HSC Section 3 - Trauma, Critical Care and Sleep Medicine

A review of caustic ingestion injury

clinically stable airway, the primary survey should proceed to evaluating for oesophageal perforation, a recognized complication of caustic ingestion injury. Clinical examina- tion for surgical emphysema and peritonitis in combination with an erect chest X-ray (CXR) which may demonstrate a widened mediastinum and air under the diaphragm raises the concern of upper gastrointestinal perforation. Indica- tions for emergency surgery rely more on clinical features than radiological features; therefore, in the presence of diagnostic doubt or suspicion, a surgical opinion should be sought immediately. 21 Focus should also be directed at relieving pain and attending to intravenous fluid replacement if the patient is shocked. Laboratory values relating to the severity of injury is poor. A raised white cell count and elevated C-reactive protein have been considered predictors of mortality in adults, 22 as has acidosis or low base excess in indicating emergency surgery in severe oesophageal injury. 23 It is felt that inflammatory markers are more useful in monitoring patient management rather than predicting outcome (level 3 evidence). 24 If the patient is deemed to have a stable airway in the absence of clinical and radiological suspicion of perforation and is haemodynamically stable, then further investigations to understand the extent of the injury are appropriate. Keypoints. • Common features of caustic ingestion are oropharyn- geal pain, chest pain and dysphagia. Associated symptoms include vomiting, drooling, odynophagia and stridor although the relationship between severity of symptoms and severity of injury is uncertain. • Airway assessment should be performed by an oto- laryngologist and anaesthetist with a definitive airway secured in those with clinical evidence of airway compromise although this is often not necessary and a period of airway observation may be appropriate. • Airway compromise should be initially managed with nebulized adrenaline and corticosteroids. • Patient should be resuscitated is accordance with the ALS guidelines. • In cases where a perforation is suspected, an immediate surgical opinion should be sought. • Blood tests although often taken have little correlation to patient outcome.

significant damage to the oesophagus, suggesting that oral burns are not a reliable indicator of oesophageal or upper airway injury. 14 When assessing the paediatric population, it is important to consider non-accidental injury. This relies on taking a careful collateral history, assessing whether the timing and mechanismof injury are consistent with the characteristics of the injury and the child’s developmental capabilities. Mul- tiple injuries, injuries in different stages of healing or a discrepant history should arouse a suspicion of abuse and specialist input from the paediatric team should be sought. 15 Airway assessment. The primary concern is that of airway compromise. Hoarseness, drooling, nasal flaring and stridor suggest laryngeal or epiglottic involvement and this should be addressed promptly with otolaryngology and anaesthetic involvement. Initial management should involve the admin- istration of nebulized adrenaline and intravenous corticos- teroid, both known to reduce laryngeal oedema in children 16,17 (level 1 evidence) and commonly used in adults. Ideally, airway assessment should take place in the form of flexible nasolaryngoscopy which can be performed readily in adults at the bedside. In children, this can be clinically challenging, as the precipitation of laryngeal spasm or irritation can be detrimental. As previously mentioned, caustic substances have a varying onset and duration of symptoms and clinical symptoms do not always reflect the severity of injury. Significant laryngeal injury does not always occur, but should always be considered. 18 The incidence of laryngeal injury requiring a definitive airway is reported as 6 – 12% in the literature (level 3 evidence) 19,20 with the incidence of tracheostomy appearing to be rarer with a reported incidence as low as 1%. 20 As a short-term adjunct nebulized adrenaline can help reduce upper airway swelling within 30 min and has an effective duration of approxi- mately 2 h. 16 Glucocorticoids can be used but take compar- atively longer to take effect (6 h), but when they do they have a longer duration of action (approximately 12 h). 17 However, progressive and rapid deterioration in the airway in patients initially thought to be unaffected is sometimes seen, and the airway can become very difficult to manage once significant airway compromise occurs. In light of this, a period of active observation should always be considered, and ideally this should take place in a high dependency or intensive care setting with airway observa- tions being recorded regularly by trained staff and the patient kept nil by mouth. If there is clinical concern or doubt, a definitive airway should be secured as a matter of priority. Further clinical assessment. Patients should be assessed for shock and appropriately resuscitated in accordance with the Advanced Life Support guidelines. In patients with a

3. Imaging and investigations. Simple radiology. When combined with clinical examination, an erect CXR may confirm suspicion of oesophageal or gastric perforation

© 2016 John Wiley & Sons Ltd Clinical Otolaryngology 42 , 701–708

134