A 10-year-old boy presents 3 hours after ingesting aerosol fluid with oropharyngeal pain, dysphagia, drooling, mild shortness of breath, stable vital signs, and mild oropharyngeal inflammation; what is the appropriate management?

Management of Pediatric Caustic Ingestion with Respiratory Symptoms

This 10-year-old boy with aerosol fluid ingestion presenting with oropharyngeal pain, dysphagia, drooling, and shortness of breath requires hospital admission with conservative management, antibiotics, and urgent flexible endoscopy within 6-24 hours to assess esophageal injury severity (Option D). 1, 2

Why Admission with Conservative Management is Correct

The presence of three major symptoms (dysphagia, drooling, and shortness of breath) is a strong predictor of severe esophageal injury requiring hospitalization and endoscopic evaluation. 3, 4

• The combination of 2 or more serious signs/symptoms (vomiting, drooling, stridor/dyspnea, dysphagia) predicts serious esophageal injury in 50% of cases, with an odds ratio of 11.97 for severe lesions when 3 or more symptoms are present 3, 4
• Even with mild oropharyngeal inflammation on examination, significant esophageal injury cannot be ruled out, as oropharyngeal burns do not reliably predict esophageal damage 3, 4
• The 3-hour timeframe since ingestion places this patient in the optimal window for endoscopic evaluation (6-24 hours), when tissue is no longer maximally friable but edema has not yet peaked 1, 2

Immediate Management Protocol

Keep the patient NPO (nothing by mouth) and initiate IV fluid resuscitation to maintain hydration while awaiting endoscopy. 2

• Maintain airway patency through positioning (head tilt-chin lift) and oropharyngeal airway insertion if needed, as airway assessment is the first priority in caustic ingestion 5, 6
• Administer high-flow oxygen if respiratory distress worsens, though current vital stability suggests adequate oxygenation 6
• Do NOT induce vomiting or give oral dilution/neutralization agents, as this re-exposes damaged tissue to the caustic substance and can worsen injury 2

Why Endoscopy is Needed (But Not Emergency Bronchoscopy)

Flexible endoscopy should be performed within 6-24 hours to grade esophageal injury using the Zargar classification system (grades 0-3B), which guides further management and prognosis. 1, 2

• Emergency bronchoscopy (Option A) is incorrect because the injury pattern in caustic ingestion is primarily esophageal and gastric, not airway-related 2
• Rigid bronchoscopy is reserved for severe central airway obstruction with critical stenosis, not for caustic ingestion evaluation 7
• Avoid endoscopy in the first 6 hours when tissue is most friable and perforation risk is highest, unless signs of perforation require immediate surgical intervention 2
• Do NOT delay endoscopy beyond 24-48 hours, as tissue edema peaks at 3-5 days making endoscopy dangerous during this period 2

Why Surgical Exploration is Not Indicated

Surgical exploration of the oropharynx (Option B) is not indicated in the absence of perforation signs. 1, 2

• Obtain chest and abdominal radiographs to rule out perforation (pneumomediastinum, pneumoperitoneum, pleural effusion) before any invasive procedures 1, 2
• Consider contrast-enhanced CT if perforation is suspected based on clinical deterioration (abdominal pain/rigidity, substernal/chest/back pain) or radiographic findings 1, 2, 5
• Surgery is reserved for confirmed perforation or failure of conservative management, not for initial evaluation 1

Why Discharge is Dangerous

Discharge with outpatient follow-up (Option C) is contraindicated given the high-risk symptom profile and potential for delayed complications. 3, 4

• The risk of severe esophageal lesions without any symptoms is very low (OR 0.13), but this patient has multiple major symptoms indicating high risk 3
• Delayed complications can include perforation, stricture formation, and respiratory compromise requiring ICU admission 5
• Asymptomatic patients with accidental ingestion and no signs may potentially avoid endoscopy, but this patient is clearly symptomatic 3

Hospital Management Components

Conservative management includes NPO status, IV hydration, pain control, airway monitoring, and prophylactic antibiotics to prevent infection from potential esophageal injury. 2, 5

• Monitor for signs of perforation: fever, cervical subcutaneous emphysema, worsening respiratory distress, or hemodynamic instability 1
• Never perform blind nasogastric tube placement before endoscopy, as this can perforate friable esophageal tissue 2
• Many patients require ICU admission for close airway and hemodynamic monitoring 5

Critical Pitfalls to Avoid

• Do NOT assume mild oropharyngeal inflammation correlates with mild esophageal injury—the two are poorly correlated 3, 4
• Do NOT wait for symptoms to worsen before admitting, as the presence of drooling, dysphagia, and dyspnea already indicates significant injury risk 3, 4
• Do NOT perform endoscopy in the first 6 hours unless perforation is suspected, as tissue friability increases perforation risk 2
• Do NOT delay endoscopy beyond 24-48 hours, as peak edema at 3-5 days makes the procedure hazardous 2