The patient typically presents with a history of ingestion. If the container is available, the label, by regulation, will indicate if the product is a corrosive by warning text and by the presence of a hazardous product symbol. If the container is not available, attempts should be made for telephone identification either by reading the label or by sending a photograph by email. The poison control center can assist with identifying the ingredients of a brand name product or chemical compound and with its potential for corrosive effect. The universal number in the United States is 1-800-222-1222.
Evaluation of the patient for airway compromise and signs of esophageal or gastric perforation is the initial priority. Oropharyngeal and laryngeal edema may develop rapidly. Patients with stridor, dyspnea, or dysphonia should be intubated under direct visualization; severe edema precluding oral intubation may require a surgical airway. Blind nasotracheal intubation is contraindicated. Immediate surgical consultation is indicated if there are signs of perforation: peritonitis, worsening chest and abdominal pain, or the presence of free air. In these critically ill patients, chest and abdominal x-rays should be obtained to assess for mediastinal or peritoneal free air indicative of perforation. Fluid resuscitation should be initiated, and pain control should be provided. The patient should be carefully examined for ocular or dermal exposure and receive copious irrigation if detected.
Patients without immediate airway issues should be observed for excessive crying, vomiting, drooling, or refusal to eat or drink, all of which may indicate a significant injury. The oral cavity should be evaluated for evidence of intraoral burns. The chest should be visualized for retractions and auscultated for wheezes or rhonchi indicating aspiration. The abdomen should be examined for distention, tenderness, or rigidity, which suggests the possibility of gastrointestinal tract perforation. All symptomatic patients should remain NPO. Diluents and buffers are not recommended because they may result in emesis and further injury of the esophagus.
Gut decontamination procedures, such as the administration of activated charcoal, syrup of ipecac, and gastric lavage, are contraindicated. Activated charcoal poorly absorbs caustics, may increase the risk of emesis, and will obscure endoscopic visualization.
Following evaluation and stabilization of the patient, the clinician must determine the need for upper gastrointestinal endoscopy. Endoscopy helps determine the extent of injury and the potential for complications.17
Patients who present without symptoms and are able to drink fluids without discomfort can be assumed to have no significant injury.16 They may be discharged from the emergency department after a 2–4-hour period of observation and a successful trial of oral fluids. Symptomatic patients require admission to hospital for investigation and management.
Historically, corticosteroids were routinely used with the intent of preventing stricture formation. However, prospective studies and literature review demonstrate no benefit.16,18–21