Caustic ingestionMANAGEMENT

TOXICOLOGIC PRESENTATIONS · 12 SECTIONS

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458 items

☷ Legend

01Approach to the Critical Patient/attcp59

Immediate priorities

›Resuscitation priorities

›Airway risk stratification

›Voice change

›Stridor

›Drooling

›Oropharyngeal edema

›Persistent vomiting

›Altered mental status

›Significant hematemesis

›If impending airway compromise, early intubation with most experienced operator

›Video laryngoscopy preferred when anatomy distorted

›Smaller endotracheal tube size readiness

›Surgical airway backup planning

›Circulation support

›Two large bore IV

›Balanced crystalloid for hypotension

›Vasopressor if shock after fluids

›NPO status

›Strict NPO for suspected significant injury

›Avoid oral neutralization attempts

›Early consultation triggers

›GI for endoscopy planning

›Surgery for peritonitis, perforation concern, mediastinitis concern

›Toxicology or poison centre for product specific guidance

High risk features

›High risk predictors

›Intentional self harm ingestion

›Large volume ingestion risk

›Co ingestion risk

›Strong alkali exposure

›Sodium hydroxide

›Potassium hydroxide

›Strong acid exposure

›Hydrochloric acid

›Sulfuric acid

›Concentrated household or industrial cleaner

›Drain cleaner

›Oven cleaner

›Button battery co ingestion concern

›Disk battery exposure history

›Symptoms suggesting deep injury

›Chest pain

›Abdominal pain

›Dysphagia or odynophagia

›Hematemesis

›Fever

›Tachycardia out of proportion

Monitoring and targets

›Monitoring framework

›Continuous monitoring

›Pulse oximetry

›Cardiac monitor

›Noninvasive blood pressure cycling

›Escalation criteria

›Increasing oxygen requirement

›Worsening pain with guarding

›Persistent tachycardia

›Rising lactate mmol/l

›Time critical diagnostics

›Early CXR for free air or aspiration

›Early CT if perforation concern

02History/hx50

Exposure characterization

›Ingestion details

›Substance identification

›Product name

›Concentration percent

›pH if available

›Route and amount

›Oral ingestion

›Liquid volume estimate

›Solid or gel form

›Timing

›Time of ingestion

›Time since ingestion

›Co exposures

›Co ingestion ethanol

›Co ingestion medications

›Dermal exposure

›Ocular exposure

Symptom profile and red flags

›Symptom pattern

›Oropharyngeal symptoms

›Pain mouth or throat

›Drooling

›Dysphonia

›Esophageal symptoms

›Dysphagia

›Odynophagia

›Retrosternal pain

›Gastric and intestinal symptoms

›Abdominal pain

›Vomiting

›Hematemesis

›Respiratory symptoms

›Cough

›Wheeze

›Dyspnea

›Stridor

›Systemic symptoms

›Fever

›Syncope

›Confusion

Risk context

›Predisposition and intent

›Intentional ingestion features

›Psychiatric history

›Suicidality screening per local protocol

›Accidental ingestion features

›Child access scenario

›Transfer to unlabeled container

›Past history

›Prior esophageal disease

›Prior caustic injury

›Dysphagia baseline

03Physical Exam/exam31

Initial survey and airway

›Primary exam domains

›Vital signs and trajectory

›Tachycardia

›Fever

›Hypotension

›Hypoxia

›Airway and voice

›Hoarseness

›Stridor

›Work of breathing

›Oropharynx

›Oral burns

›Edema

›Ulcerations

›Soot like material

Chest and abdomen

›Thoracoabdominal findings

›Chest exam

›Focal crackles aspiration concern

›Subcutaneous emphysema

›Abdominal exam

›Focal tenderness

›Guarding

›Rigidity

