eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Caustic Ingestions: Follow-up

Author: Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center
Contributor Information and Disclosures

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.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Lada Kokan, MD.



More on Toxicity, Caustic Ingestions

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Differential Diagnoses & Workup: Toxicity, Caustic Ingestions
Treatment & Medication: Toxicity, Caustic Ingestions
Follow-up: Toxicity, Caustic Ingestions
Multimedia: Toxicity, Caustic Ingestions
References

References

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  8. Pelclová D, Navrátil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion?. Toxicol Rev. 2005;24(2):125-9. [Medline].

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Further Reading

Keywords

caustic ingestion, poisoning, alkaline ingestion, acid ingestion, corrosive agent toxicity, acidic or alkaline substance toxicity, toilet bowl cleaning product ingestion, automotive battery liquid ingestion, rust removal product ingestion, metal cleaning product ingestion, cement cleaning product ingestion, drain cleaning product ingestion, soldering flux-containing zinc chloride ingestion, ammonia-containing product ingestion, oven cleaning product ingestion, swimming pool cleaning product ingestion, automatic dishwasher detergent ingestion, hair relaxer ingestion, Clinitest tablet ingestion, bleach ingestion, cement ingestion, hydrogen fluoride exposure phenol exposure, disk battery ingestion

Contributor Information and Disclosures

Author

Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center
Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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