L3: Caustics Flashcards
Def of Corrosives
Classification of Corrosives
- Mineral acids
- Organic acids
- Alkalies
- Corrosive salts
- Button batteries
Examples of corrosive Organic acids
Carbolic Acid “Phenol”
Oxalic Acid
Acetic Acid.
Examples of corrosive mineral acids
Sulphuric Acid
Nitric Acid
Hydrochloric Acid.
Examples of corrosive salts
Mercuric Chloride.
Examples of corrosive alkalis
Caustic Potash
Na Hydroxide
Ammonium Hydroxide.
what do button battries contain?
- Contain in mercuric chloride
- used in watches and calculators.
manner of poisoning by Corrosives
In children: 85% accidentally ingested in children between 1-3 years.
In adult: Intentional exposures by adults are more significant (done by suicidal patients).
what are forms of corrosives?
bleach, household cleaners, paint and rust removers and strong lyes.
Clinical picture of Corrosive Toxicity
- Patients who have ingested alkaline or acid agents have similar initial. presentations
- They most commonly affect gastrointestinal, respiratory, eye and skin.
GIT manifestations in Corrosive Toxicity
- Pain
- Dysphagia
- Others
GIT Pain in Corrosive Toxicity
- Corrosions and burning pain of of lips and oral cavity.
- Severe chest or abdominal pain (in esophageal or gastric perforation)
what is the most common symptom of Corrosive Toxicity?
Acute dysphagia
Dysphagia in Corrosive Toxicity
- Dysphagia (inability to tolerato oral fooding)
Acute dysphagia: The most common symptom
Chronic dysphagia: Stricture formation
Other GIT Symptoms in Corrosive Toxicity
- Drooling
- Hypersalivation
- Vomiting
- Hematemesis
- Shock
Does Presence or absence of oral lesions predict severity of burn?
No
Mechanism of Respiratory manifestations in Corrosive Toxicity
- By Direct exposure of upper respiratory tract to corrosive substance, inhalation of corrosive gases
(e.g. chlorine and ammonia) and aspiration of vomitus
respiratory Manifestations of Corrosive Toxicity
- Injury in Upper respiratory tract: (Epiglottitis, laryngeal edema & ulceration)
- Stridor & Hoarseness.
- Dysphonia & Aphonia
- Dyspnea, Wheezing & Coughing.
- Pneumonitis “Impaired gas exchange & Pulmonary edema “Non-cardiogenic”
Systemic manifestations of Corrosive Toxicity
- Can occur after inhalation, skin exposure or ingestion of agents with systemic effects.
what are corrosives that cause systemic manifestations?
- Hydrofluoric acid, Oxalic acid and Carbolic acid.
Complications of Corrosive Toxicity
- Early
- Late
Early complications of Corrosive Toxicity
Late Compliacations of Corrosive Toxicity
Laboratory Investigations of Corrosive Toxicity
Radiological investigations of Corrosive Toxicity
- X-rays of the chest and abdomen
- CT scans
- Endoscopy.
X-ray of the chest & abdomen in Corrosive Toxicity
- Free mediastinal and intraperitoneal air adjacent to liver
- Pulmonary aspiration and Chemical pneumonitis.
- Impacted button batteries
what does Free mediastinal and intraperitoneal air adjacent to liver denote in Corrosive toxicity?
esophageal or gastric perforation
what CT Scans are done in Corrosive Toxicity?
Barium swallow CT scan
Time of doing Barium swallow CT Scan in Corrosive Toxicity
Follow-up contrast studies 3-4 weeks after the injury if dysphagia is present.
when sould EGD by Done in Corrosive Toxicity?
- Should be performed within 12 to 24 hours after ingestion.
Endoscopy in Corrosive Toxicity
Esophagogastroduodenoscopy (EGD)
- Flexible endoscopy is the standard diagnostic tool in symptomatic patients.
Aspects of TTT in Corrosive Toxicity
- Observation
- Emergency and supportive measures
- Decontamination
- Symptomatic treatment
Observation in Corrosive Toxicity
Asymptomatic & Symptomatic
Observation of asypmtomatic patients in Corrosive Toxicity
- Asymptomatic case with unintentional caustic ingestions should be subject to close observation and monitoring for 4 hours, without the need for endoscopy.
- If the patient remains asymptomatic and able to eat and drink, he can be discharged with appropriate follow-up.
Observation of sypmtomatic patients in Corrosive Toxicity
- All symptomatic cases require admission to the intensive care unit should avoid any oral intake because of risk of perforation.
Emergency TTT in Corrosive Toxicity
Decontamination in Corrosive Toxicity
- Inhalation
- Skin & Eyes
- Ingestion
RESP Decontamination in Corrosive Toxicity
- Remove from exposure
- Give supplemental oxygen if available.
Skin & Eyes Decontamination in Corrosive Toxicity
- Remove all clothing
- Wash skin and irrigate eyes with copious water or saline.
Gastric Decontamination in Corrosive Toxicity
Prehospital & Hospital
Prehospital gastric Decontamination in Corrosive Toxicity
- DO Dilution: With 1-2 cups of milk or water
- Early & Late
- Do not do Neutralization
Hospital Decontamination in Corrosive Toxicity
Early dilution in Corrosive Toxicity
(Recommended)
- Within the first few minutes after ingestion.
- In alert patients who are not vomiting, can tolerate liquids, have no airway compromise and not complaining chest or abdominal pain.
Late dilution in Corrosive Toxicity
- not recommended because vomiting may occur.
Neutralization in Corrosive Toxicity, Is it indicated?
No
- Do not give pH-neutralizing solutions (diluted vinegar or bicarbonate), As it worsen tissue damage by forming gas and exothermic reaction.