›Rebound

›Peritoneal signs

›If peritonitis, immediate surgical involvement

Pitfalls

›Examination limitations

›Normal oropharynx does not exclude esophageal injury

›Deep injury possible without visible mouth burns

›Symptom severity imperfect correlation with grade

›Silent injury possible with delayed symptoms

04Differential Diagnosis/ddx24

Dangerous mimics and co ingestions

›Life threats and alternatives

›Esophageal perforation ICD-10 K22.3

›Sudden chest pain

›Subcutaneous emphysema

›Gastric perforation ICD-10 K25.1

›Acute abdomen

›Free air

›Aspiration pneumonitis ICD-10 J69.0

›Hypoxia

›Crackles

›Upper GI bleeding ICD-10 K92.2

›Hematemesis

›Shock

›Caustic substance poisoning ICD-10 T54 series

›Corrosive acid ingestion T54.2X1A

›Corrosive alkali ingestion T54.3X1A

›Corrosive unspecified T54.9X1A

Specific foreign body emergencies

›Alternate caustic mechanisms

›Button battery ingestion ICD-10 T18.9XXA

›Rapid liquefaction necrosis risk

›Urgent endoscopic removal pathway

›Sharp foreign body ingestion ICD-10 T18.108A

›Localized perforation risk

›Urgent endoscopy criteria

05Laboratory Tests/lt34

Baseline and severity markers

›Initial labs for significant ingestion

›Venous blood gas or arterial blood gas

›pH

›pCO2 mmHg

›HCO3 mmol/l

›Lactate mmol/l for hypoperfusion

›Rising trend suggests severe injury or sepsis

›Electrolytes and renal function

›Sodium mmol/l

›Potassium mmol/l

›Creatinine umol/l

›Glucose mmol/l

›Stress response

›Co ingestion screen support

›Complete blood count

›Leukocytosis for inflammation

›Hemoglobin for bleeding

Targeted adjuncts

›Additional tests when indicated

›Coagulation studies

›INR for bleeding risk

›Anticoagulant co ingestion concern

›Type and screen

›Significant hematemesis

›Anticipated operative management

›Toxicology tests

›Acetaminophen level if intentional ingestion

›Ethanol level if altered mental status

Interpretation pitfalls

›Lab limitations

›Normal labs do not exclude deep necrosis early

›Clinical course monitoring required

›Metabolic acidosis differential broad

›Shock

›Seizure

›Co ingestions

06Diagnostic Tests/dt48

Scoring Systems

›Endoscopic grading and risk tools

›Zargar endoscopic classification

›Grade 0 normal

›Grade 1 edema and hyperemia

›Grade 2a superficial ulcers

›Grade 2b deep or circumferential ulcers

›Grade 3a focal necrosis

›Grade 3b extensive necrosis

›Clinical application

›Higher grades correlate with stricture and perforation risk

›Grade 2b and higher high risk for complications

›Timing considerations

›Typical EGD window within 12 to 24 hours when stable

›Increased perforation risk during 5 to 15 day tissue slough phase

MRI

›MRI role

›Limited acute ED utility

›Time and availability constraints

›Motion artifact with pain and vomiting

›Considerations

›Avoid if unstable

›Not first line for perforation detection

›CT chest abdomen pelvis with IV contrast

›Indications

›Severe pain

›Peritonitis

›Fever or sepsis concern

›Suspected perforation

›Suspected transmural necrosis

›Key findings

›Pneumomediastinum

›Pneumoperitoneum

›Esophageal wall thickening

›Gastric wall thickening

›Periesophageal fluid

›Decision integration

›If CT shows perforation, operative pathway and broad spectrum antibiotics

›If CT suggests deep necrosis, early surgical consultation

›Evidence framing

›CT adjunct to endoscopy for transmural injury assessment Class IIa expert consensus

