finds its way out of the gastrointestinal tract without any serious consequences most of the time. On the other hand, disc battery ingestion has been reported to cause serious harm when ingested including death. We report two patients who had ingested disc batteries and their respective outcomes.

Multiple Gastric Erosion Early after a 3 V Lithium Battery (CR2025) Ingestion in an 18-Month-Old Male Patient: Consideration about the Proper Time of Intervention

Introduction. Button battery ingestion is considered an emergency situation in pediatric patients that needs to be managed promptly; otherwise, it may lead to serious and potentially lethal complications, especially when it is impacted in the esophagus. Less attention has been given in cases where the battery passes into the stomach, with guidelines for emergency intervention being based on the presence of symptoms. Case Report. We present a case of an 18-month-old male patient who presented to our emergency department after button battery ingestion. He did not have any symptoms and no pathological findings were encountered during clinical examination. X-ray investigation revealed the presence of the battery in the stomach. The patient was admitted for observation and two hours later he had two episodes of vomiting. He underwent urgent endoscopic removal of the battery where multiple acute gastric mucosal erosion in place of direct contact of the battery's negative pole with the mucosa of the gastric antrum was found. Conclusion. In specific cases the urgent endoscopic intervention for removal of an ingested button battery that is located in the stomach even in asymptomatic patients should be suggested.

[Fatal aorto-esophageal fistula due to accidental ingestion of button battery. Algorithm for management of disk-battery ingestion in patients younger than 6 years old]

The ingestion of disc battery is a common problem in children and current treatment may be sometime inadequate. Ingested button batteries have the potential to cause significant morbidity and mortality. Ingestion of button batteries has been seen with increasing frequency over the last decade, particularly for children aged younger than 6 years. If most cases of disc battery ingestion run uneventful courses, however, harmful outcomes are more common with ingestion of lithium batteries (3V) with a diameter greater than or equal to 16 mm. These young children have to benefit from a chest radiograph within 2hours which follow the ingestion. If the battery impacts in the esophagus, emergency endoscopic management is necessary. We report the case of one young child died followed an unknown lithium disk-battery ingestion complicated with an aorto-œsophageal fistula. We propose a protocol of specific coverage for patients aged younger than 6 years old.

Review of esophageal injuries and stenosis: Lessons learn and current concepts of management

Aim:

To review the patients with esophageal injuries and stenosis with respect to their etiology, clinical course, management, and the lessons learnt from these.

Materials and Methods:

Retrospective descriptive observation review of children with esophageal injuries and stenosis admitted between January 2009 and April 2015.

Results:

Eighteen children with esophageal injuries of varied etiology were managed and included, seven with corrosive injury, five with perforation due to various causes, three with mucosal erosion, two with trachea esophageal fistula (TEF), and one wall erosion. The five children who had perforation were due to poststricture dilatation in a child with esophageal atresia and secondary to foreign body impaction or its attempted retrieval in four. Alkaline button cell had caused TEF in two. Three congenital esophageal stenosis (CES) had presented with dysphagia and respiratory tract infection. Six corrosive stricture and two CES responded to dilatation alone and one each of them required surgery. Four of the children with esophageal perforation were detected early and required drainage procedure (1), diversion (1), and medical management (2). Pseudo diverticulum was managed expectantly. Among TEF, one had spontaneous closure and other one was lost to follow-up. All the remaining nineteen children have recovered well except one CES had mortality.

Conclusion:

Esophageal injuries though rare can be potentially devastating and life-threatening.

An incidental finding of a long-standing button battery in the floor of the nose during a routine orthodontic examination

Foreign body insertion into the ears and nose is common in children and is often witnessed by the carer or reported by the child and therefore appropriate management can be sought promptly. However, these incidents can go unreported and may be accompanied by non-specific symptoms making diagnosis difficult. Button batteries are common in everyday life and their small size and shiny appearance make them appealing to children and their ingestion or insertion is not uncommon. Due to their size, shape and electrochemical composition button batteries pose serious complications if ingested, inhaled or inserted. In the nose they usually cause intense local tissue reactions resulting in severe tissue destruction, septal necrosis or stenosis of the nasal cavity as well as posing the risk of subsequently being ingested or aspirated. This case report details an incidental finding of a button battery in the floor of the nose discovered on routine orthodontic radiographs. An upper standard occlusal and dental panoramic tomography showed a radiopaque, cylindrical, object in the floor of the nose which a subsequent CBCT localized to the floor of the right nasal fossa. The patient required orthodontic extractions and the exposure and bonding of teeth under general anaesthetic. Therefore the battery was removed by the maxillofacial surgery team at the same general anaesthetic. This is a rare case of an incidental finding of a long-standing button battery impaction which was asymptomatic and did not have any detrimental effects. This case highlights the dangers of button battery impaction and the need for prompt referral for removal.

