What will you do if a client reports to you that they have swallowed a battery by mistake? Presented here is a discussion on the topic and a case report of a 71-year-old hearing device user who swallowed a battery mistakenly.
With the advent of increasing number of devices that use batteries, the incidence of the battery ingestion has increased recently due to the increase in the use of battery operated devices (Chang, 2004). Most common sources around us: digital watches, hearing aids, and calculators. Obviously, hearing aid batteries wear out much quicker than most of the other sources and also are in untampered battery doors in most cases so, can be easily accessed by e.g. children. Furthermore, the wearer has to change them often and therefore, increased risk from discarded batteries if they are not discarded appropriately and away from children and pets. Therefore, while dishing out the battery-operated products, audiologists should be aware of the risks of battery ingestion, and more importantly, make their clients aware of the risks too. This article discusses some of the risks and their basis, along with the possible management approach.
Although the majority of battery ingestion cases involve children with a peak around the age of one to three years (unfortunately most fatalities also occur in children below four years of age), a second peak occurs in adults older than 60 years, with 10% occurring in patients aged 60 to 89 years. (Dijkstra, 2018). Clinical experience will suggest that pets also have a special affinity for the batteries. Furthermore, clinicians providing the adult audiology service should be aware that batteries can be ingested by children (and pets) belonging to their family and friends.
Fortunately, the batteries generally pass through the gastrointestinal tract relatively harmlessly within two days in over half the cases, and in two weeks in 99% of cases. The damaging outcomes occur in only about 1% of cases however, the younger or older the patient, the more like damage will occur. (Dijkstra, 2018)
Also, the larger the size (>20mm size increases the risk) or chemical content of batteries the greater the risk of potential damage (Lahmer, 2017).
Audiologists can take some solace from the fact that most batteries we use in the clinics are smaller than the negative size limit. Also, there are many brands who do mercury-free batteries.
Anorexia, nausea, vomiting, the passage of dark grey or black stools, have been reported in the literature as possible symptoms of battery ingestion. The most common symptoms of battery ingestion are abdominal pain and nausea/vomiting. (Rosenfield, 2018).
Most of the disc batteries contain one or more of the following-mercury, silver, zinc, manganese, lithium, sulphur oxide, copper, or steel as the components of the anode. The cathode also contains either sodium hydroxide or potassium hydroxide to facilitate the electrochemical reactions through electrolyte-soaked separation. This alkaline cocktail is strong enough to cause rapid tissue damage, resulting in various symptoms of battery ingestions.
Superficial erosion and minor bleeding from Oesophagus can occur within a few hours of battery ingestion. They may also cause mucosal erosions, gastritis, and minor upper gastrointestinal bleeding. Movement of battery in the gastrointestinal tract can also cause pressure damage to the tissue, just as the burn from the low voltage current present in an active battery. Some of these metals e.g. mercury are poisonous even in small amount.
Furthermore, the corrosion of battery may result in further leakage of chemicals from inside the battery or even rupture of the case, leading to further release of harmful chemicals in the gastrointestinal tract. Corrosion is less in discharged batteries. In vitro studies have shown a direct relation between corrosion of cells in an acid environment and the discharge status of the battery. (Litovitz, 1984)
There is no general consensus on the management of patients with battery ingestion. It appears that most medical professionals will manage the patient on the basis of where the battery is in the gastrointestinal tract. For the search of battery, a plane X-Ray is generally the first line investigation. In case more than several hours have passed since ingestion, it is recommended to perform a radiographic contrast test to rule out perforation. (Maron, 2010)
In terms of pharmacological treatment, it appears that Emetic agents may be considered if the battery is in Oesophagus or Stomach areas (with caution as the battery can create airway obstruction), and laxatives are considered when the battery is in the duodenum or past it. Antacids or H2 antagonists may be also be considered alongside to potentially reduce the gastric acidity and, theoretically, minimising the corrosion of the battery. Although, if the battery is in the stomach, gastric acidity itself may be able to neutralise the effect of alkaline chemicals released from the battery so, the case for using H2 antagonists or antacid is uncertain.
