Down the Tube: Caustic Ingestions. Significance & Management in the ED. Laura Chng PGY-3

Transcription

1 Down the Tube: Caustic Ingestions Significance & Management in the ED Laura Chng PGY-3

2 Caustic Ingestions Not common but you ll see them Controversial You drank WHAT? ED management can change outcome

3 Who will we see? Bimodal distribution Accidental vs Intentional What do we see? Injury to lips, oropharynx, upper airway, GI tract 18-46% caustic ingestions are esophageal burns

4 Finishing up your shift

5 4 yo M PMHx Healthy Imm UTD / 88 Crying Irritable %

6 Caustics = Corrosives Widely available Not just liquids Beware Multiple Ingestions Alkalines VS. Acids

7 ph > 11 and < 3 have increased risk for caustic injury

8 Caustics: Mechanism of Injury Direct chemical injury to tissues Extent of injury causticity of ingestion ph concentration solid vs liquid volume contact time food in stomach titratable reserve Systemic effects

9 You don t need to memorize this Sodium Hypochlorite (NaClO) NaOH KOH LiOH (NH3)

10 Alkaline Ingestions More common (85%) Liquefactive necrosis Exothermic reaction Act fast Damage over time

11 Acidic Ingestions Less common (15%) Less severe (?) Eschar! Stomach > esophagus Systemic effects

12 Acidic ingestion Coagulative Necrosis Eschar + Ischemia

13 4 yo M PMHx Healthy Imm UTD / 88 Drooling, chest and neck pain %

14 Clinical Exam HISTORY Define what, how much and when Assume worst case scenario Does the story fit? Post ingestion spitting up? Vomit? Refusal of food? PHYSICAL Focus on airway, oropharynx, secretions

15 Clinical Presentation GI Tract Upper Airway SYMPTOMS Pain Drooling Dysphagia Vomiting Dyspnea Cough SIGNS Drooling Perforation Burns/sores to lips and oropharynx Stridor Hoarseness Pulmonary edema Skin Pain Burns Erthema/vesicles

16 How can we predict the bad cases? Physical findings Lab findings

17 Clinical Presentation GI Tract SYMPTOMS Pain Drooling Dysphagia Vomiting SIGNS Drooling Perforation Burns/sores to lips and oropharynx Upper Airway Dyspnea Cough Stridor Hoarseness Pulmonary edema Skin Pain Burns Erthema/vesicles

18 Observational study (n = 162) Patients without signs or symptoms had LOW risk of severe lesions (OR 0.13) Dyspnea or stridor = BAD Endoscopy is not risk-free

19 But doc, he has sores in his mouth! I didn t see any when I looked. He ll be fine

20 Injuries of the oropharynx are therefore not a reliable index of damage to the esophagus.

21 Labs CBC WBC > 20 independent predictor mortality Ext d lytes Hypocalcemia Hydrofluoride poisoning ABG ph < 7.22 correlates to adverse outcomes Renal, liver function, Group & Screen, INR/PTT

22 4 yo M 150 PMHx Healthy Imm UTD Drooling, chest and neck pain 130 / % WNL

23 What do you want to do next? 1. Send the patient home 2. Call GI, request immediate scope in ED 3. Try activated charcoal 4. Get CXR 5. Give steroids

24 Principles of Management Risk Stratify Clinical signs of high risk? Type and Time of Ingestion Protect the Airway Treat like a burn

25 Initial Management for Symptomatic Patients Hemodynamics Fluids, fluids, fluids Airway protect airway ASAP if signs of compromise Decontaminate the skin/mouth Test salivary ph Labs + screening XR (CXR and lateral neck) Repeated evaluations of UGI tract and airway and then Steroids? PPI? Antibiotics? Esophagoscopy?

