What is the approach to managing corrosive poisoning?

Emergency Management of Corrosive Poisoning

The immediate management of corrosive poisoning requires securing the airway, breathing, and circulation, followed by prompt diagnostic evaluation with contrast-enhanced CT scan within 3-6 hours and esophagogastroduodenoscopy within 12-24 hours to assess injury severity and guide treatment decisions. 1

Initial Assessment and Stabilization

• Airway assessment: Evaluate for stridor, respiratory distress, and oropharyngeal burns

• Vital signs monitoring: Watch for signs of shock or respiratory compromise

• Physical examination: Look for:

  • Oropharyngeal burns, drooling, dysphagia
  • Abdominal pain, peritoneal signs (suggesting perforation)
  • Signs of systemic toxicity (hypocalcemia, hyponatremia, hypokalemia) 1

• Do NOT:

  • Induce vomiting
  • Attempt neutralization of the corrosive substance
  • Perform gastric lavage
  • Administer activated charcoal 2

Diagnostic Evaluation

1. Imaging studies:

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

2. Endoscopic evaluation:

   • Esophagogastroduodenoscopy (EGD) within 12-24 hours is the gold standard for assessing injury severity 1
   • Zargar classification for endoscopic grading:
     • Grade I: Mild injury
     • Grade IIa: Moderate injury without necrosis
     • Grade IIb: Moderate injury with necrosis
     • Grade III: Transmural necrosis

Management Based on Severity

Mild to Moderate Injury (Grade I and IIa)

• NPO (nothing by mouth) initially
• IV fluid resuscitation
• Proton pump inhibitors to reduce acid secretion
• Pain management
• Resume oral feeding when clinically appropriate 1

Severe Injury (Grade IIb and III)

• Strict NPO
• Aggressive fluid resuscitation
• Nutritional support (parenteral or enteral via feeding jejunostomy)
• Proton pump inhibitors
• Antibiotics if signs of infection present
• Consider corticosteroids (controversial) 1, 3

Surgical Intervention

• Immediate surgery indicated for:

  • Grade III injuries with transmural necrosis
  • Perforation
  • Peritonitis
  • Mediastinitis 1

• Surgical procedures:

  • Total gastrectomy and esophagojejunostomy for gastric necrosis
  • Feeding jejunostomy placement for nutritional support
  • Inspection of adjacent organs for concomitant necrosis 1

Complications Management

Acute Complications

• Respiratory complications: Occur in up to 52% of cases with systemic complications 4

  • Pneumonia is most common
  • Aggressive respiratory support and appropriate antibiotics

• Acute renal failure: Particularly common with concentrated acetic acid ingestion (59.67%) 5

  • May require hemodialysis

Long-term Complications

• Stricture formation: Most common in esophagus and gastric antrum/pylorus

  • Begin endoscopic dilation 3-6 weeks post-ingestion
  • Typically requires multiple sessions (median of 5) 1

• Esophageal bypass: For extensive, refractory strictures 1

• Increased cancer risk: Regular endoscopic surveillance recommended 1

Follow-up Care

• Regular endoscopic surveillance due to increased risk of esophageal carcinoma
• Psychiatric evaluation mandatory for all patients, especially for intentional ingestions
• Nutritional assessment and support
• Monitor for stricture formation with barium studies 1, 6

Prevention and Safety Precautions

• Healthcare providers should wear appropriate protective clothing, gloves, and masks when handling victims
• Take precautions against direct skin contact and inhalation of toxic fumes
• Contact Poison Control Centers for chemical-specific guidance 1

Corrosive poisonings represent a serious medical emergency with potential life-threatening complications and long-term morbidity. Early diagnosis with appropriate imaging and endoscopy, followed by prompt treatment based on injury severity, is essential for improving outcomes.