As noted earlier, most button batteries pass through the gastrointestinal tract with no adverse effects so, a more conservative approach may potentially be recommended. In the worst scenario- if the battery is held in any one position or more or if the client develops symptoms only then the surgical approach is considered. When it is unclear how much mercury concentration is present in the battery and if the battery ruptures, mercury concentrations in the serum and urine may be monitored, and chelating agents (chemical compounds that react with metal ions to form a stable, water-soluble complex) are given, if necessary.
What to do if a client reports battery ingestion to you:
The amount of damage due to the battery ingestion seems to depend on two things- the composition of components and also the status of battery i.e. if the battery is completely discharged it will probably be less damaging than an active battery in the gastrointestinal tract.
It appears that single most important thing an audiologist can do is to ask them to save the pack the battery belonged to. The batch number on the battery pack can be used to obtain information about the constituents of that particular batch of batteries. Apparently, the batteries which are sold as mercury-free could still have traces of mercury. The particular brand that I use, had mercury until a few years ago and now they are completely mercury free. This means that people with a past batch of the battery pack may still have one with mercury. So, it is important to know.
The second most important thing is to ask the client if the battery was new or used. As explained in this article, a dead battery is less likely to cause a problem.
Finally, it is important to be truthful about the situation with the client and not to undermine its serious outcomes. Therefore, if they have not already, the advice should be to immediately see the A&E or GP, whichever is more appropriate. However, be conscious that the client may require support and reassurance from the audiologists as well, having had the ongoing relationship with you as their hearing care provider. So, the last thing that you would want to do is just to shrug the client away to a medical provider as battery ingestion is clearly a medical issue. Your counselling and reassurance will go a long way to help their predicament.
The only other things that you could consider is the use of tamper-proof battery door and lobbying your provider for better packaging. Screw-secured compartments and individual blisters for batteries could prevent approximately a third of cases of battery ingestions. (Lahmer, 2017).
Presented here is a case of 71-year-old man who was a regular hearing device user for about 18 months before the incidence of battery ingestion. He took out his dead battery one night while removing the hearing device from his ear and put it on the side table near his bed. He woke up during early hours of the morning to take one of his regular medication. Incidentally, he will usually put the tablet on the same table as the dead battery and that morning, by mistake, he swallowed the battery with water instead of the tablet.
He discovered the mistake only after waking up, which was about eight hours after the battery ingestions, and immediately consulted NHS after hour service (NHS 111), and subsequently went to the nearest Emergency Department.
Day 1: He had X-ray of Chest and stomach but was returned home as there was no sign of the battery.
Day 2: He got increasingly worried about the situation and visited the Emergency department again the next day, concerned that the battery was not seen on X-ray. Further X-ray was taken of abdomen revealed battery in the small intestine. The doctors at Emergency department decided to treat this conservatively and monitored his situation.
Day 4: He had an X-ray after two days but the battery was lodged at the same place.
Day 6: Another X-ray after next two days showed only a slight movement of the battery. At this, he was booked into the next available appointment with the surgical assessment unit, which happened to be after a week.
Day 13: Had a further X-ray, which did not show any significant movement in the position of the battery, however, the Surgeon reassured him that battery will find its way out. Follow up was booked in a week.
Day 20: X-ray showed no change in battery position.
Day 26: Further X-ray showed no change in battery position.
Was asked to return in a week but developed Shingles in between so, could not make it for next two weeks.
Day 43: X-ray showed no evidence of the battery in the gastrointestinal tract.
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Lahmar J, Célérier C, Garabédian E N, Couloigner V, Leboulanger N, Denoyelle F. Esophageal lesions following button-battery ingestion in children: Analysis of causes and proposals for preventive measures. Eur Ann Otorhinolaryngol Head Neck Dis. Oct 2017. pii: S1879-7296(17)30154-0.
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Rosenfeld E H, Sola R Jr, Yu Y, St Peter S D, Shah S R. Battery ingestions in children: Variations in care and development of a clinical algorithm. J Pediatr Surg. 2018 Feb 2. pii: S0022-3468(18)30048.
Disclaimer: This article has been prepared in good faith on the basis of some of the information available in the literature. By no means, this is a substitute for a medical advice. Any cases of battery ingestions must be reported to an appropriate medical professional immediately and all advice from them should be duly followed. The author does not take any responsibility for the medical management or mis-managment of clients on the basis of the information included in this article.
Speakers: Prof Susan Scolie, Dr Josephine Marriage, Dr Jay Jindal
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