Initial Assessment

During the initial and subsequent evaluations, the emergency department (ED) staff should take precautions to prevent personal injury secondary to caustic exposure

FIG. 175-1. Guidelines for treatment of caustic exposures.

The first step is immediate airway evaluation. Patients with respiratory distress may have significant oral, pharyngeal, and/or laryngotracheal injury, and may require emergency airway management. Ideally, patients with potential airway injuries should have fiber-optic evaluation of the airway prior to intubation to determine the extent of the damage, but this may not always be possible. Blind nasotracheal intubation is contraindicated secondary to the potential for exacerbating airway injuries. Oral intubation with direct visualization is the first choice for definitive airway management, but surgical cricothyrotomy may be required if oral intubation is not possible. When in doubt, it is prudent to establish an airway early rather than risk greater difficulty later as secondary effects of injury, such as edema, complicate the situation.

A directed history and physical examination should be performed to determine the type and amount of caustic ingested. It should also be determined whether the ingestion was intentional or unintentional. Patients should be assessed for hemodynamic instability. Etiologies for shock in these patients include GI bleeding, complications of GI perforation, and volume depletion. Patients should be examined for peritoneal signs from hollow viscous perforation, and mediastinitis should be considered in patients complaining of chest discomfort. Examinations should be performed to detect dermal and ocular caustic exposures.

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