Caustic Ingestions Treatment & Management

In patients with caustic ingestion, airway monitoring and control is the first priority. When airway compromise is present, a definitive airway must be established. In patients with a stable airway and no clinical or radiological sign of perforation, medical therapy should be initiated. ^{[15, 16, 17, 18]}

Arrangements should be made for urgent esophagogastroduodenoscopy (EGD) to grade the degree of injury and establish long-term prognosis, In asymptomatic patients, however, EGD may be withheld in favor of observation. Pediatric patients who remain asymptomatic for 2 - 4 hours after an exploratory ingestion and who are tolerating a normal diet may be discharged with appropriate follow-up and return precautions. Surgical consultation is indicated for suspected perforation. Because of the risk of late complications—most commonly, esophageal stricture formation—arrangements for follow-up need to be made. ^{[15, 16, 17]}

Adult patients with an unintentional exposure may be discharged after a 2- to 4-hour observation period if the clinician has no unique concerns regarding the ingested substance (eg, large volume, high concentration, agent with potential for systemic toxicity) and the patient meets all the following criteria:

• Asymptomatic
• Clear sensorium
• Able to ingest oral fluids without difficulty
• Demonstrates easy speech
• Reliable
• Familiar with delayed symptoms and able to return if any occur

Post-discharge arrangements may include the following:

• Psychiatric evaluation for all patients with intentional ingestion
• Follow-up esophagram 3-4 weeks postingestion

Attempt to identify the specific product, concentration of active ingredients, and estimated volume and amount ingested. Obtain MSDS sheets when possible for workplace exposures. The product container or labels may be available. Avoid exposure to health care workers.

Do not induce emesis or attempt to neutralize the substance by using a weak acid or base. This induces an exothermic reaction, which can compound the chemical injury with a thermal injury. It may also induce emesis, re-exposing tissue to the caustic agent.

Small amounts of a diluent may be beneficial if administered as soon as possible after a solid or granular alkaline ingestion, to remove any particles that are adhering to the oral or esophageal mucosa. Water or milk may be administered in small amounts. It is very unlikely to be of any benefit after more than 30 minutes. This practice is controversial: Some of the literature available on this topic discourages the use of diluents because of the concern of inducing emesis resulting in re-exposure of tissue to caustic agent.

Diluents should not be used with any acid ingestion or liquid alkaline ingestion, as it could provoke vomiting. The resulting re-exposure of the oral or esophageal mucosa to the offending substance could worsen the injury or lead to perforation.

In the treatment area, patients suspected of ingesting a caustic substance should be triaged to a high priority for prompt evaluation and treatment. This includes prompt evaluation of airway and vital signs as well as immediate cardiac monitoring and intravenous access. Intravenous fluids and blood products may be required in the event of significant bleeding, vomiting, or third spacing.

Airway control

Because of the risk of rapidly developing airway edema, the patient’s airway and mental status should be immediately assessed and continually monitored. Equipment for endotracheal intubation and cricothyrotomy should be readily available. Gentle orotracheal intubation or fiberoptic-assisted intubation is preferred. Blind nasotracheal intubation should be avoided due to the increased risk of soft-tissue perforation.

If possible, it is best to avoid inducing paralysis for intubation because of the risk of anatomical distortion from bleeding and necrosis. If a difficult airway is anticipated, IV ketamine can be used to provide enough sedation to obtain a direct look at the airway.

Cricothyrotomy or percutaneous needle cricothyrotomy may be necessary in the presence of extreme tissue friability or significant edema.

Gastric emptying and decontamination

Do not administer emetics because of potential re-exposure of the vulnerable mucosa to the caustic agent. This may result in further injury or perforation.

Gastric lavage by traditional methods using large-bore orogastric Ewald tubes is contraindicated in both acidic and alkaline ingestions because of risk of esophageal perforation and tracheal aspiration of stomach contents.

In large-volume liquid acid ingestions, nasogastric tube (NGT) suction may be beneficial if performed promptly after ingestion. Pyloric sphincter spasm may prolong contact time of the agent to the gastric mucosa for up to 90 minutes. NGT suction may prevent small intestine exposure. Esophageal perforation is rare. NGT suction may be of particular value following ingestion of zinc chloride, mercuric chloride, or hydrogen fluoride, unless signs of perforation are present. Of note, intubation with sedation is likely necessary for patients to tolerate this procedure and allow clinicians to perform it without instigating secondary esophageal injury (from vomiting) and or aspiration. This should be done after consulting with a regional poison control center.

