Caustic Ingestions in the ED: Hide the Bleach

-Case-

An 18-month-old boy is brought into the ED by frantic parents who found him next to an open bottle of industrial-strength cleaner under the kitchen sink. The child is drooling excessively, refusing to eat or drink, and crying inconsolably; he’s stable but clearly uncomfortable. You check vitals: HR 140, RR 32, Sat 99% on room air. You notice erythema around his lips. What now?

-Evaluation-

Caustic ingestions are an (often pediatric ) emergency that can cause significant oropharyngeal, esophageal, and gastric injury. These substances are often alkaline or acidic household cleaners, and the damage begins almost immediately after ingestion.

  • Alkali agents (e.g. drain cleaner, bleach) cause liquefactive necrosis
  • Acids (e.g. toilet bowl cleaner) cause coagulative necrosis

Clues in the history often include:

  • Drooling
  • Dysphagia or refusal to eat
  • Vomiting
  • Stridor or respiratory distress
  • Burns around the lips or mouth

DO NOT induce vomiting or attempt to neutralize the substance with the opposite pH!

  • Chest/Abd XR may help detect free air (perforation) or complications
  • Endoscopy within 12-24 hours is the gold standard to assess injury, but only after the airway is secure
  • CT may be helpful if signs of deep or transmural injury exist

-Management-

  • Initial approach:
    • Airway protection is the priority: anticipate swelling and obstruction!
    • Make the patient NPO immediately
    • IV fluids, supportive care, and pain management
    • No activated charcoal: it does not bind caustics and obscures visualization!
    • Early GI/surgery consult for endoscopy consideration
    • No specific antidote or reversal agents exist; PPIs can be used for stress ulcer prophylaxis
  • Next steps:
    • Emergency laparotomy is required for any patient with signs of perforation and/or CT evidence of transmural necrosis in the esophagus or stomach!
    • Asymptomatic patients without significant ingestion, with a normal exam and reassuring history, can be discharged after tolerating tolerating PO intake and a few hours of observation
    • Symptomatic patients or for those with a significant ingestion require hospitalization for endoscopy. Perform laryngoscopy in unstable patients and intubate those with respiratory distress, oropharyngeal or glottic edema
      • These patients will often require ICU admission
    • Broad-spectrum antibiotics (e.g., ampicillin/sulbactam) are reserved for patients with signs of perforation or suspected mediastinitis
    • Endoscopy is typically performed within 24 hours (ideally between 3–24 hrs). Call GI early in the ED to help coordinate
  • Things to avoid:
    • Do not place an NG tube – it may provoke vomiting and worsen injury
    • Do not give neutralizing agents – the damage is near-instantaneous

-Fast Facts-

  • Alkali agents are often more dangerous than acids due to deeper penetration
  • Most injuries occur in children <5 years
  • Endoscopy should be done within 12-24 hours, but only if there is no evidence of perforation
  • Do not attempt oral neutralization!

Caustic ingestions can be deceptive – kids may look okay before airway swelling and necrosis rear their ugly heads. Be suspicious with household cleaners, drooling, and lip burns. Secure the airway, keep them NPO, and call GI early!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Accelerate your learning with our EM Question Bank Podcast

  • Rapid learning
  • Interactive questions and answers
  • new episodes every week
  • Become a valuable supporter
Sign up for the podcast

Cheers,

Tamir Zitelny, MD

-References-

  1. Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: A comprehensive review. World J Gastroenterol. 2013;19(25):3918-3930. doi:10.3748/wjg.v19.i25.3918
  2. Pelclova D, Navratil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicol Rev. 2005;24(2):125-129. doi:10.2165/00139709-200524020-00006
  3. Hawkins DB, Demeter MJ, Barnett TE. Caustic ingestion: Controversies in management. A review of 214 cases. Laryngoscope. 1980;90(1):98-109. doi:10.1288/00005537-198001000-00017
  4. Christesen HB. Prediction of complications following unintentional caustic ingestion in children. Isr Med Assoc J. 2002;4(7):535-539.
  5. Gaudreault P, Parent M, McGuigan MA, Chicoine L, Lovejoy FH. Predictability of esophageal injury from signs and symptoms: A study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.
Scroll to Top