Patient Population

-Caustic exposures have bimodal age distribution: children with accidental/exploratory ingestions, and adults with intentional ingestions.

Pathophysiology

Alkalis cause liquefactive necrosis. This process involves deep, penetrating injury to all layers of tissue in the structure exposed to alkali.

Dangerous products in this class

- Laundry powders and detergent pods

- Dishwasher detergent (gel or pods)

- Drain declogger (think Drano)

- Household bleach is also in this class, though is so dilute that it is often considered a non-harmful ingestion.

Acids cause coagulation necrosis. The pattern of tissue damage sometimes prevents deep penetrating injury.

Dangerous products in this class

- Glass etching solution

- Water softener

- Rust removers

Clinical Manifestations

-Burns to lips, mouth, throat

-Airway compromise from oropharyngeal edema

-Respiratory tract damage from inhalation or aspiration of vomit

-Direct tissue injury to GI tract, including possible perforation of esophagus or stomach

What Predicts Severe Injury?

Look out for drooing, stridor, vomiting, pain.

**However, these patients can look “ok” in the ED and still have critical tissue damage.**

**Physical exam has been shown to be UNreliable in predicting who has severe injury.**

Management

EGD ideally in 12-24 hours of ingestion for:

- any patient with intentional ingestion

- patient with accidental ingestion and stridor, drooling, vomiting, or pain

While in the ED:

- Decontaminate the patient if substance still on them

- Airway management if needed, can consider dexamethasone or racemic epi, but no data for this

- Consider other co-ingestions

- Prevent vomiting

- Do NOT attempt gastric recon with vomiting, neutralization, PO anything, NG tube, or activated charcoal. These can make the patients injury worse.

- Imaging not needed unless specific indication (e.g. suspicion for perforated viscus)

- Consult medical toxicologist, GI, possibly surgery if suspicion for perforation

References

Suryavanshi, T. Tide Pod Challenge: Managing Caustic Laundry Pod Ingestions. 2018. Canadiem. https://canadiem.org/tide-pod-challenge-managing-caustic-laundry-pod-ingestion/

Wightman, JS, Fulton, JA. Caustics. Goldfrank’s Toxicologic Emergencies. 11th edition.