Caustic burn

Background

• Substances that cause damage on contact with body surfaces
• Degree of injury determined by pH, concentration, volume, duration of contact

Systemi

• Etiologies for shock include GI bleeding, perforation, volume depletion
  • Intentional ingestion a/w higher grade injuries

Esophageal injuries

• depending severity may have full return of mobility and function or can progress to perforation followed by stricture formation
• 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
• 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 patients with significant injury or volume of ingestion

Consider:

• CBC
• Chemistry
• Lactic Acid
• Lactate
• Calcium level (if Hydrofluoric Acid exposure)
• ECG
  • May show QT-prolongation if hypocalcemic secondary to HF acid
• Screens for tylenol levels in suicidal patients at risk for congestions

Imaging

• Upright CXR
  • Look for free air under the diaphragm indicating a perforation or mediastinal air
• CT
  • Consider when perforated viscus is suspected based on severity of ingestion or peritoneal signs on exam

Treatment

First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient

Airway Management

1. Should be considered as a difficult airway
2. Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
3. First-line is awake oral intubation with direct visualization
4. LMAs, combitubes, bougies are probably may be safe depending on the type of caustic ingestion
5. Surgical back-up is recommended

Steroids

1. Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds)
2. Activated charcoal
3. 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

1. Intentional ingestion
2. Unintentional ingestion with signs of:
   1. Stridor
   2. Significant oropharyngeal burns
   3. Vomiting
   4. Drooling
   5. Food refusal

Surgical intervention

1. Indicated for perforations, peritoneal signs, free intraperitoneal or mediastinal air

Antibiotics

1. No evidence to support or reject the use of prophylactic antibiotics

Gastric Lavage

Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage

Disposition

• All patients with symptomatic from a caustic ingestion should be admitted

Special Situations

Dermal Exposure

• Acidic injuries (except HF acid)

May also have non-anion gap acidosis (e.g. HCl)

• • 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

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

• Hydrofluoric Acid
• Caustic Keratoconjunctivitis
• Airbag Injuries

Source

Tintinalli