Fluid collection in the retropharyngeal space: A wide spectrum of various emergency diseases

Fluid collections in the retropharyngeal space (RPS) result from a wide spectrum of diseases, including retropharyngeal abscess, cervical osteomyelitis, and calcific tendinitis of the longus colli muscle. These conditions should be managed by different specialties; beginning with care in the emergency room, physicians from orthopedics, pediatrics, otolaryngology, and oncology are in charge of the treatment. Since these diseases demonstrate similar fluid collections in the RPS on computed tomography (CT) and magnetic resonance imaging (MRI), the radiologist's diagnosis based on the characteristic imaging findings is very important to identify the primary disease. Also, since some of the diseases require immediate surgical intervention to avoid life-threatening mediastinitis or airway obstruction, radiologists must distinguish these diseases correctly and provide recommendations for their management to physicians. Understanding clinical features and imaging findings of these fluid collections in the RPS is crucial for the best care.

Spondylodiscitis associated with button battery ingestion: prompt evaluation with MRI

Spondylodiscitis is a rare complication of unwitnessed button battery ingestion in children. We report a case of a 20-month-old girl who presented to the emergency room 2 weeks after endoscopic removal of unwitnessed, impacted esophageal battery. Delayed presentation of spondylodiscitis after foreign body removal is related to local injury, pressure necrosis, and perforation. The bilaminar shape of an unknown ingested foreign body should alert the treating physician that it might be a battery rather than a coin. Prompt evaluation with magnetic resonance imaging is essential to prevent neurological deficit and/or spinal deformities.

Resource utilization patterns of pediatric esophageal foreign bodies

BACKGROUND

Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although some pass spontaneously through the gastrointestinal tract, the majority of esophageal-ingested foreign bodies (EFB) require removal.

MATERIALS AND METHODS

Kids' Inpatient Database (1997-2009) was used to identify children (aged <20 y) with EFB (International Classification of Diseases, Ninth Revision, Clinical Modification code 935.1). Multivariate logistic regression analyses were constructed to identify predictors of resource utilization.

RESULTS

Overall, 14,767 EFB cases were identified. Most patients were <5 y of age (72%), boys (57%), and non-Caucasian (55%), with a median (interquartile range) length of stay (LOS) of 1 (1) d, and total charges of $11,003 (8503). A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). By multivariate logistic regression, increased total charges were associated with a diagnosis of esophageal ulceration (odds ratio [OR] = 1.57), esophagoscopy (OR = 1.42), and bronchoscopy (OR = 1.62), all P < 0.001. Total charges also increased with admission to urban nonteaching hospitals (OR = 1.51) versus urban teaching hospitals, P < 0.001. Prolonged LOS (≥1 d) was associated with admission to a hospital in the Midwest (OR = 3.18) and with esophageal ulceration (OR = 2.11) and esophagoscopy (OR = 1.13), P < 0.03. Boys had higher odds of longer hospitalization (OR = 1.21), P < 0.001. Overall hospital mortality was 0.1% (n = 16).

CONCLUSIONS

Most EFB occur in children <5 y of age. Esophageal ulceration, esophagoscopy, and bronchoscopy are associated with increased total charges. Esophageal ulceration, esophagoscopy, and boys are associated with an increased LOS. Surgery and hospital mortality are both extremely rare in children with EFB.

Pick your poison: what's new in poison control for the preschooler

Accidental childhood poisonings are a major public health concern despite many efforts to alleviate this problem. While the rate of pediatric fatalities due to poisonings have decreased over the last two decades, poison control centers around the US have collectively fielded over one million calls with regard to toxic exposures in the preschool age group. According to the American Association of Poison Control Centers nearly half of all human exposures reported last year involved children under six. By focusing poison prevention efforts on the preschooler, we can attempt to decrease morbidity and mortality in the most vulnerable age group affected. Although the subject is still prevalent, current discussion on this topic is limited. Newer literature discusses past initiatives such as child resistant packaging and sticker deterrent programs and addresses their efficacy. This article revisits older mechanisms of prevention as well as the science behind the human motivation to change one's own practice and behavior.

