Caustic Ingestion

Caustics
Cause tissue injury by a chemical reaction pH < 2 strong acid pH >12 strong base

Pathophysiology
Alkaline ingestion Liquefactive necrosis Severe injury minutes after contactost commonly involved Esophagus is Tissue edema persist (48h) airway obstruction 2-4 weeks scar tissue remodels thickens may form contractures

Acid ingestion
Cause injury by coagulation necrosis formation of eschar or coagulum w/c may protect underlying tissue from further damage Stomach is most involved 3-4 days, eschar sloughs off granulation tissue fills defect perforation Acute complications: gastric and intestinal perforation and Upper GI hemorrhage

Epidemiology
Cleaning substances; 200,000 exposures per year Alkali drain cleaners, acidic toilet bowl cleaners 10% results in severe injury requiring treatment 1-2% with stricture formation 80% are accidental ingestions by children In adults, most are intentional ingestions

History
Specific agent, concentration, pH and amount ingesed Time, nature of exposure, duration of contact, immediate on scene treatment Dyspnea, Dysphagia, Oral pain and odynophagia, Chest pain, Abdominal pain, Nausea and vomiting

PE
Signs of impending airway obstruction
Stridor, cough, hoarsness, dysphonia, aphonia, respiratory distress,

Other signs of internal injury

Tachycardia, oropharyngeal burns, drooling, subcutaneous air, acute peritonitis

Hematemesis Indications of severe injury

Altered mental status, peritoneal signs, evidence of viscous perforation, stridor, hypotension, shock

Causes
ACIDS Toilet bowl cleaning products Automotive battery liquid Rust removal products ALKALIS Drain cleaning products Ammonia-containing products Oven cleaning products

Metal cleaning products Cement cleaning products Drain cleaning products

Soldering flux containing zinc chloride

Swimming pool cleaning products Automatic dishwasher detergent Hair relaxers

bleaches

Work up
pH testing of product pH testing of saliva CBC, electrolytes, BUN, Creatinine, ABG Liver function tests, DIC panel to establish baseline, if abnormal confirms severe injury after acid ingestion Urinalysis and UO, to guide fluid replacement Type and crossmatch blood (candidates for surgery or with GI bleed)

Imaging
CXR Abdominal Xray

Procres
Airway protection Cardiac monitoring Large bore IV access Endoscopy
Small children Symptomatic older children and adults Abnormal mental status with potential for severe injury

ER Care
Evaluation of airway, VS, cardiac monitoring, IV access AIRWAY control:
Equipment for ET or cricothyrotomy at bedside

Gastric emptying and decontamination

NO Emetics, Gastric lavage, no activated charcoal

Consultations
Surgical consult
Perforation, mediastinits, peritonitis

Endoscopic consult
Small children Symptomatic older children and adults Abnormal mental status with potential for seuvere injury

Psychiatric consult
Once stable

Medications
Antibiotics if with perforation
3rd gen cephalosphorin (ceftriaxone), betalactamase inhibitor + ampicillin (Unasyn)

Proton pump inhibitor

Pantoprazole

Analgesic/narcotios for pain

Morphine

Acid Ingestion
Admit to ROC under NPO Monitor VS and abdomen for guarding and tenderness Strict suicide precaution Diagnostics: CBC, crossmatching, esophagogastroscopy, ABG, CXR and abdominal films Therapeutics:
Provide airway control, ventilation and circulatory support and fluid resuscitation. May wash the oral cavity with cold water

Alkali ingestion
Admit NPO Nursing: monitor BP, HR, abdomen for guarding and tenderness Diagnostic: CBC, cross matching, electrolytes, ABG, Upright CXR and abdominal films Therapeutics:
Immediately rinse oral cavity with cold water. Protect airway, O2 suppafter 24ort, IV fluids Antibiotics if with esophageal injury Esophagoscopy and Gastroscopy immediately if with drooling, stridor or painful swallowing. Otherwise after 24h