What is the diagnosis and management for a 7-year-old female with stable vital signs (VS) who ingested approximately 5-10 mL of a calcium hypochlorite solution (approximately 5 grams of granules in 250 mL of water) and is now experiencing abdominal pain and vomiting?

Diagnosis and Management of Calcium Hypochlorite Ingestion in a 7-Year-Old

Diagnosis

This is a case of caustic ingestion with corrosive gastritis from calcium hypochlorite, presenting with moderate severity based on >5 episodes of vomiting and abdominal pain. 1

The concentration ingested (5 grams in 250 mL = 2% solution) is relatively low compared to industrial-strength caustics, but the volume (5-10 mL) and presence of granules increases risk for mucosal injury. 2, 3

Immediate Management

Contact Poison Control Center

• Call the Poison Control Center immediately for guidance on this specific caustic ingestion. 1
• This helps evaluate systemic toxicity and provides real-time management recommendations. 2

Do NOT Perform Gastrointestinal Decontamination

• Do not administer activated charcoal—it provides no benefit for alkali ingestions and may complicate endoscopic evaluation. 1
• Do not induce vomiting or perform gastric lavage as this risks re-exposure of the esophagus to the caustic agent. 3

Assess Severity and Hydration Status

With >5 episodes of vomiting, this patient meets criteria for moderate dehydration requiring aggressive oral rehydration or IV fluids. 1, 4

Rehydration Protocol

For Moderate Dehydration with Vomiting:

• Administer 100 mL/kg of oral rehydration solution (ORS) over 2-4 hours if the child can tolerate oral intake. 1
• Give small, frequent volumes (5 mL every minute initially) using a spoon or syringe. 4
• Replace each vomiting episode with an additional 10 mL/kg of ORS. 1

Consider Ondansetron:

• For persistent vomiting in a 7-year-old, administer ondansetron 0.15 mg/kg intramuscularly (maximum 16 mg/dose) to facilitate oral rehydration. 2, 4
• This improves tolerance of oral fluids and reduces need for IV access. 2

If Oral Rehydration Fails:

• Place peripheral IV line and administer normal saline bolus 20 mL/kg, repeat as needed. 2

Laboratory and Imaging Evaluation

Initial Laboratory Tests:

Obtain CBC, electrolytes (sodium, potassium, chloride, calcium, magnesium), renal function (urea, creatinine), liver tests (ALT, AST, bilirubin), pH, and serum lactate. 2

• Hypercalcemia may occur with calcium hypochlorite ingestion. 5
• Severe acidosis, elevated lactate, leukocytosis, elevated CRP, renal failure, or thrombocytopenia predict transmural necrosis and poor outcomes. 2

Imaging:

• Obtain plain radiographs of neck, chest, and abdomen to assess for free air indicating perforation. 2
• If there is concern for significant ingestion or worsening symptoms, perform contrast-enhanced CT of neck, thorax, and abdomen 3-6 hours post-ingestion. 2
• The key CT finding of transmural necrosis is absence of post-contrast wall enhancement, which indicates need for emergency surgery. 2

Endoscopic Evaluation

Fiberoptic endoscopy should be performed as soon as possible to assess severity of mucosal injury, risk of mortality, and risk of stricture formation. 3

• Endoscopy and CT are complementary in evaluating corrosive injuries. 3
• Do not delay endoscopy if clinical signs suggest significant injury (persistent pain, hematemesis, inability to swallow). 2

Monitoring and Observation Criteria

Reassessment Schedule:

Reassess clinical status every 2-4 hours for signs of deterioration including: 1

• Worsening abdominal pain
• Hematemesis
• Fever
• Respiratory distress
• Inability to tolerate oral intake

Hospitalization Indications:

Admit for observation if any of the following are present: 1

• Any signs of corrosive injury on examination or imaging
• Inability to tolerate oral intake
• Concern for significant ingestion volume or concentration
• Persistent vomiting despite antiemetic therapy
• Abnormal laboratory values suggesting systemic toxicity

Nutritional Management

Once the child can tolerate oral intake, resume age-appropriate diet immediately. 1

• Include starches, cereals, yogurt, fruits, and vegetables. 1
• Avoid foods high in simple sugars and fats. 1

Critical Pitfalls to Avoid

• Do not assume absence of oral lesions rules out gastrointestinal injury—clinical symptoms do not reliably correlate with extent of damage. 2
• Do not delay endoscopy or imaging if there is any concern for significant ingestion. 2, 3
• Household bleach (sodium hypochlorite) typically causes mild injury, but calcium hypochlorite in granular form can cause more severe damage requiring emergency resection in rare cases. 3, 5
• Monitor for delayed complications including esophageal perforation, mediastinitis, and gastric stenosis which can occur even with initially stable presentation. 6, 5

Disposition

• Discharge after 4-6 hours if the patient is back to baseline, tolerating oral fluids, has normal vital signs, and has no evidence of corrosive injury on evaluation. 2
• Transfer to ICU for further management if there is persistent hypotension, shock, extreme lethargy, respiratory distress, or evidence of transmural necrosis on imaging. 2