Caustic ingestion: Difference between revisions
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#Surgical back-up is recommended
#Surgical back-up is recommended
===Steroids<ref>Pelclová Det al.. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicological reviews. 2005 24 (2), 125-9 PMID: 16180932</ref>===
===Steroids<ref>Pelclová Det al.. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicological reviews. 2005 24 (2), 125-9 PMID: 16180932</ref>===
#Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds) with the thought of decreasing esophageal stricture formation
*Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds) with the thought of decreasing esophageal stricture formation
#Steroids may potentiate mortality in more severe esophageal caustic injuries
*Steroids may potentiate mortality in more severe esophageal caustic injuries
#Only administer under direction from a medical toxicologist
*Only administer under direction from a medical toxicologist
#'''[[Activated charcoal]]'''
 
#Only consider when coingestants pose a risk for severe systemic toxicity
==='''[[Activated charcoal]]'''===
*Only consider when coingestants pose a risk for severe systemic toxicity


===Endoscopy===
===Endoscopy===

Revision as of 22:50, 22 December 2014

Background

Caustics

  • Substances that cause damage on contact with body surfaces
  • Degree of injury determined by pH, concentration, volume, duration of contact
  • Acidic agents cause coagulative necrosis
  • Alkaline agents cause liquefactive necrosis (considered more damaging to most tissues)
  • Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

  • Accepts protons → free hydroxide ion, which easily penetrates tissue → cellular destruction
    • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
  • Examples
    • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
      • Lye present in drain cleaners, hair relaxers, grease remover
    • Bleach (sodium hypochlorite) and Ammonia (NH3)
      • Cleaning products such as oven cleaners, swimming pool chlorinator
      • Household bleach ingestion (4-6% sodium hypochlorite) rarely causes significant esophageal injury[1][2]

Acids

  • Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper involvement
    • However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
      • Mortality rate is higher compared to strong alkali ingestions
  • Can be systemically absorbed and → metabolic acidosis, hemolysis, AKI
  • Examples
    • Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
      • Found in: auto batteries, drain openers, toilet bowl, metal cleaners, swimming pool cleaners, rust remover, nail primer

Diagnosis

  • All pts w/ serious esophageal injuries have some initial sign or symptom
    • E.g. stridor, drooling, vomiting
  • Exam eyes and skin (splash and dribble injuries may easily be missed)
  • GI tract injury
    • Dysphagia, odynophagia, epigastric pain, vomiting
  • Laryngotracheal injury
    • Dysphonia, stridor, respiratory distress
    • Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes

Differential Diagnosis

Caustic Burns

Work-Up

Labs

Only necessary in patients with significant injury or volume of ingestion

Consider:

  • CBC
  • Chemistry
  • Lactic Acid
  • Lactate
  • Calcium level (if Hydrofluoric Acid exposure)
  • ECG
    • May show QT-prolongation if hypocalcemic secondary to HF acid
  • Screens for tylenol levels in suicidal patients at risk for congestions

Imaging

  • Upright CXR
    • Look for free air under the diaphragm indicating a perforation or mediastinal air[3]
  • CT
    • Consider when perforated viscus is suspected based on severity of ingestion or peritoneal signs on exam

Treatment

First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient

Airway Management

  1. Should be considered as a difficult airway
  2. Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
  3. First-line is awake oral intubation with direct visualization
  4. LMAs, combitubes, bougies are probably may be safe depending on the type of caustic ingestion
  5. Surgical back-up is recommended

Steroids[4]

  • Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds) with the thought of decreasing esophageal stricture formation
  • Steroids may potentiate mortality in more severe esophageal caustic injuries
  • Only administer under direction from a medical toxicologist

Activated charcoal

  • Only consider when coingestants pose a risk for severe systemic toxicity

Endoscopy

Should be performed <12hr after ingestion and no later than >24hr after ingestion

Indications
  1. Intentional ingestion
  2. Unintentional ingestion with signs of:
    1. Stridor
    2. Significant oropharyngeal burns
    3. Vomiting
    4. Drooling
    5. Food refusal

Surgical intervention

  1. Indicated for perforations, peritoneal signs, free intraperitoneal or mediastinal air

Antibiotics

  1. No evidence to support or reject the use of prophylactic antibiotics

Gastric Lavage

Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage

Disposition

  • All patients with symptomatic from a caustic ingestion should be admitted

Prognosis

  • depending severity may have full return of mobility and function or can progress to perforation followed by stricture formation
  • Days 2-14 post-injury are associated with highest tissue friability / risk of perforation
  • High-grade caustic burns associated with 1000x increase in esophageal SCC

See Also

Source

  • Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009;22(1):89-94. 2008 Oct 1. PMID: 18847446
  • Zargar S et al. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. The American Journal of Gastroenterology. 1992 87 (3), 337-41 PMID: 1539568
  1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:10.1016/s0022-3476(85)80119-0
  2. ↑ Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(1):122-125. doi:10.1097/00005537-199701000-00023
  3. ↑ Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621
  4. ↑ Pelclová Det al.. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicological reviews. 2005 24 (2), 125-9 PMID: 16180932
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