In a child who inhaled an alkaline fluid three hours ago and now presents with oropharyngeal pain, dysphagia, drooling, mild erythema, and stable vital signs without airway obstruction, what is the most appropriate initial management?

Management of Pediatric Alkaline Fluid Inhalation

This child requires immediate hospital admission for conservative management with close airway monitoring and urgent flexible endoscopy within 6–24 hours to assess injury severity. 1

Rationale for Admission (Option A)

Hospital admission is mandatory for any pediatric patient presenting with dysphagia, drooling, and oropharyngeal pain following caustic exposure, even with stable vital signs. 1 The clinical presentation—oropharyngeal pain, difficulty swallowing, and drooling—indicates mucosal injury that requires:

• NPO status with IV fluid resuscitation 1
• Continuous monitoring for airway compromise (fever, subcutaneous emphysema, worsening respiratory distress, hemodynamic instability) 1
• Flexible endoscopy scheduled between 6–24 hours post-ingestion to grade injury using the Zargar classification system (grades 0–3B), which directs subsequent management and provides prognostic information 1

The 3-hour timeframe places this child in the optimal window for endoscopic evaluation—the mucosa is no longer maximally friable (avoiding the first 6 hours when perforation risk is highest), yet edema has not peaked (which occurs at 3–5 days). 1

Why Not Emergency Bronchoscopy (Option B)

Emergency rigid bronchoscopy is not indicated for caustic ingestion/inhalation unless there is documented airway obstruction requiring rescue intervention. 2 The French guidelines reserve rigid bronchoscopy for "cannot intubate, cannot oxygenate" (CICO) scenarios with SpO₂ <80% and/or decreasing heart rate. 2

• This child is vitally stable with no stridor, no respiratory distress, and no signs of impending airway obstruction 1
• Flexible endoscopy is the appropriate diagnostic modality for caustic injury evaluation, as the primary concern is esophageal and gastric injury, not airway obstruction 1
• Rigid bronchoscopy is reserved for rescue ventilation in life-threatening airway emergencies, not diagnostic evaluation of caustic exposure 2

Why Not Surgical Exploration (Option C)

Surgical exploration of the oropharynx is contraindicated in the absence of perforation. 1 Surgery is reserved for:

• Confirmed perforation (pneumomediastinum, pneumoperitoneum, pleural effusion on imaging) 1
• Clinical deterioration with new abdominal pain, rigidity, chest/back pain, or abnormal radiographs suggesting perforation 1
• Failure of conservative therapy 1

This child has only mild oropharyngeal erythema and tenderness without signs of perforation, making surgical exploration inappropriate and potentially harmful. 1

Why Not Discharge (Option D)

Discharge is absolutely contraindicated given the risk of delayed complications:

• Alkaline substances cause liquefactive necrosis that can progress over hours to days, potentially leading to perforation, stricture formation, or airway compromise 1
• Drooling and dysphagia indicate significant mucosal injury requiring endoscopic assessment 1
• Many pediatric caustic ingestion patients require ICU-level monitoring during the acute phase for close airway and hemodynamic surveillance 1

Initial Conservative Management Protocol

Immediate interventions upon admission include:

• NPO status with IV fluid resuscitation to maintain hydration 1
• Avoid blind nasogastric tube placement before endoscopy, as this can perforate friable esophageal tissue 1
• Obtain chest and abdominal radiographs before any invasive procedure to exclude perforation 1
• Do not induce vomiting or give oral dilution/neutralization agents, as this can worsen injury by re-exposing damaged tissue to the caustic substance 1
• Schedule flexible endoscopy within 6–24 hours to grade injury severity 1
• Consider ICU admission for continuous airway and hemodynamic monitoring 1

Critical Pitfalls to Avoid

• Never delay endoscopy beyond 24–48 hours, as tissue edema peaks at 3–5 days and makes endoscopy dangerous during this period 1
• Never perform blind finger sweeps or nasogastric tube placement before endoscopic evaluation 1
• Do not discharge based on initial stable vital signs alone—alkaline injury can progress insidiously 1
• Avoid rigid bronchoscopy as a diagnostic tool for caustic ingestion; it is a rescue airway technique, not an evaluation method 2, 1