Introduction
Caustic ingestions can readily harm people of all ages and are one of the leading causes of morbidity and mortality. Children account for 80 percent of all cases of caustic ingestion in the US (United States). For the best results, surgical and medicinal treatments must be coordinated for caustic ingestions, which call for urgent care. Clinicians need to be aware of potential problems and accessible resources. Most ingestions (especially those involving children) are not poisonous and can be treated at home, but successful outcomes depend on prompt triage, thorough evaluation, and the initiation of treatment at the appropriate time.
What Is the Etiology of Caustic Substance Injuries or Poisoning?
Caustic ingestion can be caused by intentional or unintentional consumption, such as suicidal behavior in adults. Accidental ingestion is more common in youngsters. Children frequently consume everyday home products like ammonia or bleach. Most caustic exposures (76 percent) involve oral intake, and almost all (93 percent of cases) occur at home. The majority of these ingestions (more than 80 percent) were not deliberate. Typically, either an acid or an alkali is consumed. These groups differ from one another in terms of pathophysiology and method of care.
What Is the Pathophysiology of Caustic Substance Injury or Poisoning?
The pathophysiology varies depending on whether an acid or an alkali is present. Alkalis are chemicals with a pH (potential of hydrogen) above 7.0, and liquefaction necrosis (a pattern of cell death) usually occurs above 11.5 as a threshold for causing direct tissue damage. In contrast to coagulation necrosis, which is a form of cell death brought on by a reduction in blood flow, liquefaction necrosis involves rapid tissue dissolution. Digestive enzymes are released once the cells are lysed and start to break down the stromal architecture. Alkalis speed up the mucosa's early breakdown, allowing for more serious injury and penetration. The length of contact and alkali strength, as with all exposures, dictate the severity of the wound. However, if left in contact with tissue for a long enough period of time, even low amounts of alkali chemicals can seriously harm it.
If the pH is less than 2, coagulation necrosis is a more likely mechanism by which acids will harm the body. When tissue is hypoxic (reduced oxygen supply), or ischemic (restricted blood flow), coagulative necrosis is the default mode of necrosis for the majority of the body. The undamaged tissue stroma is thought to operate as a protective barrier against additional injury, which is why damage is thought to be less severe in acidic ingestions. The moderate alkali surface of the esophageal mucosa may aid in neutralizing acidic chemicals, further reducing the risk of harm.
What Are the Symptoms of Caustic Substance Poisoning?
The possible symptoms of caustic substance injury or poisoning are:
Immediate Symptoms:
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The pain in the mouth and throat can become intense, especially when swallowing, and it usually starts within minutes.
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Drooling.
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Difficulty swallowing.
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Vomiting.
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Vomiting blood.
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A person may experience very low blood pressure (shock), trouble breathing, or chest pain in severe situations involving potent caustics, which could result in death.
Late Symptoms:
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In the hours following consumption, the first week afterward, or at any other moment in between, perforation of the esophagus or stomach can happen, frequently following vomiting or violent coughing.
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The mediastinum, which is the space between the lungs, or the pleural cavity, which is the space around the lungs, may both be perforated by the esophagus. Either scenario results in extreme chest pain, a fever, a rapid heartbeat, a quick breathing pattern, very low blood pressure, and the requirement for surgery.
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When the stomach perforates due to peritonitis, acute abdominal pain develops.
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Scarring of the esophagus causes constriction (stricture), and it may also impair the swallowing muscles, both of which make it difficult to swallow. Strictures frequently appear weeks after a burn, occasionally in burns that at first only displayed minor symptoms.
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Years after suffering an injury, people with esophageal scars or damage may develop esophageal cancer.
How Is Caustic Substance Injury or Poisoning Assessed?
In order to choose the best course of action, the history of a patient with suspected caustic ingestion must take into account five fundamental factors. The "5 W's" are an effective mnemonic that has been compiled from several writings on this subject. This part includes a quick evaluation of important history.
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Who: In this section, patient demographics are important. Find out the patient's age and weight, as well as whether any friends, family, or witnesses are with them.
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What: The properties of drugs and toxins consumed.
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When: The time and date when the food was consumed.
