Basics
Description
- Alkalis:
- Dissociate in the presence of H2O to produce hydroxy (OH-) ions, which leads to liquefaction necrosis
- Postingestion-mainly damages the esophagus:
- Gastric damage can occur (see "Acids"Ł).
- Esophageal damage (in the order of increasing damage) consists of:
- Superficial hyperemia
- Mucosal edema
- Superficial blisters
- Exudative ulcerations
- Full-thickness necrosis
- Perforation
- Fibrosis with resulting esophageal strictures
- Do not directly produce systemic complications.
- Acids:
- Dissociate in the presence of H2O to produce hydrogen (H+) ions, which leads to a coagulation necrosis with eschar formation
- Postingestion-damages the stomach because of rapid transit time through esophagus:
- Esophageal damage can occur (see "Alkalis"Ł).
- Gastric damage (in the order of increasing damage) consists of:
- Edema
- Inflammation
- Immediate or delayed hemorrhage
- Full-thickness necrosis
- Perforation
- Fibrosis with resulting gastric outlet obstruction
- Well-absorbed and can cause hemolysis of RBCs and a systemic metabolic acidosis
Etiology
- Direct chemical injuries
- Injuries occur secondary to acid and alkali exposures.
- Many caustic agents (acids and alkalis) are found in common household and industrial products.
- Caustic substances:
- Glass cleaners:
- Formaldehyde:
- Hydrochloric acid:
- Hydrofluoric acid:
- Glass etching industry
- Microchip industry
- Rust removers
- Iodine:
- Phenol:
- Sodium hydroxide:
- Drain cleaners
- Drain openers
- Oven cleaners
- Sodium borates, carbonates, phosphates, and silicates:
- Detergents
- Dishwasher preparations
- Sodium hypochlorite
- Bleaches
- Sulfuric acid:
- Car batteries
- Button batteries
Diagnosis
Signs and Symptoms
- Oropharyngeal:
- Pain
- Erythema
- Burns
- Erosions
- Ulcers
- Drooling
- Hoarseness
- Stridor
- Aphonia
- Absence of visible lesions in the oropharynx does not exclude visceral injuries.
- Pulmonary:
- Tachypnea
- Cough
- Pneumonitis if aspirated
- GI:
- Pain
- Emesis or hematemesis
- Melena, dysphagia
- Odynophagia
- Esophageal or gastric perforation
- Peritonitis owing to perforation
- Cardiovascular:
- Tachycardia
- Hypotension
- Orthostatic changes
- Hematologic:
- Acid ingestion can cause RBC hemolysis.
- Dermatologic:
- Pain
- Erythema
- 1st-, 2nd-, or 3rd-degree burns
- Ocular:
- Pain
- Erythema
- Injection
- Corneal burns
- Full-thickness corneal damage
- Metabolic:
Essential Workup
- History of or signs and symptoms of an exposure
- Absence of oropharyngeal lesions does not exclude visceral injury.
Diagnosis Tests & Interpretation
Lab
- CBC
- Electrolytes, BUN, creatinine, glucose
- Arterial blood gas
- Blood cultures:
- If mediastinitis or peritonitis suspected
- Type and cross-match
Imaging
Chest and abdominal radiographs for: á
- Esophageal or gastric perforation
Diagnostic Procedures/Surgery
- Esophageal and gastric endoscopy:
- For symptomatic patients to determine the extent of injury
- Perform within the 1st 12-24 hr after ingestion.
- Not recommended in the presence of respiratory distress without proper airway management
- Not recommended in the presence of severe pharyngeal damage
- Radiographic oral contrast imaging not recommended acutely:
- May be used in follow-up for assessment for strictures
Differential Diagnosis
- Chemical injuries from corrosives, acids, alkalis, desiccants, vesicants, and oxidizing and reducing agents
- Foreign body ingestion
- Upper airway infection or angioedema
Treatment
Pre-Hospital
- For oral burns or symptoms: Rinse mouth liberally with water or milk.
- Water or milk can be given to following patients:
- Able to drink
- Not complaining of significant abdominal pain
- Do not have airway compromise or vomiting
- Copious irrigation for ocular or dermal exposure
Initial Stabilization/Therapy
- ABCs:
- Prophylactic intubation if there is any evidence of respiratory compromise
- Blind nasotracheal intubation contraindicated
- Treat hypotension with 0.9% NS IV fluid resuscitation.
Ed Treatment/Procedures
- Decontamination:
- Dermal or ocular exposure:
- Immediate and thorough irrigation with water or 0.9% NS until physiologic pH attained
- Alkalis typically require more irrigation than acids.
