EM Toxicology 14 - Caustic ingestions Flashcards
Remarks on caustic ingesitons
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
acids and alkali tend to cause significant injuries at what pH?
<3
>11
Describe grade 1 esophageal mucosal burns
involve tissue edema and hyperema
Describe grade 2 esophageal mucosal burns
ulcerations, blisters, and whitish exudates
2A - noncircumferential - ward
2B - circumferential - ICU
Caustic compounds found in batteries
potassium hydroxide (alkali)
lithium hydroxide (alkali)
sulfuric acid [from automobile batteries] (acid)
Describe grade 3 esophageal mucosal burns
defined by deep ulceration and necrotic lesions
Describe grade 3 esophageal mucosal burns
defined by deep ulceration
most common household alkali
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
acid ingestion may be complicated by systemic absorption. This may lead to
“MARC”
Metabolic Acidosis
Renal failure
Coagulopathy and hemolysis
what to look for in PE in caustic ingestions?
signs of
1. respiratory distress
2. circulatory shock
- oropharyngeal injury (mucosal burns, drooling)
- respiratory injury (dysphonia, coughing, stirodr, wheezing)
- mediastinitis (chest discomfort, chest subcutaneous emphysema)
- gastric injury (vomiting, epigastric tendernss)
remarks on children with caustic ingestion
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)
remarks on hydrofluoric acid exposure
an ECG is indicated to check for QT prolongation from hypocalcemia
obtain a chest radiograph in patients with
chest pain, dyspnea, or vomiting to check for peritoneal and mediastinal air
remarks on IV constrated thoracoabdominal CT
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
Indications for endoscopy
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.”
remarks on tissue friability
tissue friability after a caustic burn increases significantly at 24 to 48 hours and is maximal between days 5 and 14
Timeframe in doing endoscopy
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.”
remarks on steroids in caustic ingestion
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.
For grade 2B and 3 injuries without obvious perforation, recommendations include
- a period of esophegeal rest
- 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
remarks on long-term sequelae of caustic ingestions
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
Dispositions in caustic ingestion
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
