1) MILD TO MODERATE TOXICITY: With small exposures, local mucosal or skin irritation can occur.
2) SEVERE TOXICITY: Skin burns may occur following exposure to solubilized granular or liquid ADD. Following large ingestions or ingestion of industrial strength products, there can be significant gastrointestinal caustic injury, necrosis and perforation, or mediastinitis. Spontaneous vomiting, diarrhea, dysphagia, and drooling may occur. Esophageal burns may occur without the presence of oral burns especially when a liquid containing the ADD is ingested. Respiratory distress can develop due to aspiration or oropharynx edema and inflammation. Extensive corneal erosion may result with prolonged exposure.

1) Initial management includes irrigation if patient has had symptomatic dermal or ocular exposure. If product is ingested, rinse the mouth with water with the immediate removal of obvious granules or gels, and dilution of exposed area.

1) Respiratory support may be needed for respiratory distress, or airway edema. Initial circulatory support with adequate fluid resuscitation may be needed for dehydration, gastrointestinal bleed, and/or acid-base abnormalities due to large intentional ingestions. Endoscopy will be needed to evaluate the extent of injury.

1) PREHOSPITAL: Removal of obvious granules or gels, and dilution/irrigation of exposed areas can be initiated.
2) HOSPITAL: After an ingestion, rinse mouth and administer small amounts of water. Lavage and activated charcoal are not indicated as toxicity is secondary to local tissue injury.

1) Respiratory support may be needed for respiratory distress or airway edema.

1) None.

1) INDUSTRIAL PRODUCTS/SIGNIFICANT INGESTIONS: Should be performed as soon as possible (preferably within 12 hours, not more than 24 hours) in any patient with deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after inadvertent ingestion. Endoscopy should also be considered in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion. Children and adults who are asymptomatic after inadvertent ingestion do not require endoscopy. The grade of mucosal injury at endoscopy is the strongest predictive factor for the occurrence of systemic and GI complications and mortality. The absence of visible oral burns does NOT reliably exclude the presence of esophageal burns.

1) There is no routine role for hemodialysis.

1) HOME CRITERIA: Most small unintentional ingestions can remain at home. If an industrial product is involved, symptoms persist, self-harm ingestion, healthcare facility referral should be recommended.
2) OBSERVATION CRITERIA: Patients who are symptomatic should be observed in the emergency department until patient is asymptomatic and tolerating oral intake. Patients with eye exposures should generally be referred to a healthcare facility for evaluation and treatment.
3) ADMISSION CRITERIA: Patients who have persistent symptoms, respiratory difficulties, intolerance of oral intake, or intentional ingestions, may need to be admitted for further evaluation and endoscopy.
4) CONSULT CRITERIA: If patients are symptomatic and/or after large ingestions, call your regional poison center. For significant or symptomatic ingestions, gastroenterology may need to be consulted for endoscopic evaluation. In pediatric patients, any stridor, persistent vomiting, or drooling may be indication for endoscopy. For ocular injuries, ophthalmology consultation may be needed.

1) Failure to recognize symptoms of gastrointestinal injury, significant ingestion, or attempts to neutralize the product. Absence of oropharyngeal burns do not rule out the possibility of esophageal or gastric burns. Activated charcoal is not indicated, and will interfere with visualization of mucosa if endoscopy is indicated.

1) With alkaline caustics, hydroxide is dissociated and penetrate tissue surfaces and produce a liquefactive necrosis. This process, among other things includes, fat saponification, protein dissolution, and cell death. This is in contrast to acidic caustics, which cause a coagulation necrosis. Common ingredients in detergents include benzalkonium chloride, sodium hydroxide, sodium borates, sodium carbonates, sodium phosphates, sodium silicates, and sodium hypochlorite.

1) Other alkaline and acidic caustic agents such as cleaning agents.

1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

1) CORNEAL DAMAGE

1) SUMMARY: The pH of some ADDs is in excess of pH 12.5 and the ingestion of those products can result in the development of oropharyngeal irritation or burns (Lee et al, 1972; Muhlendahl et al, 1978; Krenzelok & Clinton, 1979; Temple & Veltri, 1979).
2) GRANULAR PRODUCTS
3) LIQUIDS

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

1) WITH POISONING/EXPOSURE

A) Patients who have persistent symptoms, respiratory difficulties, intolerance of oral intake, or intentional ingestions, may need to be admitted for further evaluation and endoscopy.

