PEM Playbook – Caustic Ingestions

Originally published at Pediatric Emergency Playbook on October 1, 2020 – Visit to listen to accompanying podcast. Reposted with permission.

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Acids: low pH, coagulation necrosis, “what you see is what you get”, more respiratory damage, less perforation

• Battery acid, pool cleaners ⇒ very caustic

Alkali: saponification necrosis, deeper, increased risk for perforation, later stricture formation

• pH > 11 ⇒ increased risk of saponification necrosis

Decide: Plan A or Plan B?

Plan A: IV, resuscitate, NPO, monitor airway and signs of perforation, admit

Plan B: Observe for 4-6 hours, PO challenge, reassess, safety talk, close follow-up

• Symptoms of caustic ingestion ⇒ Plan A
• Drain Cleaner? Lye? pH of > 11? ⇒ Plan A
• Household bleach? pH <11 ⇒ Plan B; go to plan A if fails
• Unknown exposure, no symptoms? ⇒ Plan B; go to plan A if fails

Special Shout-Outs to:

Laundry Detergent Pods — although they have a pH of 9-11, the additive propylene glycol can cause CNS depression, seizures, further aspiration.  Also, contact time (viscosity) is increased, leading to further alkali saponification

Drain cleaner — typical pH is 13-14.  Full stop.  Needs admission and scope in all cases.

Selected References

Ahsan S et al. Absence of esophageal injury in pediatric patients after hair relaxer ingestion. Arch Otolaryngol Head Neck Surg. 1999;125(9):953.

Beuhler MC. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013 Jun;29(6):743-7. doi: 10.1097/PEC.0b013e318294f3db.

Davis MG. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014. Pediatrics. 2016 May;137(5):e20154529

Hoffman RS et al. Ingestion of Caustic Substances. N Engl J Med. 2020;382(18):1739.

Lupa M. Update on the Diagnosis and Treatment of Caustic Ingestion. Ochsner J. 2009 Summer; 9(2): 54–59.

Sherenian MG et al. Caustic ingestions mimicking anaphylaxis: case studies and literature review. Pediatrics. 2015;135(2):e547. Epub 2015 Jan 12.

Slaughter RJ. The clinical toxicology of sodium hypochlorite. Clin Toxicol (Phila). 2019 May;57(5):303-311

Wason S.  The emergency management of caustic ingestions. J Emerg Med. 1985;2(3):175.