Liquid Household Bleach Ingestion in Children a Retrospective Review

Contents

• 1 Background
  • ane.i Caustics
    • 1.i.1 Alkalis
    • 1.1.2 Acids
• 2 Clinical Features
• iii Differential Diagnosis
  • 3.i Caustic Burns
• 4 Evaluation
  • 4.one Labs
  • iv.two Imaging
• 5 Management
  • 5.ane Airway Management
  • 5.ii Endoscopy
  • 5.three Esophageal Stricture Mitigation^[7]
  • v.4 Surgical Intervention
  • five.5 Caustic Specific Handling
  • 5.6 Controversial or Contraindicated
• vi Disposition
  • half-dozen.1 Prognosis
• 7 See Likewise
• 8 References

Background

Caustics

• Substances that cause damage on contact with body surfaces
• Degree of injury adamant past pH, concentration, volume, duration of contact
• Acidic agents crusade coagulative necrosis
• Element of group i agents cause liquefactive necrosis (considered more damaging to nigh tissues)
• Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

• Accepts protons → free hydroxide ion, which hands penetrates tissue → cellular destruction
  • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
• Examples
  • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
    • Lye present in bleed cleaners, pilus relaxers, grease remover
  • Bleach (sodium hypochlorite) and Ammonia (NH3)
    • Cleaning products such as oven cleaners, pond pool chlorinator
    • Household bleach ingestion (4-half dozen% sodium hypochlorite) rarely causes meaning esophageal injury^{[one] [2]}

Acids

• Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper interest
  • However, due to pylorospasm and pooling of acid, high-form gastric injuries are common
    • Mortality rate is higher compared to potent alkali ingestions
• Tin exist systemically captivated and → metabolic acidosis, hemolysis, AKI
• Examples
  • Hydrochloric acid (HCl), hydrofluoric acrid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
    • Found in: auto batteries, bleed openers, toilet bowl, metal cleaners, swimming puddle cleaners, rust remover, nail primer

Clinical Features

• Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion ^[3]
• Exam eyes and peel (splash and dribble injuries may easily be missed)
• GI tract injury
  • Dysphagia, odynophagia, drooling, epigastric pain, vomiting
• Laryngotracheal injury
  • Dysphonia, stridor, respiratory distress
  • Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes

Differential Diagnosis

Caustic Burns

• Caustic ingestion
• Caustic heart exposure (Caustic keratoconjunctivitis)
• Caustic dermal burn
• Airbag-related burns
• Hydrofluoric acid
• Tar burn
• Cement burn

Evaluation

Labs

Only necessary in patients with significant injury or volume of ingestion

• CBC
• Chemical science
• Lactic Acid
  • In Brine ingestion, presence of acidemia or hyperlactemia is likely indicative of clinically significant tissue injury^[4]
• ECG
• Calcium and Magnesium level (if hydrofluoric acid exposure)
  • Gratuitous Fluoride binds rapidly to calcium and magnesium leading to astringent hypocalcemia and hypomagnesemia that can be life threatening
• Acetaminophen and Salicylate levels (in patients with business for intentional ingestion)

Imaging

• 3-View CXR
  • Look for free air under the diaphragm or signs of mediastinal air^[5]
• Push battery XR - two rings, will likely need to remove it no matter where it is, whether postal service-pyloric or pre-pyloric
• CT with contrast
  • Consider when perforated viscus is suspected but CXR is negative

Management

• Prevent provider and continued patient exposure to the caustic agent by removing all clothing and decontaminating the patient
• In that location is a possible benefit of water ingestion immediately after ingestion of a powdered caustic to gargle adherent materials in oropharynx/esophagus if no airway concerns to prevent prolonged injury from the pulverization adhering to tissues^[6]

Airway Management

• Monitor closely for stridor, airway edema, hoarseness, or other signs of airway injury
• Intubate early if signs of airway injury be, first sign of vocalisation changes, inability to tolerate secretions or stridor earlier airway becomes more hard to manage.
• Consider awake fiberoptic or video laryngoscopy if business for difficult airway
• Blind nasotracheal intubation is contraindicated due to the potential for perforations and fake passages

Endoscopy

Should be performed in the first 24 to 48 hours after ingestion (too early on can underestimate extent of injury, too late increases risk of wound softening and perforation).

Indications

• Intentional ingestion (higher likelihood of high volume ingestion)
• Unintentional ingestion with signs of:
  • Stridor
  • Pregnant oropharyngeal burns
  • Vomiting
  • Drooling
  • Food refusal

Esophageal Stricture Mitigation^[7]

• Talk over with GI or medical toxicologist
• For grade IIb or higher esophageal burns:
  • Methylprednisolone (i g/1.73 m2 per day for 3 days)
  • Ranitidine
  • Ceftriaxone
  • Full parenteral nutrition
• Sucralfate, Mitomycin C

Surgical Intervention

• Indicated for:
  • Perforation
  • Peritoneal signs

Caustic Specific Treatment

• Can include chelation, dialysis, or specific antidotes
  • Especially in caustics that crusade systemic toxicity

Controversial or Contraindicated

• Antibiotics
  • No evidence to support or reject the employ of rubber antibiotics
  • Only indicated if also giving steriods (come across stricture mitigation higher up)
• Activated charcoal
  • May infiltrate damaged mucosa & interfere with EGD
  • Just consider when coingestants pose a take chances for severe systemic toxicity
  • Zinc chloride and mercuric chloride systemic absorptions may outweigh interference with endoscopy
• Gastric lavage
  • Contraindicated due to potential to crusade reflux of caustic amanuensis into esophagus, creating more harm
  • Blind nasogastric-tube insertion for irrigation can cause thermal injury through neutralization
• Dilution with h2o or milk causes airsickness, elevating gamble for perforation
  • Possible benefit only for solid alkali ingestions
• Neutralization generates excess oestrus
  • Milk or magnesium citrate only for hydrofluoric acid ingestion

Disposition

• All patients with symptoms from a caustic ingestion should be admitted for at to the lowest degree 24 hours of ascertainment
• All patients with intentional ingestion should be evaluated by psych prior to belch

Prognosis

• Depending on severity may have full return of mobility and function or can progress to perforation followed by stricture germination
• Days 2-14 post-injury are associated with highest tissue friability / risk of perforation
• Strictures typically develop in the offset 2 months, higher risk in those with circumferential esophageal erosions (Grade 2B burns and above)
• High-grade caustic burns associated with 1000x increase in esophageal adenocarcinoma or squamous-prison cell carcinoma

See Also

• Caustic burns

References

1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:x.1016/s0022-3476(85)80119-0
2. ↑ Harley EH, Collins Doctor. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(one):122-125. doi:10.1097/00005537-199701000-00023
3. ↑ Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(five):767-770.
4. ↑ Hoffman et al. Ingestion of Caustic Substances. Due north Engl J Med. 2020. Apr;382(18):1739-1748
5. ↑ Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621
6. ↑ Hoffman et al. Ingestion of Caustic Substances. N Engl J Med. 2020. Apr;382(xviii):1739-1748
7. ↑ Loftier Doses of Methylprednisolone in the Management of Caustic Esophageal Burns. Pediatrics 2014;133:e1518–e1524

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Source: https://www.wikem.org/wiki/Caustic_ingestion

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