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Toxicity, Caustic Ingestions: Differential Diagnoses & Workup
Updated: Nov 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
| Burns, Chemical | Pediatrics, Pertussis |
| Burns, Thermal | Phenol |
| Dysphagia | Plant Poisoning, Oxalates |
| Epiglottitis, Adult | Pneumonia, Aspiration |
| Hemolysis | Pneumonia, Bacterial |
| Hydrofluoric acid | Renal failure |
| Hypocalcemia | Shock (many potential causes) |
| Mercury chloride | Strictures, especially gastric |
| Metabolic Acidosis | Stridor |
| Munchausen Syndrome | Toxicity, Chlorine Gas |
| Pediatrics, Anaphylaxis | Toxicity, Iron |
| Pediatrics, Bronchiolitis | Toxicity, Mercury |
| Pediatrics, Croup or
Laryngotracheobronchitis | Vomiting |
| Pediatrics, Epiglottitis | Zinc chloride |
| Pediatrics, Gastroenteritis | |
| Pediatrics, Gastrointestinal Bleeding |
Other Problems to Be Considered
Airway obstruction may occur secondary to edema, bleeding, and the presence of necrotic material. Because this can develop rapidly, airway protection is paramount following caustic ingestions.
Esophageal gastric, bowel, airway, or vascular perforation may occur.
Fluid losses from vomiting, third spacing, and gastrointestinal bleeding may lead to hypovolemia and shock. This is particularly true after ingestion of metallic chlorides.
After significant acidic ingestions, the patient may develop metabolic acidosis, hemolysis, and multiorgan failure including acute renal failure.
Hypocalcemia develops precipitously after ingestion of significant amounts of hydrogen fluoride.
In patients who survive the initial phases of injury, late-developing problems include strictures, fistula, hypomotility disorders, and an increased risk of gastrointestinal cancers.
Workup
Laboratory Studies
- pH testing of product
- A pH less than 2 or greater than 12.5 indicates greater potential for severe tissue damage.
- A pH outside of this range does not preclude significant injury.
- pH testing of saliva: Unexpected high or low values may confirm ingestion in questionable cases; however, a neutral pH cannot rule out a caustic ingestion.
- Complete blood count (CBC), electrolyte levels, BUN levels, creatinine level, and ABG levels may all be helpful as baseline values and as indications of systemic toxicity.
- Liver function tests and DIC panel may also be helpful to establish baselines or, if abnormal, confirm severe injury following acid ingestions.
- Urinalysis and urine output may help guide fluid replacement.
- Type and cross are indicated for any potential surgical candidates or those with the potential for gastrointestinal bleeding.
- Obtain aspirin and acetaminophen levels as well as an ECG in any patient whose intent may have been suicidal.
- In cases of hydrofluoric acid (HF) ingestion, precipitous falls in calcium level may lead to sudden cardiac arrest. Although ionized calcium levels are likely to have too long a turnaround to be clinically useful, cardiac monitoring and serial ECGs may help anticipate this event.
Imaging Studies
- Chest radiography: Obtain an upright chest radiograph in all cases of caustic ingestion. Findings may include mediastinitis, pleural effusions, pneumoperitoneum, aspiration pneumonitis, or a button battery. However, the absence of findings does not preclude perforation or other significant injury.
- Abdominal radiography: Findings may include pneumoperitoneum, ascites, or an ingested button battery.
- If contrast studies are obtained, water-soluble contrast agents are recommended because they are less irritating to the tissues in cases of perforation.
- CT can sometimes delineate small amounts of extraluminal air.
Procedures
- Airway protection is critical following caustic ingestion if there is any indication of airway compromise. This can develop rapidly and be complicated by multiple factors. See Emergency Department Care.
- Cardiac monitoring is indicated for any patient with a caustic ingestion.
- Large-bore intravenous access allows administration of fluids and medications as needed.
- Endoscopy is generally indicated for the following patients:
- Small children
- Symptomatic older children and adults
- Patients with abnormal mental status
- Those with intentional ingestions
- Patients in whom injury is suspected for other reasons (eg, ingestion or large volumes or concentrated products)
- However, because of the risk of increased injury, esophagoscopy should not be performed in patients with evidence of esophageal or gastrointestinal perforation, significant airway edema, or necrosis and in those who are hemodynamically unstable.
- Obtaining meaningful information from endoscopy after treatment with activated charcoal is very difficult.
- Endoscopic ultrasonography has been shown to more accurately show the depth of lesions than endoscopy alone. Further studies will be necessary to determine the utility of this procedure in aiding in diagnosis and treatment.
More on Toxicity, Caustic Ingestions |
| Overview: Toxicity, Caustic Ingestions |
 Differential Diagnoses & Workup: Toxicity, Caustic Ingestions |
| Treatment & Medication: Toxicity, Caustic Ingestions |
| Follow-up: Toxicity, Caustic Ingestions |
| Multimedia: Toxicity, Caustic Ingestions |
| References |
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References
Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol. Dec 2007;45(8):815-917. [Medline].
Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, Oderda GM, Benson B, Litovitz T, et al. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med. May 1992;10(3):189-94. [Medline].
Havanond C, Havanond P. Initial signs and symptoms as prognostic indicators of severe gastrointestinal tract injury due to corrosive ingestion. J Emerg Med. Nov 2007;33(4):349-53. [Medline].
Homan CS, Maitra SR, Lane BP, Thode HC Jr, Finkelshteyn J, Davidson L. Effective treatment for acute alkali injury to the esophagus using weak-acid neutralization therapy: an ex-vivo study. Acad Emerg Med. Nov 1995;2(11):952-8. [Medline].
Homan CS, Maitra SR, Lane BP, Thode HC, Sable M. Therapeutic effects of water and milk for acute alkali injury of the esophagus. Ann Emerg Med. Jul 1994;24(1):14-20. [Medline].
Kamijo Y, Kondo I, Watanabe M, Kan'o T, Ide A, Soma K. Gastric stenosis in severe corrosive gastritis: prognostic evaluation by endoscopic ultrasonography. Clin Toxicol. 2007;45(3):284-6. [Medline].
Kim SJ, Cho SB, Cho JM, et al. CT imaging of gastric and hepatic complications after ingestion of glacial acetic acid. J Comput Assist Tomogr. Jul-Aug 2007;31(4):564-8. [Medline].
Pelclová D, Navrátil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion?. Toxicol Rev. 2005;24(2):125-9. [Medline].
Poley JW, Steyerberg EW, Kuipers EJ, Dees J, Hartmans R, Tilanus HW, et al. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointest Endosc. Sep 2004;60(3):372-7. [Medline].
Salzman M, O'Malley RN. Updates on the evaluation and management of caustic exposures. Emerg Med Clin North Am. May 2007;25(2):459-76. [Medline].
Turner A, Robinson P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J. May 2005;22(5):359-61. [Medline].
Further Reading
Keywords
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