EM Toxicology 14 - Caustic ingestions

Question 1

Remarks on caustic ingesitons

Answer 1

Alkaline ingestions predominate in the developed world
Acid ingestions are more common in developing countries

The majority of reported exposures are unintentional or accidental, but majority of serious injuries come from ***intentional ingestions

Question 2

acids and alkali tend to cause significant injuries at what pH?

Answer 2

<3
>11

Question 3

Describe grade 1 esophageal mucosal burns

Answer 3

involve tissue edema and hyperema

Question 4

Describe grade 2 esophageal mucosal burns

Answer 4

ulcerations, blisters, and whitish exudates

2A - noncircumferential - ward
2B - circumferential - ICU

Question 5

Caustic compounds found in batteries

Answer 5

potassium hydroxide (alkali)
lithium hydroxide (alkali)

sulfuric acid [from automobile batteries] (acid)

Question 5

Describe grade 3 esophageal mucosal burns

Answer 5

defined by deep ulceration and necrotic lesions

Question 5

Describe grade 3 esophageal mucosal burns

Answer 5

defined by deep ulceration

Question 6

most common household alkali

Answer 6

bleach, a 3% to 6% sodium hypochlorite solution with a pH of ~11

Household liquid bleach is minimally corrosive to the esophagus and rarely causes significant injury beyond grade 1 esophageal burns

however, ingestion of industrial-strength bleach may result in gastric and esophageal necrosis

Question 7

acid ingestion may be complicated by systemic absorption. This may lead to

Answer 7

“MARC”
Metabolic Acidosis
Renal failure
Coagulopathy and hemolysis

Question 8

what to look for in PE in caustic ingestions?

Answer 8

signs of
1. respiratory distress
2. circulatory shock

3. oropharyngeal injury (mucosal burns, drooling)
4. respiratory injury (dysphonia, coughing, stirodr, wheezing)
5. mediastinitis (chest discomfort, chest subcutaneous emphysema)
6. gastric injury (vomiting, epigastric tendernss)

Question 9

remarks on children with caustic ingestion

Answer 9

For children who *unintentionally ingest common household akali (e.g., bleach) or acids (e.g., toilet bowl cleaner), the need for ancillary testing is only necessary in those with s/s of significant injury (e.g., drooling, respiratory distress, food refusal, or vomiting)

Question 10

remarks on hydrofluoric acid exposure

Answer 10

an ECG is indicated to check for QT prolongation from hypocalcemia

Question 11

obtain a chest radiograph in patients with

Answer 11

chest pain, dyspnea, or vomiting to check for peritoneal and mediastinal air

Question 12

remarks on IV constrated thoracoabdominal CT

Answer 12

recent evidence suggests CT scans outperform endoscopy in the prediction of stricture and the need for surgical esophageal reconstruction due to the greater ability to determine the depth of injury

Question 13

Indications for endoscopy

Answer 13

traditional gold standard for evaluating the location and severity of injury to the esophagus, stomach, and duodenum after caustic ingesiton

regardless of symptoms, patients with intentional caustic ingestions should undergo early endoscopy because ingestions with suicidal intent carry the hightest risk of clinically important injury

indications:
1. intentional ingestion
2. s/s of serious injury (R. distress, oropharyngeal burns, vomiting, drooling)

Goldfranks:
”Endoscopy is also recommended in any patient with an unintentional ingestion in the presence of stridor and in any patient with 2 or more of the following findings: pain, vomiting, and drooling.”

Question 14

remarks on tissue friability

Answer 14

tissue friability after a caustic burn increases significantly at 24 to 48 hours and is maximal between days 5 and 14

Question 15

Timeframe in doing endoscopy

Answer 15

within 12 to 24 hours from the time of ingestion, to avoid iatrogenic perforation

Goldfrank:
”We recommend against the use of endoscopic assessment after 24 hours and it should be avoided between 48 hours and 2 weeks postingestion; at this time, tissue strength is most compromised and the risk of perforation is greatest.”

Question 16

remarks on steroids in caustic ingestion

Answer 16

Grade 2B and *3 injuries may theoretically benefit from steroids to inhibit inflammatory response and subsequent stricture formation

recommended by some international guidelines in grade 2B lesions**

Goldfrank:
steroids in Grde III may mask infection and make thefriable, necrotic esophageal tissue more morone to perforation
**methylprednisolone 1g/1.73m2/day for 3 days
** Although not studied, dexamethasone 10 mg (intravenous) in adults and 0.6 mg/kg up to a total dose of 10 mg in children is reasonable for patients with aiway edema or other signs of caustic-induced airway compromise.

Question 17

For grade 2B and 3 injuries without obvious perforation, recommendations include

Answer 17

1. a period of esophegeal rest
2. early gastrostomy for enteral feeding
   *3. dilation therapy (in the first 3 weeks) with or without stenting 🤔📌

Goldfrank:
*The risk of perforation from esophageal dilatation is decreased if the initial procedure is delayed beyond 4 weeks postingestion

Question 18

remarks on long-term sequelae of caustic ingestions

Answer 18

acid - gastric outlet obstruction
alkali - esophageal strictures

grade 3 caustic injuries to the esophagus have about 1000-fold increased risk for SCC of esophagus, which can occur decades after.
Because cancer can develop if a portion of the esophagus remains after reconstructive surgery for esophageal stricture, *total removal of the esophagus is recommended

Question 19

Dispositions in caustic ingestion

Answer 19

may be discharged after a period of observation
- asymptomatic patients with low-risk ingestions and no signs of drooling, stridor, or vomiting, and who tolerate food or drink

admit all patients with symptoms

grade 1 - can be discharged after endoscopy, provided they can tolerate oral fluids and food

grade 2A - warrants hospitalization to ensure that symptoms and injury do not progress

2B, 3 - ICU; enteral/parenteral nutrition, early risk for bleeding/perforation