Evidence-Based Management Of Caustic Exposures In The Emergency Department

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. Predictors Of Injury
9. Diagnostic Studies
   1. Laboratory Studies
   2. Imaging Studies
   3. Endoscopy
      1. Categorization Of Endoscopic Findings
      2. Limitations Of Endoscopy
10. Treatment
11. Special Populations And Considerations
    1. Laundry Detergent Pods
    2. Hydrofluoric Acid Exposure
       1. Treatment Of Hydrofluoric Acid Exposure
12. Controversies And Cutting Edge
    1. H₂ Blockers, Proton Pump Inhibitors, And Antibiotics
    2. Steroids
13. Disposition
14. Summary
15. Risk Management Pitfalls For Managing Caustic Ingestions In The Emergency Department
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway For Emergency Department Management Of Caustic Ingestion
19. Clinical Pathway For Emergency Department Management Of Patients With Hydrofluoric Acid Exposure
20. Tables and Figures
    1. Table 1. Common Caustics And Applications
    2. Table 2. Factors Affecting Caustic Toxicity
    3. Table 3. Approach To History-Taking In Patients With Caustic Ingestion
    4. Table 4. Caustics That Cause Systemic Toxicity
    5. Table 5. Endoscopic Grading Of Injury, Findings, And Prognosis
    6. Figure 1. Oropharyngeal Burns Secondary To Lye Ingestion
    7. Figure 2. Chest X-Ray With Evidence Of Perforation After Caustic Ingestion
    8. Figure 3. Endoscopic Findings Demonstrating Grade 2b Lesion After Ingestion Of Alkaline Caustic
21. References
22. References

Abstract

Caustics are common in household and industrial products, and, when ingested, they can pose a significant public health risk. Caustic exposures in adults typically present in the setting of occupational exposure or suicide attempt; exposures in children occur most often by unintentional ingestion. Caustics cause local damage upon contact with tissue surfaces and can lead to systemic toxicity. Endoscopy is recommended in all intentional ingestions (and many unintentional ingestions) to grade injury severity, determine treatment options, and assess prognosis; however, it is generally best performed within 24 hours post ingestion to avoid risk of perforation. Radiography and computed tomography may also be used to visualize injury in certain cases. This review examines the pathophysiology of caustic exposures, their clinical presentations, and the most current evidence on recommendations for decontamination, surgical consult, treatment, and disposition.

Case Presentations

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.")

Introduction

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.

Critical Appraisal Of The Literature

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.

Risk Management Pitfalls For Managing Caustic Ingestions In The Emergency Department

1. “My patient didn’t have any oral lesions after a caustic ingestion, so I didn’t think an endoscopy was indicated.” The presence or absence of oral findings on physical examination is not a reliable marker to predict the presence or absence of distal gastrointestinal tract injury.


2. “My patient was asymptomatic after ingesting a caustic in a suicide attempt, so I admitted him to psychiatry without endoscopic evaluation.” All patients with intentional ingestion should have an endoscopy performed. Intentional ingestions generally cause more-severe injury than unintentional ingestions due to frequently greater ingested volume and concentration. Patients may also have co-ingestions or psychiatric issues that prevent the expression or realization of pain.


3. “My patient came in complaining of severe pain to his hand after an HF exposure, but I didn’t see any skin changes, so I didn’t think there was a severe injury.” HF dermal exposures can cause significant pain and injury even without external physical examination findings. The onset may be delayed several hours.


4. “The initial electrolytes and ECG in my patient with HF ingestion were normal, so I didn’t think further testing or monitoring was necessary.” In the setting of HF ingestion or large body-surface-area dermal burns, it is important to frequently assess electrolytes because the clinical condition can rapidly deteriorate and because these patients are at risk for dysrhythmia.


5. “The patient came into the ED after caustic ingestion with tachypnea and stridor that rapidly progressed to respiratory failure. By the time the intubation medications were available and intubation was performed, he had significant airway edema. He had stable initial oxygen saturation, so I thought I had time to fully assess him prior to intubation.” Early airway intervention is key in patients with caustic exposure, and prophylactic airway management and/or intubation in patients with respiratory symptoms may need to be considered. Additionally, steroid therapy for caustic-induced airway edema should be considered.


6. “A child came into the ED immediately after ingesting an LDP. She was asymptomatic, so I sent her home. Two hours after discharge, she developed respiratory distress.” Compared to children with traditional non-pod laundry detergent exposures, LDP exposures are associated with a significantly higher incidence of adverse health effects, including mental status changes and respiratory compromise.


7. “The patient presented with difficulty swallowing 2 days post caustic ingestion. I thought it would be okay for the gastroenterologist to do an endoscopy to evaluate the extent of injury.” Endoscopy should be avoided on days 2 to 3 after a caustic injury due to increased risk of perforation.


8. “My patient with caustic ingestion was discharged home and then was readmitted for repeated exposure in a suicide attempt.” In adults, the 2 most frequent causes of caustic ingestion are occupational exposure and intentional ingestion with the goal of self-harm. Thus, in adult exposures, it is important to ask whether the caustic was ingested in a suicide attempt. All patients with intentional ingestion should be admitted to the hospital for further evaluation, including endoscopy.


9. “An 18-month-old came into the ED 1 hour after ingesting drain cleaner containing sulfuric acid. I gave her milk to try to neutralize the acid.” Any attempt at dilution of caustic ingestion should be limited to asymptomatic patients within minutes of ingestion. Attempts at neutralization can cause an exothermic reaction, worsening injury.


10. “After helping a patient with HF exposure remove his clothing, the patient care tech in the ED picked the clothing up off the floor, without gloves, to place in a patient belongings bag. He later developed severe pain to both hands consistent with HF skin exposure.” Universal precautions and staff safety are of primary importance when caring for patients with caustic exposure. Staff education and procedural steps should be taken to ensure staff do not come into direct contact with these dangerous agents.

Tables and Figures

References

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.

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