There’s been an uptick in calls to poison control centers around the country ever since President Donald Trump asked during a news briefing if disinfectants, such as bleach, could be injected to help control or prevent Covid-19. While he walked back those comments a day later, it hasn’t stopped people from ingesting bleach.
Injuries from ingesting caustic substances such as bleach are an ongoing public health concern. This is especially worrisome when it comes to children’s accidental poisonings, even with clear warnings and child-resistant packaging. “Nearly 1,000 children with caustic ingestions are hospitalized each year, for an average of 4 days, at direct hospital costs of more than $22 million,” Robert S. Hoffman, MD, from the Division of Medical Toxicology, Ronal O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and colleagues, wrote in the New England Journal of Medicine.
When a child or an adult shows up in an emergency department after having ingested a caustic substance, they can be classified by intent — for children, it is usually an exploratory ingestion, such as is the case with laundry detergent pods that look inviting to kids. Another intent, such as dramatic alkali ingestion by kids, is a bit more nefarious, often “reported as manifestations of child abuse,” Hoffman and colleagues noted. And lastly, adult ingestion of caustic substances is often intentional, such as in an attempt to do self-harm.
“A 1980 study of 214 caustic ingestions showed that 39% of children younger than 6 years of age were hospitalized, but only 8% required treatment. In contrast, 48% of adults were admitted, and 81% required treatment,” Hoffman and colleagues wrote.
The clinical trajectory after injecting a caustic substance can vary by the type of substance ingested, the amount, and the intent behind the ingestion.
The most common caustic substances include:
- Classic alkalis — including ammonium hydroxide (cleaner and grease remover), sodium hydroxide or potassium hydroxide (drain opener, oven cleaner, etc.), sodium hypochlorite (bleach, pool chlorinator).
- Classic acids — including acetic acid (food pickling, photo stop bath), hydrochloric acid (toilet bowl cleaner, mold, mildew removers), Oxalic acid (metal polish), phosphoric acid (rust remover), selenous acid (gun bluing agent), sulfuric acid (drain opener, large lead-acid batteries).
- Other caustics — including cationic detergents, hydrofluoric acid (rust graffiti remover, hydrogen peroxide (surface, food cleaner), phenol (surface disinfectant), zinc chloride (soldering flux).
When these substances are ingested, the patient can manifest in one of three ways — immediate, delayed, or remote.
“The organ systems most involved are the eyes, skin, airway, and gastrointestinal tract,” Hoffman and colleagues wrote. “Pain is often immediate, followed by loss of function. Common manifestations include swelling of the tongue and mouth, drooling, and vomiting. Bleeding can be severe if the injury involves erosion of a vessel. Swelling of the airway causes stridor, respiratory compromise, and changes in the voice. Perforation of the esophagus can lead to mediastinitis, and perforation of the stomach or bowel can lead to peritonitis. In the latter case, perforation is often not initially accompanied by classic peritoneal findings on physical examination.”
In acute episodes of poisoning from caustic substances, there can be delayed and remote complications, such as eye and skin injury resulting in cosmetic and functional issues. Esophageal strictures can occur over the course of weeks to months with resultant pain and malnutrition, even progressing to esophageal cancer “with latency measured in decades,” the study authors wrote.
When a clinically unstable patient presents to the emergency department, Hoffman and colleagues noted that their level of consciousness and evaluation of their airway needs to be assessed. Then, further assessment of the patient can be done.
“Variables common to any clinical assessment of toxicologic risk are analyzed: intent, exact substance or category of substance, concentration, dose, timing, and coingestants,” they wrote, and added that other symptoms — vomiting, coughing, choking, or abdominal pain — should be noted, as should the decontamination procedures started prior to arrival, such as induced vomiting, dilution, or irrigation. It is also important when assessing a child to be aware of developmental milestones. “For example, the pincer grasp is typically present by 9 months of age, whereas the ability to unscrew the lid of a bottle does not develop until approximately 2 years of age,” they wrote.
Product containers and material safety data sheets (for workplace ingestions) should also be looked at.
After that, the clinician should focus on tissue injuries, such as examining the face for signs of spills and splashings, especially if vomiting has occurred.
Caustic-induced gastrointestinal injuries and prognoses are classified as follows:
- Grade 0 — findings normal — complete recovery.
- Grade 1 — edema and erythema — complete recovery.
- Grade 2A — friability, hemorrhage, and superficial ulcerations — stricture unlikely.
- Grade 2B — deep ulcerations, in addition to friability, hemorrhage, and superficial ulcerations — high risk of stricture, low risk of perforation.
- Grade 3A — small, scattered areas of necrosis — high risk of stricture, greater risk of perforation than grade 2B.
- Grade 3B — extensive necrosis — high risk of perforation and strictures.
- Grade 4 — perforation — often fatal.
Hoffman and colleagues noted that children who accidentally ingested a caustic substance and who did not need endoscopy, or those who had negative endoscopies, can be discharged after a short observation period of around 6 hours. However, they did note that all other patients should be admitted and observed for 24 hours to assess their ability to take food and drink by mouth.
“All patients with intentional ingestions require psychiatric evaluation,” the authors noted. “Patients with grade 1 or 2A lesions confirmed by endoscopy can be started on a clear-liquid diet. Oral feeding must usually be withheld from patients with grade 2B injuries for variable periods of time. Patients with grade 3 injuries are best cared for in monitored care units because of the likelihood of infection, perforation, and fluid and electrolyte abnormalities. Feeding should progress orally as tolerated, with the use of parenteral nutrition or distal feeding tubes when severe injuries preclude oral feeding.”
As for follow-up, with grade 1 or 2A injuries, there is no specific follow-up needed. However, those with higher grade injuries should be periodically evaluated for the development of strictures, Hoffman and colleagues wrote. These usually develop in the first 2 months but have been reported earlier.
“Patients with grade 2B or 3 injuries are at increased risk for subsequent malignant transformation of the esophageal epithelium to adenocarcinoma or squamous-cell carcinoma,” the study authors noted.
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Ingestion of caustic substances by children results in 1,000 hospitalizations each year, for an average of 4 days, at direct hospital costs of more than $22 million.
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When a child or an adult shows up in an emergency department after having ingested a caustic substance they can be classified by intent — exploratory ingestion, child abuse, or an attempt at self-harm.
Candace Hoffmann, Managing Editor, BreakingMED™
Hoffman had nothing to disclose.
Cat ID: 254
Topic ID: 253,254,254,728,791,730,138,192,151,925
