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

Table of Contents

 

About This Issue

Exposure to alkali caustic substances can cause severe and progressing tissue damage, so prompt decontamination and evaluation are critical to minimize severe respiratory, gastrointestinal, and ophthalmic damage. In this issue, you will learn:

How history informs risk stratification: patient age, intentionality, and time from ingestion

When plain water is appropriate for decontamination and when water decontamination can be hazardous

How to know when emergent intubation is required

How the Zargar classification system specifies injury grading and how grading dictates treatment

Computed tomography versus endoscopy: which should you choose and when?

When corticosteroids may be helpful and when they increase the risk for esophageal perforation

How long to hold patients for observation, given that alkali injuries may have delayed presentation

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
   1. Scene Safety and Decontamination
   2. Prehospital Evaluation
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Testing
    2. Electrocardiogram
    3. Imaging Studies
       1. Radiography
       2. Endoscopy
       3. Computed Tomography
       4. Computed Tomography Versus Endoscopy
11. Treatment
    1. Resuscitation
    2. Decontamination
    3. Triage and Assessment
    4. Medication Use
       1. Corticosteroids
       2. Other Medications
12. Special Populations
13. Disposition
14. Risk Management Pitfalls in Emergency Department Management of Alkali Exposures
15. 5 Things That Will Change Your Practice
16. Summary
17. Case Conclusions
18. Clinical Pathway for Emergency Department Management of Patients With Alkali Ingestion
19. Tables and Figures
20. References

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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Clinical Pathway for Managing Patients Presenting with Acute Diarrhea in Urgent Care

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

11. * Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. N Engl J Med. 2020;382(18):1739-1748. (Review) DOI: 10.1056/NEJMra1810769

23. * Chirica M, Resche-Rigon M, Zagdanski AM, et al. Computed tomography evaluation of esophagogastric necrosis after caustic ingestion. Ann Surg. 2016;264(1):107-113. (Prospective; 120 patients) DOI: 10.1097/SLA.0000000000001459

28. * Zargar SA, Kochhar R, Mehta S, et al. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc. 1991;37(2):165-169. (Prospective observational; 81 patients) DOI: 10.1016/s0016-5107(91)70678-0

30. * Usta M, Erkan T, Cokugras FC, et al. High doses of methylprednisolone in the management of caustic esophageal burns. Pediatrics. 2014;133(6):E1518-E1524. (Randomized controlled trial; 83 patients) DOI: 10.1542/peds.2013-3331

33. * Crain EF, Gershel JC, Mezey AP. Caustic ingestions. Symptoms as predictors of esophageal injury. Am J Dis Child. 1984;138(9):863-865. (Retrospective chart review; 79 patients) DOI: 10.1001/archpedi.1984.02140470061020

34. * Chirica M, Resche-Rigon M, Pariente B, et al. Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy. Surg Endosc. 2015;29(6):1452-1461. (Evaluation study; 197 patients) DOI: 10.1007/s00464-014-3823-0

36. * Chirica M, Bonavina L, Kelly MD, et al. Caustic ingestion. Lancet. 2017;389(10083):2041-2052. (Review) DOI: 10.1016/S0140-6736(16)30313-0

37. * Assalino M, Resche-Rigon M, Corte H, et al. Emergency computed tomography evaluation of caustic ingestion. Dis Esophagus. 2022;35(11):1-7. (Prospective, comparative study; 414 patients) DOI: 10.1093/dote/doac032

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Keywords: alkali, caustic, ingestion, airway, esophagus, perforation, burn, decontamination, pH, Zargar, corticosteroid