Analisa Armstrong, MD Seattle Children’s Hospital September 29, 2011 Assault and Battery Analisa Armstrong, MD Seattle Children’s Hospital September 29, 2011

Analisa Armstrong, MD Seattle Children’s Hospital September 29, 2011 All Charged Up Analisa Armstrong, MD Seattle Children’s Hospital September 29, 2011

Managing Battery Ingestion Analisa Armstrong, MD Seattle Children’s Hospital September 29, 2011

Fortified with Minerals OA: 2 yo ate a small watch battery today, witnessed at 5 pm…plain films document that it has passed the esophagus, now in the stomach, no sxs, Seen by GI too. F/u x-rays are tomorrow too

OA – 2 yo M Child 2 years old Button battery x 1 swallowed Button battery small No pain, dysphagia, fever, vomiting, respiratory distress or other symptoms

OA – 2 yo M

Battery Ingestion Standard of Care XR? EGD? OR?

What about 2 batteries Battery plus magnet? Cylindrical battery

When to operate? It may depend on battery composition, size, location, symptoms, and damage done. How to tell watch battery versus coin This lineup shows a radiograph of a series of 6 disc batteries and a dime. The first disc battery on the left has the positive terminal facing toward us. The second battery from the left has its negative terminal facing toward us. On this second battery, the black plastic insulator is visible in the photograph. However, the radiograph of both the first and the second disc batteries show the internal ring sign of the plastic insulator. The black plastic insulator on the first battery is on the other side of the battery. The radiograph will still show the internal ring of the plastic insulator regardless of which way the battery is facing (AP or PA). The fourth battery from the left also shows a plastic insulator, but the radiograph of this battery does not show the internal ring. It could be absent because the battery casing is thicker than the first and second batteries. Thus, the absence of the internal ring radiographically does not rule out a disc battery since the appearance of the internal ring is highly dependent on the degree of X-ray penetration, the angle of the battery, and the thickness of the battery casing. The third and fifth batteries from the left are viewed from the side. On its side view, the battery has a rectangular appearance with a bulge on one end. This bulge represents the negative terminal of the battery as shown in the corresponding photo below it. The radiographic shadow also identifies this bulge which can be described as frosting on the cake (bilaminar appearance). However, this radiographic sign may be absent if the battery is oriented obliquely, or if the battery is very thin. The battery to the extreme right is oriented on edge. The side view of this battery does not easily show the bulge of the negative terminal because this battery is very thin as can be seen in the photograph.

Increasing Battery Ingestion Batteries represent < 2% of foreign body ingestions by children Over the past 20 years, battery ingestion frequency has increased Medline searched button battery, esophageal burn. Cases studied for type, size, source of batteries Location and battery impact in the esophagus Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Increasing Ingestion Damage From 1985 to 2009, there has been a nearly 7 fold increase in the rate of major or fatal outcomes secondary to battery ingestion Medline searched button battery, esophageal burn. Cases studied for type, size, source of batteries Location and battery impact in the esophagus Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Increasing Ingestion Damage From 1985 to 2009, there has been a nearly 7 fold increase in the rate of major or fatal outcomes secondary to battery ingestion Medline searched button battery, esophageal burn. Cases studied for type, size, source of batteries Location and battery impact in the esophagus Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Size Matters Batteries <15mm in diameter almost never lodged in the esophagus Outcomes were significantly worse for large diameter lithium cells >20mm

Size Matters 92% of battery cells identified in major outcomes and fatal ingestions were 20mm+ >99% of 20mm+ battery cells were lithium Major effects noted to mean life threatening or disabling 30/32 major effects were from batteries >20mm 1/1 death with known diameter from battery >20mm All silver dioxide cells were <15mm Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Size Matters 92% of battery cells identified in major outcomes and fatal ingestions were 20mm+ >99% of 20mm+ battery cells were lithium Major effects noted to mean life threatening or disabling 30/32 major effects were from batteries >20mm 1/1 death with known diameter from battery >20mm All silver dioxide cells were <15mm Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Age Matters Outcomes were worse for children < 4 years old In one study of nearly 9000 ingestions, all fatalities and 85% of major effects occurred in children < 6 years who ingested batteries >20mm Kids take batteries from products

Time Matters Severe burns with sequelae occurred within 2 hours Misdiagnosed and delays have led to documented severe burns, perforation, stricture, esophageal stenosis, persistent stridor, fistula, vocal cord paralysis, exsanguination, and 13 reported deaths over the past 25 years Injury may continue for days to weeks after battery removal

Composition Matters Lithium cells are 3V (most other button battery cells are 1.5V) with higher capacitance and therefore more current generating capacity and in turn more hydroxide produced Lithium cells are also generally 20mm+ The external electrolytic current generates hydroxide at the negative battery pole

Injury Mechanisms :1. Electrical burn A battery in the esophageal lumen may complete an electrolytic circuit and cause local damage. 2. Direct pressure necrosis 3. Caustic injury due to leakage Most of the toxic mercuric oxide in batteries changes into nontoxic substances after ingestion, but some batteries contain 5 g of mercuric oxide, more than a lethal dose. Batteries containing lithium, manganese, and heavy metals other than mercury do not cause toxicity.

