A 25-year-old man is brought to the emergency department by ambulance after ingesting toilet bowl cleaner an hour ago. The patient has a history of schizoaffective disorder and stopped taking his medication a week ago. His family suspected deterioration of his condition when he stopped returning their calls. They came to his house with emergency medical personnel to bring him to the hospital, but he said he "had to maintain order in the solar system" and would rather die than leave. The patient then consumed toilet bowl cleaner for a few moments before he started coughing and was subsequently restrained. He has no other medical conditions. The patient currently reports burning sensation in his throat, chest, and upper abdomen. His voice is hoarse and saliva runs out of his mouth while speaking. Temperature is 36.8 C (98.2 F), blood pressure is 148/75, pulse is 104/min, and respirations are 28/min. Pulse oximetry shows 93% on room air. The oropharynx is erythematous and edematous with gray exudates. Lung and heart sounds are normal. The abdomen is soft, nondistended, and tender in the epigastric region. There is no guarding or rebound tenderness. Which of the following is the most appropriate next step in management of this patient?

Question

A 25-year-old man is brought to the emergency department by ambulance after ingesting toilet bowl cleaner an hour ago.  The patient has a history of schizoaffective disorder and stopped taking his medication a week ago.  His family suspected deterioration of his condition when he stopped returning their calls.  They came to his house with emergency medical personnel to bring him to the hospital, but he said he "had to maintain order in the solar system" and would rather die than leave.  The patient then consumed toilet bowl cleaner for a few moments before he started coughing and was subsequently restrained.  He has no other medical conditions.  The patient currently reports burning sensation in his throat, chest, and upper abdomen.  His voice is hoarse and saliva runs out of his mouth while speaking.  Temperature is 36.8 C (98.2 F), blood pressure is 148/75, pulse is 104/min, and respirations are 28/min.  Pulse oximetry shows 93% on room air.  The oropharynx is erythematous and edematous with gray exudates.  Lung and heart sounds are normal.  The abdomen is soft, nondistended, and tender in the epigastric region.  There is no guarding or rebound tenderness.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has evidence of severe oropharyngeal damage (eg, hoarseness, odynophagia, inability to control secretions, edema, necrosis with grayish pseudomembranes) and respiratory distress (eg, tachypnea, hypoxemia) following a caustic ingestion. In such cases, laryngoscopy should be performed first to assess the likelihood of impending airway compromise. Once laryngoscopy has been performed, patients should typically undergo upper endoscopy within 24 hours to determine the severity of gastrointestinal injury. Further management depends on the extent of injury; patients with minimal damage may be discharged, whereas those with the most severe injuries require ≥7 days of monitoring for possible perforation and complications. In the event of perforation, mediastinitis, or peritonitis, patients should undergo emergency surgery. (Choice A) Although activated charcoal may be helpful in acute poisoning, it does not have a role in the management of caustic ingestions. Moreover, it can complicate management by obscuring the gastrointestinal tract during endoscopy. (Choice B) A CT scan can be helpful in determining the extent of necrosis and risk or presence of perforation. However, given the severity of this patient's airway symptoms, delaying laryngoscopy for imaging might further compromise the ability to secure the patient's airway; consequently, imaging should follow airway assessment. Moreover, portable imaging (eg, x-ray, ultrasound) is preferred in unstable patients. (Choice D) Nasogastric intubation with saline lavage is contraindicated given the increased risk of vomiting, which can cause further injury to the esophagus due to reexposure to the caustic substance and also increase the risk of perforation due to increased esophageal pressures. (Choice E) Supportive care and observation alone may be appropriate in patients who are asymptomatic and give a reliable history of small-volume, low-concentration caustic ingestion (usually accidental). It is not appropriate in this patient with a witnessed intentional caustic ingestion, respiratory distress, and multiple symptoms including odynophagia, hoarseness, and difficulty managing oral secretions. Educational objective: In patients with evidence of respiratory distress (eg, tachypnea) or severe oropharyngeal damage after a caustic ingestion, laryngoscopy should be performed first to assess the likelihood of impending airway compromise. References: Caustic ingestion injury of the upper aerodigestive tract in adults. (http://www.ncbi.nlm.nih.gov/pubmed/26263940) Caustic injury of the upper gastrointestinal tract: a comprehensive review. (http://www.ncbi.nlm.nih.gov/pubmed/23840136)

A 25-Year-Old Man Is Brought to the Emergency Department by Ambulance