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Toxicity, Caustic Ingestions: Follow-up
Updated: Nov 4, 2008
Follow-up
Further Inpatient Care
- Admit all small children, symptomatic patients, those with altered mental status, and those whose ingestions are worrisome for other reasons such as large volumes, high concentrations, or unique issues such as those posed by hydrogen fluoride or phenol for observation and possible endoscopy. Admit all symptomatic patients to the ICU to closely monitor their airway status and to watch for signs of perforation.
- Ensure that all patients take nothing per mouth (NPO) until the extent of injury has been determined.
- Begin an intravenous line to administer fluids and medications.
- Administer parenteral analgesics as needed for pain. Monitor for signs of sedation and respiratory depression.
Further Outpatient Care
- Adult asymptomatic patients with an unintentional exposure, a clear sensorium, and no unique concerns in the history (eg, large volume, high concentration, agent with potential for systemic toxicity) and no physical abnormalities may be discharged after a 2- to 4-hour observation period. Discharged patients should be able to ingest oral fluids without difficulty, demonstrate easy speech, be reliable, and be familiar with and able to return should any delayed symptoms occur.
- Obtain a psychiatric evaluation for all patients with intentional ingestion.
- Arrange for an esophagram 3-4 weeks postingestion.
Complications
- Airway edema or obstruction may occur immediately or up to 48 hours following an alkaline exposure.
- Gastroesophageal perforation may occur acutely.
- Secondary complications include mediastinitis, pericarditis, pleuritis, tracheoesophageal fistula formation, esophageal-aortic fistula formation, and peritonitis.
- Delayed perforation may occur as many as 4 days after an acid exposure.
- Deep circumferential or deep focal burns may result in strictures in more than 70% of patients; these strictures typically develop 2-4 weeks postingestion.
- Gastric outlet obstruction may develop 3-4 weeks after an acid exposure.
- Upper gastrointestinal hemorrhage may occur acutely in caustic exposures.
- Delayed upper GI bleeding may occur in acid burns 3-4 days after exposure as the eschar sloughs.
- Though many pass through without causing damage, batteries can cause perforation at any time during their course through the gastrointestinal system, particularly if damaged.
- Zinc chloride, mercuric chloride, and phenol can all cause significant systemic toxicity.
- Cardiac arrest from sudden hypocalcemia may occur in patients who have ingested hydrogen fluoride–containing substances. Patients have been successfully resuscitated with aggressive use of intravenous CaCl2.
- Long-term risks include squamous cell carcinoma, which occurs in 1-4% of all significant exposures and may occur as many as 40 years after exposure.
Prognosis
- The prognosis is directly proportional to the degree of tissue damage, which is primarily a function of the duration of exposure and the physical properties of the agent involved. These include the pH, the volume, and concentration of the agent; its ability to penetrate tissues; and its titratable reserve. The titratable reserve is a term that reflects the amount tissue required to neutralize a given amount of agent.
- Some agents have the ability to cause systemic toxicity that affects the prognosis in addition to their caustic properties. These include phenol, zinc chloride, mercuric chloride, and hydrogen fluoride.
Patient Education
- Caustic agents should be stored in their original child-resistant containers. Many accidental childhood ingestions occur as a result of caustic substances being placed in easily accessed containers, such as milk cartons or soda bottles.
- The reduced concentration of household products compared with their industrial strength counterparts has also been helpful in mitigating the severity of childhood exposures to agents such as household cleaners.
- For excellent patient education resources, visit eMedicine's Poisoning Center. Also, see eMedicine's patient education article Battery Ingestion.
Miscellaneous
Medicolegal Pitfalls
- Failure to evaluate and aggressively manage the airway in patients with respiratory distress, significant laryngeal involvement, or an altered mental status
- Attempting to neutralize the ingested caustic agent with a weak acid or alkaline agent
- Inducing emesis
- Assuming that the absence of oropharyngeal burns precludes the presence of significant distal injuries
- Failing to consult a gastroenterologist or surgeon for evaluation of all symptomatic patients
- Failure to recognize and prepare for the possibility of cardiac arrest following ingestion of a hydrogen fluoride–containing agent, or, if arrest occurs, failing to treat it aggressively enough with CaCl2
- Failure to recognize that some substances, such as phenol, can be caustic despite a near-neutral pH
- Failure to obtain sufficient information on the involved substance to make good treatment decisions - Examples include failing to confirm an agent’s key physical properties, such as concentration, or failing to appreciate the unique issues involving ingestions of some caustics such as button batteries, metallic chlorides, phenols, and hydrogen chloride.
- Lack of recognition of the unique issues involved in the management of special patient populations such as pediatrics and intentional ingestions
Special Concerns
- Although most childhood ingestions are accidental, be sure to consider child abuse in these instances.
The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Lada Kokan, MD.
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Further Reading
Keywords
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