A 2-year-old girl presents to the ED with her parents, who state that they saw her drink a mouthful of toilet bowl cleaner that was in an unmarked container that had been left unattended. She cried and vomited immediately post ingestion. Upon presentation to the ED, she is still crying. Her vital signs are: heart rate, 164 beats/ min; blood pressure, 94/65 mm Hg; respiratory rate, 30 breaths/min; and oxygen saturation, 98% on room air. She is afebrile. Inspection of the skin and oropharynx is unremarkable, without ulcerations, lesions, or evidence of edema, and she is tolerating her secretions. Her lungs are clear to auscultation, and cardiac examination is significant only for tachycardia. Her abdominal examination demonstrates mild epigastric tenderness. You wonder about the best way to manage this patient: Does she need an IV? Laboratory tests? Imaging? Admission?
A 35-year-old man presents to the ED 2 hours after deliberate ingestion of a bottle of drain cleaner containing sodium hydroxide. He experienced chest pain and abdominal pain post ingestion and had 3 episodes of bloody emesis prior to arrival. In the ED, he appears uncomfortable. His vital signs are: heart rate, 120 beats/min; blood pressure, 120/80 mm Hg; respiratory rate, 25 breaths/ min; oxygen saturation, 98% on room air. He is afebrile. His physical examination is significant for abdominal pain with guarding and rebound as well as superficial ulceration of the oral mucosa. The nurse attaches the patient to the monitor and establishes IV access and then asks you, “Doctor, what should we do next?” (You think, "Good question.")
A caustic or corrosive is a xenobiotic that causes damage to tissue surfaces upon contact. Caustics are routinely found in household and industrial products as well as cosmetics and personal care items. According to the 2013 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System, 91% of all toxic exposures occur in the home.1 A list of common caustics and their uses is presented in Table 1.
Caustic exposures can occur via dermal, ocular, inhalation, and oral routes. Ingestion is the main cause of long-term morbidity and mortality. Injuries from caustic ingestion can range from mild gastrointestinal irritation and ulceration to life-threatening necrosis, perforation, and/or systemic toxicity.
Caustic ingestions follow a bimodal pattern, with peak occurrences in the pediatric population aged 1 to 5 years and then again later in adulthood.2 Eighty percent of reported caustic injuries occur in children, most often via unintentional exposure to household products, with the greatest incidence around 2 years of age.3,4 Adults may be exposed to household or industrial products as a result of an occupational accident or a suicide attempt.5 In children, 18% to 46% of all caustic ingestions are associated with esophageal burns. This percentage is likely higher in adults, who typically have more-severe injuries due to the greater volume of exposure when a caustic is consumed with suicidal intent versus unintentional ingestion.6,7
Caustic exposures have been a public health concern throughout history. Legislative changes, such as the mandating of child-resistant packaging and mandatory concentration reductions for household chemicals, in addition to public education campaigns for safer storage practices, have been employed to prevent poisonings. However, despite these efforts, caustic exposures still occur. In the United States, it is estimated that more than 200,000 exposures to household or industrial cleaning products and 5000 to 15,000 caustic ingestions occur annually.7-9
Fortunately, serious caustic exposures are uncommon events, but the emergency clinician must be able to recognize this potentially life-threatening entity and initiate proper therapies expediently. In this issue of Emergency Medicine Practice, we review basic pathophysiology and provide best-practice management recommendations for patients with caustic exposures.
A literature search was completed using PubMed, which included MEDLINE®, Embase®, Web of Science, Cochrane Database of Systematic Reviews, Evidence-Based Medicine Reviews (EBMR), Database of Abstracts of Reviews and Effectiveness (DARE), and the National Guideline Clearinghouse databases. Studies were limited to meta-analyses, systematic reviews, clinical trials, and case reports/series. The search was separated into 3 separate concepts to include all keyword variations and achieve maximum sensitivity. The concepts included: (1) caustics, (2) ingestion, and (3) study type.
A total of 494 citations were found in MEDLINE®, 168 citations in Embase®, 76 citations in Web of Science, 0 citations in CDSR, DARE, and EBMR (searched together in 1 database), and 1 citation in the National Guidelines Clearinghouse, for a total of 739 citations. Foreign language articles with an abstract available in English were included, and those without an English-language abstract were excluded. The bibliographies of pertinent review articles and reference texts were reviewed to ensure important literature was not overlooked.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study are included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Rachel S. Wightman, MD; Kevin B. Read, MLIS, MAS; Robert S. Hoffman, MD
May 1, 2016
June 1, 2019
Upon completion of this article, you should be able to:
Physician CME Information
Date of Original Release: May 1, 2016. Date of most recent review: April 10, 2016. Termination date: May 1, 2019.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2015. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 0.25 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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