2yr old swallowed a battery from a toy car 1 hour ago. He has drooling. He is irritable crying
Pr 120/mt
Crpt normal
Other syatems normal
What should we do?
First aid — For asymptomatic children with acute button battery ingestions (eg, witnessed or likely to have occurred within 12 hours) who are older than one year of age and without allergies to honey or its components, we suggest one oral dose of pure honey (eg, 5 to 10 mL) given by the caregiver at home as soon as possible after ingestion. Once in the emergency department, the child may receive another dose of honey or, if no history of allergy, a single dose of sucralfate 500 mg prior to confirmation of esophageal impaction by radiography and emergency battery removal.
Stabilization — As with all acute ingestions, stabilization of the cardiorespiratory status is the first priority. However, most patients with button battery ingestion are asymptomatic or present in stable condition, and localization of the battery is typically the first step.
Asymptomatic, stable patients with acute battery ingestion (eg, witnessed or likely to have occurred within 12 hours of presentation) should receive honey or oral sucralfate as described above [ 39]. (.)
Symptomatic children with a delayed diagnosis of battery impaction (eg, uncertain timing of ingestion or symptoms of serious esophageal injury or mediastinitis, such as fever or chest pain) should have no oral intake prior to battery removal.
Radiographic localization
We recommend emergency evaluation and plain radiography after ingestion of a button battery for patients who meet any one of the following criteria [ ● ● ● All children ≤12 years of age All patients who have ingested a button battery that is ≥12 mm in diameter All patients for whom the diameter of the battery is not known
Coin. Vs. Button battery
Button batteries have a bilaminar structure, making them appear as a double-ring or halo on plain radiographs. The double-ring shadow helps to differentiate battery from coin ingestions
On lateral view of the foreign body, the button battery has a step-off at the separation between the anode and cathode ( image 2) [ 41]. By contrast, the coin has a sharp, crisp edge
Findings of esophageal perforation – Although rarely seen in children with esophageal button battery impaction, findings suggestive of an esophageal perforation on chest radiograph include mediastinal or free peritoneal air or subcutaneous emphysema. With
Esophagus
cervical esophageal perforations, plain films of the neck may show air in the soft tissues of the prevertebral space. Other findings suggestive of an esophageal perforation include pleural effusions, mediastinal widening, hydrothorax, hydropneumothorax, or subdiaphragmatic air. However, plain radiographs are an insensitive means for establishing the presence of esophageal perforation cervical esophageal perforations, plain films of the neck may show air in the soft tissues of the prevertebral space. Other findings suggestive of an esophageal perforation include pleural effusions, mediastinal widening, hydrothorax, hydropneumothorax, or subdiaphragmatic air. However, plain radiographs are an insensitive means for establishing the presence of esophageal perforation [
The determination of which specialist to perform button battery removal depends upon the presence and type of symptoms as follows: ● ● ●
Asymptomatic –
In asymptomatic patients, removal by any of the above specialists is reasonable and the choice should be based upon who can accomplish removal in the timeliest fashion. In many institutions, specific guidelines determine which specialty manages esophageal foreign bodies based upon a variety of factors including anatomic location and provider expertise.
Symptomatic with no bleeding –
Symptomatic patients without hematemesis have a higher likelihood of esophageal perforation with complications and warrant involvement of a pediatric surgeon. Patients with symptoms of upper airway compromise (eg, drooling, stridor, or respiratory distress) also warrant consultation with an otolaryngologist who can assess and address any airway damage. Symptomatic with bleeding – Patients with hematemesis require stabilization and battery removal in conjunction with a surgeon with cardiothoracic expertise as follows
• Patients with a low-volume sentinel bleed in association with an impacted esophageal button battery warrant rapid hemodynamic stabilization and emergent removal in the operating room with surgeons present and prepared to perform a thoracotomy.
• Patients with active bleeding warrant endotracheal intubation, hemodynamic stabilization, and emergent thoracotomy by a surgeon with cardiothoracic expertise in the operating room. Placement of a Sengstaken-Blakemore tube designed to tamponade esophageal sites of bleeding may be a temporizing measure if the tube and clinicians knowledgeable with its use are available
STOMACH
NBIH guidelines – The NBIH guidelines suggest the following approach based upon a large prospective observational experience [ 1,3,40]
• • Patients with no signs of serious gastrointestinal injury or obstruction should not undergo endoscopy and should be managed at home with a normal diet and activity. Obtain follow-up radiographs:If the patient becomes symptomatic Four days after ingestion in children under six years of age who have ingested a button battery with a diameter ≥15 mm.–
• To prove ultimate passage of the battery if not visualized intact in the stool one to two weeks after ingestion. Weekly to monitor progression of the battery through the GI tract if it has not been seen in the stool and is present on follow-up radiographs.
Endoscopic or surgical removal of the battery is suggested if:– ● The patient develops signs of gastrointestinal injury, such as occult or visible bleeding, fever, vomiting, severe abdominal pain, or acute abdomen. The battery remains in the stomach for more than four days and is unlikely to pass due to large size (eg, ≥15 mm in diameter in a child under six years of age)
NASPHAGAN
Urgent endoscopy (within 48 hours) is suggested for asymptomatic patients who are younger than five years of age and have ingested a button battery that is ≥20 mm. The primary reason for endoscopy in these patients is to exclude concomitant esophageal injury.
Repeat radiographs at 48 hours are recommended for asymptomatic patients five years of age and older who have ingested a button battery ≥20 mm.
Endoscopic removal is advised if the battery remains in the stomach at that time.
For asymptomatic patients of all ages who have ingested button batteries <20 mm in diameter, repeat radiographs are suggested at 10 to 14 days if button battery passage in the stool has not occurred.
Endoscopic removal is advised if the battery remains in the stomach at 10 to 14 days.
Complications
Complications from button battery ingestion are rare, but potentially devastating. They include, but are not limited to, tracheoesophageal fistula, vocal cord paralysis, esophageal perforation, esophageal stenosis, mediastinitis, spondylodiscitis, aspiration pneumonia, perforation of the aortic arch, gastric hemorrhage, gastric perforation, and intestinal perforation. Deaths have been reported and are associated with ingestion of large (≥20 mm) lithium cell button batteries
Superintendent, ICH.