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Where: The method of poisoning as well as the area where it occurred, might be used to identify any environmental elements that might be confusing.
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Why: Once the patient has stabilized, the clinician must determine intentionality since it may have a significant impact on discharge plans.
Patients who have consumed caustic substances may exhibit vomiting, drooling, and oral and tongue edema. Some individuals may exhibit vocal alterations, stridor (a high-pitched whistling sound during breathing due to abnormal airflow in the lungs), and respiratory discomfort in addition to upper airway edema. If a vessel has been eroded, hematemesis (vomiting blood) might be present. Mediastinitis (inflammation and swelling of the mediastinum, the space in the chest between the lungs) or peritonitis (inflammation of the membrane peritoneum that lines the stomach and protects the internal organs) can happen if the esophagus or stomach is ruptured, respectively. The physical examination comprises the typical main and secondary assessments found in emergency rooms.
How Is Caustic Substance Injury or Poisoning Evaluated?
Airway, breathing, and circulation are the main focuses of the evaluation. The appropriateness of ventilation, mental status function, and cardiac functioning must all be given particular consideration during the comprehensive assessment. Patients that are unstable should be continuously telemetry monitored and have their vital signs checked every fifteen minutes until they are stable.
A complete blood count, a metabolic profile that includes electrolytes, and an arterial or venous blood gas are some of the lab tests that can be acquired. Simple radiographs of the chest and abdomen can reveal pneumomediastinum (the area in the chest between the two lungs - mediastinum - is filled with air) or free air.
After the initial resuscitation has been completed in cases of caustic ingestion, it is important to assess the degree of the injury because this will inform the subsequent care procedures. Endoscopy has long been used as a way to assess gastrointestinal damage. For the examination of lesions, contrast-enhanced computed tomography (CECT) has been suggested as an alternative to endoscopy.
How Is Caustic Substance Injury or Poisoning Treated?
In patients exhibiting impending respiratory failures symptoms, such as drooling and voice abnormalities, the airway should be protected. According to one study, 50 percent of people who consumed caustic had to be intubated. Access to intravenous fluids must be obtained. Management will be determined by the substance that was consumed. The current guideline for caustic injury is to dilute with water. However, this has minimal efficacy because the damage is usually detected within the first few minutes following the accident. It is not advisable to utilize activated charcoal or induce emesis in these patients.
Patients who have suspected peritonitis, hemodynamic instability, or mediastinitis will need emergent surgery to determine the extent of the damage. If there is little indication of these, CECT of the neck, chest, and abdomen may be done to ascertain the severity of the injury.
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Grade I: Organs that appear normal.
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Grade II: Soft tissue inflammation and increased mucosa from edema.
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Grade III: Post-contrast wall enhancement is not present.
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Grade I typically denotes early discharge and no endoscopy.
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If CECT is non-diagnostic, Grade II often denotes non-operative therapy and endoscopy.
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Although it is debatable, certain Grade II burns may benefit from intravenous corticosteroids. Grade III denotes an urgent surgical procedure.
The conventional procedure in emergency surgery is a laparotomy, which aims to remove all necrotic tissue. The extent of the wounded surfaces determines what is removed, with options ranging from minor surgeries like a pancreaticoduodenectomy to resection of particular areas.
What Is the Prognosis of Caustic Substance Injury or Poisoning?
The severity of the initial damage determines the prognosis the most, with mild-moderate ingestions having the best prognosis and severe ingestions necessitating emergency surgery having the most difficulties. Grade III or higher injuries require prompt emergency surgery as well as post-operative care. If surgery is necessary, patients typically recover worse since the risk of complications, including mediastinitis and perforation, is considerable.
The quality of life following radical excision or esophageal reconstruction should be a very important topic that the surgical team discusses with the patient. According to one study, quality of life ratings significantly declined when compared to populations at large. Although it should not determine whether surgery is done or not, it is crucial to talk to the patient and prepare them for potential issues.
Conclusion
In conclusion, poisoning from caustic compounds is a serious public health issue. Society can work to reduce the frequency, severity, and long-term effects of this kind of poisoning by increasing awareness, implementing preventive measures, assuring proper medical interventions, and giving thorough assistance to individuals affected.
