What are the treatment guidelines for corrosive poisoning?

Treatment Guidelines for Corrosive Poisoning

Immediate First Aid and Decontamination

For skin exposure, immediately irrigate with copious running water for at least 15 minutes, and for eye exposure, begin irrigation immediately and continue for 15 minutes. 1

Skin Decontamination

• Remove all contaminated clothing and jewelry immediately to prevent trapping chemicals against the skin during decontamination 1
• For dry chemical powders (sodium hydroxide, elemental sodium, elemental potassium), brush off the powder first before water irrigation to avoid exothermic reactions that can cause additional thermal injury 1
• Use personal protective equipment when providing care to avoid contaminating yourself or others 1
• Immediate irrigation within 10 minutes significantly reduces full-thickness burns, hospital length of stay, and delayed complications compared to delayed irrigation 1

Eye Decontamination

• Begin irrigation immediately—this is the single most critical intervention for chemical eye exposure 1
• Running tap water is effective and readily available; normal saline, Ringer's lactate, or commercial eye wash solutions are reasonable alternatives if immediately available 1
• Assist the patient in keeping eyelids open during irrigation 1
• Avoid cross-contamination to the unaffected eye or other individuals 1

Critical Contraindications in First Aid

Do NOT administer anything by mouth (water, milk, activated charcoal, or any other substance) unless specifically directed by poison control, as this may cause emesis and aspiration. 1, 2

• Never induce vomiting with ipecac or any other method—this is explicitly contraindicated and causes harm by re-exposing tissues to the corrosive agent 1, 2
• Do not attempt neutralization with antacids, acids, or any other agents—these provide no clinical benefit and can cause exothermic reactions leading to additional tissue injury 2
• Activated charcoal is contraindicated—it has no effect on corrosive substances and may cause harm 1, 3

Emergency Department Management

Immediate Resuscitation (Priority #1)

Secure the airway immediately if any signs of respiratory compromise are present, as airway obstruction from laryngeal edema is a leading cause of early mortality. 2

• Assess for stridor, hoarseness, drooling, or respiratory distress—these indicate impending airway compromise requiring early intubation 2
• Vapor inhalation can cause severe airway burns even without oral ingestion 2
• Establish IV access and begin fluid resuscitation 3
• Obtain continuous cardiac monitoring, as systemic toxicity can cause life-threatening electrolyte disturbances 2

Poison Control Center Consultation

Contact the Poison Control Center (1-800-222-1222 in the US) immediately to evaluate systemic toxicity and receive agent-specific management guidance. 1, 2

• Identify the specific corrosive agent, concentration, quantity ingested, and whether ingestion was accidental or intentional 1, 2
• Massive suicidal ingestions in adults typically cause more severe injury than accidental pediatric exposures 1, 2
• Certain chemicals (hydrofluoric acid, phenol) require specific antidotes beyond simple decontamination 1

Initial Diagnostic Evaluation

Obtain complete blood count, comprehensive metabolic panel, arterial blood gas, and lactate level to assess for systemic toxicity. 2

• Check for hypocalcemia (suggests hydrofluoric or phosphoric acid), hyponatremia, hypokalemia, and metabolic acidosis 2, 4
• Hyperleukocytosis, hemolysis, and consumption coagulopathy indicate severe poisoning 5
• Obtain chest and abdominal radiographs to evaluate for free air indicating perforation 2

Endoscopic Assessment (Critical for Prognosis)

Perform urgent esophagogastroduodenoscopy within 12-24 hours of ingestion to assess injury extent and severity, as clinical symptoms and oral lesions do NOT reliably correlate with gastrointestinal damage. 1, 2, 6

• The absence of oral lesions or pain does not rule out life-threatening gastrointestinal injuries 1
• Do not advance the endoscope beyond areas of Grade 3 injury to avoid iatrogenic perforation 2
• Endoscopic grading determines prognosis: Grade 2B and 3 injuries have high risk of stricture formation 6, 7
• For ammonia ingestion specifically, repeat endoscopy is necessary as superficial hemorrhagic gastritis may progress during the first 24-48 hours 1, 2

Surgical Management

Immediate Surgical Indications

Obtain immediate surgical consultation, and proceed with emergency surgery for esophageal or gastric perforation with extensive contamination, signs of peritonitis, or hemodynamic instability despite resuscitation. 1, 2

• Surgical indications include: perforation, extensive transmural necrosis (Grade 3), uncontrolled bleeding, mediastinitis, pleural empyema, or peritonitis 1, 2
• Only surgical excision of necrotic tissues can prevent lethal complications like perforation and septic shock 5
• Upfront surgery within the first hours is the only way to achieve survival in "extremely severe" grade intoxication 5

Surgical Approach

• The surgical approach depends on location of injury and extent of contamination 1
• Esophagotomy with primary repair can be used for limited contamination with viable tissue edges 1
• Rescue esophagectomy with delayed reconstruction is necessary for extensive contamination 1
• Laparotomy determines the depth of lesions (not visible on endoscopy) and allows for tissue stripping, gastrectomy, or rarely cephalic duodeno-pancreatectomy 5

Special Considerations

Hydrofluoric Acid Exposure

Hydrofluoric acid causes systemic fluoride toxicity leading to severe hypocalcemia and hyperkalemia that can cause cardiac arrest—calcium administration is critical. 4

• Monitor calcium levels closely and replace aggressively 4
• This agent requires specific treatment beyond standard corrosive management 1

Psychiatric Evaluation

Mandatory psychiatric evaluation and follow-up are necessary for all intentional ingestions, as these patients have high risk of repeat suicide attempts. 2

• Underlying psychiatric illness negatively affects outcomes and compliance with treatment 8
• Intentional ingestions typically involve larger volumes and more concentrated substances 1, 2

Long-Term Complications

• Stricture formation occurs in 19-62% of patients with Grade 2B and 3 injuries 6, 7
• Serial endoscopic dilation and feeding tube placement may be necessary 8
• Esophageal carcinoma risk increases beginning 30-40 years after injury 6
• Mortality ranges from 8-9% even with optimal management 7

Common Pitfalls to Avoid

• Never perform gastric lavage if corrosive injury is suspected—this increases perforation risk 2
• Do not delay endoscopy—initial symptoms may not correlate with damage extent 2
• Do not rely on oral lesions to predict severity—absence of oral burns does not exclude severe esophageal or gastric injury 1, 2
• Do not give anything by mouth in the prehospital setting—despite animal studies suggesting potential benefit from dilution, no human studies demonstrate clinical improvement and risks include emesis and aspiration 1, 2, 3