A) Most small unintentional ingestions can remain at home. If an industrial product is involved, symptoms persist, self-harm ingestion, healthcare facility referral should be recommended.
B) Most ingestions of ADD involve small amounts which do not produce oral, pharyngeal, or esophageal irritation. If the patient is asymptomatic and not refusing liquids due to the discomfort of swallowing and no drooling is present, home observation is sufficient. Products with a pH of less than 11.4 are rarely associated with significant sequelae (Howell, 1987).

A) If patients are symptomatic and/or after large ingestions, call your regional poison center. For significant or symptomatic ingestions, gastroenterology may need to be consulted for endoscopic evaluation. In pediatric patients, any stridor, persistent vomiting, or drooling may be indication for endoscopy. For ocular injuries, ophthalmology consultation may be needed.

A) Patients who are symptomatic should be observed in the emergency department until patient is asymptomatic and tolerating oral intake. Patients with eye exposures should generally be referred to a healthcare facility for evaluation and treatment.

A) Ocular exposure to ADD rarely results in the need to admit. However, since these products have the potential to produce both mechanical and chemical injury, any patient suffering ocular exposure to ADDs should undergo immediate ocular irrigation followed by referral to an emergency department or ophthalmologist since over 90% of these patients will develop at least minor irritation (Krenzelok, 1989).

1) If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. The exact ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
2) USE OF DILUENTS IS CONTROVERSIAL: While experimental models have suggested that immediate dilution may lessen caustic injury (Homan et al, 1993; Homan et al, 1994; Homan et al, 1995), this has not been adequately studied in humans.
3) DILUENT TYPE: Use any readily available nontoxic, cool liquid. Both milk and water have been shown to be effective in experimental studies of caustic ingestion (Maull et al, 1985; Rumack & Burrington, 1977; Homan et al, 1995; Homan et al, 1994; Homan et al, 1993).
4) ADVERSE EFFECTS: Potential adverse effects include vomiting and airway compromise (Caravati, 2004).
5) CONTRAINDICATIONS: Do NOT attempt dilution in patients with respiratory distress, altered mental status, severe abdominal pain, nausea or vomiting, or patients who are unable to swallow or protect their airway. Diluents should not be force fed to any patient who refuses to swallow (Rao & Hoffman, 2002).

1) After an ingestion, rinse mouth and administer small amounts of water. Lavage and activated charcoal are not indicated as toxicity is secondary to local tissue injury.

1) Immediately remove any obvious granules from the lips and oral mucosa and dilute with milk or water, whichever is most accessible. The goal of dilution is to rinse the product from the mouth and pharynx.
2) If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. The exact ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
3) USE OF DILUENTS IS CONTROVERSIAL: While experimental models have suggested that immediate dilution may lessen caustic injury (Homan et al, 1993; Homan et al, 1994; Homan et al, 1995), this has not been adequately studied in humans.
4) DILUENT TYPE: Use any readily available nontoxic, cool liquid. Both milk and water have been shown to be effective in experimental studies of caustic ingestion (Maull et al, 1985; Rumack & Burrington, 1977; Homan et al, 1995; Homan et al, 1994; Homan et al, 1993).
5) ADVERSE EFFECTS: Potential adverse effects include vomiting and airway compromise (Caravati, 2004).
6) CONTRAINDICATIONS: Do NOT attempt dilution in patients with respiratory distress, altered mental status, severe abdominal pain, nausea or vomiting, or patients who are unable to swallow or protect their airway. Diluents should not be force fed to any patient who refuses to swallow (Rao & Hoffman, 2002).
7) Following immediate dilution the patient should remain NPO until a thorough ENT evaluation is completed. Excessive fluid intake may promote emesis and aggravation of existing injury.

1) Spontaneous emesis may occur. Induced emesis and gastric lavage are not indicated. Emesis or lavage may aggravate an existing corrosive injury.

1) Avoid activated charcoal since it may interfere with visualization of oral, esophageal, and gastric irritation/necrosis.

1) In significant ingestions, monitor CBC, serum electrolytes, and blood gases.
2) In significant ingestions, radiographs should be considered to evaluate for perforation or aspiration.