Ultrasound

›Ultrasound applications

›POCUS for shock differential

›IVC assessment for volume status

›Lung ultrasound for aspiration pattern

›Abdominal ultrasound limitations

›Low sensitivity for free air

›Not a replacement for CT when perforation concern

›Airway ultrasound adjunct

›Endotracheal tube confirmation when anatomy difficult

07Disposition/dispo20

Level of care selection

›Disposition framework

›ICU criteria

›Airway intervention

›Hemodynamic instability

›Perforation or mediastinitis concern

›Severe metabolic acidosis

›High grade endoscopic injury suspected

›Inpatient ward criteria

›Symptomatic ingestion without instability

›Need for EGD observation pathway

›Transfer criteria

›Need for urgent endoscopy without local capability

›Need for thoracic surgery capability

Discharge eligibility

›Discharge pathway for low risk exposure

›Small accidental taste exposure

›Asymptomatic after observation period

›Tolerating oral fluids

›Reliable follow up access

›Return precautions documented

›Poison centre contact information provided

08Treatment/t83

Supportive care bundle

›Supportive care

›NPO and aspiration precautions

›Head of bed elevation

›Suction readiness for drooling

›Antiemetics

›Ondansetron IV 4 mg

›Repeat 4 mg IV after 10 minutes if persistent vomiting

›Maximum 16 mg in 24 hours typical ED use

›Metoclopramide IV 10 mg

›Avoid in bowel obstruction concern

›Dystonia risk

›Analgesia

›Acetaminophen PO or IV 1000 mg

›Maximum 4000 mg per 24 hours

›Lower maximum in liver disease

›Fentanyl IV 25 mcg

›Titrate 25 mcg every 5 minutes to effect

›Respiratory monitoring

›Hydromorphone IV 0.2 mg

›Titrate 0.2 mg every 10 minutes to effect

›Avoid oversedation in airway risk

Acid suppression and mucosal protection

›Esophageal and gastric protection

›Proton pump inhibitor

›Pantoprazole IV 40 mg

›Daily dosing typical

›Consider higher intensity per consultant for severe injury

›Sucralfate PO 1 g

›Use only when oral intake allowed

›Separate from other meds due to binding

Therapies to avoid

›Harm avoidance

›Neutralization with acid or base

›Exothermic reaction risk

›Increased mucosal injury risk

›Activated charcoal

›Poor binding for caustics

›Aspiration risk

›Induced emesis

›Re exposure injury risk

›Blind nasogastric tube placement

›Perforation risk in severe injury

Antibiotics and antifungals

›Infection management strategy

›If perforation suspected, broad spectrum antibiotics immediately

›Piperacillin tazobactam IV 4.5 g

›Every 6 hours typical dosing

›Renal adjustment

›Ceftriaxone IV 2 g

›Every 24 hours typical dosing

›Add metronidazole IV 500 mg every 8 hours for anaerobes

›Penicillin allergy alternative

›Levofloxacin IV 750 mg daily

›Metronidazole IV 500 mg every 8 hours

›If high grade injury with fever or necrosis, antibiotics per surgery or GI Class IIb expert consensus

