Protect Your Children From Caustic Ingestion

Caustic injury may occur when a dry or chemical product is ingested or swallowed, either intentionally or accidentally. Children between the ages of 1 to 3 years old are most susceptible to accidentally ingesting ordinary caustic products. However, children under the age of 5 represent approximately half of the reported incidences. Adults with caustic ingestion injuries are usually related to either occupational exposure or suicide attempt.

Caustic injury typically occurs in your upper respiratory tract (nose, mouth, throat or pharynx, and voice box or larynx) and the upper digestive tract (esophagus, stomach, and duodenum). Injury risk increases related to how acidic or basic the level of pH (potential of hydrogen) is for the product. A neutral pH is 7. The lower the pH is, the more acidic the product is, while a higher pH is more basic. Alkaline products are involved with 70% of caustic ingestion cases; the remaining cases are mostly represented by ingesting acidic products.

Caustic vs. Corrosive Injury

In general, both caustic and corrosive terms are used interchangeably. However, they are terms that can be used to differentiate the type of chemical product that caused the injury. Caustic refers to strong chemical products that are basic or alkaline. Corrosive on the other hand refers to chemical products that strongly acidic.

Caustic and corrosive agents may also be poisonous, however not all caustic and corrosive agents are poisonous. Poisons take time to cause damage, whereas caustic and corrosive agents can damage body tissue immediately on contact. Poisons usually also do not cause isolated local damage, but rather cause systemic effects on your body.

As is the case with most literature, we will refer to both caustic and corrosive agents as "caustic."

Symptoms

There is a wide range of symptoms that may follow ingestion of caustic chemicals. This is because of the various pH of products, quantity ingested, and contact time with body tissue. In general, if you do not have any symptoms, you may not have a severe injury. However, this does not mean that you have not experienced injury and follow-up with a physician may still be needed. If you are experiencing 3 or more symptoms, severe injury to your esophagus may be indicated. You may experience symptoms immediately upon ingestion, or you may experience symptoms several hours later. Powders tend to exhibit symptoms later than ingestion of liquid caustics. Symptoms that you may experience include:

• Vomiting: most common symptom
• Dysphagia (difficulty swallowing): 2nd most common
• Odynophagia (painful swallowing)
• Shortness of breath
• Tachycardia (rapid heart rate)
• Chest pain
• Abdominal pain
• Increased production of saliva

Severe complications related to caustic injury can also occur including organ dysfunction and may include death. Because of the risk severity, you should always consult Poison Control at (800) 222-1222.

Products to Avoid

Alkaline Products

Many household cleaning products are alkaline or basic chemicals. The household products that are likely to cause caustic injury if ingested are in the pH range of 11 to 14, however even products with a pH range of 8-10 can cause some injury. Alkaline products that you should keep out of the reach of children include:

• Drain cleaners: Liquid Plumr and Liquid Drano
• Oven cleaners: Easy-Off
• Hair relaxers: Revlon Creme Relaxer
• Ammonia cleaner: Lysol All-Purpose, Windex
• Laundry detergents: Tide, Purex

A common ingredient in cleaning agents is sodium hydroxide. Lye and caustic soda are other names for sodium hydroxide, but also may be used as potassium hydroxide. Sodium hydroxide is a cheap and potent cleaning agent.

Stomach injury tends to be less severe with alkaline products because your stomach acid can neutralize or balance some of the alkalines. In the mouth and esophagus, however, alkaline products begin to immediately damage the tissue until fluid within the tissue sufficiently buffers the caustic product. Damage as a result of alkaline products is referred to as liquefactive necrosis, which means that the damage that kills the cells turns some of the tissue into a liquefied form.