Assault by battery: battery-related injury in the head and neck

OBJECTIVES/HYPOTHESIS

To estimate nationwide incidence of emergency department (ED) visits for battery-related injury (BRI) occurring in the head and neck, and analyze demographic and anatomic-specific trends.

METHODS

The National Electronic Injury Surveillance System (NEISS) was searched for BRI in the head and neck, with analysis for incidence, anatomic site, age and gender, and specific diagnoses.

RESULTS

There were an estimated 18,803 head and neck BRI ED visits from 2003 to 2012. A total of 65.8% of patients were male. A total of 92.8% of patients were treated/examined and then released, and 4.7% of patients were admitted. A plurality (34.2%) of patients had BRI related to nose injures, and this represented the youngest cohort (median: 3 years old). The vast majority of ear and nose diagnoses were "foreign bodies"; two-thirds of mouth injuries were related to burns, whereas lacerations predominated in the face and head. Nearly half of ED visits involved patients between 2 and 5 years of age. A total of 45.2% of cases involving patients ≥ 65 years of age were related to hearing aid batteries as foreign bodies.

CONCLUSION

BRI in the head and neck results in a significant amount of ED visits. Mechanisms of injury vary by age and anatomic location, but a considerable male predilection exists. Whereas pediatric patients are primarily affected, particularly patients between 2 to 5 years of age, injuries do occur among adults. Importantly, the prevalence of dislodged hearing-aid batteries in the elderly necessitates comprehensive patient education to increase awareness and counseling regarding this complication. Awareness of demographic and anatomic-specific trends reported in this analysis may be an invaluable adjunct for history-taking and clinical examination.

Hemorrhagic shock secondary to button battery ingestion

CONTEXT

Button battery ingestion is a frequent pediatric complaint. The serious complications resulting from accidental ingestion have increased significantly over the last two decades due to easy access to gadgets and electronic toys. Over recent years, the increasing use of lithium batteries of diameter 20 mm has brought new challenges, because these are more detrimental to the mucosa, compared with other types, with high morbidity and mortality. The clinical complaints, which are often nonspecific, may lead to delayed diagnosis, thereby increasing the risk of severe complications.

CASE REPORT

A five-year-old boy who had been complaining of abdominal pain for ten days, was brought to the emergency service with a clinical condition of hematemesis that started two hours earlier. On admission, he presented pallor, tachycardia and hypotension. A plain abdominal x-ray produced an image suggestive of a button battery. Digestive endoscopy showed a deep ulcerated lesion in the esophagus without active bleeding. After this procedure, the patient presented profuse hematemesis and severe hypotension, followed by cardiorespiratory arrest, which was reversed. He then underwent emergency exploratory laparotomy and presented a new episode of cardiorespiratory arrest, which he did not survive. The battery was removed through rectal exploration.

CONCLUSION

This case describes a fatal evolution of button battery ingestion with late diagnosis and severe associated injury of the digestive mucosa. A high level of clinical suspicion is essential for preventing this evolution. Preventive strategies are required, as well as health education, with warnings to parents, caregivers and healthcare professionals.

An unusual case of duodenal perforation caused by a lollipop stick: a case report

Most ingested foreign bodies often pass through the gastrointestinal tract uneventfully; however, complications such as perforation do occur. Most cases of perforation are caused by thin, pointed objects such as needles, toothpicks, or fish and chicken bones. Herein, we report an unusual case of duodenal perforation caused by a lollipop stick with blunt ends. A 23-year-old woman was admitted to the emergency department complaining of epigastric and right upper quadrant pain for the last 2 days. Abdominal computed tomography scans confirmed the presence of a foreign body in the duodenum, with signs of duodenal perforation and inflammation. The patient was not aware of ingesting the foreign body. Endoscopy revealed the presence of a lollipop stick in the duodenum, which was removed with forceps. The duodenal perforation was successfully managed by using hemoclips and a detachable snare.