›Avoid routine antibiotics for low grade injury

Steroids and stricture prevention

›Steroid considerations

›Evidence mixed for stricture prevention

›Not routine for all patients

›Consider only in selected grade 2b injury per consultant Class IIb

›If steroids used, infection screening and gastroprotection

›Concomitant antibiotics only if perforation or infection concern

›Monitor glucose mmol/l

Endoscopy pathway coordination

›Endoscopy coordination

›Early EGD planning when stable

›Typical within 12 to 24 hours Class I consensus for risk stratification

›Avoid EGD if suspected perforation until imaging and surgical plan

›Contraindications to immediate EGD

›Unstable airway

›Hemodynamic instability

›Peritonitis without imaging

Respiratory complications

›Aspiration management

›Oxygen therapy

›Nasal cannula escalation as needed

›Noninvasive ventilation caution with vomiting

›Bronchospasm

›Salbutamol inhaled 4 puffs

›Repeat every 20 minutes for 1 hour if needed

›Tachycardia monitoring

Nutrition and long term complications

›Nutritional strategy

›Enteral feeding plan guided by grade

›Early oral intake for grade 0 to 1 when asymptomatic

›Delayed oral intake for higher grades per GI

›Stricture surveillance

›Dysphagia weeks later triggers endoscopic evaluation

›Dilatation planning by GI

09Special Populations/sp29

Pregnancy

›Pregnancy considerations

›Maternal stabilization priority

›Airway first with aspiration risk awareness

›Left uterine displacement if hypotensive in later pregnancy

›Imaging considerations

›CT with IV contrast when maternal life threat

›Shielding when feasible

›Medication safety

›Ondansetron use risk benefit discussion

›Avoid NSAIDs in later pregnancy

Geriatric

›Older adult considerations

›Higher baseline aspiration risk

›Early airway vigilance

›Lower threshold for admission

›Comorbidity impact

›Heart failure fluid strategy

›Chronic kidney disease antibiotic dosing adjustment

›Polypharmacy co ingestion risk

›Acetaminophen level if unclear ingestion

Pediatrics

›Pediatric considerations

›Weight based dosing

›Ondansetron IV 0.15 mg per kg

›Maximum single dose 8 mg

›Small volume high concentration risk

›Higher severity with concentrated alkali

›Symptom absence does not exclude injury

›Caregiver education

›Safe storage counseling

›Poison centre number reinforcement

10Background/b37

Epidemiology

›Epidemiology summary

›Common settings

›Pediatric accidental ingestion

›Adult intentional ingestion

›Substance patterns

›Alkali in drain and oven cleaners

›Acids in toilet bowl cleaners and industrial agents

›Outcomes distribution

›Most accidental exposures minor

›Intentional exposures higher grade injury rates

Pathophysiology

›Injury mechanisms

›Alkali injury

›Liquefaction necrosis

›Deep penetration risk

›Esophageal predominance common

›Acid injury

›Coagulation necrosis

›Eschar formation with variable depth

›Gastric injury prominence possible

›Timeline of tissue vulnerability

›Early inflammation within hours

›Tissue slough and friability days 5 to 15

›Stricture formation weeks to months

Therapeutic Considerations

›Treatment principles

›Supportive care mainstay

›Airway protection prevents mortality

›Early risk stratification guides nutrition and monitoring

›Endoscopy role

›Direct mucosal grading supports prognosis

›Avoid during peak friability window when possible

›Imaging role

›CT identifies transmural injury and perforation

›CT complements EGD in severe cases

›Guideline framing

›Early GI involvement Class I consensus

›Avoid neutralization and emesis Class III harm consensus

›Steroids selective use only Class IIb consensus

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions for low risk exposure

›Fluids and soft diet as tolerated if no pain with swallowing

›Avoid alcohol and spicy foods for 24 to 48 hours

›Small frequent sips if throat irritation

›Medication guidance

›Take prescribed acid suppression as directed

›Use acetaminophen for pain within safe limits

›Return to ED now for any red flags

›Trouble breathing

›Noisy breathing

›Drooling or inability to swallow saliva

›Vomiting that will not stop

›Vomiting blood or black stools

›Chest pain

›Severe belly pain

›Fever

›New confusion or fainting

›Follow up plan

›Primary care within 2 to 3 days if symptoms persist

›GI follow up if swallowing difficulty develops in coming weeks

›Prevention counseling

›Store chemicals locked and original containers

›Do not transfer cleaners to drink bottles

12References/r20

Clinical guidelines and consensus

›Key guidance sources

›European Society of Gastrointestinal Endoscopy guideline on caustic ingestion management

›Early endoscopy risk stratification recommendations

›Avoidance of neutralization and emesis recommendations

›American Society for Gastrointestinal Endoscopy guidance on caustic ingestion

›Endoscopy timing and contraindications

›Management of strictures and long term follow up

›Poison control and toxicology consensus references

›Substance specific risk profiles

›Home exposure triage criteria

Evidence based sources

›Foundational evidence

›Zargar classification original and follow up studies

›Correlation of endoscopic grade with outcomes

›Stricture risk with higher grades

›Observational studies on CT predictors of transmural injury

›CT findings associated with need for surgery

›CT as adjunct to endoscopy in severe cases

›Systematic reviews on corticosteroids for stricture prevention

›Mixed results and selective use conclusions

›Adverse effect considerations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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