What is the emergency management of acid poisoning in children?

Emergency Management of Acid Poisoning in Children

Immediately activate EMS if the child exhibits altered mental status, seizures, respiratory difficulty, or vomiting, and contact Poison Control Center (1-800-222-1222) while simultaneously beginning decontamination—do NOT give anything by mouth. 1, 2

Immediate Stabilization and Poison Control Contact

• Activate EMS immediately for any life-threatening signs including altered mental status, seizures, respiratory difficulty, or vomiting 1
• Contact Poison Control Center immediately (1-800-222-1222 in the United States) for specific guidance on systemic toxicity management 1
• Identify the specific corrosive agent including nature, physical form, quantity ingested, and whether ingestion was accidental or intentional 2
• Remove all contaminated clothing and jewelry to prevent continued exposure, ensuring you do not contaminate yourself in the process 1

Critical "Do NOT" Actions

These are absolute contraindications that can worsen outcomes:

• Never administer anything by mouth (water, milk, or activated charcoal) unless specifically advised by poison control, as it may cause emesis and aspiration 1, 2
• Never induce vomiting or administer ipecac—this is contraindicated and provides no clinical benefit while potentially causing harm 1, 2, 3
• Never attempt dilution with water or milk—no human studies demonstrate clinical benefit and administration may cause vomiting and aspiration 1, 2
• Never attempt neutralization with opposite pH substances 2
• Never perform gastric lavage—risk of perforation and increased tissue damage 2

Decontamination Protocol for External Exposure

If acid contacted skin or eyes:

• Brush off any powdered chemicals with a gloved hand or cloth first, then immediately irrigate 1
• Rinse eyes immediately with copious amounts of water for at least 15 minutes of continuous irrigation 1
• Use warmed water for pediatric decontamination to prevent hypothermia, and apply lower pressure to prevent additional skin damage 1
• Use heat lamps, blankets, and warming mechanisms to prevent hypothermia during decontamination, especially in cold climates 1

Airway, Breathing, and Circulation Management

Children are physiologically more vulnerable than adults:

• Children have higher minute ventilation and less fluid reserves, making them more susceptible to toxic effects 4, 1
• Children dehydrate more quickly following vomiting and diarrhea, requiring careful fluid management 4, 1
• Cardiac output is rate-dependent in children, necessitating continuous hemodynamic monitoring 4, 1
• Elective intubation and ventilation are indicated for persistent shock despite fluid resuscitation or severe respiratory symptoms 2

Clinical Assessment and Monitoring

The absence of oral lesions does NOT rule out life-threatening gastrointestinal injuries:

• Clinical symptoms correlate poorly with the extent of internal damage 2
• Assess for cardiovascular effects including tachycardia, altered peripheral pulse volume, cool peripheries, and prolonged capillary refill time 1
• Evaluate for signs of shock: hypotension, prolonged capillary refill (≥2 seconds), altered consciousness 1
• Monitor for multi-organ toxicity requiring intensive supportive care 1

Laboratory and Imaging Evaluation

Obtain immediately:

• Renal function tests (urea and creatinine) 2
• Liver function tests (bilirubin, ALT, AST) 2
• Arterial blood gas with pH and serum lactate 2

Endoscopic Evaluation

• Perform endoscopy 6 hours to 4 days after injury in all symptomatic patients 2
• This timing allows assessment of injury severity while avoiding the period of maximal tissue friability

Surgical Management

Emergency surgery is indicated for:

• Mediastinitis or pleural empyema 2
• Minimally invasive techniques should be first-line in referral centers 2
• Limited contamination: esophagotomy/gastrotomy with primary repair 2
• Extensive contamination: rescue esophagectomy or gastrectomy with delayed reconstruction 2

Medication Considerations

• Do NOT prescribe acid suppression therapy (PPIs or H2RAs)—no proven efficacy for caustic injury and may mask ongoing damage 2
• For hydrofluoric acid exposure specifically: Calcium gluconate may be indicated for topical or systemic treatment, but this requires specific poison control guidance 5

Common Pitfalls to Avoid

• Do not delay EMS activation while attempting home interventions 1
• Do not assume dilution helps—this is not evidence-based and may worsen outcomes 1, 2
• Do not overlook hypothermia risk during decontamination in pediatric patients 1
• Do not contaminate yourself while removing the child's clothing or during decontamination 1
• Do not assume absence of oral burns means no serious injury—esophageal and gastric injuries can occur without visible oral lesions 2

Unique Pathophysiology of Acid Ingestion

• Liquid acids transit rapidly through the esophagus but cause severe gastric burns, distinguishing acid injuries from alkali injuries which typically cause more esophageal damage 2