Acids: low pH, coagulation necrosis, “what you see is what you get”, more respiratory damage, less perforation
- Battery acid, pool cleaners ⇒ very caustic
Alkali: saponification necrosis, deeper, increased risk for perforation, later stricture formation
- pH > 11 ⇒ increased risk of saponification necrosis
Decide: Plan A or Plan B?
Plan A: IV, resuscitate, NPO, monitor airway and signs of perforation, admit
Plan B: Observe for 4-6 hours, PO challenge, reassess, safety talk, close follow-up
- Symptoms of caustic ingestion ⇒ Plan A
- Drain Cleaner? Lye? pH of > 11? ⇒ Plan A
- Household bleach? pH <11 ⇒ Plan B; go to plan A if fails
- Unknown exposure, no symptoms? ⇒ Plan B; go to plan A if fails
Special Shout-Outs to:
Laundry Detergent Pods — although they have a pH of 9-11, the additive propylene glycol can cause CNS depression, seizures, further aspiration. Also, contact time (viscosity) is increased, leading to further alkali saponification
Drain cleaner — typical pH is 13-14. Full stop. Needs admission and scope in all cases.
Selected References
Ahsan S et al. Absence of esophageal injury in pediatric patients after hair relaxer ingestion. Arch Otolaryngol Head Neck Surg. 1999;125(9):953.
Beuhler MC. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013 Jun;29(6):743-7. doi: 10.1097/PEC.0b013e318294f3db.
Davis MG. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014. Pediatrics. 2016 May;137(5):e20154529
Hoffman RS et al. Ingestion of Caustic Substances. N Engl J Med. 2020;382(18):1739.
Lupa M. Update on the Diagnosis and Treatment of Caustic Ingestion. Ochsner J. 2009 Summer; 9(2): 54–59.
Sherenian MG et al. Caustic ingestions mimicking anaphylaxis: case studies and literature review. Pediatrics. 2015;135(2):e547. Epub 2015 Jan 12.
Slaughter RJ. The clinical toxicology of sodium hypochlorite. Clin Toxicol (Phila). 2019 May;57(5):303-311
Wason S. The emergency management of caustic ingestions. J Emerg Med. 1985;2(3):175.
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