Algorithm of Management Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management – Battery Ingestion Suspected NPO and X ray Measure button diameter on XR National Battery Ingestion Hotline 202-625-3333 for specific battery ID If child is 1. asymptomatic, 2. only ingested one battery and 3. no magnets, 4. battery is less than 12 mm with 5. no pre-existing esophageal disease and 6. caregiver is reliable … COIN VS BATTERY Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management – Battery Ingestion Suspected NPO and X ray Measure button diameter on XR National Battery Ingestion Hotline 202-625-3333 for specific battery ID If child is 1. asymptomatic, 2. only ingested one battery and 3. no magnets, 4. battery is less than 12 mm with 5. no pre-existing esophageal disease and 6. caregiver is reliable … Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management – Battery Ingestion Suspected NPO and X ray Measure button diameter on XR Battery in Esophagus? National Battery Ingestion Hotline 202-625-3333 for specific battery ID If child is 1. asymptomatic, 2. only ingested one battery and 3. no magnets, 4. battery is less than 12 mm with 5. no pre-existing esophageal disease and 6. caregiver is reliable … Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management - Esophagus Battery in Esophagus? Yes Immediately remove batteries lodged in the esophagus. Serious burns can occur in 2h. Do not delay because the patient has eaten. Prefer endoscopic removal for direct visualization of tissue injury. Inspect mucosa for extent, depth, and location of tissue damage. Note position of battery and direction negative pole faces. Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management – Battery Ingestion Suspected NPO and X ray Measure button diameter on XR Battery in Esophagus? National Battery Ingestion Hotline 202-625-3333 for specific battery ID If child is 1. asymptomatic, 2. only ingested one battery and 3. no magnets, 4. battery is less than 12 mm with 5. no pre-existing esophageal disease and 6. caregiver is reliable … Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? Yes Remove battery endoscopically, if able, or to OR for ex-lap Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? No, No Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? No, No Is the patient < 12 years old? Is the battery button >12mm? Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? No, No Is the patient < 12 years old? Is the battery button >12mm? No, No Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? No, No No, No Is the patient < 12 years old? Is the battery button >12mm? Patient may return home and follow-up within 10-14 days if continued asymptomatic Confirm passage within 2 weeks Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? No, No Yes Is the patient < 12 years old? Is the battery button >12mm? Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Algorithm of Management Battery in Esophagus? No Was magnet co-ingested? Is the patient symptomatic? No, No Yes Is the patient < 12 years old? Is the battery button >12mm? Especially for patients < 6 years and batteries > 15mm Xray within 4 days of ingestion and if still in stomach, battery should be removed endoscopically Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Monitored Progession

Monitored Progession

Monitored Progession

Monitored Progession

Call from Dad And It’s Out…

Summary Batteries that are in the esophagus must be removed within 2 hours Damage is predominately from current generating electrolysis Battery in stomach or beyond in an asymptomatic patient should be left to pass spontaneously Children younger than 6 who have swallowed batteries > 20mm should be watched particularly carefully

Summary Indications for surgery include: esophageal lodging ingestion symptoms kids <6 with batteries > 20mm that have not passed within 4 days Battery and magnet co-ingestion Endoscopic retrieval should be attempted preferentially

References Bekhof, J et al. Babies and Batteries. Lancet. 2004; 364 (9435): 708. Chang, YJ et al. Clinical Analysis of Disc Battery Ingestion in Children. Chung Gung Medical Journal. 2004; 27 (9): 673-77. Hamilton, JM et al. Severe Injuries from Coin Cell Battery Ingestions: 2 Case Reports. Journal of Pediatric Surgery. 2009; 44(3): 644-47. Imamoglu, M et al. Acquired Tracheo-Esophageal Fistulas Caused by Button Battery Lodged in the Esophagus. Pediatric Surgery International. 2004; 20 (4): 292-294. Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010;125;1168. Litovitz, Toby et al. Preventing Battery Ingestions: An Analysis of 8648 Cases. Pediatrics 2010; 125; 1178. Litovitz, Toby et al. Battery Button Ingestions: A Review of 56 cases. JAMA 1983 May 13; 249 (18) 2495-500. Marom, T. Battery Ingestion in Children. International Journal of Pediatric Otorhinolaryngology. 2010 Aug; 74 (8): 849-54. Yardeni, D et al. Severe Esophageal Damage Due to Button Battery Ingestion: Can it be Prevented? Pediatric Surgery International. 2004 July; 20 (7): 496-501.

Age vs. Battery Type Litovitz, Toby et al. Preventing Battery Ingestion: A Review of 8648 Cases. Pediatrics 2010; 125; 1179.

Number of Batteries Ingested Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.

Button Cells vs Cylindrical Cells Litovitz, Toby et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010; 125; 1168.