The markedly swollen lips and drooling in this photo are seen following a caustic ingestion. Potassium hydroxide, also known as potash, is a caustic substance found in fertilizers, cleaning supplies, and some hair products. As a strong alkali, it causes deep mucosal damage through liquefactive necrosis . In comparison, acid agents cause coagulative necrosis. Whether a caustic agent is acid or alkaline, the overall clinical picture and management are similar. Caustic injuries remain a common public health issue despite efforts to raise public awareness about the safe handling of household products. Unfortunately, many of these injuries worldwide involve children .
What are possible signs and symptoms of a caustic ingestion? [1-6]
Occurs immediately in the lips, mouth, throat, and possibly chest and abdomen.
Erythema, swelling, and burns to the lips and oral cavity
Dysphagia and odynophagia (esophageal injury)
Epigastric pain and hematemesis (gastric injury)
CAUTION: Patients may still have a severe injury despite few initial signs and symptoms.
What are possible complications?
Long-term complications in survivors may include gastrointestinal strictures, stenoses, and fistula formation. The severity and extent of symptoms depend on the concentration, dosage, and form of caustic ingested.
Deaths following caustic ingestion typically result from perforation, hemorrhage, mediastinitis, peritonitis, or sepsis.
What diagnostic testing should be obtained? [1-6]
CBC, basic metabolic panel, venous blood gas
Serial hemoglobin levels may be useful to evaluate for hemorrhage
Metabolic acidosis is commonly seen with acid ingestions and GI tract necrosis
Upright chest xray or abdominal xray
Can assess for pneumomediastinum or pneumoperitoneum
Can assess for perforation and hemorrhage and may be of utility to detect burns
What is the management of a caustic ingestion? [1-6]
Contraindication: Gastric lavage, activated charcoal, or attempts to neutralize the acid or alkali
Standard supportive measures with close attention to airway management
Decontamination with removal and bagging of clothing and copious irrigation with normal saline if exposure to eyes or on skin
Esophagogastroduodenoscopy (EGD) – ideally performed within 24 hours of a caustic ingestion
Recommended for all intentional ingestions
Recommended for patients with stridor
Recommended for patients with 2 of the following symptoms:
If signs of infection
Recommended for patients with respiratory compromise from upper airway edema
May be considered for grade IIb burns
Surgical intervention may be required in cases of perforation, hemorrhage, necrosis, or shock.
Decontamination should occur if indicated with attention to preventing secondary exposure to caregivers
Patients may have few initial symptoms with a severe gastrointestinal tract injury
Watch carefully for respiratory compromise due to upper airway edema.
CT imaging may be useful to evaluate for perforation, hemorrhage, and burns.
EGD is the gold standard to identify, evaluate, and plan for management for the caustic injury. This should ideally performed within 24 hours of ingestion.
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