Caustic ingestion: Difference between revisions
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{{Caustics background}}
{{Caustics background}}


===Esophageal injuries===
==Clinical Features==
*depending severity may have full return of mobility and function or can progress to perforation followed by stricture formation
*Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion <ref>Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.</ref>
*'''Days 2-14''' post-injury are associated with highest tissue friability / risk of perforation
*High-grade caustic burns associated with 1000x increase in esophageal SCC
 
==Diagnosis==
*All pts w/ serious esophageal injuries have some initial sign or symptom
**E.g. stridor, drooling, vomiting
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*GI tract injury
*GI tract injury
**Dysphagia, odynophagia, epigastric pain, vomiting
**[[Dysphagia]], odynophagia, drooling, [[epigastric pain]], [[vomiting]]
*Laryngotracheal injury
*Laryngotracheal injury
**Dysphonia, stridor, respiratory distress
**Dysphonia, [[stridor]], [[respiratory distress]]
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes


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{{Caustic burn types}}
{{Caustic burn types}}


==Work-Up==
==Evaluation==
===Labs===
===Labs===
Only necessary in patients with significant injury or volume of ingestion
Only necessary in patients with significant injury or volume of ingestion


Consider:
*CBC
*CBC
*Chemistry
*Chemistry
*Lactic Acid
*Lactic Acid
*Lactate
**In Alkali ingestion, presence of acidemia or hyperlactemia is likely indicative of clinically significant tissue injury<ref>Hoffman et al. Ingestion of Caustic Substances. N Engl J Med. 2020. Apr;382(18):1739-1748</ref>
*Calcium level (if Hydrofluoric Acid exposure)
*[[ECG]]
*ECG
*Calcium and Magnesium level (if [[hydrofluoric acid]] exposure)
**May show QT-prolongation if hypocalcemic secondary to HF acid
**Free Fluoride binds rapidly to calcium and magnesium leading to severe hypocalcemia and hypomagnesemia that can be life threatening
*Screens for tylenol levels in suicidal patients at risk for congestions
*Acetaminophen and Salicylate levels (in patients with concern for intentional ingestion)


===Imaging===
===Imaging===
*Upright CXR
*3-View [[CXR]]
**Look for free air under the diaphragm indicating a perforation or mediastinal air<ref>Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621</ref>
**Look for free air under the diaphragm or signs of mediastinal air<ref>Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621</ref>
*CT
*Button battery XR - two rings, will likely need to remove it no matter where it is, whether post-pyloric or pre-pyloric
**Consider when perforated viscus is suspected based on severity of ingestion or peritoneal signs on exam
*CT with contrast
**Consider when perforated viscus is suspected but CXR is negative
 
==Management==
*Prevent provider and continued patient exposure to the caustic agent by removing all clothing and decontaminating the patient
*There is a possible benefit of water ingestion immediately after ingestion of a powdered caustic to irrigate adherent materials in oropharynx/esophagus if no airway concerns to prevent prolonged injury from the powder adhering to tissues<ref>Hoffman et al. Ingestion of Caustic Substances. N Engl J Med. 2020. Apr;382(18):1739-1748</ref>


==Treatment==
;First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
===Airway Management===
===Airway Management===
#Should be considered as a difficult airway
*Monitor closely for [[stridor]], airway edema, hoarseness, or other signs of airway injury
#Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
*[[Intubate]] early if signs of airway injury exist, first sign of voice changes, inability to tolerate secretions or stridor before airway becomes more difficult to manage.
#First-line is awake oral intubation with direct visualization
*Consider awake fiberoptic or video laryngoscopy if concern for difficult airway
#LMAs, combitubes, bougies are probably may be safe depending on the type of caustic ingestion
*Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
#Surgical back-up is recommended
 
===Steroids<ref>Pelclová Det al.. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicological reviews. 2005 24 (2), 125-9 PMID: 16180932</ref>===
#Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds) with the thought of decreasing esophageal stricture formation
#Steroids may potentiate mortality in more severe esophageal caustic injuries
#Only administer under direction from a medical toxicologist
#'''Activated charcoal'''
#Only consider when coingestants pose a risk for severe systemic toxicity
===Endoscopy===
===Endoscopy===
Should be performed <12hr after ingestion and no later than >24hr after ingestion
Should be performed in the first 24 to 48 hours after ingestion (too early can underestimate extent of injury, too late increases risk of wound softening and perforation).


