Diferencia entre revisiones de «Caustic ingestion»
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Línea 12: Línea 12:
Only necessary in patients with significant injury or volume of ingestion
Only necessary in patients with significant injury or volume of ingestion


Consider:
*CBC
*CBC
*Chemistry
*Chemistry
*Lactic Acid
*Lactic Acid
*Lactate
*ECG
*Calcium level (if Hydrofluoric Acid exposure)
*Calcium level (if Hydrofluoric Acid exposure)
*ECG
*Acetaminophen and Salicylate levels (in pts with concern for intentional ingestion)
**May show QT-prolongation if hypocalcemic secondary to HF acid
*Screens for tylenol levels in suicidal patients at risk for congestions


===Imaging===
===Imaging===
*Upright CXR
*3-View CXR 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>
**Look for free air under the diaphragm or signs of 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
*CT
**Consider when perforated viscus is suspected based on severity of ingestion or peritoneal signs on exam
**Consider when perforated viscus is suspected but CXR is negative


==Treatment==
==Treatment==
;First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
*Prevent provider and continued patient exposure to the caustic agent by removing all clothing and decontaminating the patient


===Airway Management===
===Airway Management===
*First-line is awake oral intubation with direct visualization
*Monitor closely for stridor, airway edema, hoarseness, or other signs of airway injury
**Should be considered as a difficult airway
*Intubate early if signs of airway injury exist, before airway becomes more difficult to manage.
**Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
*Consider awake fiberoptic or video laryngoscopy if concern for difficult airway
**LMAs, combitubes, bougies are probably may be safe depending on the type of caustic ingestion
*Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
**Consider surgical back-up


===Endoscopy===
===Endoscopy===
Should be performed <12hr after ingestion and no later than >24hr after ingestion
Should be performed within 12-24 hours of ingestion.


;Indications:
;Indications:
#Intentional ingestion
#Intentional ingestion (higher likelihood of high volume ingestion)
#Unintentional ingestion with signs of:
#Unintentional ingestion with signs of:
##Stridor
##Stridor
Línea 60: Línea 56:
===Surgical Intervention===
===Surgical Intervention===
*Indicated for:
*Indicated for:
**Perforations
**Perforation
**Peritoneal signs
**Peritoneal signs
**Free intraperitoneal or mediastinal air


===Controversial or Contraindicated===
===Controversial or Contraindicated===
Línea 85: Línea 80:
*[[Caustic burns]]
*[[Caustic burns]]


==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
*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
*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

Revisión del 08:30 21 jun 2015

Background

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

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)
  • GI tract injury
    • Dysphagia, odynophagia, epigastric pain, vomiting
  • Laryngotracheal injury
    • Dysphonia, stridor, respiratory distress
    • Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes

Differential Diagnosis

Caustic Burns

Work-Up

Labs

Only necessary in patients with significant injury or volume of ingestion

  • CBC
  • Chemistry
  • Lactic Acid
  • ECG
  • Calcium level (if Hydrofluoric Acid exposure)
  • Acetaminophen and Salicylate levels (in pts with concern for intentional ingestion)

Imaging

  • 3-View CXR CXR
    • Look for free air under the diaphragm or signs of mediastinal air[3]
  • CT
    • Consider when perforated viscus is suspected but CXR is negative

Treatment

  • Prevent provider and continued patient exposure to the caustic agent by removing all clothing and decontaminating the patient

Airway Management

  • Monitor closely for stridor, airway edema, hoarseness, or other signs of airway injury
  • Intubate early if signs of airway injury exist, before airway becomes more difficult to manage.
  • Consider awake fiberoptic or video laryngoscopy if concern for difficult airway
  • Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages

Endoscopy

Should be performed within 12-24 hours of ingestion.

Indications
  1. Intentional ingestion (higher likelihood of high volume ingestion)
  2. Unintentional ingestion with signs of:
    1. Stridor
    2. Significant oropharyngeal burns
    3. Vomiting
    4. Drooling
    5. Food refusal

Esophageal Stricture Mitigation[4]

  • Discuss with GI or medical toxicologist
  • For grade IIb or higher esophageal burns:
    • Methylprednisolone (1 g/1.73 m2 per day for 3 days)
    • Ranitidine
    • Ceftriaxone
    • Total parenteral nutrition

Surgical Intervention

  • Indicated for:
    • Perforation
    • Peritoneal signs

Controversial or Contraindicated

  • Antibiotics
    • No evidence to support or reject the use of prophylactic antibiotics
    • Only indicated if also giving steriods (see stricture mitigation above)
  • Activated charcoal
    • Only consider when coingestants pose a risk for severe systemic toxicity
  • Gastric lavage
    • Contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage

Disposition

  • All patients with symptomats from a caustic ingestion should be admitted
  • All patients with intentional ingestion should be evaluated by psych prior to discharge

Prognosis

  • depending severity may have full return of mobility and function or can progress to perforation followed by stricture formation
  • Days 2-14 post-injury are associated with highest tissue friability / risk of perforation
  • High-grade caustic burns associated with 1000x increase in esophageal SCC

See Also

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
  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. ↑ Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621
  4. ↑ High Doses of Methylprednisolone in the Management of Caustic Esophageal Burns. Pediatrics 2014;133:e1518–e1524
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