Author:

PaulKolecki

Signs and Symptoms

• Oropharyngeal:
  • Pain
  • Erythema
  • Burns
  • Erosions
  • Ulcers
  • Drooling
  • Hoarseness
  • Stridor
  • Aphonia
  • Absence of visible lesions in the oropharynx does not exclude visceral injuries
• Pulmonary:
  • Tachypnea
  • Cough
  • Pneumonitis if aspirated
• GI:
  • Pain
  • Emesis or hematemesis
  • Melena, dysphagia
  • Odynophagia
  • Esophageal or gastric perforation
  • Peritonitis owing to perforation
• Cardiovascular:
  • Tachycardia
  • Hypotension
  • Orthostatic changes
• Hematologic:
  • Acid ingestion can cause RBC hemolysis
• Dermatologic:
  • Pain
  • Erythema
  • First-, second-, or third-degree burns
• Ocular:
  • Pain
  • Erythema
  • Injection
  • Corneal burns
  • Full-thickness corneal damage
• Metabolic:
  • Metabolic acidosis

Essential Workup

• History of or signs and symptoms of an exposure
• Absence of oropharyngeal lesions does not exclude visceral injury

Diagnostic Tests & Interpretation

Differential Diagnosis

• Chemical injuries from corrosives, acids, alkalis, desiccants, vesicants, and oxidizing and reducing agents
• Foreign body ingestion
• Upper airway infection or angioedema

Prehospital

• For oral burns or symptoms: Rinse mouth liberally with water or milk within first seconds to minutes following ingestion
• Water or milk can be given to following patients:
  • Able to drink
  • Not complaining of significant abdominal pain
  • Do not have airway compromise or vomiting
• Copious irrigation for ocular or dermal exposure

Initial Stabilization/Therapy

• ABCs:
  • Prophylactic intubation if there is any evidence of respiratory compromise
  • Blind nasotracheal intubation contraindicated
  • Caustic induced airway edema
• Consider dexamethasone
• Treat hypotension with 0.9% NS IV fluid resuscitation

ED Treatment/Procedures

• Decontamination:
  • Dermal or ocular exposure:
    • Immediate and thorough irrigation with water or 0.9% NS until physiologic pH attained
    • Alkalis typically require more irrigation than acids
  • Ipecac, activated charcoal, gastroesophageal lavage and a neutralizing acid or base are all contraindicated with caustic ingestions
• Dilution:
  • Water or milk within the first seconds to minutes following ingestion:
    • Especially useful for solid caustic alkali ingestions
    • Excessive intake may induce vomiting and worsen esophageal damage
  • Contraindicated if nausea, drooling, stridor, potential vomiting, or if esophageal or gastric perforation suspected
• Keep patient NPO if oral exposure
• Broad-spectrum antibiotics if mediastinitis or peritonitis suspected
• Antiemetics for nausea and vomiting
• Treat dermal exposures according to stand ard burn recommendations
• Detailed exam for ocular exposures
• IV proton pump inhibitors or H₂ blockers for symptomatic relief
• Gastroenterology and surgical consultation
• Benefit of corticosteroids following esophageal damage is controversial:
  • May prevent the formation of esophageal stricture
  • May promote bacterial invasion, immune suppression, and tissue softening
  • The decision to initiate corticosteroids requires input from the entire team caring for patient
  • Consider broad-spectrum antibiotics if corticosteroids are given
• Laparoscopy or laparotomy for perforation and full-thickness necrosis
• Topical hydrofluoric acid exposure (options depend on severity and location):
  • IM injection of 5% calcium gluconate (0.5 mL/cm² of skin with 30G needle)
  • Intra-arterial infusion of 10 mL of 10% calcium gluconate in 40 mL D₅W over 4 hr

Medication

• Dexamethasone: 10 mg IV (peds: 6 mg/kg IV up to a total dose of 10 mg IV)
• Methylprednisolone: 40 mg q8h IV (peds: 2 mg/kg/d IV); the course of therapy is 14-21 d followed by a corticosteroid taper
• Ondansetron: 4 mg (peds: 0.1-0.15 mg/kg) IV
• Pantoprazole: 40 mg IV
• Prochlorperazine (Compazine): 5-10 mg IV (peds: 0.13 mg/kg per dose IM)
• Ranitidine (Zantac): 50 mg IV q6-8h

Disposition

Follow-up Recommendations

Psychiatric referral for intentional ingestion

• ChiricaM, BonavinaL, KellyMD, et al. Casutic Ingestion . Lancet. 2017;389(10083):2041-2052.
• ContiniS, ScarpignatoC. Caustic injury of the upper gastrointestinal tract: A comprehensive review . Word J Gastroenterol. 2013;19(25):3918-3930.
• FultonJA. Caustics. Goldfrank's Toxicologic Emergencies. 10th ed.McGraw-Hill; 2015.

ICD9

• 947.0 Burn of mouth and pharynx

• 947.2 Burn of esophagus

• 947.3 Burn of gastrointestinal tract

• 947.1 Burn of larynx, trachea, and lung

• 947.8 Burn of other specified sites of internal organs

• 947.9 Burn of internal organs, unspecified site

ICD10

• T28.5XXA Corrosion of mouth and pharynx, initial encounter

• T28.6XXA Corrosion of esophagus, initial encounter

• T28.7XXA Corrosion of other parts of alimentary tract, init encntr

• T27.5XXA Corrosion involving larynx and trachea w lung, init encntr

• T28.90XA Corrosions of unspecified internal organs, initial encounter

• T28.99XA Corrosions of other internal organs, initial encounter

SNOMED

• 23509002 Caustic esophageal injury (disorder)

• 37693008 Caustic injury gastritis (disorder)

• 235021001Chemical burn of oral mucosa (disorder)

• 212039008 Corrosion involving larynx and trachea with lung (disorder)

• 219171000Suicide and selfinflicted injury by caustic substances, excluding poisoning (navigational concept)

• 219362003 Injury undetermined whether accidentally or purposely inflicted, by caustic substances, excluding poisoning (disorder)

• 269737002 Injury of unknown intent by local effect of caustic substance (disorder)

• 418409002 Poisoning of undetermined intent by corrosive, acid or caustic alkali (disorder)