14.3 Button Battery & Foreign-Body Ingestions, Bites & Envenomations, and Hazardous-Material Exposures

Button Batteries, Envenomations & Hazardous Materials

Button Battery Ingestion

Lithium coin cells (especially 20 mm cells, such as the CR2032) are the most dangerous. A battery lodged in the esophagus generates an electrical current that produces hydroxide at the negative pole. The result is liquefactive (alkaline) tissue injury that can begin within about 2 hours.

Recognition

• The ingestion is often unwitnessed. Symptoms may be mild or absent at first: drooling, refusal to eat, vomiting, coughing, or chest discomfort.
• Radiograph from nose to anus: a coin-shaped object with a double-ring or "halo" sign on the frontal view and a step-off on the lateral view distinguishes a battery from a coin.
• The negative pole (narrow side) usually causes the worst injury.

Management

• Esophageal battery = emergency endoscopic removal, ideally within about 2 hours of ingestion. Transport should go to a center with pediatric endoscopy available immediately.
• Honey and sucralfate: The National Capital Poison Center guideline supports giving honey (10 mL every 10 minutes, up to 6 doses) to children 1 year or older with a known or suspected ingestion within about 12 hours, and sucralfate in the hospital before removal, unless there is suspected perforation, sepsis, or allergy. These coat the battery and slow tissue injury. They are not a substitute for removal. Honey is avoided in infants younger than 1 year because of botulism risk.
• Do not induce vomiting.
• Delayed complications can occur days to weeks after removal: esophageal perforation, tracheoesophageal fistula, mediastinitis, vocal cord paralysis, and aortoesophageal fistula with catastrophic hemorrhage. A small "herald bleed" (hematemesis) in a child with a recent battery ingestion is an emergency.
• A battery that has passed beyond the esophagus is usually managed with follow-up imaging, but it may need removal depending on symptoms, size, and time.

Magnets and other foreign bodies

• Multiple magnets, or a magnet plus a metal object, can attract across bowel loops and cause pressure necrosis, perforation, fistula, and volvulus. They require urgent surgical or gastroenterology evaluation.
• Airway foreign bodies are covered in Section 11.1.

Bites and Envenomations

Pit vipers (rattlesnakes, copperheads, cottonmouths)

• Local effects: Pain, swelling, ecchymosis, and blistering that spread over hours
• Systemic effects: Hypotension, coagulopathy (low fibrinogen and platelets, prolonged clotting times), bleeding, and occasionally neurotoxicity with some rattlesnake species
• Transport care:
  • Immobilize the limb in a neutral position around heart level.
  • Remove rings and tight clothing.
  • Mark the swelling edge with times to track progression.
  • Provide analgesia (opioids rather than NSAIDs because of coagulopathy).
  • Monitor for shock and bleeding.
• Do not apply tourniquets or ice, incise, suction, or use electric shock.
• Antivenom (for example, Crotalidae polyvalent immune Fab or Crotalidae immune F(ab')2) is dosed by severity and progression, not body weight. Children receive the same number of vials as adults. Consult a poison center (1-800-222-1222 in the U.S.) and a medical toxicologist.

Coral snakes

Neurotoxic venom. Symptoms (cranial nerve palsies, weakness, respiratory failure) can be delayed for hours. Transport suspected bites for observation and possible antivenom even when the child looks well, and anticipate respiratory failure.

Spiders and scorpions

• Black widow (latrodectism): Severe muscle cramping, abdominal rigidity mimicking an acute abdomen, hypertension, and diaphoresis. Treat with analgesia and benzodiazepines. Antivenom is reserved for severe cases because of anaphylaxis risk.
• Brown recluse (loxoscelism): Necrotic skin lesions. Children can rarely develop systemic hemolysis, so check hemoglobin, urine, and renal function.
• Bark scorpion (southwestern U.S.): Children are at highest risk of severe neurotoxicity (roving eye movements, agitation, respiratory distress, hypersalivation). Specific antivenom is available. Support the airway.

Mammalian bites

• Dog bites to the face, head, and neck are common in young children and can involve the airway, vessels, and skull (penetrating skull injuries in infants).
• Cat bites cause deep puncture wounds with high infection risk.
• Rabies post-exposure prophylaxis (rabies immune globulin plus vaccine) is considered for bat exposures and bites from unvaccinated or wild animals.
• Antibiotic prophylaxis with amoxicillin-clavulanate is common for high-risk wounds.

Hymenoptera stings

Single stings usually cause local reactions. Anaphylaxis is treated with IM epinephrine (Section 12.2). Massive envenomation from many stings can cause rhabdomyolysis, hemolysis, and kidney injury.

Hazardous-Material Exposures

Why children are more vulnerable

• Higher minute ventilation per kilogram, so they inhale more gas per kilogram
• Shorter stature, so they breathe closer to the ground, where many heavier-than-air gases settle
• Thinner skin and a larger surface area per kilogram, so they absorb more through the skin and lose more heat during decontamination
• Less ability to escape or recognize danger

Decontamination comes first

• Remove clothing. This removes a large share of the contaminant, then irrigate skin with water (lukewarm to avoid hypothermia in children).
• Decontaminate before loading the patient. CAMTS requires services to have a plan for patient decontamination before transport. A contaminated patient in a closed cabin can make the crew sick and ground the aircraft.
• Crew wear PPE matched to the hazard. Uncontrolled scenes belong to hazmat teams (Section 2.5).

Organophosphates and carbamates (pesticides, nerve agents)

• Cholinergic toxidrome (Section 14.1): Bronchorrhea, bronchospasm, bradycardia (tachycardia is also possible), miosis, salivation, lacrimation, urination, diarrhea, vomiting, fasciculations, weakness, and seizures. The "killer Bs" are bronchorrhea, bronchospasm, and bradycardia.
• Atropine 0.02–0.05 mg/kg IV, repeated and doubled every few minutes until bronchial secretions dry and breathing improves. Large total doses may be needed. The endpoint is dry lungs, not pupil size or heart rate.
• Pralidoxime (2-PAM) about 25–50 mg/kg IV reactivates acetylcholinesterase for organophosphates if given before "aging."
• Benzodiazepines for seizures.
• Avoid succinylcholine, because cholinesterase inhibition prolongs paralysis.

Irritant and toxic gases

• Highly water-soluble gases (ammonia, chlorine at high concentration) injure the upper airway quickly (stridor, eye and throat burns). Less soluble gases (phosgene, nitrogen dioxide) cause delayed pulmonary edema hours later. Observe exposed children even when they look well initially.
• Treat with humidified oxygen, bronchodilators, early airway control for upper airway edema, and lung-protective ventilation.

Hydrocarbon aspiration (pneumonitis)

• Low-viscosity hydrocarbons (lamp oil, gasoline, mineral spirits, furniture polish) are easily aspirated, causing chemical pneumonitis. Cough, choking, or vomiting after ingestion suggests aspiration.
• Symptoms and radiographic changes may develop over the first few hours (commonly observed for about 6 hours).
• Do not induce vomiting or place a gastric tube for lavage. Give oxygen, support ventilation (with PEEP for severe cases), and do not give prophylactic steroids or antibiotics.
• Some hydrocarbons (halogenated solvents, aromatic compounds) also cause arrhythmias ("sudden sniffing death" from sensitization to catecholamines). Minimize catecholamine surges and avoid epinephrine unless needed for arrest.