Author: Cullen O’Donnell, DO, Emergency Medicine Resident, PGY I
Faculty: Alexis Cates, DO, Medical Toxicology/Emergency Medicine Attending
The Case:
A 3 year-old male presents to the emergency department via EMS after his parents found him on the kitchen floor crying with a wet face, clothes, and a spilled container of bleach next to him. The parents stated that they have been cleaning the house regularly since the pandemic began and must have left the bleach out. Upon arrival, rapid decontamination was performed with removal of clothes and rinsing of the skin with soap and water. Examination of the oropharynx revealed extensive erythema along with mucosal edema and drooling. There was no crepitus palpated along the neck. Vitals showed a heart rate of 140 beats per minute, respiratory rate of 40 breaths per minute, a blood pressure of 100/60 mmHg, oxygen saturation of 90% on room air and a temperature of 37 degrees Celsius.
Two large bore IVs were placed and the decision was made to intubate the patient to protect their airway and provide ventilation in the setting of caustic ingestion with upper airway compromise.
Learning Point 1: Caustic agents
During the current SARS-CoV-2 pandemic and throughout quarantine periods, many people have been disinfecting their homes in an effort to prevent household illness. This increase in household cleaning has also increased exposure to toxic, caustic cleaning chemicals, as the CDC noted a sharp increase in daily calls to poison control centers as early as March 2020. Out of all cleaning products implicated, bleaches were the most common (62.1%) via inhalation exposure (35.3% increase) when compared to other products and routes of exposure. [1]
As early as 1927, warning labels were mandated on lye and acid- containing products. In 1970, the Federal Hazardous Substances Act and Poison Prevention Act made it so that caustics with a concentration >10% had to be placed in child-resistant packaging, dropping to 2% concentration by 1973. [2]
Learning Point 2: Pathophysiology
Alkali
When exposed to alkaline xenobiotics, OH- ions dissociate and are able to penetrate tissue surfaces in a process known as liquefactive necrosis (protein dissolution, collagen destruction, fat saponification, cell membrane emulsification, transmural thrombosis, and cell death). [2]
Animal esophageal studies have shown exposure to alkali caustics cause tissue injury within seconds with inflammation penetrating down to the submucosal and muscular layers. This penetration will continue to occur until all OH- has been neutralized by tissues. [2] This process can take days to weeks. [4]
There are two products available at industrial strength: ammonium chloride and sodium hypochlorite. Most commercial alkali substances have a pH of 9-11 and rarely cause injuries unless in large amounts. Smaller yet concentrated gel packs are more cause for concern, particularly those that are colorful and may appeal to the pediatric population as a type of sweet or treat. Solid caustic materials may be more concentrated and cause deeper burns on the mucosa of the oropharynx and even further down into the esophagus. Powdered and granular formulations of caustics tend to injure the upper airway due to increased inhalation and aspiration risks. [4]
Acids
Exposure to acids causes H+ ions to desiccate cells. This will lead to eschar formation that prevents further penetration of the acid, known as coagulation necrosis. The dissociated anions also sequester H+, leading to reduced spread of the acid and further tissue injury. Acids are systemically absorbed and can lead to end organ damage, acidosis, hemolysis, and death. In a study that compared 179 patients hospitalized for ingestion of caustic agents, those that were found to have ingested acidic substances had less favorable outcomes with more severe mucosal injury, systemic complications, admission to the ICU. [5]
Learning Point 3: Injury
Children are more likely to present with less severe exposures to caustics due to the likely exploratory nature of their ingestion and presumed lower amounts of exposure. Adults may have accidental exposures due to occupation. More serious exposures tend to occur in adults with intentional ingestions where large amounts have been consumed.
Though the initial presentation of a patient with an exposure to an acid or alkali are quite similar, the severity of the injury depends upon the type, concentration, formulation, and exposure time of the substance. Ingestion can lead to drooling and rapid upper airway compromise, particularly if there has been aspiration, secondary swelling. Esophageal involvement can lead to odynophagia, dysphagia and hematemesis. Inhalation or aspiration of vomitus can lead to hoarseness, stridor, respiratory distress, pneumonitis, and impaired gas exchange. [2, 3] Other possible routes of exposure can occur, such as ocular and dermal.
For alkali ingestions, presence of drooling and stridor was indicative of significant esophageal injury with stridor being found to be 100% specific for significant esophageal injury. Fever, chest pain, crepitance, and dyspnea would be indicative of esophageal perforation. [2]
Classification of Esophageal Burns (by endoscopy)
Grade I: hyperemia or edema of the mucosa without ulcer formation
Grade II: Submucosal lesions, ulcerations, and exudates.
(IIa noncircumferential lesions, and IIb being near circumferential)
Grade III: Deep ulcers and necrosis into periesophageal tissues.
Burns of the esophagus follow typical healing with the recruitment of fibroblasts, neovascularization and the formation of granulation tissue. These burns may persist up to 8 weeks followed by esophageal shortening. If the injury is deep enough (Grade II 75%, and Grade III approaching 100%) , it can lead to stricture formation. [2, 3]
Learning Point 4: ED Management
1. Initial evaluation
a. Airway, breathing and circulation
b. Look for signs of burns or injury, drooling, and stridor or other signs of airway compromise
c. Consider early intubation if airway compromise. Video laryngoscopy or fiberoptic intubation should be considered in presence of edematous tissues.
d. 10mg IV dexamethasone in adults or 0.6mg/kg in children can reduce airway edema secondary to caustic ingestion
2. Resuscitation
a. 2 large bore peripheral IVs
b. Volume resuscitation is needed due to the presence of third-spacing that can occur with significant alkali ingestions
3. Serial Vital Sign evaluations, paying attention to heart rate, oxygen saturations and blood pressure
a. Follow urine output (for newborns and infant up to 1 year: 2 mL/kg/hr, for toddlers and children: 1.5 mL/kg/hr, for adolescents: 1mL/kg/hr, for adults: 0.5mL/kg/hr)
4. Decontamination (if needed)
a. Dermal and ocular irrigation for those routes of exposure
b. Gastrointestinal decontamination is not of benefit due to potential for aspiration and increased injury
c. Suctioning via nasogastric tube may also risk aspiration and perforation and is not routinely recommended
d. Avoid dilution and neutralization
5. Ophthalmologic exposures
a. Copious irrigation with ocular pH paper testing (normal pH is 7.40)
b. Ophthalmology should be consulted for ocular exposures, especially with alkali compounds that can penetrate deeper into the globe
6. Consult appropriate services as indicated, such as toxicology and/or Poison Control Center, gastroenterology, surgery or otolaryngology
7. Usual laboratory testing, particularly for those with significant and symptomatic ingestions, may include:
a. Blood gas, complete metabolic panel, complete blood count, coagulation factors, acetaminophen and salicylate concentrations for intentional ingestions (as common coingestants), and a urinalysis
b. Watch for: abnormal coagulation factors, acidosis, elevated lactic acid
8. Potential radiologic studies may include chest and abdominal radiographs looking for esophageal or gastric perforations, although a negative study does not exclude the possibility of a perforation. Computed tomography scans may be utilized if the patient is stable enough for more advanced imaging as indicated.
Learning Point 5: Long-Term Management
When indicated such as with intentional ingestions, high concentration ingestions, and significantly symptomatic ingestions, endoscopies should be performed within 12 hours and no later than 24 hours after ingestion. After this time period, endoscopies are discouraged as wound healing occurs from 5 days to 2 weeks, and with increased friable tissue this increases the risk of perforation. Though reassuring, even if no burns are found in the esophagus, there may still be some damage distally into the stomach or duodenum, though this is less likely to occur.
Late complications of injury can occur secondary to remodeling, such as esophageal strictures, loss of airway, gastric atony, gastric outlet obstructions, or vascular erosion. These patients can also become septic easily due to a compromised barrier and invasion of oropharyngeal bacteria. Stricture formation can lead to long-term esophageal motility disorders from impaired smooth muscle reactivity. [4]
The Case Concluded:
After initial decontamination, intubation and resuscitation in the ED, chest radiographs were obtained which did not show evidence of esophageal or gastric perforation. The patient’s labs returned, and they were normal. Gastroenterology was consulted for endoscopy to evaluate the extent of esophageal burns. They discovered grade IIa lesions present and the patient was sent to the PICU for management.
References:
1. Chang A, Schnall AH, Law R, Bronstein AC, Marraffa JM, Spiller HA, Hays HL, Funk AR, Mercurio-Zappala M, Calello DP, Aleguas A, Borys DJ, Boehmer T, Svendsen E. Cleaning and Disinfectant Chemical Exposures and Temporal Associations with COVID-19 – National Poison Data System, United States, January 1, 2020-March 31, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr 24;69(16):496-498. doi: 10.15585/mmwr.mm6916e1. PMID: 32324720; PMCID: PMC7188411.
2. McGraw-Hill Medical. (2011). In Goldfrank’s toxicologic emergencies 9th ed. (pp. 1364–1371). essay.
3. Tintinalli, J. E. (2019). In Tintinalli’s emergency medicine: A comprehensive study guide, 9th edition (pp. 1294–1300). essay, McGraw-Hill Education.
4. Caustic esophageal injury in adults – UpToDate (lecom.edu)
5. Poley JW, Steyerberg EW, Kuipers EJ, Dees J, Hartmans R, Tilanus HW, Siersema PD. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointest Endosc. 2004 Sep;60(3):372-7. doi: 10.1016/s0016-5107(04)01722-5. PMID: 15332026.
6. Beuhler M, Gala P, Wolfe H, Meaney P, Henretig F. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013;29(6):743-747.
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