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Caustic Ingestions - Dr. Ford

1/9/2014

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Picture
Mechanism of GI injury
Damage is due to multiple factors:
- tissue contact time
- pH and concentration
- ability of caustic to penetrate tissues
- presence of absence of food in stomach
- titratable acid/allkaline reserve (TAR)
            - amount of neutralizer needed to titrate pH of caustic to physiologic pH of tissues
            - higher TARs produce more damaged tissue


Alkalis
- injury is due to LIQUEFACTION NECROSIS - bad because injury keeps penetrating until neutralized or penetration of organ occurs - can get esophageal and gastric injuries

  > Sodium hydroxide
  > Sodium hypochlorite (household bleach) - worry about ingestion of larger amounts or higher concentrations
  > Ammonium hydroxide (toilet bowel cleaner)
  > Household detergents - usually dont cause GI injury but massive ingestions can be bad

Acids
- + ion causes COAGULATION NECROSIS - ulceration and perforation can occur; can get gap or nonanion gao acidosis; both esophageal and gastric injuries as well as pylorospasm


Classification of caustic injury of esophagus

     Grade I - hyperemia
                        - diet as tolerated, early D/C (likely need to be brought in initially for obs)
     Grade II - ulcerations and exudates
     Grade III - necrosis and deep ulcerations

* Be aware - these people can have an initially benign presentation
* Don’t use presence or absence of oral pharyngeal lesions to determine damage distally



Management

- Hydration
- Steroids for airway edema (not research base)
- CBC, lytes, VBG, coags
- Not unusual to have GI bleed early on, but check type and cross
- Airway - manage early (WEAR MASK), get good visualization

- No NG tube for alkali ingestions, but with acid ingestions use w/in 30-60 min, don't do charcoal unless bad ingestion (ex, Zinc Chloride)

- Endoscopy for all intentional ingestions
        - perform in first 12-48 hrs, up to 96 hrs is safe
        - unless they ingest very concentrated products or large amounts - then scope immediately
        - If you do not scope - observe for 6-12 hrs with serial exams and small sips of water

        - Contraindications to endoscopy
                - perforation, supraglottic or epiglottic burns (concern for perforation if you scope)
                - if can’t do endoscopy - perform esophagram and upper GI series 24 hrs after ingestion - use water soluble contrast initially

Sequelae
- scarring
- motility issues
- gastric outlet obstruction
- tracheoesphogeal fistulas
- strictures which SIGNIFICANTLY increases risk for Cancer - need lifelong monitoring

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  • RESIDENCY
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    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • Ultrasound
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • PGY-3
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    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
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  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Incentive Shifts & Moonlighting >
      • AEC Incentive Shifts
      • STICU Moonlighting
      • Pineville Cardiac Rehab
    • Schedules >
      • Block Schedule
      • ED Shift Schedule
      • Conference and Resident Lectures
      • Journal Club
      • CQR
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction