Diferencia entre revisiones de «Caustic burn»
(Replaced content with "==Background== {{Caustics background}} ==Diagnosis== {{General approach to caustic burns}} ==See Specific Types== {{Caustic burn types}} ==See Also== *Hydrofluoric Ac...")
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{{General approach to caustic burns}}
{{General approach to caustic burns}}


==Types==
==See Specific Types==
{{Caustic burn types}}
{{Caustic burn types}}
==Work-Up==
===Labs===
Only necessary in patients with significant injury or volume of ingestion
Consider:
*CBC
*Chemistry
*Lactic Acid
*Lactate
*Calcium level (if Hydrofluoric Acid exposure)
*ECG
**May show QT-prolongation if hypocalcemic secondary to HF acid
*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===
#Indicated for perforations, peritoneal signs, free intraperitoneal or mediastinal air
===Antibiotics===
#No evidence to support or reject the use of prophylactic antibiotics
===Gastric Lavage===
Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
==Disposition==
*All patients with symptomatic from a caustic ingestion should be admitted
==Special Situations==
===Esophageal injuries===
*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
===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]]
*[[Hydrofluoric Acid]]
*[[Caustic Keratoconjunctivitis]]
*[[Airbag Injuries]]


==Source==
==Source==
*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
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[[Category:Derm]]
[[Category:GI]]
[[Category:GI]]
[[Category:Tox]]
[[Category:Tox]]

Revisión del 22:44 22 dic 2014

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

See Specific Types

Caustic Burns

See Also

Source

  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
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