Extern Conference
16 Aug 2007
A one-year-old boy was
referred to Siriraj hospital
due to an accidental
ingestion of unknown liquid
substance for two and a half
hours prior to admission.
Present history
2 ½ hours PTA, the patient was
brought to his uncle’s house by his
father and his step-mother. While his
father and his uncle were watching
the television, the step-mother found
that her son was drinking some
amount of liquid substance from
plastic bottle which was used for
battery refilling.
3
Present history
The child was crying and
sweeping his hand over his mouth.
His father washed the patient’s
mouth with drinking water and gave
his son some milk to induce
vomiting. The patient vomited the
ingested milk with sputum and
saliva for 4 times.
4
Present history
Before his parents brought him
to a nearby hospital, he vomited
some streaks of blood with gastric
contents.
The parents did not notice that
the patient was aspirated or not.
5
Present history
At emergency room, the patient
was given
•
•
•
•
•
Activated charcoal 10 g orally
Metoclopramide 2 mg intravenously
Ranitidine intavenously
Cetriaxone intravenously
NPO
Then the patient was referred to
Siriraj hospital.
The patient was admitted at AN 5
on 6/8/50
6
Past history
• He has no underlying disease.
• He has no previous history of
unexplained injuries or poisoned.
• He has normal developmental
milestones.
• He has no previous history of drugs
or food allergy.
7
Family history
• The patient lived with his father, his
step-mother, and his grandmother.
8
Physical Examination
o
V/S: T 37 c, PR 148/min, RR 40/min,
BP 98/72 mmHg
GA: A crying Thai boy, looked distress,
no pallor, no jaundice, no dyspnea,
no cyanosis, no evidence of trauma,
Ht 87 cm (P75-P90), Wt 11.5 kg (P50-P75)
9
Physical Examination
HEENT:
nose: no swelling turbinate, no
discharge
ears: normal tympanic membranes,
both sides
mouth & throat: mild dry lips, mild
injected upper & lower lips, no
injected oral mucosa, mild injected
oropharynx
10
Physical Examination
RS: no stridor, normal breath sound,
no adventitious sound
CVS: normal S1&S2, no murmur
Abd: soft, no tenderness, active bowel
sound, liver & spleen cannot
palpable
NS: pupil size 3 mm both RTL,
otherwise unremarkable
11
Problem list
1. Ingestion of unknown liquid
substance
2. Mild injected upper and lower
lips with mild injected
oropharynx
12
Impression
• Suspected caustic ingestion
13
Management in poisoned child
1. Assessment and resuscitation
2. Diagnosis of poisoning
3. Decontamination / Enhanced elimination
4. Disposition
1. Assessment and
Resuscitation
• Airway : Maintain airway
• Breathing : Proper ventilation and
oxygenation
• Circulation : Adequate perfusion
• Disability : Assess level of consciousness
and neurological examination
15
2. Diagnosis of poisoning
• History taking :
– including the containers and labels of
the ingested substance
• Physical Examination:
Focus on
– Cardiopulmonary
– Respiratory
– Neurological
– Toxidromes
• Proper investigation
16
How to obtain a
poisoning history?
What has been ingested?
• Ask for containers of the substance,
they may offer more details.
• What is the substance used for?
• The details of ingredients of the
commercial products and
medications can be obtained from the
poison center.
18
Label
น้ ำกลัน่ -กรด ตรำปลำทอง
ใช้สำหรับเติมในแบตเตอรี่ เท่ำนั้น
คำเตือน ถ้ำสัมผัสถูกสำรนี้ให้รีบใช้น้ ำสะอำดล้ำงทันที
โทร : 081-xxxxxxx
NOTE : Information from patient’s father
The information from the manufacturer:
1.5 % Sulfuric Acid
19
How much has been intake?
• Ask the parents or the caregivers
who has been in the situation.
• In liquid ingestion, it is noted that the
amount of the ingested substance
may be over reported but should not
be assumed to be wrong.
20
When was it taken?
• Time since ingestion
• This can help you to know a time for
onset of symptoms consequently
you can obtain proper investigations
and management.
• Crucial for poisons that require blood
level monitoring (example:
paracetamol)
21
What symptoms or signs
have been shown?
• These information can help to narrow
down that class of ingested substance.
• Physical examination focused on
cardiopulmonary, respiratory and
neurological systems and look for
secondary trauma : burned lips and
oral cavity in the patient with caustic
ingestion.
• Look for the signs and symptoms of
toxidromes.
