What is the management for a pediatric patient who has ingested a caustic substance like sodium hydroxide?

Management of Pediatric Caustic Substance Ingestion

The immediate management of pediatric caustic substance ingestion should focus on contacting a Poison Control Center (800-222-1222 in the US), avoiding administration of anything by mouth, and immediate irrigation with copious amounts of water for external exposure. 1

Initial Assessment and Management

First Steps

• Do not administer anything by mouth (water, milk, activated charcoal, or syrup of ipecac) unless specifically advised by poison control or emergency personnel 1
• Do not attempt to induce vomiting as this can cause re-exposure of the esophagus to the caustic agent 1
• Contact Poison Control Center immediately (800-222-1222 in the US) 1
• For external exposure: Remove contaminated clothing and irrigate affected skin/eyes with copious amounts of water 1

Emergency Department Management

• Assess airway, breathing, and circulation
• Look for signs of:
  • Oral burns, ulcerations, or edema
  • Drooling, dysphagia, or refusal to swallow
  • Respiratory distress (stridor, hoarseness, wheezing)
  • Abdominal pain or vomiting
  • Hematemesis

Diagnostic Evaluation

Laboratory Studies

• Complete blood count (CBC)
• Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium)
• Renal function tests (urea, creatinine)
• Liver function tests
• Arterial blood gas/serum lactate
• Coagulation profile 1

Imaging

• Computed tomography (CT) with contrast is the preferred initial imaging study 1
  • Grade I: Homogenous enhancement of esophageal wall
  • Grade IIa: Internal enhancement with hypodense wall thickening
  • Grade IIb: Fine rim of external wall enhancement
  • Grade III: Absence of post-contrast wall enhancement (indicates transmural necrosis)
• Chest and abdominal radiographs to assess for free air if perforation is suspected 1

Endoscopy

• Emergency endoscopy should be performed if:
  1. CT is unavailable
  2. CT with contrast is contraindicated
  3. CT suggests transmural necrosis but interpretation is uncertain
  4. In pediatric patients where radiation exposure is a concern 1

Treatment Based on Severity

Mild Injury (Grade I on CT)

• Patients can be fed immediately
• Discharge within 24-48 hours
• No long-term follow-up required 1

Moderate Injury (Grade IIa on CT)

• Introduce oral nutrition as soon as pain diminishes and patient can swallow
• Low risk of stricture formation (<20%)
• Follow-up at 4-6 months post-ingestion 1

Severe Injury (Grade IIb on CT)

• High risk of stricture formation (>80%)
• Consider nutritional support via parenteral nutrition or feeding jejunostomy if oral intake is limited
• Follow-up at 4-6 months post-ingestion 1

Critical Injury (Grade III on CT)

• Emergency surgery indicated for transmural necrosis
• Surgical options include:
  • Stripping esophagectomy and gastrectomy for combined esophageal and gastric necrosis
  • Total gastrectomy with preservation of native esophagus if necrosis is confined to stomach 1

Long-term Management

Stricture Management

• Endoscopic dilation should be attempted 3-6 weeks after ingestion for patients with few (<3) short (<5 cm) esophageal strictures 1
• Reconstructive esophageal surgery should be considered after recurrent failure of endoscopic dilation 1

Follow-up Care

• Psychiatric evaluation is mandatory for all patients prior to hospital discharge 1
• Long-term monitoring for patients with Grade II injuries as strictures typically develop within 4 months 1

Special Considerations for Children

• Warm water should be used for decontamination to avoid hypothermia 1
• Lower pressure water should be used to prevent additional skin damage 1
• In cold climates, heat lamps and blankets may be needed to prevent hypothermia 1

Common Pitfalls to Avoid

• Do not delay contacting Poison Control Center
• Do not administer activated charcoal, which is ineffective and potentially harmful 1
• Do not attempt to neutralize acids with bases or vice versa
• Do not underestimate injuries based on absence of oral lesions, as the absence of visible burns does not rule out severe esophageal or gastric injury 1

By following this algorithmic approach to managing pediatric caustic ingestion, healthcare providers can optimize outcomes and minimize complications for these potentially life-threatening exposures.