Caustic Ingestions Treatment & Management

Updated: Oct 27, 2018
  • Author: Eric M Kardon, MD, FACEP; Chief Editor: David Vearrier, MD, MPH  more...
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Treatment

Approach Considerations

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. [14, 15, 16, 17]

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 several hours (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. [14, 15, 16]

 

 

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Prehospital Care

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. The risk of vomiting with re-exposure of the oral or esophageal mucosa to the offending substance can result in worsening injury or perforation.

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Emergency Department Care

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 risks of 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 are 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 rapidly 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. 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. There is a risk of heat production resulting from this exothermic reaction. In addition, the risk of emesis makes this a hazardous intervention.

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Consultations

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 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
  • Others 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.

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