Because of the risk of rapidly developing airway edema, the patient’s airway and mental status should be immediately assessed and continually monitored. Equipment for endotracheal intubation and cricothyrotomy should be readily available. Gentle orotracheal intubation or fiberoptic-assisted intubation is preferred. Blind nasotracheal intubation should be avoided due to the increased risk of soft-tissue perforation.
If possible, it is best to avoid inducing paralysis for intubation because of the risk of anatomical distortion from bleeding and necrosis. If a difficult airway is anticipated, IV ketamine can be used to provide enough sedation to obtain a direct look at the airway.
Cricothyrotomy or percutaneous needle cricothyrotomy may be necessary in the presence of extreme tissue friability or significant edema.
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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.
