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==Background==
==Background==
*Substances that cause damage on contact with body surfaces
{{Skin anatomy background images}}
*Degree of injury determined by pH, concentration, volume, duration of contact
{{Caustics background}}
*Acidic agents denature proteins via coagulative necrosis
*Alkaline agents may be more dangerous by causing liquefactive necrosis
*Corrosive agents have reducing, oxidising, denaturing or defatting potential


===Alkalis===
==Clinical Features==
*Hydroxide ion easily penetrates tissue causing immediate cellular destruction
[[File:1215px-My hand with minor chemical burns.jpg|thumb|Hand with minor chemical burns exposure to commercial-grade dishwasher with concentrated chlorine.]]
**May cause deep penetration into surrounding tissues (e.g. abd/mediastinal necrosis)
[[File:Sodium hydroxide burn.png|thumb|Chemical burn caused by sodium hydroxide solution (lye) 44 hours after exposure.]]
*Examples
[[File:Chemical burn CaCN2.png|thumb|Lower leg chemical burn caused by calcium cyanamide.]]
**Bleach, drain openers, oven cleaners, toilet cleaner, hair relaxers
[[File:Silbernitrat-Verätzung Collage.jpg|thumb|Water-thinned silver nitrate chemical burn on hand. Left: 7 hours after injury. Right: 26 hours after injury.]]
**Household bleach rarely causes significant injury
[[File:Mustard gas burns.jpg|thumb|Caustic burn caused by exposure to [[mustard gas]] (World War I).]]
===Acids===
[[File:HF burned hands.jpg|thumb|Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.]]
*Hydrogen ion leads to cell death and eschar formation, which limits deeper involvement
*Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion <ref>Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.</ref>
**However, due to pylorospasm and pooling, high-grade gastric injuries are common
***Mortality rate is higher compared to strong alkali ingestions
*Ingestion may be complicated by systemic absorption (met acidosis, hemolysis, ARF)
*Examples
**Auto batteries, drain openers, metal cleaners, swimming pool products, rust remover
 
==Diagnosis==
*All pts w/ serious esophageal injuries have some initial sign or symptom
**E.g. stridor, drooling, vomiting
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*GI tract injury
*GI tract injury
**Dysphagia, odynophagia, epigastric pain, vomiting
**[[Dysphagia]], odynophagia, [[epigastric pain]], [[vomiting]]
*Laryngotracheal injury
*Laryngotracheal injury
**Dysphonia, stridor, respiratory distress
**[[Dysphonia]], [[stridor]], [[respiratory distress]]
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes


==Work-Up==
==Differential Diagnosis==
===Labs===
{{Caustic burn types}}
 
{{Burn DDX}}
 
==Evaluation==
*Clinical diagnosis
 
===Work-up===
Only necessary in patients with significant injury or volume of ingestion
Only necessary in patients with significant injury or volume of ingestion


Consider:
Consider:
*CBC
*CBC
*Chemistry
*Metabolic panel
*Lactic Acid
*[[Lactate]]
*Lactate
*Calcium level (if [[Hydrofluoric acid]] exposure)
*Calcium level (if Hydrofluoric Acid exposure)
*[[ECG]]
*ECG
**May show QT-prolongation if hypocalcemic secondary to Hydrofluoric acid
**May show QT-prolongation if hypocalcemic secondary to HF acid
*APAP/ASA levels if concerned about coingestion (suicidal patients)  
*Screens for tylenol levels in suicidal patients at risk for congestions
 
===Imaging===
*Upright CXR
**Look for free air under the diaphragm indicating a perforation or mediastinal air<ref>Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621</ref>
*CT
**Consider when perforated viscus is suspected based on severity of ingestion or peritoneal signs on exam
 
==Treatment==
;First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
===Airway Management===
#Should be considered as a difficult airway
#Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
#First-line is awake oral intubation with direct visualization
#LMAs, combitubes, bougies are probably may be safe depending on the type of caustic ingestion
#Surgical back-up is recommended
===Steroids<ref>Pelclová Det al.. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicological reviews. 2005 24 (2), 125-9 PMID: 16180932</ref>===
#Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds) with the thought of decreasing esophageal stricture formation
#Steroids may potentiate mortality in more severe esophageal caustic injuries
#Only administer under direction from a medical toxicologist
#'''Activated charcoal'''
#Only consider when coingestants pose a risk for severe systemic toxicity
===Endoscopy===
Should be performed <12hr after ingestion and no later than >24hr after ingestion
 
;Indications:
#Intentional ingestion
#Unintentional ingestion with signs of:
##Stridor
##Significant oropharyngeal burns
##Vomiting
##Drooling
##Food refusal


===Surgical intervention===
==Management==
#Indicated for perforations, peritoneal signs, free intraperitoneal or mediastinal air
*First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
*Brush any dry chemicals off the patient
*Irrigate all wounds and areas of exposure with copious amounts of water
**Exception: dry lime, phenol, metals such as potassium and sodium, causes harmful exothermic reaction


===Antibiotics===
===Acidic injuries (except [[Hydrofluoric acid]])===
#No evidence to support or reject the use of prophylactic antibiotics
*May also have [[non anion gap acidosis]] (e.g. HCl)
*Respond well to copious saline or water irrigation


===Gastric Lavage===
===Alkali injuries===
Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
*May appear superficial but often are deeper with ongoing burn
*Treat with copious irrigation and local wound debridement to remove residual compound


==Disposition==
==Disposition==
*All patients with symptomatic from a caustic ingestion should be admitted
*Admit the following:
 
**Injuries that cross flexor or extensor surfaces
==Special Situations==
**Facial injuries
===Esophageal injuries===
**Perineum injuries
*depending severity may have full return of mobility and function or can progress to perforation followed by stricture formation
**Partial-thickness injuries >10-15% of [[BSA]]
*'''Days 2-14''' post-injury are associated with highest tissue friability / risk of perforation
**All full-thickness burns
*High-grade caustic burns associated with 1000x increase in esophageal SCC
 
 
===Dermal Exposure===
*Acidic injuries (except HF acid)
May also have non-anion gap acidosis (e.g. HCl)
**Respond well to copious saline or water irrigation
*Alkali injuries
**May appear superficial but often are deeper w/ ongoing burn
**Treat w/ copious irrigation and local wound debridement to remove residual compound
*Disposition
**Admit the following:
***Injuries that cross flexor or extensor surfaces
***Facial injuries
***Perineum injuries
***Partial-thickness injuries >10-15% of BSA
***All full-thickness burns
 
===Airbag-Related Burns===
*Deployment releases small amount of alkali
**Skin burns are usually minor
**Ocular burns require irrigation, pH testing and ophto f/u
***Long-term sequelae are rare
 
===Ocular Exposure===
*Ocular alkali exposures are an ophthalmologic emergencies
*Prior to aggressive lavage with 2L water first check for globe perforation
*See [[Caustic Keratoconjunctivitis]] for further management


==See Also==
==See Also==
*[[Hydrofluoric Acid]]
*[[Burns]]
*[[Caustic Keratoconjunctivitis]]
*[[Caustic keratoconjunctivitis]]
*[[Airbag Injuries]]
*[[Caustic ingestion]]


==Source==
==References==
*Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009;22(1):89-94. 2008 Oct 1.  PMID: 18847446
*Zargar S et al. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. The American Journal of Gastroenterology. 1992 87 (3), 337-41 PMID: 1539568
<references/>
<references/>


[[Category:GI]]
[[Category:Dermatology]]
[[Category:Tox]]
[[Category:Toxicology]]
[[Category:Trauma]]
[[Category:Symptoms]]

Revisión actual - 16:18 11 dic 2024

Background

Normal dermal anatomy.

Caustics

  • Substances that cause damage on contact with body surfaces
  • Degree of injury determined by pH, concentration, volume, duration of contact
  • Acidic agents cause coagulative necrosis
  • Alkaline agents cause liquefactive necrosis (considered more damaging to most tissues)
  • Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

  • Accepts protons → free hydroxide ion, which easily penetrates tissue → cellular destruction
    • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
  • Examples
    • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
      • Lye present in drain cleaners, hair relaxers, grease remover
    • Bleach (sodium hypochlorite) and Ammonia (NH3)
      • Cleaning products such as oven cleaners, swimming pool chlorinator
      • Household bleach ingestion (4-6% sodium hypochlorite) rarely causes significant esophageal injury[1][2]

Acids

  • Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper involvement
    • However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
      • Mortality rate is higher compared to strong alkali ingestions
  • Can be systemically absorbed and → metabolic acidosis, hemolysis, AKI
  • Examples
    • Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
      • Found in: auto batteries, drain openers, toilet bowl, metal cleaners, swimming pool cleaners, rust remover, nail primer

Clinical Features

Hand with minor chemical burns exposure to commercial-grade dishwasher with concentrated chlorine.
Chemical burn caused by sodium hydroxide solution (lye) 44 hours after exposure.
Lower leg chemical burn caused by calcium cyanamide.
Water-thinned silver nitrate chemical burn on hand. Left: 7 hours after injury. Right: 26 hours after injury.
Caustic burn caused by exposure to mustard gas (World War I).
Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.
  • Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion [3]
  • Exam eyes and skin (splash and dribble injuries may easily be missed)
  • GI tract injury
  • Laryngotracheal injury

Differential Diagnosis

Caustic Burns

Burns

Evaluation

  • Clinical diagnosis

Work-up

Only necessary in patients with significant injury or volume of ingestion

Consider:

  • CBC
  • Metabolic panel
  • Lactate
  • Calcium level (if Hydrofluoric acid exposure)
  • ECG
    • May show QT-prolongation if hypocalcemic secondary to Hydrofluoric acid
  • APAP/ASA levels if concerned about coingestion (suicidal patients)

Management

  • First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
  • Brush any dry chemicals off the patient
  • Irrigate all wounds and areas of exposure with copious amounts of water
    • Exception: dry lime, phenol, metals such as potassium and sodium, causes harmful exothermic reaction

Acidic injuries (except Hydrofluoric acid)

Alkali injuries

  • May appear superficial but often are deeper with ongoing burn
  • Treat with copious irrigation and local wound debridement to remove residual compound

Disposition

  • Admit the following:
    • Injuries that cross flexor or extensor surfaces
    • Facial injuries
    • Perineum injuries
    • Partial-thickness injuries >10-15% of BSA
    • All full-thickness burns

See Also

References

  1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:10.1016/s0022-3476(85)80119-0
  2. ↑ Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(1):122-125. doi:10.1097/00005537-199701000-00023
  3. ↑ Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.
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