Close follow-up needed after removal

Patient Safety: We use this forum to regularly report on findings from patient safety organizations, expert review committees of the Office of the Chief Coroner and inquests.

When treating children who have ingested button batteries, health care professionals should establish triage protocols and procedures that reflect the importance of rapid diagnosis and removal of the battery. And even once the battery is removed, close follow-up investigation is essential to determine the state of ongoing injury, recommends a Committee of the Chief Coroner’s Office.

The recommendation from the Pediatric Death Review Committee follows its investigation into the circumstances in the death of a 22-month-old child who ingested a battery. The toddler died of an upper gastrointestinal hemorrhage nearly three weeks after the battery was removed.

“The consequences of battery ingestion in small children can be severe because of the corrosive nature of batteries. The damage to the esophageal mucosa occurs within hours of ingestion and there is a level of urgency about their removal,” stated the report.

Battery ingestion can become a life-threatening event if not identified and dealt with expeditiously, and the object removed. Even then, severe damage to the esophagus can occur because of pressure necrosis, alkaline leakage and current leakage from the negative pole of the battery. Follow-up investigations are required to assess the degree of ongoing injury, stated the Committee’s report.

Following removal of ingested batteries from children, health care professionals should provide caregivers with discharge information that clearly states when immediate medical attention should be sought from the closest hospital emergency department.

Given the consequences of battery ingestion, CPSO urges family physicians to speak to parents with young children about the importance of storing such batteries out of reach of children.

The Case

At 0012 hours on December 17, 2020, the child presented to the emergency department (ED) at Hospital A because of suspected ingestion of a button battery. The child’s mother had not witnessed the event, but suspected that it may have occurred on December 16 when the child had an episode of vomiting and gagging. She noticed that a battery was missing from a device in her home.

Admission vital signs were within normal limits and the child was not in distress. A chest x-ray confirmed that there was a button battery (2cm x 2cm in size) located in the mid esophagus.

At 0300 hours, the child was transported by land ambulance to a Children’s Hospital for removal of the battery. Further imaging at the Children’s Hospital confirmed the position of the battery and at 0730 hours, the child was taken to the operating room (OR) for an emergency esophagoscopy under general anesthesia.

The battery was removed without difficulty and an area of erosion and burn was identified where it had been lodged. There were no post-operative complications, except for a mild fever and rise in white blood cell count post-operatively. He was initially treated with antibiotics and remained in hospital until December 20, 2020, when he was discharged on clindamycin and omeprazole.

The family was provided with contact and general information from the ear, nose and throat (ENT) clinic, and a virtual follow-up was scheduled for three weeks’ time.

At 0400 hours on January 6, 2021, the child was taken by his mother to the ED at Hospital A with a history of hematemesis. The child had reportedly vomited a small amount of blood 20 minutes before arrival in the ED.

After the child was admitted, he continued to deteriorate, vomiting greater amounts of blood. He was observed to vomit both blood clots and fresh blood. His hemoglobin was measured at 59gm/L. The amount of hematemesis and melena then increased significantly.

At 0855 hours, cardiac arrest occurred and cardiopulmonary resuscitation (CPR) was initiated. Tranexamic acid (TXA) was given and blood was transfused with a pressure bag. Intraosseous access was gained.

At 0911 hours, the child was intubated.

At 0917 hours, the pediatric intensive care unit (PICU) at the Children’s Hospital was contacted via the bridge line. Management advice was given and the acute care transport service (ACTS) was dispatched.

At 0929 hours, a perfusing cardiac rhythm was restored. The on-call general surgeon and attending pediatrician were called to assist. Attempts were made to tamponade the bleeding site in the esophagus using a Blackmore tube and a Foley catheter without success.

At 1010 hours, the ACTS team arrived at Hospital A. At 1033, the child arrested again and CPR was recommenced. Resuscitation continued with RBCs, calcium, fresh frozen plasma and epinephrine without return of spontaneous circulation.

At 1109 hours, CPR was discontinued and the child died.

Given the consequences of battery ingestion, CPSO urges family physicians to speak to parents with young children about the importance of storing such batteries out of reach of children.

The post-mortem examination found cause of death to be upper gastrointestinal hemorrhage. Considering the post-mortem finding that there was a focus of acute inflammation involving a thick-walled artery, it is highly likely this was arterial bleeding, which accounts for the terminal volume and rapidity of blood loss. “Even in the most skillful hands, this would have been very difficult to control,” stated the Committee’s report.

Following the death of this child, a battery ingestion working group was established at the Children’s Hospital. The focus of the discussion was on the initial management of battery ingestion. The group used a published algorithm-flow-diagram (source not attributed), which recommended lithium batteries be removed within two hours of diagnosis, where possible. In this case, there was a four-hour interval between the time the child arrived at the Children’s Hospital and the removal of the battery.

In separate advice to health care professionals, the Children’s Hospital Colorado says upon discharge from the hospital, anticipatory guidance should be given to families regarding the range of potential complications of esophageal button battery impaction, which include vascular injury with hemorrhage, tracheoesophageal fistula, mediastinitis, vocal cord injury, esophageal stenosis, and spondylodiscitis.

Prior to hospital discharge, in all patients with moderate-severe esophageal injury, the Colorado hospital suggests endoscopic or radiologic surveillance studies to look for evidence of poor healing or evidence of extra-esophageal injury. Because catastrophic hemorrhage has been seen up to three weeks after battery removal, consideration of the timing of hospital discharge must include the proximity of the family to a pediatric facility capable of managing life-threatening bleeding.