Rapidly obtaining reliable information on the particular agent involved is vital. This is particularly true of uncommon caustic agents, some of which have important toxic concerns beyond those of a simple caustic ingestion.
A good example of this is the potential for abrupt, life-threatening hypocalcemia following ingestion of hydrogen fluoride, even in a relatively dilute form such as that found in some rust removers. Case reports of patients surviving such suicidal ingestions underline the value of being able to anticipate and aggressively manage the systemic hypocalcemia, which is unique to hydrogen fluoride, with intravenous calcium. Other examples of caustic agents with unique toxicities include phenol, zinc chloride, and mercuric chloride, all of which can cause significant systemic toxicity and which may require specifically directed management.
Material Safety Data Sheets (MSDS), online databases, and consultations with the local poison center are all ways for clinicians to rapidly familiarize themselves with unfamiliar caustic agents.
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Caustic ingestions. Endoscopic view of the esophagus in a patient who ingested hydrochloric acid (Lime-a-way). Note the extensive thrombosis of the esophageal submucosal vessels giving the appearance similar to chicken wire. Courtesy of Ferdinando L. Mirarchi, DO, Fred P. Harchelroad Jr, MD, Sangeeta Gulati, MD, and George J. Brodmerkel Jr, MD.
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Caustic ingestions. Endoscopic view of the esophagus in a patient who ingested hydrochloric acid (Lime-a-way). Note the appearance of the thrombosed esophageal submucosal vessels giving the appearance of chicken wire. Courtesy of Ferdinando L. Mirarchi, DO, Fred P. Harchelroad Jr, MD, Sangeeta Gulati, MD, and George J. Brodmerkel Jr, MD.
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Caustic ingestions. Endoscopic view of the esophagus in a patient who ingested hydrochloric acid (Lime-a-way). Note the extensive burn and thrombosis of the submucosal esophageal vessels, which gives the appearance of chicken wire. Courtesy of Ferdinando L. Mirarchi, DO, Fred P. Harchelroad Jr, MD, Sangeeta Gulati, MD, and George J. Brodmerkel Jr, MD.
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Algorithm for the diagnosis and management of caustic ingestions. In all cases of caustic ingestion, the airway should be assessed initially and protected if necessary. If endoscopy is not rapidly available and severe injury is strongly suspected, obtain a contrast-enhanced computed tomographic (CT) study. The Usta protocol consists of methylprednisolone (1 g per 1.73 m2 of body-surface area per day, given intravenously for 3 days) plus ranitidine (4 mg per kilogram of body weight per day in children or the standard adult dose in adults, given intravenously) plus ceftriaxone (100 mg per kilogram per day in children or the standard adult dose in adults, given intravenously). NPO denotes nothing by mouth, and TPN total parenteral nutrition.
