What is the appropriate emergency management and treatment for a patient who has ingested a corrosive surface‑cleaner liquid?

Emergency Management of Surface Cleaner Liquid Poisoning

For corrosive surface cleaner ingestion, immediately irrigate the mouth with copious water for at least 15 minutes, assess airway patency and signs of respiratory distress, contact Poison Control, and absolutely do NOT induce vomiting, perform gastric lavage, or administer activated charcoal. 1, 2

Immediate First Aid and Stabilization

Initial Actions (Within First Minutes)

• Remove any remaining substance from the oral cavity and irrigate the mouth with copious amounts of water for at least 15 minutes 1, 2
• Contact Poison Control Center immediately (US: 1-800-222-1222; Canada: 1-800-268-9017) while initiating irrigation to obtain product-specific guidance on concentration, expected toxicity, and monitoring needs 3, 1
• Remove all contaminated clothing around the mouth and face area to prevent further exposure 2
• Activate EMS immediately if the patient exhibits altered mental status, seizures, respiratory difficulty, drooling, stridor, or hemodynamic instability 1

Airway Assessment (Critical Priority)

• Assess for airway compromise immediately by checking for stridor, drooling, difficulty swallowing, or respiratory distress, as corrosive cleaners can cause severe oropharyngeal and laryngeal edema 1, 4
• Prepare for early endotracheal intubation if signs of upper airway edema, respiratory distress, or inability to protect the airway are present 1
• Monitor for aspiration and toxic gas inhalation complications, particularly if the patient has vomited 1

Absolutely Contraindicated Interventions

These interventions are harmful and must be avoided:

• DO NOT induce vomiting or administer ipecac - provides no benefit and causes aspiration and further corrosive injury 1, 2
• DO NOT perform gastric lavage - contraindicated in corrosive ingestions, can cause perforation and worsen esophageal injury 3, 1
• DO NOT administer activated charcoal - ineffective for corrosive substances, may cause aspiration or obstruct endoscopic visualization 3, 1, 2
• DO NOT attempt dilution with water or milk for ingestion - insufficient evidence supporting this practice and may spread the caustic substance further 2

Clinical Assessment and Risk Stratification

Physical Examination

• Examine the oropharynx for burns, erythema, or ulceration, though absence of oral lesions does NOT exclude esophageal or gastric injury 3, 1, 2
• Assess for symptoms of corrosive esophagitis: chest pain, dysphagia, odynophagia, drooling, hematemesis, or abdominal pain 1
• Monitor for signs of perforation: fever, tachycardia, peritoneal signs, pneumomediastinum, or hemodynamic instability 1

Laboratory Evaluation

• Obtain initial laboratory tests including: CBC, serum sodium, potassium, chlorine, magnesium, calcium, urea, creatinine, liver function tests (bilirubin, ALT, AST), pH, serum lactate, and β-HCG in women of childbearing age 3
• Abnormal values predictive of transmural necrosis and poor outcomes include: severe acidosis (low pH, high lactate), deranged liver function tests, leukocytosis, elevated CRP, renal failure, and thrombocytopenia 3
• Monitor kinetics of laboratory data as initial normal values do not rule out transmural necrosis 3

Diagnostic Imaging and Endoscopy

Computed Tomography (Preferred Initial Diagnostic Tool)

• Obtain contrast-enhanced CT of neck, chest, and abdomen 3-6 hours post-ingestion for symptomatic patients or those with significant ingestions 3, 1, 2
• CT protocol: Perform before and after intravenous injection (2-3 mL/s) of nonionic contrast agent (2 mL/kg), with 18-25 second acquisition time and 90-second scan delay 3
• The main sign of transmural digestive necrosis is absence of post-contrast wall enhancement, which is an indication for emergency surgery 3
• CT outperforms endoscopy in detecting transmural injuries and predicting esophageal stricture formation 3, 1

Endoscopy

• Consider upper endoscopy within 12-48 hours to assess injury severity and guide prognosis, but only after CT evaluation and with experienced practitioners 1, 2
• AVOID endoscopy between 1-3 weeks post-ingestion due to significantly higher perforation risk during the healing phase 1, 2
• Contraindications to endoscopy include: radiological suspicion of perforation or burns to the supraglottic and epiglottic areas 2

Supportive Care and Medical Treatment

• Provide analgesia as needed for pain control 1
• Administer diazepam 0.1-0.3 mg/kg IV (maximum 10 mg) if seizures occur 1
• Provide standard airway management and treatment of hypotension or dysrhythmias according to BLS and ACLS protocols 3

Surgical Consultation and Intervention

Indications for Immediate Surgical Consultation

• Obtain immediate surgical consultation if CT shows: transmural necrosis, perforation, mediastinitis, or peritonitis 3, 1
• Emergency surgery is indicated for: signs of perforation, full-thickness necrosis of esophagus or stomach, hemodynamic instability, or severe systemic sepsis 1, 2
• Surgical approach: Primary repair with adequate drainage is preferred when feasible; esophageal exclusion or resection may be necessary for extensive injury 1

Non-Operative Management

• Patients without full-thickness necrosis can be offered non-operative management with close clinical and biological monitoring 2

Disposition and Follow-Up

Admission Criteria

• Admit for observation any patient with: symptomatic ingestion, intentional ingestion requiring psychiatric evaluation, or evidence of corrosive injury on imaging 1
• Psychiatric evaluation is mandatory for all intentional ingestions prior to hospital discharge 1

Long-Term Monitoring

• Monitor for delayed stricture formation (typically within 4 months) requiring endoscopic dilation in patients with Grade IIb or higher injuries 1, 2
• For established strictures, endoscopic dilatation is the mainstay of treatment, with recommended time intervals between dilatations of less than 2-3 weeks 2
• Avoid dilatation within 3 weeks of initial caustic ingestion due to higher risk of complications 2

Critical Pitfalls to Avoid

• Clinical symptoms do not correlate reliably with extent of gastrointestinal damage - absence of pain and oral lesions does not rule out life-threatening injuries 3, 2
• The physical form of the ingested substance affects injury pattern: solids produce maximum damage to mouth and pharynx, while liquids cause burns of esophagus and stomach 3, 2
• Specific corrosives may cause severe systemic effects such as hypocalcemia, hyponatremia, hypokalemia, and acidosis requiring specific monitoring 3