Acute Management of Corrosive Injury

1. Airway — First Priority

• Assess for oral, pharyngeal, and laryngotracheal injury causing respiratory distress
• Fiberoptic evaluation of the airway before intubation is ideal to assess the extent of damage
• Oral intubation with direct visualization is the first choice for definitive airway management — establish a secure airway early before edema worsens
• Cricothyrotomy may be needed if oropharyngeal edema or bleeding makes intubation impossible
• Contraindicated: Blind nasotracheal intubation (risks exacerbating airway injury), laryngeal mask airways, and retrograde intubation techniques

2. Decontamination

• Remove soiled clothing and perform copious irrigation; staff should wear protective gowns, gloves, and face shields
• Activated charcoal is contraindicated — it does not adsorb caustics well and impairs endoscopic visualization
• Ipecac/emetics are contraindicated — vomiting re-exposes mucosa and airway to the caustic and risks perforation
• Neutralization and dilution are not recommended (risk of gastric distension, vomiting, perforation, and exothermic reaction)
• Nasogastric tubes should not be inserted until after endoscopic evaluation (may be placed under endoscopic guidance for high-grade burns)

3. Fluid Resuscitation & IV Access

• Establish large-bore IV access
• Resuscitate with crystalloids
• Monitor for shock from bleeding, third-spacing, co-ingestants, or acid-base derangements
• Central venous access may be required for resuscitation monitoring

4. Assessment & Physical Examination

• Assess for hemodynamic instability and peritoneal signs (hollow viscous perforation)
• Consider mediastinitis in patients with chest discomfort; palpate for subcutaneous emphysema
• Inspect eyes for ocular burns, and skin for splash/dribble burns
• Note: oropharyngeal burns may be absent even with significant esophageal injury

Acid ingestion with dermal dribble burns on upper chest (Tintinalli's Emergency Medicine)

5. Laboratory Testing

• Venous/arterial blood gas
• Electrolytes, hepatic profile, CBC, lactate
• Blood type and screen
• Acetaminophen and salicylate levels (to screen for co-ingestants in suicidal patients)
• ECG after hydrofluoric acid exposure (risk of QT prolongation from hypocalcemia)

6. Imaging

• Chest X-ray for peritoneal or mediastinal free air in patients with chest pain, dyspnea, or vomiting
• IV-contrasted thoracoabdominal CT scan is recommended by the World Society of Emergency Surgery (2015) and may outperform endoscopy in predicting transmural injury

7. Endoscopy

• Should be performed within 12–24 hours of ingestion
• Mandatory for all intentional (suicidal) ingestions regardless of symptoms
• Recommended for unintentional ingestions with symptoms: stridor, drooling, vomiting, food refusal, or significant oropharyngeal burns
• Examination beyond the first level of severe burn should be done with caution to avoid perforation

8. Steroids & Antibiotics

• Steroids: Highly controversial. One RCT found benefit for grade 2B lesions; pooled meta-analysis has not shown benefit and steroids may increase risk of infection, perforation, and hemorrhage. Steroids are no longer recommended by most guidelines
• Prophylactic antibiotics: No current evidence supports routine use, but may be added if steroids are used or in grade 2B/3 injury (e.g., penicillin-based cover)

9. Alkali vs Acid — Key Differences

• Alkalis (e.g., NaOH, drain cleaners): Cause liquefaction necrosis — deeper tissue penetration; primarily damage the esophagus
• Acids (e.g., H₂SO₄, HCl): Cause coagulation necrosis — creates an eschar that may limit penetration; more commonly cause gastric and duodenal injury
• Both agents are hygroscopic and adhere to mucosal surfaces; there is no effective immediate antidote

What to Avoid (Summary)

Recent evidence note: A 2025 systematic review and meta-analysis (PMID: 40961829) on corrosive ingestion-induced esophageal injuries is available and may provide updated evidence on outcomes and management strategies.