History

Fact Explanation
Loss of vision, skin burns or irritation, severe pain or burning sensation in the nose, eyes, ears, lips, tongue, mouth etc, excessive tear formation These symptoms develop when cleaning substances that contain corrosive agents come in contact with the eyes, skin or the mucosal surfaces of the upper airway and gastrointestinal tract and cause damage, Ingestion or skin contact with phenol, (contained in disinfectants) can cause characteristic chemical burns to the mucous membranes. These burned areas are initially white in color but change brown with time and are painless due to destruction of nerve endings [2]
Dyspnea, cough, sore throat, 'runny' nose, chest pain, wheeze, drooling of saliva, frothy/blood stained sputum production These symptoms indicate toxic effect of the substance on the respiratory system. It is important to be cautious and be prepared to manage airway obstruction caused by edema in airways. Inhalation of chlorine gas released when substances containing chlorine (such as house hold bleaches) with acidic lavatory cleaners can give rise to such symptoms. In severe exposure paients may develop acute chemical pneumonitis, pulmonary edema, acute respiratory distress syndrome and respiratory failure. Inhalation of ammonia can also give rise to similar symptoms[2][5][7]
Nausea, vomiting, hematemesis, diarrhea, presence of blood in stools, dysphagia, odynophagia, severe abdominal pain Indicate gastrointestinal involvement following ingestion of a corrosive substance. Poisoning with house hold bleaches which contain sodium hypochlorite, cause nausea ,vomiting, diarrhea, abdominal pain and rarely mucosal ulceration when taken in high concentrations. These symptoms can also occur after ingestion of corrosive acidic substances such as hydrochloric acid, sulfuric acid etc or alkali substances such as ammonia, sodium hydroxide, contained in cleaning substances[2][4][5]
Fainting, dizziness Is seen when the patient develops hypotension as seen following ingestion of substances that contain corrosives,phenol, surfactants (contained in detergents) etc.[3]
Headache, seizures, coma Indicate central nervous system involvement associated with severe toxicity, which is rare. Is seen in poisoning with agents such as disinfectants and fabric stain removers containing phenol, hydrogen peroxide, isopropanol etc. [1][3][6]
History of coming to contact with/ ingestion of a particular cleaning substance It is important to determine the agent which caused the toxicity in order to anticipate complications and make appropriate changes in management[1][3][5]
References
  1. MüLLER D, DESEL H. Common Causes of Poisoning: Etiology, Diagnosis and Treatment Dtsch Arztebl Int [online] 2013 Oct, 110(41):690-700 [viewed 13 July 2014] Available from: doi:10.3238/arztebl.2013.0690
  2. TURNER A, ROBINSON P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J [online] 2005 May, 22(5):359-61 [viewed 19 July 2014] Available from: doi:10.1136/emj.2004.015610
  3. BETALLI P, ROSSI A, BINI M, BACIS G, BORRELLI O, CUTRONE C, DALL'OGLIO L, D'ANGELIS GL, FALCHETTI D, FARINA ML, GAMBA P, GANDULLIA P, LOMBARDI G, TORRONI F, ROMANO C, DE ANGELIS P. Update on Management of Caustic and Foreign Body Ingestion in Children Diagn Ther Endosc [online] 2009:969868 [viewed 20 July 2014] Available from: doi:10.1155/2009/969868
  4. MCKENZIE LB, AHIR N, STOLZ U, NELSON NG. Household cleaning product-related injuries treated in US emergency departments in 1990-2006. Pediatrics [online] 2010 Sep, 126(3):509-16 [viewed 23 July 2014] Available from: doi:10.1542/peds.2009-3392
  5. PRESGRAVE RDE F, CAMACHO LA, VILLAS BOAS MH. A profile of unintentional poisoning caused by household cleaning products, disinfectants and pesticides. Cad Saude Publica [online] 2008 Dec, 24(12):2901-8 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19082281
  6. PRITCHETT S, GREEN D, ROSSOS P. Accidental ingestion of 35% hydrogen peroxide Can J Gastroenterol [online] 2007 Oct, 21(10):665-667 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658134
  7. DUNN S, OZERE RL. Ammonia inhalation poisoning-household variety. Can Med Assoc J [online] 1966 Feb 19, 94(8):401 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20328511

