Corrosives - Caustic Poisoning

  • See also

    Poisoning - Acute Guidelines For Initial Management 
    Burns / management of burn wounds
    Analgesia and sedation 
    Foreign body ingestion

    Key Points

    1. Alkali ingestion can often be asymptomatic early and this does not exclude serious injury
    2. Absence of mouth or pharyngeal ulcers does not preclude gastro-oesophageal lesion
    3. Nasogastric insertion should only be performed by an endoscopist
    4. If threatened airway, consider early intubation
    5. If inhalational exposure, respiratory symptoms can be delayed 

    Background

      Alkalis Acids
        Common agents

    Drain cleaners

    Oven cleaners

    Automatic dish washing liquids & powder, pod

    Laundry detergents

    Pool cleaners

    Portland cement

    Drain cleaners

    Anti-rust products/metal cleaners

    Batteries

        Exposure

    Inhalation, ingestion and / or topical injury (skin/eye involvement)

     

    o             pH of > 11 or < 2 is likely to cause significant GI ulceration

    o             liquid preparations can travel further than powders

          Pathophysiology

    Usually odourless liquids

       

    Liquefactive necrosis – deep penetration of tissues (hours to days)

    Often bitter taste and painful

       

    Coagulative necrosis – depth of burn is limited by scar / eschar formation

    Children requiring assessment

    All patients with deliberate self-poisoning or significant accidental ingestion 
    Any symptomatic patient 
    Any patient whose developmental age is inconsistent with accidental poisoning as non-accidental poisoning should be considered.

    Risk Assessment

    History

    Intentional overdose or accidental

    Dose: 
    Stated or likely dose taken
    Find the following information (where possible)

    • Obtain container to check contents and strength of substance/photos
    • Check preparations with the Victorian Poisons Information Centre (131126) to determine the corrosive potential of the product with severe toxicity.

    Co-ingestants eg paracetamol

    Examination

    Symptoms      

    • May be minimal and / or delayed
    • Pain, nausea & vomiting, drooling or refusing to eat and drink
    • Stridor, respiratory distress
    • Splash burns (skin / eyes)
    • Systemic features – circulatory collapse and / or multi-organ failure

    Investigations (if symptomatic)

    • Blood tests may be required if systemic features
    • CXR
    •  Endoscopy (best method for assessing GI injury within 12 - 24 hours) in symptomatic patients and is required in spite of a normal chest x-ray and lab investigations

    Pathology

    Paracetamol concentration in all intentional overdoses

    Acute Management

    Depends on type of injury

    Ingestion / Inhalational

    Decontamination: Activated charcoal / GI decontamination / neutralisation procedures are contraindicated

    Standard resuscitation may be required in severe poisoning

    If asymptomatic – observe, trial of oral intake at 4 hours after exposure, earlier if low suspicion or likely benign ingestion after discussion with Poisons Information Centre

    If any symptoms admit for oesophagoscopy (within 24 hours) (PIPER, local paed surg)

    • Keep NBM
    • Commence intravenous PPI 

      Analgesia – see Anlagesia and Sedation guideline. If opiate or parenteral analgesia required, please consult local pain management service.

      Dermal

      Remove clothing / particulate matter. 
      Copious low pressure water for minimum 10-15 minutes, or until pH of skin is normal (pH 6 – 7 in children). 
      Recheck pH of affected areas after a period of 15-20 minutes and repeat irrigation if abnormal (several hours may be required). 
      Then treat as per thermal injury (see Burns CPG)

      Eye

      Alkaline exposure is an ophthalmic emergency.

      Remove contact lenses if present. Use topical anaesthetic (if available), immediate irrigation with 1L normal saline (via a giving set) for minimum 10-15 minutes regardless of pH. 
      This procedure may require sedation to ensure prompt management.
      Aim for a final conjunctival pH of 7.5 - 8.0; or similar to other eye if unaffected. 
      The conjunctivae may be tested with indicator paper. 
      Retest 20 minutes after irrigation; repetitive irrigation may be necessary.
      Record Visual Acuity (if possible) and assess presence of corneal damage with fluorescein uptake.
      Prompt referral to ophthalmology services.

      Consider consultation with local paediatric team when

      • All symptomatic patients
      • Admission should be considered for all children and young people with an intentional overdose

      Consult Contact Victorian Poisons Information Centre 131126 for advice

      When to consider transfer to a tertiary centre

      • Patients requiring escalation of care beyond the comfort of the hospital and local paediatric team. 
      • Any patient requiring intensive care

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

      Consider discharge when

      If asymptomatic after 4 hours and able to eat and drink the patient can be safely discharged.
      Suspected non-accidental injury / mental health concerns may independently warrant admission and need to be addressed. 
      For deliberate ingestion a risk assessment should indicate that the patient is at low risk of further self-harm in the discharge setting.

      Discharge information and follow-up

      Poisoning prevention for children Parent information

      Victorian Poisons Information Centre: 13 11 26 www.austin.org.au/poisons

      Intentional self –harm: Referral to local mental health services eg Orygen Youth Health: 1800 888 320 

      Recreational poisoning: Referral to YoDAA, Victoria's Youth Drug and Alcohol Advice service: 1800 458 685

      Last updated January 2019