HSC Section 3 - Trauma, Critical Care and Sleep Medicine

A review of caustic ingestion injury

debated 41 and nutritional delivery should be made on a case-by-case basis.

4. Medical therapy. Neutralization, gastric emptying. Attempts to neutralize acids or alkalis are strongly discour- aged due to the production of an exothermic reaction that may cause thermal damage, further increasing injury (level 3 evidence). 34 The effectiveness of milk and water both as antidotes or to dilute the corrosive agents has never been proven and therefore not recommended. Gastric lavage should be avoided for fear of re-exposing the upper digestive tract and airway to corrosive agents. Activated charcoal is contraindicated due to obscuring subsequent endoscopy (level 3 evidence). 35 Steroids. Corticosteroids can decrease inflammation, granulation tissue and fibrous tissue formation and have therefore been hypothesized in those with caustic inges- tion injuries to prevent stricture formation. Indeed, it is due to these benefits that they play a role in reducing upper airway oedema and obstruction. However, when used in the treatment of caustic injuries of the oesoph- agus, they appear not to have any significant benefit in preventing oesophageal strictures. 36,37 A meta-analysis of studies between 1990 and 2004 also concluded that steroids did not prevent stricture formation (level 2 evidence). 37,38 It is therefore felt that steroids should be reserved for those with airway compromise, rather than all patients with a caustic injury. Antibiotics. The routine use of antibiotics in patients with caustic ingestion is controversial. A study in 1952 reported decrease stricture formation with the use of antibiotics in caustic ingestion, 39 but to date no prospective trial evaluat- ing the isolated use of antibiotics in the absence of infection and the role in reducing stricture formation in caustic ingestion has been published. Antibiotics may be used to manage associated respiratory sepsis or if perforation is suspected. Prophylactic antibiotics may be indicated during dilatation procedures as cerebral abscesses have been reported following repeated oesophageal dilatation. 40 We recommend the administration of broad- spectrum antibiotics if corticosteroids are used as part of airway management, or if lung or mediastinal involvement is identified. 35 Nasogastric tube. Nutritional support in those with per- sistent symptoms of dysphagia and poor oral intake is going to be essential. We recommend not passing a nasogastric (NG) tube blindly at initial presentation as the extent caustic injury is not fully known and perforation is a possibility. 35 A decision to pass an NG tube or consider alternative feeding methods should be taken when grading the extent of the injury at endoscopy. Whether NG placement may precipitate stricture formation is still

Proton pump inhibitors. The use of H2 receptor antagonist and proton pump inhibitors (PPIs) in caustic ingestion injuries seems rational and reasonable. To date, there has been no controlled study comparing outcomes in those who have an H2 antagonist or PPI to those who do not. A case series in a population of 13 adults suggested a bolus of high- dose intravenous omeprazole (80 mg) followed by an infusion of 8 mg/h demonstrated markedly improved healing on repeat endoscopy at 72 h (level 4 evidence). 42 Although the evidence is minimal, if well tolerated and with no contraindications it would appear reasonable to com- mence intravenous PPI on those who present with caustic ingestion injury. Keypoints. • Neutralization and gastric emptying is not recom- mended. • Steroids should be reserved for those with airway compromise and not routinely continued in those with a stable airway. They do not prevent stricture forma- tion. • In those with pneumonitis, mediastinitis, suspected perforation or in those requiring steroids, antibiotics should be commenced. • NG tube should not be passed blindly due to theoret- ical risk of perforation, but nutritional support in those with persistent symptoms will be a necessity and considered on a case-by-case basis. • High dose PPI would appear to increase to rate of burn healing and should be started in those who tolerate it. 5. Surgical management. In the presence of airway compro- mise, the decision to proceed to surgical tracheostomy as a means of securing a definitive airway should be made between the otolaryngologist and anaesthetist following initial airway assessment as previously discussed in this article. The implications of intubating a scalded larynx are not well documented, however within the burns literature the principle of securing a definitive airway still applies and then proceeding to tracheostomy if necessary. Early tracheostomy in children with severe thermal burns is safe, effective and may result in improvement in ventilator management 43 (level 4 evidence) and this may be relevant for those children who have ingestion injury involving the larynx with a related pneumonitis. The role of early general or paediatric surgical intervention relies on the outcomes of examination and investigations. Those with clinical or radiological evidence of perforation

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

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