Alkali Exposure: An Evidence-Based Approach to Diagnosis and Treatment

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Publication Date: January 2024 (Volume 27, Number 1)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 01/01/2028.

Authors

Peer Reviewers

Abstract

Alkali caustic exposures can occur in the workplace with industrial chemicals, or in the home with common household products. These exposures, whether accidental or intentional, create risk for death or acute injury, such as airway compromise and esophageal or gastric perforation, as well as long-term complications such as stricture formation. Swift diagnosis and grading of these injuries will guide management options and are essential to reduce morbidity and mortality in these patients. This issue reviews the evidence on emergency department management of alkali caustic exposures, with a focus on decontamination, resuscitation, and appropriate disposition.

Case Presentations

A 3-year-old boy is brought to the ED by his parents after swallowing a “drain cleaner”...

• The parents say that they had stored drain cleaner in an old soda bottle with a twist-off cap, and the boy mistook it for a beverage.
• Soon after ingestion, while at home, the patient vomited once and started crying. The parents said they washed the boy’s face and mouth with cold water at home and gave him water to drink before bringing him to the ED.
• His vital signs are: temperature, 37.2°C; heart rate, 100 beats/min; blood pressure, 96/67 mm Hg; and respiratory rate, 20 breaths/min.
• The boy is currently asymptomatic, and you wonder: since he looks so well, is observation the best approach? If so, for how long?

A 14-year-old girl arrives, vomiting and with abdominal pain, after ingesting laundry detergent pods…

• The girl says she was taking part in an online social media “challenge” among peers and ate several pods. She is awake, alert, and oriented, but unable to tolerate oral intake, and is vomiting and complaining of abdominal pain. She says her left eye is burning and tearing.
• Her vital signs are: temperature, 37°C; heart rate, 115 beats/min; blood pressure, 110/70 mm Hg; and respiratory rate, 16 breaths/min. She soon develops central nervous system depression.
• You wonder whether there could be some co-ingestant, or is this due to the detergent pods?

A 45-year-old man is brought in by EMS, in respiratory distress…

• The prehospital clinicians tell you that the patient said he had intentionally ingested “a lot of grease cleaner.” They brought the bottle with them, and the label states that it contains an industrial-strength concentration of sodium hydroxide.
• His vital signs are: temperature, 38°C; heart rate, 120 beats/min sinus tachycardia; blood pressure, 100/67 mm Hg; respiratory rate, 26 breaths/min, and oxygen saturation at 96% on room air.
• You consider whether you should give him corticosteroids and prophylactically intubate him…

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