;Indications:
;Indications:
#Intentional ingestion
*Intentional ingestion (higher likelihood of high volume ingestion)
#Unintentional ingestion with signs of:
*Unintentional ingestion with signs of:
##Stridor
**[[Stridor]]
##Significant oropharyngeal burns
**Significant oropharyngeal [[burns]]
##Vomiting
**[[Vomiting]]
##Drooling
**Drooling
##Food refusal
**Food refusal


===Surgical intervention===
===Esophageal Stricture Mitigation<ref>High Doses of Methylprednisolone in the Management of Caustic Esophageal Burns. Pediatrics 2014;133:e1518–e1524</ref>===
#Indicated for perforations, peritoneal signs, free intraperitoneal or mediastinal air
*Discuss with GI or medical toxicologist
*For grade IIb or higher esophageal burns:
**[[Methylprednisolone]] (1 g/1.73 m2 per day for 3 days)
**[[Ranitidine]]
**[[Ceftriaxone]]
**Total parenteral nutrition
*Sucralfate, Mitomycin C


===Antibiotics===
===Surgical Intervention===
#No evidence to support or reject the use of prophylactic antibiotics
*Indicated for:
**Perforation
**Peritoneal signs


===Gastric Lavage===
===Caustic Specific Treatment===
Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
*Can include chelation, dialysis, or specific antidotes
**Especially in caustics that cause systemic toxicity
 
===Controversial or Contraindicated===
*[[Antibiotics]]
**No evidence to support or reject the use of prophylactic [[antibiotics]]
**Only indicated if also giving [[steriods]] (see stricture mitigation above)
*[[Activated charcoal]]
**May infiltrate damaged mucosa & interfere with EGD
**Only consider when coingestants pose a risk for severe systemic toxicity
**Zinc chloride and mercuric chloride systemic absorptions may outweigh interference with endoscopy
*[[Gastric lavage]]
**Contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
**Blind nasogastric-tube insertion for irrigation can cause thermal injury through neutralization
*Dilution with water or milk causes vomiting, elevating risk for perforation
**Possible benefit only for solid alkali ingestions
*Neutralization generates excess heat
**Milk or magnesium citrate only for [[hydrofluoric acid]] ingestion


==Disposition==
==Disposition==
*All patients with symptomatic from a caustic ingestion should be admitted
*All patients with symptoms from a caustic ingestion should be admitted for at least 24 hours of observation
*All patients with intentional ingestion should be evaluated by psych prior to discharge
[[File:Ingestion.png|thumb]]
 
===Prognosis===
*Depending on severity may have full return of mobility and function or can progress to perforation followed by stricture formation
*'''Days 2-14''' post-injury are associated with highest tissue friability / risk of perforation
*Strictures typically develop in the first 2 months, higher risk in those with circumferential esophageal erosions (Grade 2B burns and above)
*High-grade caustic burns associated with 1000x increase in esophageal adenocarcinoma or squamous-cell carcinoma


==See Also==
==See Also==
*[[Caustic burns]]
*[[Caustic burns]]
*[[Hydrofluoric Acid]]


==Source==
==References==
*Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009;22(1):89-94. 2008 Oct 1.  PMID: 18847446
*Zargar S et al. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. The American Journal of Gastroenterology. 1992 87 (3), 337-41 PMID: 1539568
<references/>
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:Tox]]
[[Category:Toxicology]]

Revision as of 11:06, 2 October 2020

Background

Caustics

  • Substances that cause damage on contact with body surfaces
  • Degree of injury determined by pH, concentration, volume, duration of contact
  • Acidic agents cause coagulative necrosis
  • Alkaline agents cause liquefactive necrosis (considered more damaging to most tissues)
  • Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

  • Accepts protons → free hydroxide ion, which easily penetrates tissue → cellular destruction
    • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
  • Examples
    • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
      • Lye present in drain cleaners, hair relaxers, grease remover
    • Bleach (sodium hypochlorite) and Ammonia (NH3)
      • Cleaning products such as oven cleaners, swimming pool chlorinator
      • Household bleach ingestion (4-6% sodium hypochlorite) rarely causes significant esophageal injury[1][2]

Acids

  • Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper involvement
    • However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
      • Mortality rate is higher compared to strong alkali ingestions
  • Can be systemically absorbed and → metabolic acidosis, hemolysis, AKI
  • Examples
    • Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
      • Found in: auto batteries, drain openers, toilet bowl, metal cleaners, swimming pool cleaners, rust remover, nail primer