Activated charcoal is relatively contraindicated in caustic ingestions because of poor adsorption and endoscopic interference.

Dilution

Dilution may be beneficial for ingestion of solid or granular alkaline material if performed within 30 minutes after ingestion using small volumes of water. Because of the risk of emesis, carefully consider the risks versus benefits of dilution.

Do not dilute acids with water; this would result in excessive heat production.

Neutralization

Do not administer a weak acid in alkaline ingestions or a weak alkaline agent in acid ingestions. This may cause an exothermic reaction, with damage from the resulting heat. In addition, the risk of emesis makes this a hazardous intervention.

Hospitalization

Admit, for observation and possible endoscopy, 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. 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. Establish an intravenous line to administer fluids and medications.

Administer parenteral analgesics as needed for pain. Monitor for signs of sedation and respiratory depression.

Rollin et al have proposed an algorithm for surgical management of caustic ingestion injuries in adult patients. ^[8]

If an ICU bed is not available or if endoscopy is not available when indicated, transfer is advised.

Airway management can be a multifaceted problem and may be best approached with the availability of a wide array of visualization techniques, and, if time allows, a team of experts. However, the rapid development of airway edema may prompt the need for rapid airway management with the best immediately available visualization approach.

Obtain a surgical consultation when any of the following are expected or observed:

• Perforation
• Mediastinitis
• Peritonitis

Obtain an endoscopic consultation for the following patients:

• Small children
• Symptomatic older children and adults
• Patients with altered mental status
• Patients with intentional ingestions
• Cases with a potential for significant injury (eg, ingestion or large volumes or concentrated products)

Consultation with the local poison control center may be helpful, particularly if unfamiliar or unique agents are involved. These may include industrial strength detergents, button batteries, zinc chloride, mercuric chloride, hydrogen fluoride, phenol, and Clinitest tablets.

Once a patient is stabilized, obtain a psychiatric consultation for any patients with a history of an intentional ingestion.

Corticosteroids remains a controversial treatment to attempt to decrease morbidity from caustic and corrosive injuries. Early use was driven by decreased stricture formation in animal models, but this benefit was not demonstrated in subsequent patient cohorts. ^{[19, 20]}  A more recent study that focused on high risk injuries only found a benefit from a short 3-day course (in contrast to longer duration treatment in earlier studies) of methylpredisonolone in pediatric patients with grade 2B esophageal injuries. ^[21] At this time, recommendations on the use, dose, and duration of corticosteroids remains contentious even among experts in the field.

Esophageal stricture can develop as early as 3 weeks after caustic ingestion, but typically occurs 8 weeks or longer afterwards. Strictures can be treated with esophageal dilatation, using bougies (usually Savary) or balloon catheters. Savary bougies are considered more reliable for treatment of consolidated and fibrotic strictures or long, tortuous ones, and bougie dilatation may pose lower risk of perforation, compared with rates as high as 30% reported with balloon dilatation of caustic strictures. ^[17]

However, in a study by Uygun et al, fluoroscopically guided esophageal balloon dilatation (EBD) was found to be a safe procedure, with a low rate of complications; and it had a 100% success rate. In their review of of 369 EBD sessions in 38 children (aged 14 months to 14 years, median 3.5 years) with caustic esophageal strictures, six (1.6%) esophageal perforations occurred in five patients (13.2%). ^[22]

Ugyun et al recommend that in children, dilatation should be performed gently with balloons of gradually increasing appropriate diameters over consecutive sessions. In addition, the study findings showed that EBD treatment was significantly faster and shorter in patients who began EBD earlier (mean, 15 days) after caustic ingestion than in those who began it later (mean, 34 days). ^[22]

When esophageal dilatation is not possible or fails to provide an adequate esophageal caliber in the long-term, esophageal replacement by retrosternal stomach or, preferably, right colonic interposition should be considered. Arguments can be made for either bypass or resection of the native esophagus. ^[17]

In the home, caustic substances should be kept in their original labeled containers to avoid accidental ingestion. They should be stored out of reach of toddler-aged children.

In the workplace, policies and procedures need to be developed and disseminated, so that employee exposures can be treated quickly and effectively.

Patients who have experienced caustic injury are at increased risk for esophageal cancer (both adenocarcinoma and squamous cell carcinoma), typically developing 1 to 3 decades after ingestion. Consequently, long-term endoscopic screening is recommended for these patients. ^[17]