1) Immediately remove any obvious granules from the lips and oral mucosa and dilute with milk or water, whichever is most accessible.
2) Following immediate dilution the patient should remain NPO until a thorough ENT evaluation is completed. Excessive fluid intake may promote emesis and aggravation of existing injury.
3) NEUTRALIZATION

1) SUMMARY: Obtain consultation concerning endoscopy as soon as possible, and perform endoscopy within the first 24 hours when indicated.
2) INDICATIONS: Endoscopy should be performed in adults with a history of deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after unintentional ingestion (Crain et al, 1984). Endoscopy should also be performed in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion (Gaudreault et al, 1983; Nuutinen et al, 1994). Children and adults who are asymptomatic after accidental ingestion do not require endoscopy (Gupta et al, 2001; Lamireau et al, 2001; Gorman et al, 1992).
3) RISKS: Numerous large case series attest to the relative safety and utility of early endoscopy in the management of caustic ingestion.
4) The risk of perforation during endoscopy is minimized by (Zargar et al, 1991):
5) GRADING
6) FOLLOW UP - If burns are found, follow 10 to 20 days later with barium swallow or esophagram.
7) SCINTIGRAPHY - Scans utilizing radioisotope labelled sucralfate (technetium 99m) were performed in 22 patients with caustic ingestion and compared with endoscopy for the detection of esophageal burns. Two patients had minimal residual isotope activity on scanning but normal endoscopy and two patients had normal activity on scan but very mild erythema on endoscopy. Overall the radiolabeled sucralfate scan had a sensitivity of 100%, specificity of 81%, positive predictive value of 84% and negative predictive value of 100% for detecting clinically significant burns in this population (Millar et al, 2001). This may represent an alternative to endoscopy, particularly in young children, as no sedation is required for this procedure. Further study is required.
8) MINIPROBE ULTRASONOGRAPHY - was performed in 11 patients with corrosive ingestion . Findings were categorized as grade 0 (distinct muscular layers without thickening, grade I (distinct muscular layers with thickening), grade II (obscured muscular layers with indistinct margins) and grade III (muscular layers that could not be differentiated). Findings were further categorized as to whether the worst appearing image involved part of the circumference (type a) or the whole circumference (type b). Strictures did not develop in patients with grade 0 (5 patients) or grade I (4 patients) lesions. Transient stricture formation developed in the only patient with grade IIa lesions, and stricture requiring repeated dilatation developed in the only patient with grade IIIb lesions (Kamijo et al, 2004).

1) The use of corticosteroids to prevent stricture formation is controversial. Corticosteroids should not be used in patients with grade I or grade III injury, as there is no evidence that they are effective. Evidence for grade II burns is conflicting, and the risk of perforation and infection is increased with steroid use, so routine use is not recommended.
2) CORROSIVE INGESTION/SUMMARY: The use of corticosteroids for the treatment of caustic ingestion is controversial. Most animal studies have involved alkali-induced injury (Haller & Bachman, 1964; Saedi et al, 1973). Most human studies have been retrospective and generally involve more alkali than acid-induced injury and small numbers of patients with documented second or third degree mucosal injury.
3) FIRST DEGREE BURNS: These burns generally heal well and rarely result in stricture formation (Zargar et al, 1989; Howell et al, 1992). Corticosteroids are generally not beneficial in these patients (Howell et al, 1992).
4) SECOND DEGREE BURNS: Some authors recommend corticosteroid treatment to prevent stricture formation in patients with a second degree, deep-partial thickness burn (Howell et al, 1992). However, no well controlled human study has documented efficacy. Corticosteroids are generally not beneficial in patients with a second degree, superficial-partial thickness burn (Caravati, 2004; Howell et al, 1992).
5) THIRD DEGREE BURNS: Some authors have recommended steroids in this group as well (Howell et al, 1992). A high percentage of patients with third degree burns go on to develop strictures with or without corticosteroid therapy and the risk of infection and perforation may be increased by corticosteroid use. Most authors feel that the risk outweighs any potential benefit and routine use is not recommended (Boukthir et al, 2004; Oakes et al, 1982; Pelclova & Navratil, 2005).
6) CONTRAINDICATIONS: Include active gastrointestinal bleeding and evidence of gastric or esophageal perforation. Corticosteroids are thought to be ineffective if initiated more than 48 hours after a burn (Howell, 1987).
7) DOSE: Administer daily oral doses of 0.1 milligram/kilogram of dexamethasone or 1 to 2 milligrams/kilogram of prednisone. Continue therapy for a total of 3 weeks and then taper (Haller et al, 1971; Marshall, 1979). An alternative regimen in children is intravenous prednisolone 2 milligrams/kilogram/day followed by 2.5 milligrams/kilogram/day of oral prednisone for a total of 3 weeks then tapered (Anderson et al, 1990).
8) ANTIBIOTICS: Animal studies suggest that the addition of antibiotics can prevent the infectious complications associated with corticosteroid use in the setting of caustic burns. Antibiotics are recommended if corticosteroids are used or if perforation or infection is suspected. Agents that cover anaerobes and oral flora such as penicillin, ampicillin, or clindamycin are appropriate (Rosenberg et al, 1953).
9) STUDIES

