A stable child who inhaled an alkaline substance 3 hours ago presenting with oropharyngeal pain, dysphagia, drooling, and oropharyngeal erythema—should he be admitted for observation and conservative management, undergo emergency bronchoscopy, have surgical exploration, or be discharged with follow‑up?

Management of Pediatric Alkaline Inhalation Injury

Admit this child for observation and conservative management (Option A). A vitally stable child presenting 3 hours after alkaline inhalation with oropharyngeal pain, dysphagia, drooling, and erythema requires hospital admission for close monitoring, even with only mild physical findings, because alkaline injuries can progress unpredictably and life-threatening airway compromise may develop hours after the initial exposure.

Rationale for Admission Over Discharge

• Alkaline substances cause liquefactive necrosis that continues to penetrate tissues for hours after exposure, making the initial clinical appearance deceptively benign while deeper injury evolves 1
• Drooling and dysphagia are red-flag symptoms indicating significant mucosal injury that warrant continuous monitoring for potential airway edema or obstruction 1
• The 3-hour window since exposure is insufficient to rule out progressive airway compromise, as edema and tissue damage from alkaline burns typically peak 12-24 hours post-exposure 1
• Vital stability at presentation does not exclude the risk of rapid deterioration from evolving upper airway edema or aspiration pneumonitis 1

Why Emergency Bronchoscopy Is Not Indicated

• Emergency bronchoscopy (Option B) is reserved for patients with respiratory distress, stridor, or clinical evidence of lower airway involvement, none of which are present in this stable child 1
• Flexible bronchoscopy under sedation carries significant risks in children with compromised airways, including oxygen desaturation (especially in the mid-trachea), respiratory depression from sedation, and potential for laryngospasm 1
• The procedure should preserve spontaneous ventilation to assess dynamic airway changes, but this child's symptoms localize to the oropharynx without signs of bronchial involvement 1
• Bronchoscopy would be considered later if the child develops progressive respiratory symptoms, persistent oxygen dependency, or radiographic changes suggesting lower airway injury 1

Why Surgical Exploration Is Inappropriate

• Operative exploration (Option C) is indicated only for full-thickness injuries with perforation, mediastinitis, or peritonitis, which are not suggested by mild oropharyngeal tenderness and redness 1
• The absence of hemodynamic instability, signs of hemorrhage, or evidence of visceral perforation makes emergency surgery unnecessarily morbid 2
• Conservative management allows time to delineate the full extent of injury before committing to irreversible surgical intervention 2

Conservative Management Protocol

Immediate measures:

• Maintain NPO status initially to prevent aspiration through potentially injured mucosa and because sedation for potential procedures increases aspiration risk 1
• Establish continuous pulse oximetry and cardiac monitoring to detect early respiratory compromise 1
• Position the child upright or semi-upright to minimize aspiration of secretions and optimize upper airway patency 3
• Administer supplemental oxygen if oxygen saturation falls below 95%, recognizing that oxygen desaturation is common in children with airway compromise 1

Monitoring parameters:

• Assess respiratory status every 1-2 hours for the first 12-24 hours, watching specifically for stridor, increased work of breathing (accessory muscle use, tracheal tug, intercostal retractions), and changes in voice or cry 3
• Monitor for progressive dysphagia or inability to handle secretions, which signal worsening edema 1
• Inspect the oropharynx serially for increasing erythema, edema, or ulceration 3
• Keep emergency airway equipment at bedside: bag-valve-mask, appropriately sized endotracheal tubes (including one size smaller), laryngoscope, and suction 3

Duration of observation:

• A minimum 24-hour observation period is prudent because alkaline injury progression typically peaks within this timeframe 4
• Pediatric observation units successfully manage similar cases with average stays of 8.4 hours for respiratory conditions, but alkaline injuries warrant longer monitoring given their potential for delayed complications 4

Critical Pitfalls to Avoid

• Never discharge a child with drooling and dysphagia after caustic exposure, even if vital signs are stable, because these symptoms indicate significant mucosal injury with potential for airway compromise 1, 3
• Do not delay admission based on mild initial physical findings, as the extent of alkaline injury is often underestimated on initial examination 1
• Avoid aggressive oral intake or feeding trials in the first 12-24 hours, as this may worsen aspiration risk or disrupt healing mucosa 1
• Do not perform blind instrumentation of the airway if respiratory distress develops; use direct visualization or fiberoptic guidance 3

When to Escalate Care

Indications for urgent bronchoscopy during observation:

• Development of stridor, significant respiratory distress, or oxygen desaturation despite supplemental oxygen 1
• Clinical suspicion of lower airway involvement (persistent cough, wheezing, tachypnea) 1
• Inability to maintain airway patency with conservative measures 1

Indications for surgical consultation:

• Signs of perforation (subcutaneous emphysema, pneumomediastinum on imaging) 3
• Hemodynamic instability or evidence of hemorrhage 5
• Progressive airway obstruction requiring definitive airway management 3