Examination

Fact Explanation
Dyspnea, tachypnea, stridor, audible or auscultatory wheeze These signs indicate respiratory system involvement. Even though these signs are not common, they indicate severe airway involvement and patient may require rapid air way management. These can be seen with inhalation of substances such as chlorine, ammonia, hydrogen peroxide and ingestion of corrosive acids , alkali etc [1][2][3]
Tachycardia, hypotension Arise with cardio-respiratory involvement seen with intoxication of agents containing corrosive acids or alkali, hydrogen peroxide, isopropanol etc.[1][2][3]
Swollen lips, hematemesis, ulcerated oral mucosa, melena These gastrointestinal signs develops when corrosive cleaning substances are ingested[1]
Abdominal guarding, rebound tenderness, and diminished bowel sounds These signs indicate the presence of acute peritonitis following bowel perforation [1]
Altered mental status, seizures Develops when there is central nervous system involvement which occurs with severe toxicity. Poisoning with agents containing phenol, hydrogen peroxide, isopropanol etc can cause central nervous system toxicity[1][2][3]
References
  1. TURNER A, ROBINSON P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J [online] 2005 May, 22(5):359-61 [viewed 19 July 2014] Available from: doi:10.1136/emj.2004.015610
  2. PRESGRAVE RDE F, CAMACHO LA, VILLAS BOAS MH. A profile of unintentional poisoning caused by household cleaning products, disinfectants and pesticides. Cad Saude Publica [online] 2008 Dec, 24(12):2901-8 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19082281
  3. PRITCHETT S, GREEN D, ROSSOS P. Accidental ingestion of 35% hydrogen peroxide Can J Gastroenterol [online] 2007 Oct, 21(10):665-667 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658134

Differential Diagnoses

Fact Explanation
Chemical burns Other chemicals which can cause burns, such as petroleum products, pesticides, urea etc should be considered in patients presenting with burns. In case of a child, child abuse should always be considered[1]
Gastroesophageal Reflux Disease and Esophagitis These patients can also present with burning retrosternal pain, dysphagia, nausea, vomiting etc[3]
Anaphylaxis Patient can present with features of respiratory compromise, skin involvement, gastrointestinal symptoms etc[6]
Epiglottitis Presents with stridor, respiratory difficulty, difficulty swallowing,drooling of saliva and fever. Is commoner in children than adults. Proper airway management is extremely important in these patients as epiglottitis can cause considerable mortality[5]
Perforated Peptic Ulcer Can present with severe abdominal pain, gastrointestinal bleeding and signs of peritonitis[4]
Aspiration Pneumonia Aspiration of foreign material into the lungs can cause aspiration pneumonia and pneumonitis. Gastric content aspiration is not an uncommon occurrence in critically ill patients[2]
Gastroenteritis Can present with nausea, vomiting, abdominal cramps etc.[6]
References
  1. RAMAKRISHNAN KM, MATHIVANAN T, JAYARAMAN V, BABU M, SHANKAR J. Current scenario in chemical burns in a developing country: Chennai, India Ann Burns Fire Disasters [online] 2012 Mar 31, 25(1):8-12 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3431731
  2. RAGHAVENDRAN K, NEMZEK J, NAPOLITANO LM, KNIGHT PR. Aspiration-Induced lung injury Crit Care Med [online] 2011 Apr, 39(4):818-826 [viewed 22 July 2014] Available from: doi:10.1097/CCM.0b013e31820a856b
  3. KAO SS, CHEN WC, HSU PI, CHUAH SK, LU CL, LAI KH, TSAI FW, CHANG CC, TAI WC. The Frequencies of Gastroesophageal and Extragastroesophageal Symptoms in Patients with Mild Erosive Esophagitis, Severe Erosive Esophagitis, and Barrett's Esophagus in Taiwan Gastroenterol Res Pract [online] 2013:480325 [viewed 22 July 2014] Available from: doi:10.1155/2013/480325
  4. THORSEN K, SøREIDE JA, SøREIDE K. Scoring systems for outcome prediction in patients with perforated peptic ulcer Scand J Trauma Resusc Emerg Med [online] :25 [viewed 22 July 2014] Available from: doi:10.1186/1757-7241-21-25
  5. TROLLFORS B, NYLéN O, STRANGERT K. Acute epiglottitis in children and adults in Sweden 1981-3. Arch Dis Child [online] 1990 May, 65(5):491-494 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1792127
  6. HOWIDI M, AL KAABI N, EL KHOURY AC, BRANDTMüLLER A, NAGY L, RICHER E, HADDADIN W, MIQDADY MS. Burden of acute gastroenteritis among children younger than 5 years of age - a survey among parents in the United Arab Emirates BMC Pediatr [online] :74 [viewed 22 July 2014] Available from: doi:10.1186/1471-2431-12-74