Symptomaic TTT in Corrosive Toxicity
- Parental nutrition
- Gastric acid reduction
- Antiemetics
- Analgesic
- Corticosteroids
- Antibiotics
- Surgical consultation
- Endoscopy
Is oral intake Recommended in Corrosive Toxicity?
No, Withholding oral intake until the condition stabilized
Parentral nutrition in Corrosive Toxicity
Total parenteral nutrition should be instituted rapidly.
Gastric acid reduction in Corrosive Toxicity
H2 Antagonists, and/or Proton Pump Inhibitors.
Antiemetics in Corrosive Toxicity
In children to prevent additional esophageal injury from emesis
analgesics in Corrosive Toxicity
Narcotic analgesics to reduce the pain.
Corticosteroids in Corrosive Toxicity
Recommended:
- In patients with circumferential superficial ulcers in esophagus after corrosive ingestion, Intravenous dexamethasone should be administered for a short period (3 days),
- To prevent the development of esophageal stricture.
Not recommended:
- In a patient with perforation
- Corticosteroid may be harmful because they mask early signs of inflammation.
Surgical consultation in Corrosive Toxicity
Immediate surgical consultation in esophageal and gastric perforation.
Antibiotics in Corrosive Toxicity
- Broad spectrum antibiotics (Cephalosporin) indicated in:
- If their evidence of a superficial and deep ulcers in esophagus
- If there is evidence of perforation.
- If there is evidence of mediastinitis or peritonitis.
If corticosteroid therapy is used.
Endoscopy TTT in Corrosive Toxicity
Endoscopic dilation
- For esophageal stricture and gastric outlet obstruction.
Endoscopic removal
- “immediately” for any lodged Button Batteries in / esophagus or trachea.
Characters of Phenol (Carbolic acid)
- Phenol has characteristic odor.
Uses of Phenol (Carbolic acid)
- It is one of the oldest antiseptic agents.
- Currently it is used as a disinfectant.
Forms of Phenol (Carbolic acid)
Phenolic compounds include
- Dinitrophenols
- Hydroquinone
- Hexachlorophone
- Creosol
- Chloroxylenol (in Detlol)
Execretion of Phenol (Carbolic acid)
- Its elimination half-life is 0.5-4.5 hours.
Absorbtion of Phenol (Carbolic acid)
- Rapidly absorbed following inhalation, skin exposure and ingestion.
CP of Phenol (Carbolic acid)
It can give both local and systemic effects
Manifestation due to local actions of Phenol (Carbolic acid)
- Skin exposure
- Eye exposure
- Lung exposure
- GIT exposure
Skin exposure to Phenol (Carbolic acid)
- It produces painless deep white patches that turn erythematous (red) and finally brown.
- Phenol appears to have local anesthetic properties and can cause extensive damage before pain is felt.
Eye exposure in Phenol (Carbolic acid)
- Contact with eyes produces irritation and severe corneal damage.
Lung exposure in Phenol (Carbolic acid)
- Inhalation produces respiratory tract irritation, tracheobronchitis and chemical pneumonia.
GIT Exposure in Phenol (Carbolic acid)
- Ingestion causes diffuse local corrosions, pain, nausea, vomiting and diarrhea.
Cardiac manifestations due to Phenol (Carbolic acid)
- Hypotension and arrhythmias.
Manifestations due to systemic action of Phenol (Carbolic acid)
- Cardiac
- Metabolic
- Neural
- Renal
- Hematological
Neural manifestations due to Phenol (Carbolic acid)
1st:
- Initial, transient CNS stimulation
(Agitation, confusion & seizures).
2nd:
- Followed rapidly by CNS depression.
(Lethargy or coma & respiratory arrest).
Metabolic manifestations due to Phenol (Carbolic acid)
- Acidosis and shock
Renal manifestations due to Phenol (Carbolic acid)
- Acute toxic glomer/onephritis which causes acute renal failure.
- Oliguria (scanty urine) and albuminuria.
- Urine Contains red cast and turns green if exposed to air (Due to presence of oxidative product of phenol).
Hematological manifestations due to Phenol (Carbolic acid)
Hemolysis and methemoglobinemia in some phenolic compounds (eg, dinitrophenol and hydroquinone).
TTT of Phenol (Carbolic acid) Toxicity
- Emergency and supporlive measures
- Decontamination
- Antidote
- Enhanced elimination
Emergency TTT of Phenol (Carbolic acid) Toxicity
Decontamination in Phenol (Carbolic acid) Toxicity
- Inhalation
- Skin and eyes
- Ingestion
RESP decontamination in Phenol (Carbolic acid) Toxicity
- Remove victims from exposure and administer supplemental oxygen.
Ingestion decontamination in Phenol (Carbolic acid) Toxicity
Skin & Eyes decontamination in Phenol (Carbolic acid) Toxicity
- Remove contaminated clothes and wash exposed skin with soapy water or olive oil.
- Immediately flush exposed eyes with water or saline for at least 15 minutes.
When to consider Gastric lavage in Phenol (Carbolic acid) Toxicity?
if:
- A large dose has been ingested.
- The patient’s condition is evaluated within 30 minutes.
- The patient has oral lesions or persistent esophageal discomfort.
When to avoid Gastric lavage in Phenol (Carbolic acid) Toxicity?
- Gastric lavage is not necessary after small to moderate ingestions if activated charcoal can be given promptly.
Caution during gastric lavage in Phenol (Carbolic acid) Toxicity
Care must be taken when placing the nasogastric tube
Antidote in Phenol (Carbolic acid) Toxicity
- No specific antidote is available.
- Methylene blue: If methemoglobinemia occurs, administer it.
Enhanced Elimination in Phenol (Carbolic acid) Toxicity
- Repeated dose activated charcoal in hexachlorophene (excreted in the bile).