22
3.Decontamination/Enhanced
elimination
• Gastric lavage
• Ipecac
• Activated charcoal
• Whole bowel irrigation
• Hemodialysis
23
4. Disposition
• Discharge from emergency
department
– Intensive care unit
– Ward
– Nonmedical facility eg. Psychiatric
24
Recognition of child abuse
• Unexplained delay in seeking
treatment
• Parents are uninterested by an
accident
• Is the history consistent each time?
• Mechanism of injury inconsistent with
developmental capability
• Reluctance to give information or
mention about previous injury.
• Unexplained injury on examination.
25
Investigations
(in this patient)
•
•
•
•
•
•
BUN
Cr
Na+
K+
ClHCO3-
17.0
0.4
135
4.4
99
11
mg/dl
mg/dl
mmol/L
mmol/L
mmol/L
mmol/L
26
CXR
1st day of admission
27
Activated charcoal
Functions of activated charcoal
1. Initial toxin absorption
2. Interruption of enterohepatic
circulation of toxic metabolite
3. gastrointestinal dialysis
28
Activated charcoal
• Activated charcoal is being
increasingly used in the
management of childhood
poisoning
• Adsorb toxic material in the gut
by offering alternative binding
site
29
Activated charcoal
No advantage in
Alkali, Boric acid, Cyanide, DDT,
Ferrous sulfate, Lithium, Mineral
acids, Methanol, Malathion, Nmethyl carbamate
30
Activated charcoal
Route and doses
• 1 gm/kg/dose (maximum, 50-60
gm) oral
• Repeated every 2-6 hrs until
charcoal is passed through the
rectum
31
Activated charcoal
Contraindications
1. People with an obstruction of
the intestines
2. Person swallowed a corrosive
agent, such as a strong acid or
alkali
32
Accidental caustic
ingestion
Accidental caustic ingestion
•
•
•
High risk group is children younger
than 5 years old.
Male > Female
The extent and severity of the
caustic injury depends on :
1. The corrosiveness of the ingested
substance
2. Quantity and concentration
3. Duration of contact time
4. Subsequence secondary infection
34
Caustic agents
• Caustics are typically classified as
acids or alkalis.
• Zinc chloride, Phenol and button
battery are capable of producing
severe burns even though they have
near physiologic pH.
• Hydrofluoric acid has not only local
effects but also has fatal systemic
effects eg. hypocalcemia,
hypomagnesemia, hyperkalemia.
35
Caustic agents
• Acid
– Coagulation necrosis of tissue that
produces an “eschar” to have some
protective effect on deeper tissue.
• Alkali
– Saponification of lipids
– Liquefaction necrosis which causes
much deeper ulceration because of no
barrier to the alkali until it is sufficiently
buffered by proteins, tissue fluid, and
soaps.
36
Complications
• Early complications
– Local complications
• Upper GI Perforation
• Respiratory inflammation (rare)
– Systemic complications
• Renal insufficiency, hepatic
dysfunction, DIC, hemolysis
37
Complications
• Late complications
– Esophagus
• Stricture, fistula
• Peptic esophagitis, hiatus hernia,
Barrett’s esophagus, esophageal
carcinoma
– Stomach
• Stricture, fistula
• Anemia, vitamin B12 deficiency,
growth retardation in case of total
gastrectomy
38
Complications
• Children VS adults
– In children, most such events are
inadvertent.
– In adults, ingestion usually is a
deliberate attempt to commit suicide.
– The lower mortality in series of pediatric
patients might be explained by ingestion
of smaller amounts of the chemical
agent.
– However, stricture formation in pediatric
patient is relatively common.
39
Management in caustic
ingestion
• Acute management
– Initial assessment and stabilization
should focus on airway.
– Steroids : The use of corticosteroids
remains controversial. There was a
reduction in the number of dilatations
required and the number of patients
who developed stricture when using
1 mg/kg/day of dexamethasone.
40
Management in caustic
ingestion
• Acute management
– Antibiotics
• There are no control trials that identify
the routine use of antibiotics after caustic
ingestion
• Indications:
– Grade 2 or greater lesion with deep ulcer
– Elevated in temperature
– Grade 3 lesion or perforation, antibiotics
should be started immediately
41
Management in caustic
ingestion
• Acute management
– Acid suppression
• Should be used in cases of grade 2-3
esophageal injury.
• The refluxing acid from stomach will
damage the exposed tissues of the
esophageal wall and may inhibit the
healing process by damaging in-growing
new cells.
42
Management in caustic
ingestion
• Decontamination, dilution,
neutralization
– Dilutional therapy is of limited
benefit beyond the first few
moments following ingestion but
should be avoid in patient with
nausea, drooling, stridor or
abdominal distension as it may
induce vomiting.
