• Caustic products are readily accessible in most households cleaning products.
• Includes strong acids and bases:
  • drain cleaner
  • oven cleaner
  • toilet bowl cleaner
  • swimming pool cleaner
  • rust remover
  • dishwasher detergent
  • bleach
• High associated morbidity and mortality, even if initially well-appearing.
• High degree of suspicion and basic understanding of common caustics required.
• Majority of accidental ingestions occur in children <6 years old, typically small volume and exploratory.
• May also occur amongst elderly population.
• Storage of products in alternative containers contributes to accidental ingestions.
• Adults and teenagers typically have intentional ingestions in self-harm attempt, typically larger volume.
• Damage depends on volume, concentration, pH, duration of contact and viscosity.
• Intentional ingestions may have fewer external signs despite being more serious.
• Consider non accidental trauma especially if developmental age does not match mechanism (e.g., unable to unscrew lids before age 2).
• Short term complications include perforation, mediastinitis, sepsis, tracheal necrosis, airway compromise, metabolic acidosis, electrolyte disturbances, and resultant dysrhythmias.
• Long term complications include esophageal strictures and squamous cell carcinoma.

Common caustic substances:

• Gather information including type/volume of agent, on-scene treatments (e.g. inducing emesis, attempts to dilute substance by giving fluids).
• Poison control for recommendations regarding specific substance.
• Ideally obtain product container for specific material safety data sheet (MSDS) review.
• If product available but lacking identifying information, test pH using litmus paper (serious ingestions typically pH <3 or >10).

Investigations:

• ECG and CBC, chemistry, renal function, liver function, VBG, lactate.
• ASA, acetaminophen and ethanol level for intentional ingestions.
• Extended electrolytes for hydrofluoric acid exposure.
• CT chest/abdomen can be used to grade esophageal injury, but typically EGD is preferred (especially in children due to radiation).

Airway:

• Consider need for immediate airway intervention (stridor, hoarseness, respiratory distress, drooling or inability to handle secretions).
• May rapidly deteriorate as necrosis and inflammation progress for several hours to days.
• Consider early intubation.
• Video laryngoscopy preferred to minimize manipulation.
• Nebulized epinephrine can be used during set-up if stridor present.
• Consider larger tube size if significant hypoxemia (bronchoscopy may be required).

Decontamination:

• Any dermal exposures: remove clothing, wash with soap and water.
• Ocular exposures require irrigation with minimum 2L NS until pH is within normal limits (once globe perforation ruled out).

Excretion:

• AVOID any attempts at gastric lavage, activated charcoal or attempted dilution/neutralization.
• These can worsen injury as emesis causes corrosive agents to be re-exposed to esophagus.

General management:

• NPO.
• Provide antiemetics and analgesia.
• GI for EGD (required for all intentional ingestions, most accidental ingestions).
• Ideally performed at 12-24 hours (too early risks missing injury, too late risks perforation).
• Accidental pediatric ingestions may not require EGD if fully asymptomatic or unclear ingestion, but at minimum require observation for several hours.
• Therapies with lack of evidence include PPIs, antibiotics (unless concern for perforation) and steroids.
• Steroids may be considered based on EGD grading, but should not be empirically administered (association with increased risk of perforation).

Perforation:

• Consider in rapidly deteriorating patients, acute peritonitis, palpable subcutaneous air, severe chest or abdominal pain.
• Resuscitation, portable CXR/AXR, broad spectrum antibiotics and contact general surgery.

Special cases:

• Hydrofluoric acid can cause profound hypocalcaemia.
• Provide empiric calcium for any significant exposure, QTC prolongation or dysrhythmia.
• Tide pods can cause severe metabolic acidosis and caustic injury.
• Hydrogen peroxide can cause gas emboli.
• Place on 100% O2 and obtain imaging based on symptoms (e.g. CT head for altered mental status).
• House bleach has neutral pH, and EGD typically not required if asymptomatic and tolerating fluids.

Disposition:

• Psychiatry for intentional self-harm ingestions.
• Counsel patients re safe storage of caustics for any accidental ingestions.
• Consider need to involve social worker or child protection.

Example orals case of a caustic ingestion:

• https://www.acep.org/tox/case-files/08_Caustic%20Ingestion.pdf

1. Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. New England Journal of Medicine. 2020 Apr 30;382(18):1739-48.

   
   

2. Tringali A, Thomson M, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, Spaander M, Hassan C, Tzvinikos C, Ijsselstijn H, Viala J. Pediatric gastrointestinal endoscopy: European society of gastrointestinal endoscopy (ESGE) and European society for paediatric gastroenterology hepatology and nutrition (ESPGHAN) guideline executive summary. Endoscopy. 2017 Jan;49(01):83-91.