1) SUMMARY: Initially if severe esophageal burns are found a string may be placed in the stomach to facilitate later dilation. Insertion of a specialized nasogastric tube after confirmation of a circumferential burn may prevent strictures. Dilation is indicated after 2 to 4 weeks if strictures are confirmed. If dilation is unsuccessful colonic intraposition or gastric tube placement may be needed. Early laparotomy should be considered in patients with evidence of severe esophageal or gastric burns on endoscopy.
2) STRING - If a second degree or circumferential burn of the esophagus is found a string may be placed in the stomach to avoid false channel and to provide a guide for later dilation procedures (Gandhi et al, 1989).
3) STENT - The insertion of a specialized nasogastric tube or stent immediately after endoscopically proven deep circumferential burns is preferred by some surgeons to prevent stricture formation (Mills et al, 1978; (Wijburg et al, 1985; Coln & Chang, 1986).
4) DILATION - Dilation should be performed at 1 to 4 week intervals when stricture is present(Gundogdu et al, 1992). Repeated dilation may be required over many months to years in some patients. Successful dilation of gastric antral strictures has also been reported (Hogan & Polter, 1986; Treem et al, 1987).
5) COLONIC REPLACEMENT - Intraposition of colon may be necessary if dilation fails to provide an adequate sized esophagus (Chiene et al, 1974; Little et al, 1988; Huy & Celerier, 1988).
6) LAPAROTOMY/LAPAROSCOPY - Several authors advocate laparotomy or laparoscopy in patients with endoscopic evidence of severe esophageal or gastric burns to evaluate for the presence of transmural gastric or esophageal necrosis (Cattan et al, 2000; Estrera et al, 1986; Meredith et al, 1988; Wu & Lai, 1993).

1) Should not be used prophylactically but should be used only for specific indications of infection. Intravenous antibiotics should be considered in patients with evidence of esophageal or gastric perforation (Howell, 1986).

1) CASE REPORT: The administration of 1 gram in 100 milliliters of water was reported to decrease odynophagia by 50 percent within 24 hours in a woman who ingested crystalline Drano(R); however, stricture formation was not prevented and cimetidine was given concurrently, making assessment of any therapeutic benefit from sucralfate difficult (Reddy & Budhraja, 1988).
2) CONCLUSION - More studies will be needed before sucralfate can be recommended for treatment of caustic ingestions.

1) An ophthalmologic examination should follow irrigation to determine the extent of injury. This should include fluorescein staining and a slit lamp examination.

1) Remove any contaminated clothing and irrigate the exposed area with a large volume of water. Gentle soap and water washes should follow the general irrigation procedure. If irritation or pain persists, medical evaluation is necessary.

a) For example, sodium metasilicate 0.5% has a pH value of 12.5 (Gosselin et al, 1984), whereas sodium phosphate 1.4% has a pH value of 7.0 to 7.5 (Grant & Schuman, 1993) and sodium carbonate 10% has a pH of 10.7 (Grant & Schuman, 1993). The higher the percentage of nonphosphate salts relative to phosphate salts, the more potential for extensive damage (Lee et al, 1972; Muhlendahl et al, 1978).
b) Ocular toxicity research using rabbit eyes demonstrates that phosphates have a relatively low toxicity index compared to nonphosphates (Scharpf et al, 1972). However, phosphates can be as damaging as nonphosphates if the concentration is high and the duration of exposure prolonged. Nonphosphates produce more irreversible conjunctival and corneal damage than the phosphates (Scharpf et al, 1972; Seabrough et al, 1977).
c) Sodium metasilicate greatly enhances the corrosive action of phosphate-containing compounds.

a) Dilute solutions of sodium metasilicate can produce irreversible ocular injury within 60 seconds (Scharpf et al, 1972). A 10% sodium carbonate solution (pH 10.7) dripped into a rabbit eye for 30 seconds followed by irrigation with water produced no detectable injury (Grant & Schuman, 1993).
b) Although the typical sodium carbonate solutions with pH values of up to 11.6 would be expected to produce injury to the corneal epithelium prompt irrigation makes permanent corneal damage unlikely (Grant & Schuman, 1993).
c) In general, the higher the concentration and the longer the exposure, the more extensive the tissue damage (Seabrough et al, 1977; Vancura et al, 1980).