Caustic burn: Difference between revisions
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##Indicated for peritoneal signs, free intraperitoneal or mediastinal air | ##Indicated for peritoneal signs, free intraperitoneal or mediastinal air | ||
#No evidence to support prophylactic abx | #No evidence to support prophylactic abx | ||
#Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage | |||
==Disposition== | ==Disposition== |
Revision as of 15:58, 26 May 2014
Background
- Substances that cause damage on contact with body surfaces
- Degree of injury determined by pH, concentration, volume, duration of contact
- Etiologies for shock include GI bleeding, perforation, volume depletion
- Intentional ingestion a/w higher grade injuries
- Esophageal injuries
- Mild injuries - normal function is restored
- Severe injuries - strictures
- Days 2-14 post-injury are associated with highest tissue friability / risk of perforation
- High-grade caustic burns associated with 1000x increase in esophageal SCC
Alkalis
- Hydroxide ion easily penetrates tissue causing immediate cellular destruction
- May cause deep penetration into surrounding tissues (e.g. abd/mediastinal necrosis)
- Examples
- Bleach, drain openers, oven cleaners, toilet cleaner, hair relaxers
- Household bleach rarely causes significant injury
Acids
- Hydrogen ion leads to cell death and eschar formation, which limits deeper involvement
- However, due to pylorospasm and pooling, high-grade gastric injuries are common
- Mortality rate is higher compared to strong alkali ingestions
- However, due to pylorospasm and pooling, high-grade gastric injuries are common
- Ingestion may be complicated by systemic absorption (met acidosis, hemolysis, ARF)
- Examples
- Auto batteries, drain openers, metal cleaners, swimming pool products, rust remover
Diagnosis
- All pts w/ serious esophageal injuries have some initial sign or symptom
- E.g. stridor, drooling, vomiting
- Exam eyes and skin (splash and dribble injuries may easily be missed)
- GI tract injury
- Dysphagia, odynophagia, epigastric pain, vomiting
- Laryngotracheal injury
- Dysphonia, stridor, respiratory distress
- Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes
Work-Up
Labs
Only necessary in pts w/ significant injury
- CBC
- Chemistry
- VBG
- Anion gap acidosis due to lactate production (tissue injury) or from the acid itself
- May also have non-anion gap acidosis (e.g. HCl)
- Anion gap acidosis due to lactate production (tissue injury) or from the acid itself
- Lactate
- LFTs
- Coags
- Type and screen
- Calcium level
- If HF acid exposure
- ECG
- Screens for coingestants in suicidal pts
- May show QT-prolongation if hypocalcemic 2/2 HF acid
Imaging
- Upright CXR
- Detect peritoneal and mediastinal air
- Left-side down CXR
- Indicated if unable to tolerate upright CXR
- CT
- Consider when perforated viscus is suspected or after intentional ingestion
Treatment
- Prevent personal exposure to the caustic agent
- Airway
- Should be considered as a difficult airway
- Blind nasotracheal intubation is contraindicated
- First-line is awake oral intubation w/ direct visualization
- LMAs, combitubes, bougies are probably unsafe; should be used as last resort
- Surgical back-up is recommended
- Steroids
- Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds)
- Decontaminate in usual manner
- Activated charcoal
- Only consider when coingestants pose a risk for severe systemic toxicity
- Endoscopy
- Should be performed <12hr after ingestion and no later than >24hr after ingestion
- Indications:
- Intentional ingestion
- Unintentional ingestion with signs of:
- Stridor
- Significant oropharyngeal burns
- Vomiting
- Drooling
- Food refusal
- Surgery
- Indicated for peritoneal signs, free intraperitoneal or mediastinal air
- No evidence to support prophylactic abx
- Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
Disposition
- All pts w/ symptomatic caustic ingestions should be admitted
Special Situations
Dermal Exposure
- Acidic injuries (except HF acid)
- Respond well to copious saline or water irrigation
- Alkali injuries
- May appear superficial but often are deeper w/ ongoing burn
- Treat w/ copious irrigation and local wound debridement to remove residual compound
- Disposition
- Admit the following:
- Injuries that cross flexor or extensor surfaces
- Facial injuries
- Perineum injuries
- Partial-thickness injuries >10-15% of BSA
- All full-thickness burns
- Admit the following:
Airbag-Related Burns
- Deployment releases small amount of alkali
- Skin burns are usually minor
- Ocular burns require irrigation, pH testing and ophto f/u
- Long-term sequelae are rare
See Also
Source
Tintinalli