What are the latest guidelines for managing corrosive injuries?

Management of Corrosive Injuries: Latest Guidelines

The cornerstone of managing corrosive injuries is immediate identification of the nature, physical form, and quantity of the ingested agent, followed by appropriate diagnostic evaluation with CT scan as the preferred modality to guide treatment decisions. 1

Initial Assessment and Management

Immediate First Aid

• For skin exposure to corrosive chemicals:
  • Immediate skin decontamination with running water for at least 15 minutes 1
  • Remove contaminated clothing, jewelry, and surrounding material 1
  • For dry chemicals, brush off the substance before irrigation with water 1
  • Contact Poison Control Centers for chemical-specific guidance 1

Clinical Evaluation

• Identify the nature, physical form, and quantity of the ingested agent 1
• Determine if ingestion was accidental (more common in children) or voluntary (suicidal attempts in adults) 1
• Note: Clinical symptoms do not reliably correlate with the extent of gastrointestinal damage - absence of pain or oral lesions does not rule out severe injuries 1

Laboratory Investigations

• Complete blood count (CBC)
• Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium)
• Renal function (urea, creatinine)
• Liver function tests
• Arterial blood gas (pH and serum lactate)
• Blood alcohol levels
• β-HCG in young women 1

Diagnostic Imaging

Computed Tomography (CT)

• CT scan is the preferred initial diagnostic modality and should be performed 3-6 hours after ingestion 1
• CT outperforms endoscopy in detecting transmural injuries and predicting stricture formation 1
• Key finding: Absence of post-contrast wall enhancement indicates transmural digestive necrosis and is an indication for emergency surgery 1
• CT classification of esophageal caustic injuries:
  • Grade I: Homogenous enhancement of esophageal wall
  • Grade IIa: Internal enhancement of esophageal mucosa with hypodense wall
  • Grade IIb: Fine rim of external wall enhancement
  • Grade III: No wall enhancement (transmural necrosis) 1

Endoscopy

• Role of emergency endoscopy is now reduced to situations where:
  1. CT is unavailable
  2. CT with contrast is contraindicated (renal failure, iodine allergy)
  3. CT suggests transmural necrosis but interpretation is difficult
  4. In pediatric population 1
• Remains the main diagnostic tool for evaluating strictures in symptomatic patients 1

Treatment Approach

Non-operative Management

• Indicated for patients without full-thickness necrosis of digestive organs 1
• Close clinical and biological monitoring is essential
• Any clinical deterioration should prompt repeat CT examination 1
• Oral feeding should be reintroduced as soon as patients can swallow normally
• Enteral feeding via nasogastric tubes or jejunostomy for patients unable to eat 1
• Psychiatric evaluation is mandatory prior to hospital discharge for all patients 1

Surgical Management

• Indications for emergency surgery:
  • Transmural necrosis of any part of the gastrointestinal tract (identified by absence of wall enhancement on CT) 1
  • Perforation with extensive pleural/mediastinal contamination 1
  • Deterioration of clinical condition during non-operative management 1
• Surgical approach depends on location of injury, patient comorbidities, and condition 1
• Minimally invasive techniques should be considered first-line treatment in referral centers 1

Management of Strictures

• Strictures are the most common long-term complication, usually occurring within 4 months after ingestion 1
• Endoscopic dilation is the first-line treatment, starting 3-6 weeks after ingestion 1
• Dilation should be attempted for patients with few (<3) short (<5 cm) esophageal strictures 1
• Reconstructive esophageal surgery should be considered after recurrent failure of endoscopic dilation 1

Special Considerations

Pediatric Patients

• In children, ingestion is mostly accidental and severe injuries are rare 1
• Endoscopy remains the upfront evaluation examination in children due to concerns about radiation exposure 1
• Surgical procedures for corrosive-induced gastric injuries should be tailored according to the patient's condition and extent of injury 2

Acid vs. Alkali Injuries

• Strong acids and alkalis are responsible for most severe caustic injuries 1
• Acids typically cause more damage to the stomach while alkalis tend to affect the esophagus more severely 3
• Both can cause extensive necrosis of the gastrointestinal tract in cases of massive ingestion 1

Common Pitfalls and Caveats

• Do not induce vomiting as it may cause additional trauma or perforation 3
• Do not attempt neutralization of the corrosive substance 3
• Do not perform gastric lavage 3
• Activated charcoal is ineffective and not indicated 3
• Never rely solely on clinical symptoms to rule out severe injuries - absence of pain or oral lesions does not exclude life-threatening gastrointestinal damage 1
• Abnormal laboratory values (severe acidosis, deranged liver function, leukocytosis, elevated CRP, renal failure, thrombocytopenia) predict transmural necrosis and poor outcomes 1

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with corrosive injuries, reducing morbidity and mortality while preserving quality of life.