Management of Acid Poisoning
Immediate First Aid and Emergency Response
For acid exposure to skin or eyes, immediately irrigate the affected area with copious amounts of water for at least 30 seconds, and continue irrigation for chemical burns 1, 2. This is the single most critical initial intervention that can prevent deeper tissue injury.
What NOT to Do - Critical Contraindications
Do not administer water, milk, or any substance by mouth unless specifically directed by poison control, as this may induce vomiting and aspiration 1, 2. This contradicts older practices and is based on evidence showing possible adverse effects including emesis.
Do not administer activated charcoal for caustic acid ingestions - it is ineffective for caustic substances and will obscure subsequent endoscopic evaluation 2.
Do not induce vomiting or administer syrup of ipecac - this is strictly contraindicated as it can cause intractable emesis, aspiration, and delay definitive care 1, 2, 3.
Do not perform gastric lavage except in extremely rare life-threatening situations where the acid is not adsorbed by charcoal, as it carries serious risks 3, 4.
Emergency Medical Services Activation
Immediately activate EMS if the patient shows any signs of respiratory distress, vomiting, altered mental status, or other life-threatening conditions 2. Contact the Poison Help hotline immediately for expert guidance on the specific acid involved 2.
Decontamination Steps
- Remove any remaining acid from the oral cavity 2
- Remove all contaminated clothing and jewelry around the mouth and face to prevent continued exposure 2
- For powdered acid chemicals, brush off with a gloved hand before washing 5
Hospital-Based Management
Diagnostic Evaluation
Perform emergency contrast-enhanced CT examination 3-6 hours after ingestion to detect transmural injuries 2. This timing is critical as it allows identification of full-thickness necrosis that may require emergency surgery.
Conduct upper gastrointestinal endoscopy within 12-48 hours to determine prognosis and guide management 2. This should not be delayed but also should not be performed too early when tissue injury is still evolving.
Obtain laboratory evaluation including complete blood count, electrolytes, liver function tests, arterial pH, and serum lactate 2. These identify systemic effects including hemolysis, metabolic acidosis, and organ dysfunction that commonly occur with significant acid ingestions 6.
Supportive Care and Treatment
For severe metabolic acidosis, administer sodium bicarbonate (1-2 mEq/kg IV) only after effective ventilation has been established 2. Correcting acidosis before securing the airway can worsen respiratory status.
Provide aggressive intravenous fluid therapy, antibiotics, and opiates for pain control in most significant ingestions 3. Acid burns cause immediate severe pain and fluid shifts requiring substantial volume resuscitation.
For evidence of transmural necrosis on CT or endoscopy, emergency surgery should be considered as it may be lifesaving 2. This typically involves gastrectomy for severe gastric injury.
For patients without full-thickness necrosis, non-operative management with close clinical monitoring may be offered 2.
Special Considerations for Specific Complications
In cases of severe hemolysis (particularly with acetic acid or formic acid), plasma separation is the quickest and most effective detoxification method 6. Exchange transfusion may be necessary for severe hemolysis 6.
For secondary renal failure, hemodialysis is recommended 6.
Manage disseminated intravascular coagulation with low-dose heparin, erythrocyte transfusion, and antithrombin III substitution as needed 6.
Understanding Acid Injury Patterns - Critical Clinical Pearls
Acids cause coagulative necrosis forming an eschar that may limit deeper penetration, but they tend to cause more severe gastric injury than esophageal injury 2. This occurs because acids transit rapidly through the esophagus but pool in the distal stomach due to pylorospasm 3.
Clinical symptoms do not correlate with the extent of gastrointestinal damage - absence of oral lesions or pain does not rule out serious internal injuries 2. This is a critical pitfall that can lead to underestimation of injury severity.
Liquid acids cause burns of both the esophagus and stomach, with the distal antrum being particularly vulnerable 2, 3.
Long-Term Complications and Follow-Up
Pyloric stricture is the most common late complication among survivors 3. Stricture formation may require endoscopic dilation, though this should be avoided within 3 weeks of initial ingestion due to higher risk of complications 2.
Careful attention must be paid to fluid management, calorie intake, and excluding esophageal or gastric stricture formation during recovery 6.
Timing Considerations
Due to the rapidity with which acid acts, all interventions must be expeditious 3. Acid causes immediate tissue damage upon contact, making the first minutes to hours critical for outcome.