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Corrosive injury
Acid > 180 ml, Base > 80 ml
Acids tend to cause significant injuries at a pH <3 and alkalis at a pH >11.
酸
Coagulation necrosis 凝固壞死
Less tissue penetration
以前認為酸對胃傷害 > 食道
教科書 : endoscopy following an acid ingestion finds a
similar incidence of gastric and esophageal injury
可能合併 metabolic acidosis, hemolysis, and renal failure
Acid ingestions may result in additional systemic toxicity
from absorption of the acid 酸較有全身毒性傷害
甚至 Acute lung injury (noncardiogenic pulmonary edema)
鹼
Liquid alkali ingestions -> more extensive esophageal and gastric injuries
鹼 : Deep tissue injury called liquefaction necrosis 液化壞死
The most common household alkali is bleach,
3% to 6% sodium hypochlorite solution with a pH of approximately 11
Household liquid bleach : minimally corrosive
Industrial-strength bleach : gastric and esophageal necrosis
除了酸鹼外, 還有 Bleach 強氧化劑, Ammonia
* Patient survival
* Early complication
* Prevent delayed sequelae
- 鹼 Esophageal strictures / 酸 scar the pylorus -> gastric outlet obstruction
- SCC of the esophagus
* Nutrient
- Confirm ingestion, Time, amount
Co-ingestion, Suicide
- Oropharyngeal injury (mucosal burns, drooling) 口腔狀況不代表消化道狀況
- Respiratory injury (dysphonia, coughing, stridor, wheezing)
- Gastric injury (vomiting, epigastric tenderness)
- Airway edema, Tracheobronchial necrosis
- Esophageal perforation, Hallow organ peforation : peritoneal signs
- Aortoesophageal fistula, Emphysema
- Eletrolyte imbalance, Acidosis
- Consider mediastinitis if chest discomfort
- GI bleeding
- 坐高避免 Aspiration, 不 Lavage
- 喝水喝牛奶稀釋可能 Thermal injury
Dilution and neutralization therapy are not recommended 不建議稀釋
- Gastric decontamination with activated charcoal
is contraindicated if a caustic is the only ingestion.
單純腐蝕吞入不能活性碳
- Intubation if horseness, stridor -> The first priority is airway protection
Oral intubation with direct visualization is the first choice
還是直接插
Blind nasotracheal intubation is contraindicated ; Avoid LMA, bougies
- NG 除非 PES guide 不然不要放
- 區分保守治療或需要手術介入
- Antacid, steroid, Antibiotics still questionable efficacy
教科書 : 類固醇/抗生素 = 沒有共識 ; PPI 沒有實證
- Lab : VBG, Electrolyte, Lactate
anion gap acidosis based on lactate production due to direct tissue injury or shock.
Endoscopy
The primary purpose of endoscopy is diagnosis
Experts recommend that endoscopy should be performed early after ingestion,
within 12 - 24 hours from the time of ingestion, to avoid iatrogenic perforation.
Endoscopic guidance of an OG or NG
** 12 - 24 小時內 PES **
Early phases of remodeling, particularly days 2 - 14 after exposure,
are associated with increased tissue friability and higher risk of
perforation, both spontaneous and iatrogenic.
Tissue friability after a caustic burn increases significantly
at 24 - 48 hours after injury and is maximal between days 5 -14
Grade 1 burns involve tissue edema and hyperemia 組織紅腫
Grade 2 burns include ulcerations, blisters, and whitish exudates, which are subdivided into
grade 2A (noncircumferential) and 2B (deeper or circumferential) lesions
Grade 3 burns are defined by deep ulcerations and necrotic lesions 深潰瘍 + 壞死組織
Zargar 3b 以上開刀
CT examination is reliable and reproducible in assessing transmural digestive necrosis
and improves the selection of patients for surgery
IV contrasted thoracoabdominal CT scans in caustic ingestion management
CT : Oropharynx to include neck + upper GI
CT grade 3 = Zargar 3b = Operation
Caustic ingestion Lancet 2017
乾燥劑 - 矽膠
不會被腸胃道吸收, 不會有中毒情況
誤食矽膠類乾燥劑不需要洗胃跟催吐
乾燥劑 - 氧化鈣 CaO (生石灰)
遇水變成 氫氧化鈣 Ca(OH)₂ = Alkaline corrosive
鹼水 : 碳酸鈉 Sodium carbonate, 碳酸鉀 Potassium carbonate, 氫氧化鈉 Sodium hydroxide
Mild to Moderate oral toxicitiy
Early endoscopy (within 12 hours) in patients with stridor, drooling, vomiting,
significant oral burns, difficulty swallowing or abdominal pain,
and in all patients with deliberate ingestion.
If burns are absent or grade I severity, patient may be discharged when
able to tolerate liquids and soft foods by mouth.
If mild grade II burns, admit for intravenous fluids, slowly advance diet as tolerated.
Perform barium swallow or repeat endoscopy several weeks after ingestion
(sooner if difficulty swallowing) to evaluate for stricture formation.
Severe oral toxicitiy
Resuscitate with NS; blood products may be necessary.
Early airway management in patients with upper airway edema or respiratory distress.
Early (within 12 hours) gastrointestinal endoscopy to evaluate for burns.
Early bronchoscopy in patients with respiratory distress or upper airway edema.
Early surgical consultation for patients with severe grade II or grade III burns,
large deliberate ingestions,
or signs, symptoms or laboratory findings concerning for tissue necrosis or perforation.
Dilute with 4 to 8 ounces of water may be useful if it can be performed shortly
after ingestion in patients who are able to swallow,
with no vomiting or respiratory distress; then the patient should be
NPO until assessed for the need for endoscopy.
Neutralization, activated charcoal, and gastric lavage are all contraindicated.
No antidote
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