Caustics

source: Acids and alkalis (e.g drain cleaner, bleach)

Caustic substance ingestion

Caustic (corrosive) substance ingestion is a common emergency department presentation in adults and children. The majority of cases are accidental exposures to household products: these are usually of little clinical consequence. Conversely, significant morbidity can occur when the substance is consumed in larger quantities with the intention of deliberate self-harm.

Types of substance* - vital to obtain bottle/label if possible

• Oxidising agents, e.g. hydrogen peroxide, sodium hypochlorite (found in household bleach)
• Strong alkali, e.g. sodium hydroxide, potassium hydroxide (found in dishwasher cleaner, industrial cleaners) -> liquefactive necrosis, more commonly resulting in oesophageal injury
• Strong acid, e.g. hydrochloric, nitric acid (found in car batteries, WC cleaner) -> coagulative necrosis, more commonly resulting in gastric injury

Acute management - (general principles, local guidance on timing of endoscopy and PPI may vary)

• ABCDE approach, particular caution to airway swelling and compromise, look for peri-oral oedema
• Urgent upper GI surgical referral if signs of perforation present (surgical emphysema, mediastinal widening on chest x-ray)
• Neutralisation of ingested substance (e.g. with milk) should be avoided as the resulting exothermic reaction will release heat and may cause further injury
• High dose IV PPI
• Symptomatic ingestion (drooling, vomiting, dysphagia, odynophagia, chest pain) requires urgent assessment with upper GI endoscopy to assess the degree of ulceration (Zargar classification). Extensive injury on endoscopy should prompt consideration of urgent surgical exploration
• Asymptomatic ingestion can usually be discharged after a trial of oral fluid and a period of observation

Complications

Acute

• Upper GI ulceration, perforation
• Upper airway injury and compromise
• Aspiration pneumonitis