Investigations - Fitness for Management

Fact Explanation
pH testing of saliva Unexpected high or low values may confirm ingestion and predict degree of tissue injury but a neutral pH cannot rule out a caustic ingestion[1]
Complete blood count (CBC) Done to determine base line values[1]
Electrolyte levels Done to detect presence of electrolyte imbalances[1]
Creatinine level Done to assess renal function[1]
Arterial blood gases Done in patients with respiratory failure[1]
Liver function tests Done to establish baseline levels. If abnormal may indicate severe injury[1]
Electrocardiogram May help to detect presence of cardiac rhythm abnomalities [1]
Chest X ray Should be done for all who ingested caustic substances. Expected findings may include pneumomediastinum, mediastinitis, pleural effusions, pneumoperitoneum, aspiration pneumonitis, The absence of findings does not exclude perforation or other significant injury[2]
Upper gastrointestinal endoscopy Can be done to visualize the injuries in the upper gastrointestinal tract, but there is controversy about its use. It shouldn't be performed in who with evidence of esophageal, gastrointestinal perforation, or hemodynamical instability [2]
References
  1. BETALLI P, ROSSI A, BINI M, BACIS G, BORRELLI O, CUTRONE C, DALL'OGLIO L, D'ANGELIS GL, FALCHETTI D, FARINA ML, GAMBA P, GANDULLIA P, LOMBARDI G, TORRONI F, ROMANO C, DE ANGELIS P. Update on Management of Caustic and Foreign Body Ingestion in Children Diagn Ther Endosc [online] 2009:969868 [viewed 20 July 2014] Available from: doi:10.1155/2009/969868
  2. TURNER A, ROBINSON P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J [online] 2005 May, 22(5):359-61 [viewed 19 July 2014] Available from: doi:10.1136/emj.2004.015610