43
Management in caustic
ingestion
• Decontamination, dilution,
neutralization
– GI decontamination is usually
limited in the patient with caustic
ingestion.
– Induce emesis is contraindicated.
– Caustic agents are poorly
absorbed by activated charcoal.
44
Management in caustic
ingestion
• Decontamination, dilution,
neutralization
– Neutralization of caustics should
be avoided because of potentially
tissue damaging by forming gas
and generating heat.
45
Management in caustic
ingestion
• Surgical management :
– Evidence of perforation either by
endoscopic or diagnostic imaging
– Severe abdominal rigidity
– Persistent hypotension
– Severe extensive burns
46
Management in caustic
ingestion
• Subacute management
– Early endoscopy should be
performed in every patients to
assess
• Extent of lesions
• Severity
• Further management.
47
Classification of
Caustic injury
Grade
Visible effect
Clinical Significance
Grade 0
History of ingestion, no visible
damage or symptoms.
Able to take fluid
immediately.
Grade 1
Edema, loss of normal vascular
pattern, hyperemia. No
transmucosal injury.
Temporary dysphagia,
able to swallow within
0-2 days. No long-term
sequalae.
Grade 2a Trans-mucosal injury with fragility,
Scarring, no
hemorrhage,blistering, exudates, circumferential damage
scattered superficial ulceration.
= no stenosis. No long
term sequelae.
49
Grade
Visible effect
Clinical Significance
Grade 2b
Plus deep discrete ulceration
and/or circumferential.
Small risk of
perforation. Scarring
which may result in
later stenosis.
Grade 3a
Scattered deep ulceration with
necrosis of tissue.
Risk of perforation.
High risk of later
stenosis.
Extensive necrotic tissue.
High risk of perforation
and death. High risk of
stenosis.
Grade 3b
Note : Grade 4 may be used to indicate perforation
50
Progression
52
EGD
Progress
Cefotaxime
Ranitidine
Dexamethasone
NPO
TPN
53
Pictures
54
Esophagogastroduodenoscopy
55
Esophagogastroduodenoscopy
56
Esophagogastroduodenoscopy
EG
junction:
White
membrane
at junction
57
Esophagogastroduodenoscopy
Body:
Erythema,
bleeding,
necrotic,
friability,
ulcer
58
Esophagogastroduodenoscopy
Body:
Erythema,
bleeding,
necrotic,
friability,
ulcer
59
Esophagogastroduodenoscopy
Body:
Erythema,
bleeding,
necrotic,
friability,
ulcer
60
Esophagogastroduodenoscopy
Body:
Erythema,
bleeding,
necrotic,
friability,
ulcer
61
Esophagogastroduodenoscopy
Antrum:
Erythema,
bleeding,
necrotic,
friability,
ulcer
62
Esophagogastroduodenoscopy
Bulb:
Some
erythema,
white lesion,
desquamation
of mucosa
63
Esophagogastroduodenoscopy
Bulb:
Some
erythema,
white lesion,
desquamation
of mucosa
64
Esophagogastroduodenoscopy
2nd portion of
duodenum:
Marked edema,
necrotic
65
Esophagogastroduodenoscopy
3rd portion of
duodenum:
Marked
edema,necrotic
66
Esophagogastroduodenoscopy
3rd portion of
duodenum:
Marked
edema,necrotic
67
Summary of EGD Report
• Procedure
• Complication
: none
: no immediate
complication
•
•
•
•
•
Diagnosis
CLO test
Recommendation
Specimens
Plan
: caustic ingestion
: not done
::: Re-EGD 17/8/50
68
Preventing childhood
poisoning
1. Insist on packages with safety
closures and learn how to use properly
69
Preventing childhood
poisoning
2. Keep household cleaning supplies,
medicines, garage products, and
insecticides out of the reach and
sight of your child
3. Never store food and cleaning
products together. Store medicine
and chemicals in original containers
and never in food or beverage
containers
70
Preventing childhood
poisoning
4. Avoid taking medicine in your child’s
presence. Children love to imitate.
Never suggest that medicine is
candy.
5. Never use medicine from an
unlabeled or unreadable container
6. If you are interrupt while using a
product take it with you.
71
Preventing childhood
poisoning
7. Know what your child can do
physically. For example , if you have
a crawling infant, keep household
product stored above floor level.
8. Keep the phone numbers of your
doctor, poison center ,hospital ,police
department, and emergency medical
system near the phone
72
Toxic center
• Toxbuster@hotmail.com
• Siriraj Poison Center
– Tel.02-419-7007
73
Thank you for your attention