Read the halo, beat the clock — oesophageal button battery in a toddler

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses radiographic recognition of an oesophageal button battery, leadership of the two-hour emergency endoscopy pathway, the safe use of a temporising demulcent, communication with the family, and the written safety net for delayed bleeding. [1] [3]

Candidate instructions

You are the paediatric registrar called to the acute assessment room. Confirm the diagnosis from the radiograph, declare the urgency tier and the time target, and call the right teams in parallel. Speak directly to the child and parent in plain language. State what you would do; do not perform painful manoeuvres on the actor. Finish with a structured handover and a written safety net. [3]

Room setup and observable starting state

The encounter. Maya is three and is sitting upright on the assessment trolley, drooling into a bowl, refusing a drink her parent offers, and pointing to the front of her chest. The parent says a remote-control battery is missing and they think Maya swallowed it about forty minutes ago. The anteroposterior chest radiograph on the lightbox shows a 20-millimetre disc-shaped radiopacity at the thoracic inlet with a concentric ring appearance. The candidate should read the halo sign confidently, declare an emergency within two hours, and mobilise the endoscopy and anaesthetic teams without delay. [10] [3]

Simulation safety. Maya remains upright on the trolley and is never laid flat or made to swallow. Cards or the assessor supply radiographs, monitor readings and endoscopic findings. The parent does not obstruct urgent care. [3]

Actor cues

Parent actor

• Begin with "She's been drooling and won't drink since we found the remote battery missing."
• If asked what happened, answer: "She was playing with the remote. The back was off and the battery gone. She started drooling about half an hour ago."
• Express anxiety about the procedure and ask what the risk is.

Child actor

• Drool, refuse drinks, and point to the front of the chest on request.
• Remain alert and responsive throughout, unless the assessor cues a deterioration.

Assessor cues and clinical data

Release findings as the candidate reaches each decision point. Reward confident radiograph reading and correct urgency-tier assignment; penalise misreading the battery as a coin or choosing observation. [1]

Radiograph

Anteroposterior chest radiograph shows a 20-millimetre disc-shaped radiopacity at the thoracic inlet with a concentric ring (halo) appearance. A lateral view confirms a step-off at the rim. Expected strong behaviour: diagnose a button battery lodged in the upper oesophagus from the halo and step-off signs; declare an emergency within two hours; call anaesthetics, the paediatric endoscopist, and retrieval if two-hour removal is not possible locally. [10]

Resuscitation and parallel calls

Maya is alert, drooling, protecting her airway, with normal observations. Expected strong behaviour: keep her nil by mouth and upright, suction oral secretions, place on continuous monitoring, and call anaesthetics, paediatric gastroenterology or surgical endoscopy, and retrieval in parallel. Confirm the time of ingestion and the time of last food for anaesthetic planning. [1] [3]

Delayed endoscopy branch

The on-call endoscopist is ninety minutes away in theatre. Expected strong behaviour: give honey by mouth at approximately 10 millilitres every ten minutes up to six doses, because the child is over twelve months, has no perforation, and the battery is confirmed in the oesophagus; state the contraindications (infant under twelve months, suspected perforation, unprotected airway, battery beyond the pylorus); reaffirm that honey is an adjunct to emergency endoscopy, not a substitute. [3]

Endoscopic finding

Endoscopy confirms a 20-millimetre button battery at the thoracic inlet with a deep oesophageal burn extending into the submucosa. Expected strong behaviour: admit for inpatient observation because of the risk of delayed perforation and fistula; involve paediatric gastroenterology and surgery; start a proton-pump inhibitor; plan follow-up endoscopy for stricture surveillance. [5]

Communication and safety net

Expected strong behaviour: explain to the parent in plain language that the battery caused a burn, that the team removed it, and that a delayed complication can still occur; provide a written safety net naming haematemesis, coffee-ground vomit, melaena, chest pain, fever, dyspnoea and dysphagia as immediate-return symptoms; give the access route back to the emergency department; direct the family to product-safety advice on button batteries. [5] [3]

Marking domains

Debrief prompts

• What radiographic sign changed the urgency tier from observation to emergency?
• What would you have done differently if the child had been eight months old and the endoscopist delayed?
• What symptom, weeks after removal, would make you treat this child as a maximal emergency?
• How would your management have differed if the radiograph had shown two spherical radiopacities in the stomach instead of a single disc in the oesophagus?