In a hemodynamically stable child who inhaled alkaline fluid three hours ago and now has oropharyngeal pain, dysphagia, drooling, and mild oropharyngeal erythema, what is the most appropriate next step in management?

Management of Pediatric Alkaline Fluid Inhalation

This hemodynamically stable child with oropharyngeal symptoms following alkaline fluid inhalation requires hospital admission for conservative management with urgent flexible endoscopy within 6–24 hours—the answer is A: Admission for conservative management. 1

Why Admission and Conservative Care Is Correct

Hospital admission is mandatory for any pediatric patient presenting with dysphagia, drooling, and oropharyngeal pain following caustic exposure, regardless of hemodynamic stability. 1 The presence of two or more serious symptoms (drooling, dysphagia, and oropharyngeal pain) predicts a 50% risk of serious esophageal injury, making observation and endoscopic evaluation essential. 2

Initial Conservative Management Protocol

• Keep the patient NPO (nothing by mouth) and initiate IV fluid resuscitation to maintain hydration while protecting the potentially injured esophagus from further trauma. 1

• Administer prophylactic antibiotics and consider steroids as part of the conservative regimen, though steroids do not prevent stricture formation in full-thickness injuries. 3

• Obtain chest and abdominal radiographs before any invasive procedure to exclude perforation signs such as pneumomediastinum, pneumoperitoneum, or pleural effusion. 1

• Monitor continuously for perforation indicators: fever, cervical subcutaneous emphysema, worsening respiratory distress, or hemodynamic instability during the acute phase. 1

Timing of Endoscopic Evaluation

Flexible endoscopy should be performed between 6 and 24 hours after ingestion—this child at 3 hours post-exposure is in the optimal window. 1, 4 The mucosa is no longer maximally friable (as it is in the first 6 hours), while tissue edema has not yet peaked (which occurs at 3–5 days). 1

• Use flexible endoscopy, not rigid bronchoscopy, to assess esophageal and gastric injury using the Zargar classification system (grades 0–3B). 1

• The Zargar grade directs subsequent management: Grade 0–I injuries typically heal without sequelae, while Grade 2B–3B injuries carry high risk of stricture formation requiring long-term follow-up. 3

Why Emergency Bronchoscopy Is Wrong (Option B)

Rigid bronchoscopy is solely a rescue ventilation technique for "cannot intubate, cannot oxygenate" (CICO) scenarios with SpO₂ <80% and/or decreasing heart rate—it is not a diagnostic tool for caustic injury assessment. 1, 5 This child is hemodynamically stable with adequate oxygenation, making emergency bronchoscopy inappropriate and potentially harmful.

• The injury from caustic ingestion/inhalation is primarily esophageal and gastric, not airway-related, unless there is documented airway obstruction requiring immediate rescue intervention. 1

• Rigid bronchoscopy should not be employed diagnostically in caustic exposure cases; its appropriate use is limited to emergency airway rescue when conventional ventilation fails. 1

Why Surgical Exploration Is Wrong (Option C)

Surgical exploration of the oropharynx is not indicated in the absence of perforation signs; surgery is reserved for confirmed perforation or failure of conservative therapy. 1 This child has only mild oropharyngeal erythema and tenderness without signs of perforation (no subcutaneous emphysema, no mediastinal air, no hemodynamic instability).

• Clinical symptoms do not always represent the depth of intestinal tract lesions, making premature surgical intervention both unnecessary and potentially harmful. 4

• Even patients without visible oropharyngeal changes can have significant esophageal burns, so the absence of severe oral findings does not exclude injury—but it also does not mandate immediate surgery. 4

Why Discharge Is Wrong (Option D)

Discharge is contraindicated when a child presents with two or more serious symptoms (drooling, dysphagia, pain) following caustic exposure. 2 The presence of multiple symptoms predicts a 50% risk of serious esophageal injury, and 29% of patients with esophageal burns may develop strictures requiring intervention. 3, 4

• Symptoms are common at presentation and do not reliably predict injury severity, but their presence mandates endoscopic evaluation within 24 hours. 4, 6

• Many pediatric caustic exposure patients require admission to an intensive-care unit for close airway and hemodynamic surveillance during the acute phase. 1

Critical Pitfalls to Avoid

• Never perform blind nasogastric tube placement before endoscopy in caustic ingestion/inhalation, as this can perforate friable esophageal tissue. 1

• Do not induce vomiting or give oral dilution/neutralization agents, as this worsens injury by re-exposing damaged tissue to the caustic substance. 1

• Do not delay endoscopy beyond 24–48 hours, as tissue edema peaks at 3–5 days and makes endoscopy dangerous during this period. 1

• The character of the ingested caustic material is the most important determinant of injury severity, with alkaline preparations (like the fluid in this case) being highly injurious and carrying significant risk of full-thickness burns. 3