What is the management of acid ingestion poisoning?

Management of Acid Ingestion Poisoning

Immediate First Aid and Decontamination

Do NOT administer anything by mouth—including water, milk, or activated charcoal—unless specifically directed by poison control, as this may cause emesis and aspiration. 1, 2

Critical First Steps

• Activate emergency medical services immediately if the patient exhibits any life-threatening signs including altered mental status, seizures, respiratory difficulty, or vomiting 1

• Contact the Poison Control Center (1-800-222-1222 in the US) immediately to receive agent-specific guidance on systemic toxicity management 1, 2, 3

• Remove all contaminated clothing from around the mouth and face area to prevent further exposure 2

What NOT to Do

• Never induce vomiting with ipecac or any other method—this is explicitly contraindicated as it causes re-exposure of the esophagus to the caustic agent and increases aspiration risk 1, 2, 3

• Never administer neutralizing agents or antacids—these provide no clinical benefit and may cause exothermic reactions leading to additional thermal injury 3

• Never perform gastric lavage if corrosive injury is suspected, as this increases perforation risk 3

• Do not administer activated charcoal unless specifically advised by poison control—it is ineffective for caustic substances and may obscure subsequent endoscopic evaluation 1, 2

Initial Hospital Assessment and Stabilization

Airway Management (Highest Priority)

• Assess airway patency immediately and prepare for early intubation if stridor, hoarseness, drooling, or respiratory distress are present, as vapor inhalation can cause severe airway burns and laryngeal edema is a leading cause of early mortality 3

• Secure the airway, establish breathing support, and stabilize circulation as the first priority in acute corrosive poisoning 3

Laboratory Evaluation

Obtain the following tests to assess systemic toxicity and metabolic derangements 3:

• Complete blood count
• Electrolytes (sodium, potassium, calcium, chloride)
• Renal function tests
• Liver enzymes
• Arterial blood gas
• Serum lactate level

Note: Hypocalcemia suggests phosphoric or hydrofluoric acid ingestion and requires specific antidote therapy 3

Imaging Studies

• Obtain chest and abdominal radiographs to evaluate for free air indicating perforation 3

• Consider emergency contrast-enhanced CT performed 3-6 hours after ingestion to detect transmural injuries and predict esophageal stricture formation 2

Endoscopic Assessment

Perform urgent esophagogastroduodenoscopy within 12-24 hours of ingestion to assess the extent and severity of injury, as clinical symptoms and oral lesions do not correlate reliably with gastrointestinal damage 2, 3

Important Caveats

• Do not advance the endoscope beyond areas of Grade 3 injury to avoid perforation 3

• Absence of oral burns does not rule out serious esophageal or gastric injury—acids cause rapid transit through the esophagus and tend to pool in the stomach, causing more severe gastric injury than esophageal injury 2, 4

• Contraindications to endoscopy include radiological suspicion of perforation or burns to the supraglottic and epiglottic areas 2

Surgical Management

Indications for Immediate Surgery

Obtain immediate surgical consultation and proceed with emergency surgery for 2, 3:

• Esophageal or gastric perforation with extensive pleural or mediastinal contamination
• Signs of peritonitis
• Hemodynamic instability despite resuscitation
• Extensive transmural necrosis
• Uncontrolled bleeding
• Mediastinitis or pleural empyema

Surgical Approach

The surgical approach depends on location of injury and extent of contamination 3:

• Esophagotomy with primary repair for limited contamination with viable tissue edges
• Rescue esophagectomy with delayed reconstruction for extensive contamination
• Total gastrectomy may be required for severe gastric necrosis 5

Non-Operative Management

Patients without full-thickness necrosis can be offered non-operative management with close clinical and biological monitoring 2

Management by Injury Grade

• Grade I injuries typically heal spontaneously and patients can be fed immediately 2

• Grade III injuries usually require surgical intervention, with emergency resection being lifesaving 2

Long-Term Complications and Follow-Up

Stricture Management

• Gastric outlet obstruction is a common late complication following acid ingestion and may develop after an asymptomatic interval 4

• Avoid dilatation within 3 weeks of initial caustic ingestion due to higher risk of complications 2

• For established strictures, endoscopic dilatation is the mainstay of treatment, with recommended intervals of less than 2-3 weeks between dilatations 2

Psychiatric Evaluation

Mandatory psychiatric evaluation and follow-up are necessary for all patients with intentional ingestion, as these patients have underlying psychiatric disease and high risk of repeat suicide attempts 3

Special Considerations for Specific Acids

Acetic Acid Poisoning

• Requires treatment of hemolysis and renal failure 6
• Plasma separation is the quickest and most effective detoxification method when acid is absorbed systemically 6
• Exchange transfusion may be necessary in severe hemolysis 6
• Monitor for disseminated intravascular coagulation and secondary renal failure requiring hemodialysis 6

Hydrofluoric Acid

• Requires calcium administration as a specific antidote beyond simple decontamination 3