Caustic ingestion

Question 1

Alkali substances (NaOH or ammonia) more commonly lead to _____ necrosis

Answer 1

liquefactive

this causes more damage to the esophagus than the stomach and is buffered by the stomach

Question 2

Acidic substances more commonly will lead to ______ necrosis

Answer 2

coagulative

this causes immediate pain in the oropharynx (often limiting ingestion) and will cause more gastric damage

Question 3

Caustic ingestion will lead to … ?

Answer 3

Affects lips, tongue, oral mucosa & esophagus

oropharyngeal, chest, and abdominal pain

dysphagia

odynophagia

vomiting with occasional hematemesis

Question 4

What is the first step with a suspected caustic ingestion?

Answer 4

Perform ABCs then Decontamination*

• Remove contaminated clothing, brush off visible chemical, irrigate exposed skin.

Question 5

Is activated charcoal indicated with caustic ingestion?

Answer 5

No

Do not induce vomiting or give charcoal

Question 6

Why do initial interventions for caustic ingestion need to be carefully considered?

Answer 6

Any intervention that could provoke vomiting should be avoided. This includes administration of milk, water, activated charcoal, vinegar, or nasogastric lavage, as vomiting can increase the extent of injury. In addition, vinegar combined with an alkaline substance can cause an exothermic reaction and burn the mucosa, exacerbating the existing injury.

NG tubes should not be placed blindly due to the risk of perforation.

Question 7

What are the appropriate emergency room steps performed for a patient with caustic ingestion?

Answer 7

Emergency department:
* Confirm decontamination; chest & abdominal x-rays
* Endotracheal intubation for significant oropharyngeal injury
* Consider gastric lavage if nasogastric tube is placed

Question 8

What are the appropriate inpatient steps performed for a patient with caustic ingestion?

Answer 8

Inpatient:
* Endoscopy within 12-24 hr if hemodynamically stable & without respiratory distress or perforation. During endoscopy, a nasogastric feeding tube can be placed under direct visualization.
* Serial x-rays to rule out perforation
* Tube feedings & surgical intervention for severe injury

Question 9

When would an upper endoscopy be contraindicated?

Answer 9

Usually this is done for either significant symptoms (hematemesis) but is contraindicated with hemodynamic instability or a surgical complication.

Question 10

When should barium swallow tests be performed following caustic ingestion?

Answer 10

Barium swallow studies are usually not helpful initially in determining the extent of injury in the acute setting. All patients with persistent dysphagia or significant esophageal burns on endoscopy should undergo barium contrast studies 2-3 weeks after ingestion to assess for esophageal strictures or pyloric stenosis.

Question 11

Are steroids ever indicated with caustic ingestion?

Answer 11

Steroids are not recommended given the lack of proven efficacy in preventing strictures and potential increased chance of perforation.

Question 12

What is the definitive management for caustic ingestion?

Answer 12

supportive care