- Acids—cause immediate coagulative necrosis. Usually self-limiting injury
- Alkalis—cause liquefactive necrosis resulting in deeper penetration and more extensive injury. Neutralization by the tissues themselves will terminate reaction
- NB: Alkalis are typically odorless and tasteless, which can lead to consumption of larger volumes than acids
- Alkalis also cause blood vessel thrombosis, which can worsen necrosis
Common Caustic Substances Ingested
|Sodium hydroxide||Industrial chemicals, drain openers, oven cleaners|
|Potassium hydroxide||Drain openers, batteries|
|Calcium hydroxide||Cement, hair relaxers, and perm products|
|Ammonium hydroxide||Hair relaxers and perm products, dermal peeling/exfoliation, toilet bowl cleaners, glass cleaners, fertilizers|
|Lithium hydroxide||Photographic developer, batteries|
|Sulfuric acid||Car batteries, drain openers, explosives, fertilizer|
|Acetic acid||Printing and photography, disinfectants, hair perm neutralizer|
|Hydrochloric acid||Cleaning agents, metal cleaning, chemical production, swimming pool products|
|Hydrofluoric acid||Rust remover, glass and microchip etching, jewelry cleaners|
|Formic acid||Model glue, leather and textile manufacturing, tissue preservation|
|Chromic acid||Metal plating, photography|
|Nitric acid||Fertilizer, engraving, electroplating|
|Phosphoric acid||Rustproofing, metal cleaners, disinfectants|
- Amount of caustic fluid ingested
- Type of caustic (pH)
- Duration of contact with mucosa—if vomiting, duration of contact will be lengthened
- The main issues to decide are:
- Should the patient be intubated?
- Is there an indication for immediate surgical intervention?
- Is there an indication for early (before 6 hours) esophagoscopy?
- History—type and amount of caustic ingested. ±Vomiting? If pediatric ingestion, parents should bring container of caustic ingested for correct identification
- Hoarseness, stridor, dyspnea → indicate airway injury
- Odynophagia, drooling, refusal of food → indicate orophayngeal/nasophayngeal and esophageal injury
- Abdominal pain and peritoneal signs: immediate CXR and abdominal x-ray to r/o intraperitoneal or mediastinal air
- Substernal chest pain, abdominal pain, rigidity → indicate profound injury or perforation of esophagus/stomach
- Signs of perforated viscus, peritonitis, mediastinitis, or hemodynamic instability: immediate surgical evaluation
- Criteria for emergent surgery:
- Presence of shock
- Disseminated intravascular coagulation
- Need for hemodialysis
- Acidosis (arterial pH <7.22 or base excess <−12)
- Grade 3 esophageal injury (see below) seen on endoscopy (controversial)
- Physical exam—injury to lips, chin, hand, clothing, mouth, and pharynx
- Note: Absence of injury to mouth/pharynx is not predictive of esophageal or laryngeal injury
- If airway stable—examine pharynx and hypopharynx with flexible fiber-optic scope
Patients with caustic ingestions should always be considered “difficult airways”.
- Respiratory distress and stridor indicate pharyngeal or laryngotracheal injuries
- Place oral/nasal airway early in management prior to rapid worsening of airway edema
- Consider administration of dexamethasone (10 mg IV) to counteract upper airway edema
- Intubate if symptomatic, or if massive ingestion, even without symptoms
- Awake oral intubation using flexible fiber-optic scope is preferred
- Surgical backup should always be available for emergent cricothyroidotomy/tracheotomy as tissue friability, bleeding, and edema may make intubation impossible
- Avoid long-acting paralytics as airway edema and muscle relaxation may make mask ventilation impossible
- Contraindicated: blind ...
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