Management - General Measures

Fact Explanation
Emergency management Supportive care is the mainstay of management. Assess and secure the airway, breathing and circulation. Rapid airway management may necessitate owing to rapid development of airway edema. Once there is no acute threat to life take a relevant brief history and do relevant examination to recognize agent ingested. Patient with caustic ingestion are kept nil by mouth until upper gastrointestinal perforation is excluded. Intravenous fluid therapy should be initiated[1][3][5]
Oxygen therapy and assissted ventilation Is given to patients who require respiratory support[1][4]
Physiotherapy These patients require physiotherapy to prevent further neuromuscular morbidity and deformity. Chest physiotherapy will be required to prevent accumulation of pulmonary secretions and to prevent development of orthostatic pneumonia[3]
Psychiatric referral Should be done if the patient committed deliberate self harm/had suicide intent or if he/she is a known patient with a psychiatric disorder. This will help to reduce recurrence of similar incidents[2]
References
  1. DESFORGES JANE F., KULIG KENNETH. Initial Management of Ingestions of Toxic Substances. N Engl J Med [online] 1992 June, 326(25):1677-1681 [viewed 16 July 2014] Available from: doi:10.1056/NEJM199206183262507
  2. ADEDEJI TO, TOBIH JE, OLAOSUN AO, SOGEBI OA. Corrosive oesophageal injuries: a preventable menace Pan Afr Med J [online] :11 [viewed 20 July 2014] Available from: doi:10.11604/pamj.2013.15.11.2495
  3. BETALLI P, ROSSI A, BINI M, BACIS G, BORRELLI O, CUTRONE C, DALL'OGLIO L, D'ANGELIS GL, FALCHETTI D, FARINA ML, GAMBA P, GANDULLIA P, LOMBARDI G, TORRONI F, ROMANO C, DE ANGELIS P. Update on Management of Caustic and Foreign Body Ingestion in Children Diagn Ther Endosc [online] 2009:969868 [viewed 20 July 2014] Available from: doi:10.1155/2009/969868
  4. TURNER A, ROBINSON P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J [online] 2005 May, 22(5):359-61 [viewed 19 July 2014] Available from: doi:10.1136/emj.2004.015610
  5. SøREIDE JA, VISTE A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours Scand J Trauma Resusc Emerg Med [online] :66 [viewed 22 July 2014] Available from: doi:10.1186/1757-7241-19-66

Management - Specific Treatments

Fact Explanation
Antibiotics Parenteral antibiotics is administered if evidence of perforation exists. Third-generation cephalosporins or ampicillin/sulbactam will be considered.[1][4]
Proton pump inhibitors Are given to reduce exposure of injured esophagus to gastric acid, so that there will be decreased stricture formation[2][4][5]
Narcotic analgesics Given parenteral to reduce the pain associated with these ingestions. It is important to monitor for signs of sedation and respiratory depression[1]
Skin irrigation If there is skin contact, washing of the skin should be done. If the substance came into contact with any mucus membrane rapid irrigation is recommended[1][3]
Gastric aspiration and lavage Is not routinely done for all patients. Useful if only done within 1-2 hours from a life threatening ingestion. Done in the presence of a doctor and in a patient with a protected airway.Should not be done if the patient develops seizures, uncooperative or clinically unstable. In case of caustic ingestion aspiration is done via a nasogastric tube[1][3]
Surgical management Surgical consultation is needed when there is evidence of perforation, mediastinitis, peritonitis, stricture formation need for debridement of skin, burn patients etc[2]
References
  1. BETALLI P, ROSSI A, BINI M, BACIS G, BORRELLI O, CUTRONE C, DALL'OGLIO L, D'ANGELIS GL, FALCHETTI D, FARINA ML, GAMBA P, GANDULLIA P, LOMBARDI G, TORRONI F, ROMANO C, DE ANGELIS P. Update on Management of Caustic and Foreign Body Ingestion in Children Diagn Ther Endosc [online] 2009:969868 [viewed 20 July 2014] Available from: doi:10.1155/2009/969868
  2. CONTINI S, SCARPIGNATO C. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol [online] 2013 Jul 7, 19(25):3918-30 [viewed 20 July 2014] Available from: doi:10.3748/wjg.v19.i25.3918
  3. MüLLER D, DESEL H. Common Causes of Poisoning: Etiology, Diagnosis and Treatment Dtsch Arztebl Int [online] 2013 Oct, 110(41):690-700 [viewed 13 July 2014] Available from: doi:10.3238/arztebl.2013.0690
  4. SøREIDE JA, VISTE A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours Scand J Trauma Resusc Emerg Med [online] :66 [viewed 22 July 2014] Available from: doi:10.1186/1757-7241-19-66
  5. CHENG HT, CHENG CL, LIN CH, TANG JH, CHU YY, LIU NJ, CHEN PC. Caustic ingestion in adults: The role of endoscopic classification in predicting outcome BMC Gastroenterol [online] :31 [viewed 22 July 2014] Available from: doi:10.1186/1471-230X-8-31