Clinical Features

  • Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion [3]
  • Exam eyes and skin (splash and dribble injuries may easily be missed)
  • GI tract injury
  • Laryngotracheal injury

Differential Diagnosis

Caustic Burns

Evaluation

Labs

Only necessary in patients with significant injury or volume of ingestion

  • CBC
  • Chemistry
  • Lactic Acid
    • In Alkali ingestion, presence of acidemia or hyperlactemia is likely indicative of clinically significant tissue injury[4]
  • ECG
  • Calcium and Magnesium level (if hydrofluoric acid exposure)
    • Free Fluoride binds rapidly to calcium and magnesium leading to severe hypocalcemia and hypomagnesemia that can be life threatening
  • Acetaminophen and Salicylate levels (in patients with concern for intentional ingestion)

Imaging

  • 3-View CXR
    • Look for free air under the diaphragm or signs of mediastinal air[5]
  • Button battery XR - two rings, will likely need to remove it no matter where it is, whether post-pyloric or pre-pyloric
  • CT with contrast
    • Consider when perforated viscus is suspected but CXR is negative

Management

  • Prevent provider and continued patient exposure to the caustic agent by removing all clothing and decontaminating the patient
  • There is a possible benefit of water ingestion immediately after ingestion of a powdered caustic to irrigate adherent materials in oropharynx/esophagus if no airway concerns to prevent prolonged injury from the powder adhering to tissues[6]

Airway Management

  • Monitor closely for stridor, airway edema, hoarseness, or other signs of airway injury
  • Intubate early if signs of airway injury exist, first sign of voice changes, inability to tolerate secretions or stridor before airway becomes more difficult to manage.
  • Consider awake fiberoptic or video laryngoscopy if concern for difficult airway
  • Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages

Endoscopy

Should be performed in the first 24 to 48 hours after ingestion (too early can underestimate extent of injury, too late increases risk of wound softening and perforation).

Indications
  • Intentional ingestion (higher likelihood of high volume ingestion)
  • Unintentional ingestion with signs of:

Esophageal Stricture Mitigation[7]

  • Discuss with GI or medical toxicologist
  • For grade IIb or higher esophageal burns:
  • Sucralfate, Mitomycin C

Surgical Intervention

  • Indicated for:
    • Perforation
    • Peritoneal signs

Caustic Specific Treatment

  • Can include chelation, dialysis, or specific antidotes
    • Especially in caustics that cause systemic toxicity

Controversial or Contraindicated

  • Antibiotics
    • No evidence to support or reject the use of prophylactic antibiotics
    • Only indicated if also giving steriods (see stricture mitigation above)
  • Activated charcoal
    • May infiltrate damaged mucosa & interfere with EGD
    • Only consider when coingestants pose a risk for severe systemic toxicity
    • Zinc chloride and mercuric chloride systemic absorptions may outweigh interference with endoscopy
  • Gastric lavage
    • Contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
    • Blind nasogastric-tube insertion for irrigation can cause thermal injury through neutralization
  • Dilution with water or milk causes vomiting, elevating risk for perforation
    • Possible benefit only for solid alkali ingestions
  • Neutralization generates excess heat

Disposition

  • All patients with symptoms from a caustic ingestion should be admitted for at least 24 hours of observation
  • All patients with intentional ingestion should be evaluated by psych prior to discharge
Ingestion.png

Prognosis

  • Depending on severity may have full return of mobility and function or can progress to perforation followed by stricture formation
  • Days 2-14 post-injury are associated with highest tissue friability / risk of perforation
  • Strictures typically develop in the first 2 months, higher risk in those with circumferential esophageal erosions (Grade 2B burns and above)
  • High-grade caustic burns associated with 1000x increase in esophageal adenocarcinoma or squamous-cell carcinoma

See Also

References

  1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:10.1016/s0022-3476(85)80119-0
  2. ↑ Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(1):122-125. doi:10.1097/00005537-199701000-00023
  3. ↑ Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.
  4. ↑ Hoffman et al. Ingestion of Caustic Substances. N Engl J Med. 2020. Apr;382(18):1739-1748
  5. ↑ Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621
  6. ↑ Hoffman et al. Ingestion of Caustic Substances. N Engl J Med. 2020. Apr;382(18):1739-1748
  7. ↑ High Doses of Methylprednisolone in the Management of Caustic Esophageal Burns. Pediatrics 2014;133:e1518–e1524
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