The essence of the physical examination is to try to determine the extent of the injury. The examination begins with a careful history, including the type, amount, and brand name of the ingested product. The precise location and extent of the burn in the oropharynx and pharynx should be noted. Complete examination, including the extremities, groin, and chest, is necessary to detect caustic spills to those areas. Patients with oral mucosal burns and tongue edema should be monitored closely for developing airway obstruction, which may be heralded by dyspnea, hoarseness, and stridor. Because symptoms can develop as early as 1 h postingestion or as late as 5 h postingestion, emergency departments should observe children who have ingested caustic substances for at least 5 h. 28 The patient should be given nothing by mouth. Gastric lavage and emesis are contraindicated.
Fiberoptic laryngoscopy is a valuable adjunct in the assessment of the larynx and hypopharynx for injury. Blind nasotracheal or nasogastric intubation may lead to obstructive bleeding or esophageal or pharyngeal perforation, and should not be performed. In a patient with rapid airway deterioration and poor visualization of the larynx, emergency cricothyrotomy or tracheotomy may be necessary. Intravenous steroids are used by many otolaryngologists, but the issue remains very controversial.
Chest and neck radiographs may reveal airway edema, free air, aspiration, mediastinal air, or obstruction. Immediate esophagoscopy and laryngoscopy should be performed in any caustic or acidic ingestion in a symptomatic patient.31 Asymptomatic patients observed for 5 h may be safely discharged as long as home observation can be provided, the patient is close to medical care, and follow-up can be provided the next day. 31
Bleach ingestion is the one exception to the general rule of performing immediate endoscopy and bronchcospy. 31 Bleaches are chlorides that are oxygenating compounds. Sodium hypochlorite is the most common component in such products as Clorox and Comet. In the United States, bleaches typically are only 2.5 percent acid, which produces a superficial ulceration that does not result in stricture or residual sequelae. Management of chlorine bleach ingestion includes careful oropharyngeal examination. If no burns are present and the patient is tolerating fluids by mouth, the patient may be safely discharged with follow-up scheduled in 12 h.31
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