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    Caustic Injuries – Diagnosis and Management

    Gastrointestinal, Pediatrics, Toxicology

    Last Updated Jul 01, 2021
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    Context

    Caustic products are readily accessible in most households cleaning products, including strong acids and bases like:

    • Drain cleaner.
    • Oven cleaner.
    • Toilet bowl cleaner.
    • Swimming pool cleaner.
    • Rust remover.
    • Dishwasher detergent.
    • Bleach.

    Caustic substances are related to:

    • High associated morbidity and mortality, even if initially well-appearing.
    • High degree of suspicion and basic understanding of common caustics required.
    • Majority of accidental ingestions occur in children <6 years old, typically small volume and exploratory.
    • May also occur amongst elderly population.
    • Storage of products in alternative containers contributes to accidental ingestions.
    • Adults and teenagers typically have intentional ingestions in self-harm attempts, typically larger volume.
    • Damage depends on volume, concentration, pH, duration of contact, and viscosity.
    • Intentional ingestions may have fewer external signs despite being more serious.
    • Consider non-accidental trauma especially if developmental age does not match mechanism (e.g. unable to unscrew lids before age 2).
    • Short term complications include perforation, mediastinitis, sepsis, tracheal necrosis, airway compromise, metabolic acidosis, electrolyte disturbances, and resultant dysrhythmias.
    • Long term complications include esophageal strictures and squamous cell carcinoma.

    Common Caustic Substances:

    Diagnostic Process

    • Gather information including type/volume of agent, on-scene treatments (e.g. inducing emesis, attempts to dilute substance by giving fluids).
    • Poison control for recommendations regarding specific substance.
    • Ideally, obtain product container for specific material safety data sheet (MSDS) review.
    • If product available but lacking identifying information, test pH using litmus paper (serious ingestions typically pH <3 or >10).

    Investigations:

    • ECG and CBC, chemistry, renal function, liver function, VBG, lactate.
    • ASA, acetaminophen, and ethanol level for intentional ingestions.
    • Extended electrolytes for hydrofluoric acid exposure.

    CT chest/abdomen can be used to grade esophageal injury, but typically EGD is preferred (especially in children due to radiation).

    Recommended Treatment

    Airway

    • Consider the need for immediate airway intervention (stridor, hoarseness, respiratory distress, drooling or inability to handle secretions).
    • May rapidly deteriorate as necrosis and inflammation progress for several hours to days.
    • Consider early intubation.
    • Video laryngoscopy preferred to minimize manipulation.
    • Nebulized epinephrine can be used during set-up if stridor present.
    • Consider larger tube size if significant hypoxemia (bronchoscopy may be required).

    Decontamination:

    • Any dermal exposures: remove clothing, wash with soap and water.
    • Ocular exposures require irrigation with minimum 2L NS until pH is within normal limits (once globe perforation is ruled out).

    Excretion:

    • AVOID any attempts at gastric lavage, activated charcoal or attempted dilution/neutralization.
    • These can worsen injury as emesis causes corrosive agents to be re-exposed to esophagus.

    General management:

    • NPO.
    • Provide antiemetics and analgesia.
    • GI for EGD (required for all intentional ingestions, most accidental ingestions).
    • Ideally performed at 12-24 hours (too early risks missing injury, too late risks perforation).
    • Accidental pediatric ingestions may not require EGD if fully asymptomatic or unclear ingestion, but at minimum require observation for several hours.
    • Therapies with lack of evidence include PPIs, antibiotics (unless concern for perforation) and steroids.
    • Steroids may be considered based on EGD grading, but should not be empirically administered (association with increased risk of perforation).

    Perforation:

    • Consider in rapidly deteriorating patients, acute peritonitis, palpable subcutaneous air, severe chest or abdominal pain.
    • Resuscitation, portable CXR/AXR, broad spectrum antibiotics and contact general surgery.

    Special cases:

    • Hydrofluoric acid can cause profound hypocalcaemia.
    • Provide empiric calcium for any significant exposure, QTC prolongation or dysrhythmia.
    • Tide pods can cause severe metabolic acidosis and caustic injury.
    • Hydrogen peroxide can cause gas embolism.
    • Place on 100% O2 and obtain imaging based on symptoms (e.g. CT head for altered mental status).
    • House bleach has neutral pH, and EGD is typically not required if asymptomatic and tolerating fluids.

    Disposition:

    • Psychiatry for intentional self-harm ingestions.
    • Counsel patients re safe storage of caustics for any accidental ingestions.
    • Consider need to involve social worker or child protection.

    Quality Of Evidence?

    Justification

    Most evidence is of moderate quality, based on expert consensus recommendation. Most experts advocate for EGD for nearly all patients with caustic exposures. There is little evidence for some treatments which have been traditionally used without clear benefits (PPIs, antibiotics, steroids, sucralfate, etc).

    Moderate

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