What is the management approach for corrosive poisoning?

Emergency Management of Corrosive Poisoning

The management of corrosive poisoning requires immediate airway assessment, hemodynamic stabilization, and early diagnostic evaluation with contrast-enhanced CT scan and esophagogastroduodenoscopy within 12-24 hours to determine injury severity and guide treatment decisions. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC):

  • Secure airway first - assess for stridor, respiratory distress, and oropharyngeal burns
  • Evaluate for signs of perforation: abdominal pain, peritoneal signs, pneumomediastinum 1
  • Monitor vital signs and establish IV access for fluid resuscitation

• Immediate Interventions:

  • DO NOT induce vomiting, attempt neutralization, or perform gastric lavage 2
  • DO NOT administer activated charcoal (ineffective for corrosives) 2
  • Dilution with water or milk may be considered only within 60 minutes of ingestion 2
  • Withhold oral intake until injury severity is determined 1

Diagnostic Evaluation

• Imaging:

  • Chest and abdominal radiographs to assess for free air (perforation) 1
  • Contrast-enhanced CT scan 3-6 hours post-ingestion to assess injury extent and detect transmural necrosis 1

• Endoscopy:

  • Esophagogastroduodenoscopy within 12-24 hours is the gold standard for assessing injury severity 1
  • Zargar classification for endoscopic grading:
    • Grade I: Edema and hyperemia
    • Grade IIA: Superficial ulceration, hemorrhage, exudates
    • Grade IIB: Deep discrete or circumferential ulceration
    • Grade IIIA: Focal necrosis
    • Grade IIIB: Extensive necrosis

Management Based on Injury Severity

• Grade I and IIA injuries:

  • Supportive care with IV fluids
  • Proton pump inhibitors to reduce acid secretion
  • Resume oral intake when tolerated
  • Discharge with follow-up in 2-3 weeks 1

• Grade IIB injuries:

  • NPO (nothing by mouth)
  • Nutritional support (parenteral or enteral via feeding tube)
  • Proton pump inhibitors
  • Monitor for stricture formation
  • Consider antibiotics if signs of infection present 1

• Grade III injuries:

  • Immediate surgical consultation
  • NPO with nutritional support
  • Broad-spectrum antibiotics
  • Surgical intervention for transmural necrosis - total gastrectomy and esophagojejunostomy reconstruction when indicated
  • Careful inspection of adjacent organs for concomitant necrosis 1

Monitoring for Complications

• Early complications:

  • Perforation (can occur within hours of ingestion)
  • Metabolic abnormalities: hypocalcemia, hyponatremia, hypokalemia 1
  • Acute renal failure (particularly with concentrated acetic acid ingestion) 3
  • Sepsis

• Late complications:

  • Esophageal and/or gastric strictures (develop in approximately 19% of patients) 3
  • Increased risk of esophageal and stomach cancer 3

Management of Strictures

• Endoscopic dilatation:

  • Typically started 3-6 weeks after ingestion
  • Median of five sessions needed to achieve symptom resolution
  • Either bougie or balloon dilators can be used
  • Graded stepwise approach to dilatation between 13-20 mm 1

• Refractory strictures:

  • Consider stent placement
  • Esophageal bypass for extensive, refractory strictures 1

Long-term Follow-up

• Regular endoscopic surveillance:

  • Due to increased risk of esophageal carcinoma 1
  • Monitor for stricture formation

• Psychiatric evaluation:

  • Mandatory for all patients prior to discharge, especially for intentional ingestions 1
  • High risk of repeated suicide attempts in intentional ingestions

Prevention for Healthcare Providers

• Wear appropriate protective clothing and gloves when handling victims
• Use masks with non-return valve systems
• Take precautions against direct skin contact and inhalation of toxic fumes 1

Pitfalls to Avoid

• DO NOT attempt neutralization of corrosives - this can generate heat and worsen injury
• DO NOT induce vomiting - re-exposure of the esophagus to corrosive agent
• DO NOT perform blind nasogastric tube insertion - risk of perforation
• DO NOT delay endoscopic evaluation beyond 24 hours - reduced accuracy in assessing injury severity
• DO NOT overlook the possibility of concomitant injuries to adjacent organs