Emergent Treatment of Button Batteries in the Esophagus

Objectives:

The evolving epidemiology of pediatric button battery ingestion is alarming. Currently, assessment of the degree of damage relies heavily on the initial esophagoscopy in a manner similar to the management of caustic ingestion. We have noted that use of this classic approach may delay the return to normal oral intake. Using several cases treated at our institution, we illustrate the value of “close second-look esophagoscopy” (CSLE) in expediting a return to normal oral intake after button battery ingestion.

Methods:

We present a retrospective case series.

Results:

Five patients (11 to 18 months of age) with button batteries trapped in the cervical esophagus were recently managed at our institution. The batteries were lodged in the esophagus for durations ranging from 6 hours to 4 months. Three cases of initial grade III circumferential necrotic injury were downgraded to grade IIa after a CSLE performed 2 to 4 days after removal, and their management was appropriately changed.

Conclusions:

The injury and healing of cases of button batteries in the proximal esophagus appear to be variable; caustic injury, electrical mucosal damage, and direct pressure are thought to be several contributory factors. Performing a CSLE within 2 to 4 days after battery removal may provide more useful prognostic information. In certain cases, downgrading of the injury may facilitate an earlier return to an oral diet, use of fewer diagnostic tests, and a shorter hospital stay. The utility and timing of imaging, management of diet and medications, and acceptable follow-up plans are discussed within the context of guiding future research.

When button batteries become breakfast: the hidden dangers of button battery ingestion

Injuries due to button battery ingestion continue to evolve with worsening clinical outcomes reported in recent years. These batteries pose a unique hazard to children due to the severity of complications that may arise within a short period of time as well as their availability in almost every home environment in the United States. It is crucial that health care providers maintain a high level of clinical suspicion for foreign body ingestion and facilitate rapid triage and treatment in these cases. Nurses should educate all children and families about button battery safety to prevent injury and decrease the morbidity and mortality related to ingestion.

Button battery foreign bodies in children: hazards, management, and recommendations

OBJECTIVE

The demand and usage of button batteries have risen. They are frequently inadvertently placed by children in their ears or noses and occasionally are swallowed and lodged along the upper aerodigestive tract. The purpose of this work is to study the different presentations of button battery foreign bodies and present our experience in the diagnosis and management of this hazardous problem in children.

PATIENTS AND METHODS

This study included 13 patients. The diagnostic protocol was comprised of a thorough history, head and neck physical examination, and appropriate radiographic evaluation. The button batteries were emergently extracted under general anesthesia.

RESULTS

The average follow-up period was 4.3 months. Five patients had a nasal button battery. Four patients had an esophageal button battery. Three patients had a button battery in the stomach. One patient had a button battery impacted in the left external ear canal. Apart from a nasal septal perforation and a tympanic membrane perforation, no major complications were detected.

CONCLUSION

Early detection is the key in the management of button battery foreign bodies. They have a distinctive appearance on radiography, and its prompt removal is mandatory, especially for batteries lodged in the esophagus. Physicians must recognize the hazardous potential and serious implications of such an accident. There is a need for more public education about this serious problem.

Spondylodiscitis: a rare complication of button battery ingestion in a 10-month-old boy

Nowadays, button battery ingestion accounts for one of the common foreign body ingestions among pediatric population. Unexpected manifestations in this setting, particularly after late removal, are confusing and might be misleading and postpone the proper management. We report a case of button battery ingestion in a 10-month-old boy who was primarily considered uncomplicated. However, he was readmitted with neck stiffness, which later turned to be due to spondylodiscitis. Based on this report, we strongly recommend considering spondylodiscitis as a late but serious complication of button battery ingestion in any patient who presents with restricted neck movement following foreign body ingestion.

Emergency care of esophageal foreign body impactions: timing, treatment modalities, and resource utilization

Esophageal foreign body impaction (EFBI) often requires urgent evaluation and treatment, but characteristics of emergency department (ED) care such as timing of presentation and therapeutic procedures and costs of care are unknown. We aimed to study health-care utilization for patients with EFBI presenting to the ED. Cases of EFBI from 2002 to 2009 were identified by querying three different databases from the University of North Carolina Hospitals for all records with ICD-9 CM code 935.1: 'foreign body in the esophagus.' Charts were reviewed to confirm EFBI and extract pertinent data related to the ED visit, including time of presentation, length of ED stay, medications administered, type of procedure performed, characteristics of procedures, and time to therapeutic procedure. Hospital charges for EFBI encounters and consult fees were determined from the Physicians' Fee Reference 2010, and were compiled to estimate costs. Of the 548 cases of EFBI identified, 351 subjects (64%) presented to the ED. A total of 118 (34%) patients received a medication to treat EFBI, which was only effective in 8% of those patients. Two hundred ninety (83%) subjects underwent a procedure including esophagogastroduodenoscopy (EGD) (n=206) or ear, nose, and throat surgery (ENT)-performed laryngoscopy/esophagoscopy (n=138). Admission to the hospital occurred in 162 (46%) of cases. There was no relationship between ED arrival time and time-to-procedure or total time in ED. There was also no significant relationship between delivery of ED medications and likelihood of undergoing a procedure, or between ED arrival time and delivery of medications. The charges associated with a typical EFBI episode ranged from $2284-$6218. In conclusion, the majority of patients with EFBI at our institution presented to the ED. Medical management was largely ineffective. A therapeutic procedure was required to clear the EFBI in most patients. Time of ED arrival made no difference in time-to-procedure, indicating that gastroenterology and ENT specialists recognize the urgency of treating EFBI regardless of time of day.

Unwitnessed lithium ion disc battery ingestion: case report and review of best practice management of an increasing clinical concern

Objective:

To describe a case of unwitnessed lithium ion disc battery ingestion, with a review of radiology findings and current best practice management.

Case report:

A three-year-old girl presented following ingestion of a foreign body, which her four-year-old brother claimed was a one pound coin. The patient was managed non-urgently and transferred for specialist ENT assessment 6 hours following the initial ingestion, with no evidence of airway compromise. A corroded battery was removed from the level of the cricopharyngeus after 8 hours, with an associated circumferential mucosal burn.

Conclusion:

There is increasing concern regarding the acknowledged rising incidence of lithium ion disc battery ingestion. The lack of a high index of suspicion and the inability to recognise subtleties on imaging may lead to suboptimal management with a higher degree of unnecessary immediate and delayed morbidity. The recently published American Academy of Pediatrics Guidelines may guide the approach to managing battery ingestions.

A rare case of lithium battery ingestion in a neonate with no complications

We report an extremely rare case of homicidal lithium battery ingestion in a neonate hitherto unreported in the medical literature. Although a definitive diagnosis was initially missed in the baby, the patient survived with no complications whatsoever even after retention of the said foreign body for 10 days.

Emergency care of esophageal foreign body impactions: timing, treatment modalities, and resource utilization

Esophageal foreign body impaction (EFBI) often requires urgent evaluation and treatment, but characteristics of emergency department (ED) care such as timing of presentation and therapeutic procedures and costs of care are unknown. We aimed to study health-care utilization for patients with EFBI presenting to the ED. Cases of EFBI from 2002 to 2009 were identified by querying three different databases from the University of North Carolina Hospitals for all records with ICD-9 CM code 935.1: 'foreign body in the esophagus.' Charts were reviewed to confirm EFBI and extract pertinent data related to the ED visit, including time of presentation, length of ED stay, medications administered, type of procedure performed, characteristics of procedures, and time to therapeutic procedure. Hospital charges for EFBI encounters and consult fees were determined from the Physicians' Fee Reference 2010, and were compiled to estimate costs. Of the 548 cases of EFBI identified, 351 subjects (64%) presented to the ED. A total of 118 (34%) patients received a medication to treat EFBI, which was only effective in 8% of those patients. Two hundred ninety (83%) subjects underwent a procedure including esophagogastroduodenoscopy (EGD) (n=206) or ear, nose, and throat surgery (ENT)-performed laryngoscopy/esophagoscopy (n=138). Admission to the hospital occurred in 162 (46%) of cases. There was no relationship between ED arrival time and time-to-procedure or total time in ED. There was also no significant relationship between delivery of ED medications and likelihood of undergoing a procedure, or between ED arrival time and delivery of medications. The charges associated with a typical EFBI episode ranged from $2284-$6218. In conclusion, the majority of patients with EFBI at our institution presented to the ED. Medical management was largely ineffective. A therapeutic procedure was required to clear the EFBI in most patients. Time of ED arrival made no difference in time-to-procedure, indicating that gastroenterology and ENT specialists recognize the urgency of treating EFBI regardless of time of day.