- Ipecac, activated charcoal, gastroesophageal lavage (large-bore or an NG tube), and a neutralizing acid or base are all contraindicated with caustic ingestions.
- Dilution:
- Water or milk in the 1st 30 min of ingestion:
- Especially useful for solid caustic alkali ingestions
- Excessive intake may induce vomiting and worsen esophageal damage.
- If respiratory distress, intubate before dilution.
- Contraindicated if esophageal or gastric perforation suspected
- Keep patient NPO if oral exposure.
- Broad-spectrum antibiotics if mediastinitis or peritonitis suspected
- Antiemetics for nausea and vomiting
- Treat dermal exposures according to standard burn recommendations.
- Detailed exam for ocular exposures
- IV proton pump inhibitors or H2 blockers for symptomatic relief
- Gastroenterology and surgical consultation
- Benefit of corticosteroids following esophageal damage is controversial:
- May prevent the formation of esophageal stricture
- May promote bacterial invasion, immune suppression, and tissue softening
- The decision to initiate corticosteroids requires input from entire team caring for patient.
- Initiate broad-spectrum antibiotics if corticosteroids are given.
- Laparoscopy or laparotomy for perforation and full-thickness necrosis
- Topical hydrofluoric acid exposure (options depend on severity and location):
- IM injection of 5% calcium gluconate (0.5 mL/cm2 of skin with 30G needle)
- Intra-arterial infusion of 10 mL of 10% calcium gluconate in 40 mL D5W over 4 hr
Medication
- Methylprednisolone: 40 mg q8h IV (peds: 2 mg/kg/d IV); the course of therapy is 14-21 days followed by a corticosteroid taper.
- Ondansetron: 4 mg (peds: 0.1-0.15 mg/kg) IV
- Pantoprazole: 40 mg IV
- Prochlorperazine (Compazine): 5-10 mg IV (peds: 0.13 mg/kg per dose IM)
- Ranitidine (Zantac): 50 mg IV q6-8h
Follow-Up
Disposition
Admission Criteria
- All symptomatic patients
- Nonaccidental ingestion
Discharge Criteria
- Asymptomatic patients who accidentally ingested and are able to swallow without difficulty
- Minimal oropharyngeal pain with a corresponding visible lesion; no drooling; no respiratory compromise; no deep throat, chest, or abdominal pain; and able to swallow without difficulty
Followup Recommendations
Psychiatric referral for intentional ingestion á
Pearls and Pitfalls
- Dilute with milk or water at home or in the ED within the 1st 30 min.
- Perform copious irrigation of ocular or dermal exposure:
- Alkalis require more irrigation than acids.
Additional Reading
- Lupa áM, Magne áJ, Guarisco áL, et al. Update on the diagnosis and treatment of caustic ingestions. Ochsner J. 2009;9:54-59.
- Riffat áF, Cheng áA. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009;22:89-94.
- Salzman áM, O'Malley áRN. Updates on the evaluation and management of caustic exposures. Emerg Med Clin North Am. 2007;25(2):459-476.
Codes
ICD9
- 947.0 Burn of mouth and pharynx
- 947.2 Burn of esophagus
- 947.3 Burn of gastrointestinal tract
- 947.1 Burn of larynx, trachea, and lung
- 947.8 Burn of other specified sites of internal organs
- 947.9 Burn of internal organs, unspecified site
ICD10
- T28.5XXA Corrosion of mouth and pharynx, initial encounter
- T28.6XXA Corrosion of esophagus, initial encounter
- T28.7XXA Corrosion of other parts of alimentary tract, init encntr
- T27.5XXA Corrosion involving larynx and trachea w lung, init encntr
- T28.90XA Corrosions of unspecified internal organs, initial encounter
- T28.99XA Corrosions of other internal organs, initial encounter
SNOMED
- 23509002 Caustic esophageal injury (disorder)
- 37693008 Caustic injury gastritis (disorder)
- 235021001 Chemical burn of oral mucosa (disorder)
- 212039008 Corrosion involving larynx and trachea with lung (disorder)
- 219171000 Suicide and selfinflicted injury by caustic substances, excluding poisoning (navigational concept)
- 219362003 Injury undetermined whether accidentally or purposely inflicted, by caustic substances, excluding poisoning (disorder)
- 269737002 Injury of unknown intent by local effect of caustic substance (disorder)
- 418409002 Poisoning of undetermined intent by corrosive, acid or caustic alkali (disorder)