26 Airway? Not common to intubate caustic ingestions Issues with anatomy and post-intubation stability Videolaryngoscopy +/- fibreoptic visualzation +/- surgical back-up

27 To Dilute or Not Best for alkaline granules Water or Milk Small amounts < 30 min Avoid in acidic or liquid alkali ingestions Beware inducing emesis and aspiration NO PROVEN BENEFIT

28 Decontamination? Immediately rinse external tissues and mouth Activated charcoal ph neutralization Gastric lavage or NG tube (until endoscopy)

29 Multiple Ingestions 58M acute ingestion of: 900ml windex 900ml degreaser 600cc nail polish remover Deadly mixtures: Bleach + ammonia = chloramines Bleach + acid = chlorine gas Bleach + acetone = chloroform Alkalines + bases = exothermic reactions AMMONIA ALKALINE ACETONE

30 Who needs endoscopy? Asymptomatic children (and some adults) Symptomatic Children Symptomatic Adults Suicidal Adults Bleach ingestion Questionable ingestion Definite ingestion Monitor for 2-4 hours Clear fluids + food No or Moderate Symptoms Severe Symptoms Airway compromise HOME ENDOSCOPY < 24 hours ENDOSCOPY under General Anaesthesia

31 When is the best time to do esophagoscopy? A. ASAP B hours C hours D. After 2 days E. Never scope a patient who has ingested a caustic substance **Do not scope unstable patients, evidence of GI perforation and those significant airway edema

32 Esophagoscopy GRADES OF INJURY Grade 1 erythema/hyperemia Grade 2a mucosal injury/ulcers/ erosions Grade 2b circumferential Grade 3 necrosis

33 Treatment: Round Up Corticosteroids Pendulum has swung NO ROLE Antibiotics Only for fever, perforation or high grade esophageal injury PPI or H2 blockers? Evidence acutely Usually started by GI on follow-up

34 Case reports: Tide Pod Intoxication 2011: Laundry pods introduced 2013: multiple case series on toxic effects Many systems: GI, pulmonary, metabolic, ocular and CNS Profound rapid neurologic deterioration June 2013: Case series: 3/4 peds patients required intubation TIDE PODS ARE BAD

35 Take it Home Oral findings are not a reliable predictor of esophageal injury ph corrosiveness Not everyone needs urgent esophagoscopy Say NO to steroids BEWARE adult ingestions, tide-pods, multiple substances, drooling, stridor, SOB, food avoidance

36 References (+ Rosens + Uptodate) Riffat, F. Cheng, A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Diseases of the Esophagus. Volume 22, Issue 1, pages 89 94, February 2009 Gorman RL, Khin-Maung-Gyi MT. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med. 1992;10: Ramasamy K., Gumaste V. Corrosive ingestion in adults. J Clin Gastroenterol. 2003;37(2): Cheng, Y. Eing-Long, K. Arterial Blood Gas Analysis in Acute Caustic Ingestion Injuries. Surgery Today. July 2003, Volume 33, Issue 7, pp Siew MK, McManus K. Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma. World J Gastroenterol 2006 July 28;12(32): Haller JA Jr, Andrews HG, White JJ, Tamer MA, Cleveland WW. Pathophysiology and management of acute corrosive burns of the esophagus: results of treatment in 285 children. J Pediatr Surg 1971; 6: Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. Am J Gastroenterol 1992; 87: 1-5 Beuhler MC. Laundry Detergent Pod Ingestions: A Case Series and Discussion of Recent Literature. Pediatr Emerg Care 2013;29: Gaudreault P, Parent M, McGuigan MA. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics 1983; 71:767. Betalli, P. Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study. Gastrointestinal Endoscopy, Volume 68, Issue 3, Riordan M, Rylance G. Poisoning in children 4: Household products, plants, and mushrooms. Arch Dis Child 2002;87: Abaskharoun RD, Depew WT, Hookey LC. Nonsurgical management of severe esophageal and gastric injury following alkali ingestion. Canadian Journal of Gastroenterology. 2007;21(11): Harley EH, Collins M D. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope 1997; 197 (1): Anderson K D, Rouse T M, Randolph J G. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 1990; 323: 637. Arevalo-Silva C, Eliashar R. Ingestion of caustic substances: a 15-year experience. Laryngoscope 2006; 116: