Caustics

Dr. Peter Krampl

Dr. Randall Berlin

21 February 2001

Introduction

Caustics Any substance in which pH neutralization takes

place at the expense of the tissues

Alkali; usually pH > 11 Liquefaction necrosis Deeper penetration Immediate injury and pain

Acid; usually pH < 3 Coagulation necrosis

Introduction

Injury depends on Volume pH Concentration TAR

Titratable acid or alkali reserve History

Name, amount, concentration Time of ingestion Accidental vs. purposeful Vomiting after ingestion

Introduction

Drain cleaners / lye Sodium or potassium hydroxide

Laundry / dishwasher detergents Sodium hydroxide

Batteries Potassium hydroxide

Deoderizers Formaldehyde

Cleaners Ammonia Acids in toilet bowel cleaners

Disinfectants, household bleaches Oxalic acid

Introduction

Inflammatory phase 0-48 hours

Granulation phase 2 days to 2 weeks

Stricture formation Usually seen after 4 weeks

Controversies

Dilutional vs Neutralization Therapy? Do all Patients Need Endoscopy? Use of Antibiotics / Steroids? Who Needs Surgery?

Case 1

A 14 month old presents to the ED after being found with a bottle of drain cleaner (pH 13). The mother is unsure if the child drank any. In the ED the child looks well with normal vital signs, no respiratory distress, no stridor, no drooling, no vomiting and no oral lesions.

Case 1

How would you manage this patient? ? GI decontamination, ? dilutional, ? endoscopy, ? disposition)

S/S as Predictors

Gaudreault et al; Pediatrics; 1983 378 cases over 10 years Vomiting 33% Grade 2/3 lesions Dysphagia 25% Abdo Pain 24% Oral burn 18%

S/S as Predictors

Crain et al; AJDC; 1984 79 patients Retrospective review Presence of symptoms (Crain criteria: vomit,

drool, stridor) plus oropharyngeal burns compared to endoscopy

2/3 symptoms gave 50% (7/14) indication of serious injury

1/3 gave 0% (7/14)

S/S as Predictors

Previtera et al; Ped EM Care; 1990 Prospective study 156 cases over 10 years

Symptoms compared to endoscopy within 24h Observation of visible lesions of cheeks, lips

and oropharynx 38.4 % visible lesions

Absence cannot rule out Grade 2 Burn Presence indicates higher risk of Grade 2/3 burns

S/S as Predictors

Gorman et al; AJEM; 1992 Prospective trial Endoscopy blinded to symptoms 36 ingestions

Vomit, dysphagia, abdo pain, oral burns (sens 94; spec 49

Vomit, dysphagia, abdo pain, dysphagia (sens 89; spec 58

Crain Score: vomit, drool, stridor (sens 56; Spec 91)

S/S as Predictors

Christeen. Acad Pediatrics.1995. Retrospective study 115 cases over 19 years Stridor, vomit or drool

1 S/S Sens 1.0; Neg PV 1.0 3 S/S Pos PV 0.91; Spec 99%

S/S as Predictors

Textbook: Evaluate for vomiting, drooling, stridor If assymptomatic w.r.t. above, endoscopy

not necessary ‘endoscopy should be entertained if one

symptom present’ Remember though, if stridor present , Gorman

et al showed it to carry higher degree of specificity.

Case 2

A 14 yo female presents to the ED after drinking something in chemistry class that she thought was apple juice. Substance is later identified as a mixture of DMSO, potassium hydroxide, sodium hydroxide and Luminal (pH 12). Upon presentation to the ED she was complaining of a burning sensation in her mouth and chest and was vomiting. She is able to swallow but it is extremely painful, her mouth is erythematous and blistered.

HR 120; BP 100/60. RR 20, O2 saturation 95%

How would you manage this patient?? GI decontamination? Dilutional? diagnostic tests

labsxrayUGI

 

Her chest xray is normal

How would you manage this patient??endoscopy ? steroids ? antibiotics Endoscopy showed: The esophageal mucosa showed

diffused exudative esophagitis, the depth could not be adequately demonstrated. It was, however, circumferential.

What Grade is this?

Initial Tx: Decontamination

Textbook: Orogastric and nasogastric tubes carry risk of

perforation Listed as contraindicated in one source but noted may

be used in first 90 minutes in another source to remove substance from GI tract?

Activated charcoal contraindicated as it will interfere with endoscopy

Most caustics not absorbed by charcoal Ipicac contraindicated

Addition of another caustic

Initial Tx: Milk / Water Dilution

Rumack et al. Clinical Tox. 1977 Review of laboratory temperature

measurements of adding milk, water and weak acid neutralizers to corrosive injuries

Milk and water produced the lowest temperatures though water had a greater area under the time-temperature curve

Initial Tx: Dilution/Neutralization Kimball et al. Annals of EM; 1985 Compared buffering, dilution and

neutralization Buffering ? Slow neutralization no benefit

May be harmful due to temperature rise Dilution variable secondary to strength of ingested

material Neutralization may be beneficial only in the case

of weak acid to strong base… minimal temperature rise

Initial Tx: Saline / Water / Milk Dilution Homan et al. Annals of EM; 1993

60 rat esophogi 60 minute saline infusion started at 0, 5, 30

minutes after ingestion At 0 minutes 54% show Grade 2 or more At 30 minutes 100% showed Grade 2 or more May be beneficial but time to institution critical

Similar trial with mil in 1995 which showed slight improvement at 0,5 minutes but no change in outcome at 30 minutes

Initial Tx:Dilution / Neutral / Buffering Textbook:

Dilutional therapy with water or milk may compromise airway because of potential for vomiting; vomiting can lead to re-exposure.

Studies show benefit only in first few minutes ‘use of milk or water should be limited to first few

minutes after exposure in patients with no airway compromise, no vomiting, no abdo pain, are alert and are old enough to speak’

Neutralization therapy may worsen by exothermic heat reaction

Tests: Radiography

Textbook: Limited benefit in initial stabilization May be useful for judging type of foreign material

in case of batteries, and for signs and symptoms of severe injury:

Pneumomediastinum Pleural effusions Pneumoperitoneum CXR usually most helpful film in stabilization

Contrast studies such as GI series of benefit in follow-up of Grade 2a lesions and higher

Tests: Endoscopy

Showkat et al; GI/GI Endo; 1989/91 Prospective studies 41 patients/81 patients 87 % esophageal injury seen by scope

within 36 hours

Classification grade 0 to 3 within 36hrs 0 normal 1 edema and hyperemia of mucosa 2 a blister / friable 2 b: 2a with ulceration

“Near” circumferential Important point for stricture formation

3 multiple deep ulcerations circumferential

– 3a small scattered areas– 3b large extensive areas of necrosis (11/11 deaths)

All 0, 1, 2a recovered without squeal

Tests: Endoscopy

Surfeit et al. Br. J. Surgery. 1987 Retrospective review 484 patients over 12 years Reaffirmed endoscopy indications All 250 patients assigned Superficial- Grade 1

on endoscopy healed without sequelae Note study done prior to Showkat criteria and I

superimposed their definition of superficial to fall within grade 1.. Possibly Grade 2a.

Tests: Endoscopy

Textbook: Indications

Stridor Both vomiting and drooling Intentional ingestions in adults

Not indicated Assyptomatic accidental exposures Patients who fit operative criteria

Timing of scope ? 6 hours to grade full extent of injury

Tests: Endoscopy

Textbook: Optimal < 12 hours Increased risk or perforation from

endoscopy usually not until 24 hrs Graded as per modified Showkat criteria

2a is a main cut-off– < / equal 2a soft diet; NG; stricture risk very low– > 2a serial endoscopies

• Increased complications such as perforation, stricture and therefore increased surveillance

Tx: assympotmatic or Grade 0 and 1 on endoscopy Textbook:

Humidified air Analgesia Parenteral fluids prn Progressive oral fluids

Case 3

A 14 month old male presents to the ED after drinking HD Liquid Pipeline Cleaner (sodium hydroxide, sodium hyperchlorite, polyacrylate sodium). Immediately after drinking the cleaner the child began to vomit and have respiratory difficulty “choking”.

In the ED the child has a decreased level of consciousness, HR 138, RR 28, BP 121/77, T 36.4 C. The child is drooling thick yellow secretions and has burns to her tongue, face and chest. The child is stridorous, wheezing and continuing to vomit. Abdomen has some guarding but generally felt to be non-peritoneal.

How would you manage this patient?(? ABCs, diagnostic tests , GI decontamination, neutralization therapy) The child is intubated. CXR normal. ABG 7.41/27/119/17 Lytes:

134/4.2/106/23 glucose 6.6, BUN 2.4 How would you manage this patient?(? steroids, ? antibiotics, ? endoscopy) Endoscopy shows circumferential burns, 3rd degree burns, extensive

exudate in the stomach.

 

Tx: Steroids

Initial benefit shown in non-randomized, non controlled trials Spain et al. 1950 Haller et al. 1960

Steroids mainstay of treatment into the 1970’s

Tx: Steroids

Webb et al. Annal of Thoracic Sx; 1970. 68 patients; prospective; non-random Initial esophageal grade >1 Steroid administration showed no difference in

stricture rates among 2nd or 3rd degree lesions. Ferguson et al. AJ Surg; 1989

Retrospective study 1974-1987; 47 patients Retrospectively reviewed incidence of esophageal

stricture in relation to endoscopic grade in non steroid vs. steroid groups.

No difference but p<0.15; not powered to find

Tx: Steroids

Anderson et al. NEJM. 1988. Prospective; 60 children; not blinded Strictures in 10/31 versus 11/29 in

treated versus untreated; p>0.05 Problems included

Ampicillin given in steroid group Endoscopy criteria poorly adhered Multiple exclusions including ammonia

Tx: Steroids Howell et al. AJEM. 1992 Met analysis of 361 patients

10 retrospective and 3 prospective studies Either treatment with steroids and antibiotics (T) versus

no treatment (NT) No intermediate group T group 25% stricture in 2nd/3rd degree NT group 52%; p<0.01 Higher percentage of 3rd degree in NT group

Poor study because not enough good studies to do meta-analysis

Tx: Steroids

Textbook: Variable studies Not indicated in Grade 0,1 lesions since strictures do

not develop May not be useful in high Grade 3 lesions

may progress to stricture regardless of therapy High risk of perforation Mask s/s of peritonitis

In between grade of Grade 2a-3a have poor/ limited studies

Current review recommendation is no steroids until well-controlled prospective study available

Tx: Antibiotics

Textbook: Usually concomitant therapy with steroids Also given due to belief that tissue

disruption may cause alternate pathway for infection deep to mucosal layer of GI tract

No good trials either w or w/o steroids

‘reserve antibiotics for identified source of infection unless steroids are used’

Case 4

 

A 30 year old female presents to the emergency department 3 hours after ingesting an unknown amount of “drain opener” (concentrated sulfuric acid) in a suicide attempt. On presentation the patient is drooling and has frothy sputum. BP 90/50, HR 140, O2 saturation 92% on 5 L by mask, T 38 C. She is lethargic but able to answer questions with nodding. Her mouth is swollen and erythematous. Her lungs are clear. Her abdomen is diffusely tender with peritoneal signs.

How would you manage this patient?(ABCs, GI decontamination, diagnostics) Her blood pressure continues to fall and she is started on vasopressors.

CXR: normal; electrolytes: 147/6.9/112/11/120; glucose 6.0; 6.97/40/101/9; amylase 774, PT 19.2, PTT 126.8

 How would you manage this patient?(? endoscopy, ? antibiotics, ? steroids, ? surgery) 

 

Tx: Surgery

Estera et al. Ann Thoracic Sx. 1986. 62 patients reviewed 1974-1980 First 2 years management was endoscopy,

steroids, ABX and dilatation Last 4 years treatment for Grade 2/3 included

surgical intraluminal stents and resection; Sequalae in (2a/b) reduced from 5/7 to 0/3

Study seemed to omit differentiation between 2a/b No specific inclusion criteria for surgery Death in 3b reduced from 3/4 to 0/3

Tx: Surgery Horvath et al. Ann Thor. Sx. 1991. Case reports of good outcomes of 4/8 Grade 3

patients after early esophagogastrectomy No trial criteria. Not consistent with regard to initial treatment based on

esophageal grades Wu et al. Surgery. 1993.

Retrospective review 28 patient with severe ingestions underwent surgery. Mortality 50%; 100% GI morbidity Difficult to apply initial criteria

Tx: Surgery

Textbook: Serum pH < 7.2 Gastric ph > 7.3 Perforation seen on CXR, endoscopy S/S shock with respiratory compromise Hemoglobnuria Ascites Coagulation abnormalities

Other Points

Lathryogens Penicillamine, NAC, colchicine inhibit collagen

synthesis and/or breakdown Experimental non-trial evidence so far

Strictures management Prevention

Stents, NG tubes Steroids / Abx

Serial dilatation Usually after 4 weeks

Surgery

In summary……

Studies

Mainly retrospective Mainly case studies Those that are prospective suffer

Non-randomization Poorly defined inclusion criteria Poorly adhered inclusion criteria

I.e endoscopy criteria

Few numbers P value to large

Studies not powered to be significant Difficult to do meta analysis studies

Pete’s Treatment Algorithm ABC’s

Manage airway aggressively similar to inhalational burn

Decontamination Consider NG Dilution based on early time from exposure, i.e. at

home No lavage No charcoal No emesis

Pete’s Treatment Algorithm

Use signs and symptoms to decide upon endoscopy Usually at 4-6 hours If you are worried enough to do endoscopy, get

CXR and labs while you wait If meet criteria for surgery bypass go….. do not

collect $200. Based on initial S/S, ABG, CXR, presence of shock,

bleeding Once to endoscopy, grade will aid decision

Pete’s Treatment Algorithm

Steroids / ABX not indicated in ER because Limited studies Possible use in Grade 2 needs to be confirmed by

endoscopy first so no role for ER

If grade 0 or 1 endoscopy: Humidified air Analgesia Parenteral fluids Progressive oral fluids

Pete’s Treatment Algorithm

If grade 2 or 3 endoscopy: Treat as per Grade 0 or 1 injury, but

No oral fluids initially ? Consider steroids ? Consider antibiotics Consider stent / stricture prophylaxis Review at 2-4 weeks for stricture evaluation

– dilatation

Pete’s Treatment Algorithm

Disposition? Assymptomatic and Grade 0 on endoscopy

Home

Grade 1 may be admitted for pain control Observation Social / psych issues

GI likely to be involved in decision process Resume enteric feeds sooner than later Ongoing monitoring