Caustic Ingestions Clinical Presentation

The physician should try to identify the specific agent ingested, as well as the concentration, pH, and amount of substance ingested. The time, nature of exposure, duration of contact, and any immediate on-scene treatment that was provided are important in determining management of toxicity.

The presence or absence of the following symptoms should be determined, since the presence of any of them suggests the possibility of significant internal injury (although their absence does not preclude significant injury):

• Dyspnea
• Dysphagia
• Oral pain and odynophagia
• Chest pain
• Abdominal pain
• Nausea and vomiting

Rapidly obtaining reliable information on the particular agent involved is vital. This is particularly true of uncommon caustic agents, some of which have important toxic concerns beyond those of a simple caustic ingestion.

A good example of this is the potential for abrupt, life-threatening hypocalcemia following ingestion of hydrogen fluoride, even in a relatively dilute form such as that found in some rust removers. Case reports of patients surviving such suicidal ingestions underline the value of being able to anticipate and aggressively manage the systemic hypocalcemia, which is unique to hydrogen fluoride, with intravenous calcium. Other examples of caustic agents with unique toxicities include phenol, zinc chloride, and mercuric chloride, all of which can cause significant systemic toxicity and which may require specifically directed management.

Material Safety Data Sheets (MSDS), online databases, and consultations with the local poison center are all ways for clinicians to rapidly familiarize themselves with unfamiliar caustic agents.

As with the history, physical examination findings may be deceptively unremarkable after a significant caustic ingestion, despite the presence of significant tissue necrosis.

Signs of impending airway obstruction may include the following:

• Stridor
• Hoarseness
• Dysphonia or aphonia
• Respiratory distress, tachypnea, hyperpnea
• Cough

Other signs of injury may include the following:

• Tachycardia
• Oropharyngeal burns – These are important when identified; however, significant esophageal involvement may occur in the absence of oropharyngeal lesions
• Drooling
• Subcutaneous air
• Acute peritonitis – Abdominal guarding, rebound tenderness, and diminished bowel sounds
• Hematemesis

Indications of severe injury include the following:

• Altered mental status
• Peritoneal signs
• Evidence of viscous perforation
• Stridor
• Hypotension
• Shock

Immediate, general complications of caustic and corrosive exposures may include airway edema or obstruction, which may occur immediately or up to 48 hours following an alkaline exposure. Gastroesophageal perforation and upper gastrointestinal hemorrhage may occur acutely in caustic exposure. Secondary complications include the following:

• Mediastinitis
• Pericarditis
• Pleuritis
• Tracheoesophageal fistula formation
• Esophageal-aortic fistula formation
• Peritonitis

Disk batteries deserve special attention because they can adhere to the esophageal or gastric mucoa, leading to perforation due to prolonged contact with extruded substances and residual electric discharge. See Disk Battery Ingestion for a detailed discussion.

Delayed perforation may occur as many as 4 days after an acid exposure. Delayed upper GI bleeding may occur in acid burns 3-4 days after exposure as the eschar sloughs. 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.

Some agents have the ability to cause systemic toxicity that affects the prognosis in addition to their caustic properties. These include the following:

• Phenol
• Zinc chloride
• Mercuric chloride
• Hydrogen fluoride
• Oxalic acid
• Detergent pods

In pediatric patients, detergent pods have been observed to sometimes cause altered mental status and lactic acidosis, hypothesized to be due to their ingredients of propylene glycol and or alcohol ethoxylates.

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 calcium chloride.

Long-term risks include squamous cell carcinoma, which occurs in 1-4% of all significant exposures and may occur as late as 40 years after exposure.

The alkali drain cleaners and acidic toilet bowl cleaners are responsible for the most fatalities from corrosive agents. In adults, 10% of caustic ingestions result in death. ^[8]

Approximately 10% of caustic ingestions result in severe injury requiring treatment. Approximately 1-2% of caustic ingestions result in stricture formation. ^[8]