Acidic Products

Acidic injury occurs less frequently since acidic products generally cause pain when in the mouth. Acidic products also tend to be thinner, which results in less overall damage to the esophagus as the liquid reaches the stomach faster. The lower stomach (also known as the antrum) is a common point for extensive damage to occur as the flow of the acidic substance stops here. Food in the stomach can help reduce the damage that occurs as the food can absorb the acid. Acidic products with a pH less than 2 are the most dangerous. Products that you should keep away from children include:

• Toilet bowl cleaners: Lysol, Kaboom
• Swimming pool cleaners
• Rust removers: CLR (Calcium, Lime, Rust), Evapo-Rust

Acidic products cause damage that is referred to as coagulative necrosis, which forms clots and scar tissue at the site of damage. It is believed that because of the scar-barrier and that less is often ingested due to acidic pain in the mouth that less overall damage occurs with ingestion of acids when compared to alkali.

What About Bleach?

Bleach is a caustic alkaline agent, however, it is commonly misperceived as causing serious injury. Bleach is commonly sold as a neutral pH product (meaning around a pH of 7). Because of the pH neutrality, bleach is actually considered more as an irritant than a caustic substance. Usually, ingestion of bleach requires only close observation of the symptoms listed above. While only categorized as an irritant, breathing difficulties and other harmful side-effects can occur if the quantity is sufficient or inhalation occurs.

Severity of Injury

The severity of the caustic injury is rated similar to the same system as burns. However, some physicians may add a 4th grade for the most severe injuries.

1. Swelling (edema) and redness (hyperemia)
2. Ulceration
   1. 2a: localized superficial ulcers and bleeding white membranes 
   2. 2b: deep ulcers and bleeding that extend beyond the point of contact
3. Destroyed tissue
   1. 3a: a small number of scattered areas where tissue has died
   2. 3b: extensive areas where the tissue has died
4. Perforation: ruptured or torn tissue leading to other areas of the body

The extent of injury can be determined by visualizing the area during an endoscopic procedure called an EGD. The best outcomes tend to occur if you have only experienced a grade 1 or grade 2a injury; full recovery usually occurs. If you have a grade 2b or grade 3a injury, you will most likely have some chronic restriction (strictures) to the injured site. A grade 3b or 4 carries a significant risk for causing death; about 65%.

Treatment

• Do not ingest charcoal, as it does not bind to caustic substances
• Do not induce vomiting; it risks second exposure of esophagus, airways, mouth, and nose to the caustic substance

After recognition that ingestion of a caustic (or potentially caustic) substance has occurred, you should always contact Poison Control. It is also generally considered safe to drink water or milk following the ingestion of either an alkaline or acidic substance in order to dilute the substance. However, you should avoid drinking too much by avoiding more than 15 milliliters of fluid for every kilogram (2.2 pounds) of body weight.

There's undoubtedly a sense of panic that results once you realized what happened. Knowing what to expect can help ease the panic and drive you to take action. Know that everything that happens is done for a reason—to help you recover and continue living well. Poison Control will help you decide whether or not you need to go to a hospital. However if breathing appears to be difficult, you should always call EMS—Emergency Medical Services (911 in the United States), and seek medical help immediately. If your ability to maintain your airway is a concern, EMS or the emergency department (ED) physician will place a breathing tube (intubation).

Upon arrival at the emergency department, the need for an upper endoscopy (EGD) will be assessed. Generally, an EGD will be performed if the exposure occurred between 12 and 48 hours. If the test is performed too early, the extent of damage may not be able to be fully seen. After 48 hours, you risk worsening injury by perforating the esophagus with the scope.

Depending on the severity of the injury, you may be discharged, observed for less than 24 hours, or admitted to the hospital for further management of your injuries. If your injuries are severe enough, a feeding tube may be placed during the EGD to avoid further injury of a "blind" placement. You may also have a feeding tube placed later under fluoroscopy. Antibiotics are also likely to be started depending on the degree of injury and risk of infection. The is currently not a strong recommendation for steroids, however, you may see it prescribed in some settings.

If you have experienced a severe injury or were unable to have an EGD done prior to 48 hours, then you will likely also have a barium swallow study to assess for any restrictions (strictures) or pierced linings (perforation). If strictures are identified, they will usually perform an esophageal dilation. If follow-up is needed, you can generally anticipate the test to be performed around 3 weeks later.

In the most severe injuries, reconstructive surgery of your esophagus or removal of part of the esophagus (esophagectomy) may be required.