Rosen & Barkin's 5-Minute Emergency Medicine Consult (138 page)

• Direct chemical injuries
  
• Injuries occur secondary to acid and alkali exposures.
  
• Many caustic agents (acids and alkalis) are found in common household and industrial products.
  
• Caustic substances:
  
  • Ammonia hydroxide
    
• Glass cleaners:
  
  • Formaldehyde:
    
    • Embalming agent
      
  • Hydrochloric acid:
    
    • Toilet bowel cleaners
      
  • Hydrofluoric acid:
    
    • Glass etching industry
      
    • Microchip industry
      
    • Rust removers
      
  • Iodine:
    
    • Antiseptics
      
  • Phenol:
    
    • Antiseptics
      
  • Sodium hydroxide:
    
    • Drain cleaners
      
    • Drain openers
      
    • Oven cleaners
      
  • Sodium borates, carbonates, phosphates, and silicates:
    
    • Detergents
      
    • Dishwasher preparations
      
    • Sodium hypochlorite
      
    • Bleaches
      
  • Sulfuric acid:
    
    • Car batteries
      
    • Button batteries
      

DIAGNOSIS

• 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
    
  • 1st-, 2nd-, or 3rd-degree burns
    
• Ocular:
  
  • Pain
    
  • Erythema
    
  • Injection
    
  • Corneal burns
    
  • Full-thickness corneal damage
    
• Metabolic:
  
  • Metabolic acidosis
    

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

• CBC
  
• Electrolytes, BUN, creatinine, glucose
  
• Arterial blood gas
  
• Blood cultures:
  
  • If mediastinitis or peritonitis suspected
    
• Type and cross-match
  

Chest and abdominal radiographs for:

• Esophageal or gastric perforation
  

• Esophageal and gastric endoscopy:
  
  • For symptomatic patients to determine the extent of injury
    
  • Perform within the 1st 12–24 hr after ingestion.
    
  • Not recommended in the presence of respiratory distress without proper airway management
    
  • Not recommended in the presence of severe pharyngeal damage
    
• Radiographic oral contrast imaging not recommended acutely:
  
  • May be used in follow-up for assessment for strictures
    

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

TREATMENT

• For oral burns or symptoms: Rinse mouth liberally with water or milk.
  
• 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
  

• ABCs:
  
  • Prophylactic intubation if there is any evidence of respiratory compromise
    
  • Blind nasotracheal intubation contraindicated
    
• Treat hypotension with 0.9% NS IV fluid resuscitation.
  

• 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 (large-bore or an NG tube), and a neutralizing acid or base are all contraindicated with caustic ingestions.
    
• Dilution:
  
  • Water or milk in the 1st 30 min of ingestion:
    
    • Especially useful for solid caustic alkali ingestions
      
    • Excessive intake may induce vomiting and worsen esophageal damage.
      
  • If respiratory distress, intubate before dilution.
    
  • Contraindicated 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 standard burn recommendations.
  
• Detailed exam for ocular exposures
  
• IV proton pump inhibitors or H
  ₂
  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 entire team caring for patient.
    
  • Initiate 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/cm
    ²
    of skin with 30G needle)
    
  • Intra-arterial infusion of 10 mL of 10% calcium gluconate in 40 mL D
    ₅
    W over 4 hr
    

• Methylprednisolone: 40 mg q8h IV (peds: 2 mg/kg/d IV); the course of therapy is 14–21 days 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
  

FOLLOW-UP

• All symptomatic patients
  
• Nonaccidental ingestion
  

• Asymptomatic patients who accidentally ingested and are able to swallow without difficulty
  
• Minimal oropharyngeal pain with a corresponding visible lesion; no drooling; no respiratory compromise; no deep throat, chest, or abdominal pain; and able to swallow without difficulty
  

Psychiatric referral for intentional ingestion

• Dilute with milk or water at home or in the ED within the 1st 30 min.
  
• Perform copious irrigation of ocular or dermal exposure:
  
  • Alkalis require more irrigation than acids.
    

• Lupa M, Magne J, Guarisco L, et al. Update on the diagnosis and treatment of caustic ingestions.
  Ochsner J
  . 2009;9:54–59.
  
• Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature.
  Dis Esophagus.
  2009;22:89–94.
  
• Salzman M, O’Malley RN. Updates on the evaluation and management of caustic exposures.
  Emerg Med Clin North Am
  . 2007;25(2):459–476.
  

CODES

• 947.0 Burn of mouth and pharynx
  
• 947.2 Burn of esophagus
  
• 947.3 Burn of gastrointestinal tract