Management of Caustic Injuries

Immediate First Aid and Decontamination

Immediately irrigate exposed skin with running water for at least 15 minutes after any caustic chemical contact, and remove all contaminated clothing, jewelry, and surrounding materials to prevent chemicals from being trapped against the skin, according to the American Heart Association, as published in Circulation 1, 2.
For dry chemical powders, brush off the powder before water irrigation to prevent additional injury, as recommended by the American Heart Association, as published in Circulation 1, 2.
Use personal protective equipment when providing first aid to avoid contaminating yourself, as advised by the American Heart Association, as published in Circulation 1.
Call emergency medical services immediately if the patient has respiratory symptoms, systemic symptoms, or large chemical exposures, and contact regional poison control centers for chemical-specific treatment recommendations, as recommended by the American Heart Association, as published in Circulation 1, 2, and the World Journal of Emergency Surgery 3.

Absence of oral lesions or pain does NOT rule out life-threatening gastrointestinal injuries, which is a critical pitfall, as noted by the World Journal of Emergency Surgery 3, 4.
Identify the nature, physical form, quantity ingested, and whether ingestion was accidental or intentional, as recommended by the World Journal of Emergency Surgery 3.
Obtain CBC, electrolytes, renal function, liver function tests, arterial pH, serum lactate, and β-HCG in women of childbearing age, as recommended by the World Journal of Emergency Surgery 3.
Severe acidosis, deranged liver function, leukocytosis, elevated CRP, renal failure, and thrombocytopenia predict transmural necrosis and poor outcomes, as reported by the World Journal of Emergency Surgery 3.
Plain radiographs of neck, chest, and abdomen may reveal free air indicating perforation, as noted by the World Journal of Emergency Surgery 3.
Contrast-enhanced CT of neck, thorax, and abdomen should be performed 3-6 hours after ingestion, as recommended by the World Journal of Emergency Surgery 3, 4.
The CT grading system includes Grade I: Homogeneous wall enhancement, no edema or fat stranding, Grade IIa: Internal mucosal enhancement with hypodense thickened wall, possible "target" appearance, Grade IIb: Fine rim of external wall enhancement only, and Grade III: Absence of post-contrast wall enhancement indicating transmural necrosis, which mandates emergency surgery, as reported by the World Journal of Emergency Surgery 3, 4.

Patients with low-grade injuries can be fed immediately and discharged within 24-48 hours, as stricture formation risk is minimal, as recommended by the Praxis Medical Insights 4.
Hospitalization is mandatory for high-grade injuries due to high risk of stricture formation and complications, as recommended by the Praxis Medical Insights 4.
Provide nutritional support via nasogastric tube for temporary needs or feeding jejunostomy for severe cases, as recommended by the Praxis Medical Insights 4.
Transmural necrosis detected on CT or endoscopy, gastrointestinal perforation with free air, development of mediastinitis or peritonitis, and multi-organ failure are emergency surgical indications, as reported by the World Journal of Emergency Surgery 3.
Place feeding jejunostomy at the end of emergency surgery to provide nutritional support during recovery, as recommended by the Praxis Medical Insights 4.

Hydrofluoric acid and phenol require decontamination with substances other than water, as recommended by the Circulation 1, and the Praxis Medical Insights 5.
Some dry chemicals react with water causing additional injury, so brush off first, as recommended by the Circulation 1, 2.
Specific corrosives may cause systemic effects, such as hypocalcemia, hyponatremia, hypokalemia, and acidosis, as reported by the World Journal of Emergency Surgery 3.

Schedule follow-up visit 4-6 months post-ingestion, as most strictures develop within this timeframe, as recommended by the Praxis Medical Insights 4.
Attempt endoscopic dilation 3-6 weeks after ingestion for patients who develop strictures, as recommended by the Praxis Medical Insights 4.
Consider reconstructive esophageal surgery after recurrent failure of endoscopic dilation, as recommended by the Praxis Medical Insights 4.
Mandatory psychiatric evaluation is required for all patients prior to hospital discharge, particularly for intentional ingestions, as recommended by the Praxis Medical Insights 4.

Never assume absence of symptoms means absence of injury, as clinical presentation does not correlate with injury severity, as noted by the World Journal of Emergency Surgery 3, 4.
Avoid the "danger period" of 1-3 weeks post-injury for endoscopic procedures, as recommended by the Praxis Medical Insights 4.