Case: A patient presents to your ED after ingesting household bleach. The resident is getting the airway box ready to intubate but then attending says “Don’t worry. If it’s a household bleach, then it’s probably not dangerous but call Toxicology if you want”. Puzzled at the different responses, you’re not sure how to approach this patient.
This week: Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. New England Journal of Medicine. 2020 Apr 30;382(18):1739-48.
We’re talking about caustic ingestions. Luckily, the New England Journal of Medicine has a great succinct review article for us (Tintinalli’s also has a nice overview).
What: An 8-page review article on caustic ingestions from our Toxicology colleagues on the east coast and Canada. It covers the basic pathophysiology and delineates a framework for evaluation, treatment, and disposition.
For adjunct reading, EMDocs has a succinct blurb on Caustic Eye injuries: http://www.emdocs.net/toxcard-caustic-eye-injuries/
Why: We will see a variety of ingestions and exposures in the ED. We’re fortunate to always have easy access to our robust Toxicology service at Cook County, but we should have a basic understanding of caustic ingestions and their management too. As such this article is full of great learning points for the ED physician. Rather than reiterate the article, here are some good take-home points:
1. Pediatric patients tend have small exploratory ingestions with more benign presentations compared to adolescents and adults with large-volume intentional ingestions. But stay vigilant for non-accidental trauma. Children shouldn’t be able to unscrew a lid before they are ~2 years of age.
- One study showed only 8% pediatric ingestions requiring treatment compared to 81% adult ingestions.
2. Lack of external injury in the face and oropharynx is not enough to rule out serious injury. The article recommends assessing the airway (hoarse voice, stridor, dyspnea) and then evaluating for drooling and vomiting/PO intolerance.
3. Endoscopy, if necessary, should ideally occur within 24-48 hrs, so consult GI early if you think it’s necessary
4. Don’t forget to evaluate the skin and eyes for injury. If there is a significant exposure of the eyes, they will require aggressive irrigation via Morgan Lens, pH paper assessment, and an Ophtho consult
5. Steroids might have a role, but only in injuries of certain severity (< 2B Zargar classification). In the ED, we should hold off and leave it to our colleagues upstairs
6. Hydrofluoric acid, in addition to caustic injury, can also rapidly cause life-threatening systemic symptoms including hypocalcemia and hypomagnesemia.
There’s much more information in the article itself. I’ve also attached their algorithm below. Keep in mind that this is only one approach and framework, but it can help guide our conversations with specialists. This topic is nuanced and we should certainly reach out to our local poison control and/or toxicology service if available, but the article certainly can help inform our initial approach.
As always, read for yourself and discuss with your attendings/colleagues/friendly Toxicologist.
Written by Dr. Jorge Aceves, MD
Chief Resident
Twitter: @joaceve91
Peer Reviewed by Dr. Neeraj Chhabra, MD
Twitter: @NeerajBC