A 3-year-old boy is brought to the emergency department after swallowing a battery. About an hour ago, his father was changing his watch battery when the patient grabbed and swallowed it and then coughed for several minutes. Since then, he has been able to drink and talk normally. Vital signs are normal. The patient appears alert and comfortable. He is not drooling, and the posterior oropharynx is clear. The lungs are clear to auscultation bilaterally. Cardiac examination is unremarkable. The abdomen is soft and nontender. Chest x-ray on anteroposterior view shows a radiopaque, circular object with a halo sign. The lateral view is shown below: Which of the following is the best next step in management of this patient?

Question

A 3-year-old boy is brought to the emergency department after swallowing a battery.  About an hour ago, his father was changing his watch battery when the patient grabbed and swallowed it and then coughed for several minutes.  Since then, he has been able to drink and talk normally.  Vital signs are normal.  The patient appears alert and comfortable.  He is not drooling, and the posterior oropharynx is clear.  The lungs are clear to auscultation bilaterally.  Cardiac examination is unremarkable.  The abdomen is soft and nontender.  Chest x-ray on anteroposterior view shows a radiopaque, circular object with a halo sign.  The lateral view is shown below:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8f0_d01f_bc81_49256141433a_MD0003_00 Button battery ingestion has serious and life-threatening complications, particularly if the battery is lodged in the esophagus, as seen in this patient. Button batteries create an external current that can lead to tissue corrosion. In addition, leaking alkaline battery solution causes liquefaction necrosis of surrounding mucosa. As with any lodged object, pressure necrosis can also occur because of local inflammation and ischemia. Prolonged impaction can result in esophageal ulceration and perforation, hemorrhagic shock, and death. Patients are often initially asymptomatic but may experience nausea/vomiting, anorexia, and chest pain. Fever, hematemesis, and shock are signs of life-threatening perforation. Radiographic features that distinguish the bilaminar structure of a button battery from a flat coin include: a halo or double-ring around the circular object on anteroposterior view (described but not visualized in this case). a step-off or beveled edge on lateral view (occasionally but not always seen). Emergency endoscopic removal is the treatment for an esophageal button battery. Administering honey soon after ingestion in an asymptomatic patient may provide a partial protective barrier but should not delay definitive management. Treatment delay increases the risk of late complications (eg, esophageal stricture or stenosis). (Choice A) Barium esophagography may be performed months after button battery ingestion to assess for stricture formation in patients with severe esophageal injury. Contrast is avoided in the acute management because it can obscure visualization and hinder removal of the object. (Choice B) "Blind sweep" refers to using a finger to clear an object that cannot be seen from the airway of a choking patient. This maneuver is never recommended because it can push an object distally into the airway. (Choice C) An aspirated foreign body, which can be removed by bronchoscopy, typically causes sudden-onset respiratory distress and asymmetric breath sounds. In addition, this patient's lateral x-ray shows the button battery posterior to the trachea, suggesting an esophageal location. lateral x-ray (Choice D) An asymptomatic patient with ingestion of a small, blunt object (eg, coin) may be observed with repeat x-rays after 24 hours to confirm object progression beyond the stomach. This patient's witnessed button battery ingestion with supportive x-ray findings warrants immediate removal. Educational objective: A button battery lodged in the esophagus can cause tissue corrosion, necrosis, and life-threatening perforation. A circular object with a halo sign on chest x-ray is consistent with a button battery, and management is immediate endoscopic removal. References: Serious complications after button battery ingestion in children. (http://www.ncbi.nlm.nih.gov/pubmed/29717359) Button battery ingestion in children. (http://www.ncbi.nlm.nih.gov/pubmed/28858893)

A 3-Year-Old Boy Is Brought to the Emergency Department After