A 34-year-old man is brought to the emergency department by paramedics. His friend called emergency medical services after receiving a text message saying he was going to commit suicide. At the hospital, the patient is conscious and alert. He repeats, "It's not worth it anymore," but refuses to give any history. Temperature is 36.8 C (98.2 F), blood pressure is 130/70 mm Hg, pulse is 90/min, and respirations are 28/min. The patient is conscious and alert but in severe pain. The pupils are 3 mm bilaterally. The oropharynx is erythematous with some mild ulcerations. There is heavy drooling. The abdomen is benign with normal bowel sounds. Ingestion of which of the following is the most likely explanation for this patient's symptoms?

Question

A 34-year-old man is brought to the emergency department by paramedics.  His friend called emergency medical services after receiving a text message saying he was going to commit suicide.  At the hospital, the patient is conscious and alert.  He repeats, "It's not worth it anymore," but refuses to give any history.  Temperature is 36.8 C (98.2 F), blood pressure is 130/70 mm Hg, pulse is 90/min, and respirations are 28/min.  The patient is conscious and alert but in severe pain.  The pupils are 3 mm bilaterally.  The oropharynx is erythematous with some mild ulcerations.  There is heavy drooling.  The abdomen is benign with normal bowel sounds.  Ingestion of which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

This patient is conscious and alert with an erythematous, ulcerated oropharynx leading to difficulty swallowing his secretions (drooling). This presentation is most consistent with a caustic ingestion. Mucosal injury results from local contact with the caustic substance rather than from systemic absorption; therefore, patients are conscious and alert but often have severe pain. Oropharyngeal damage leads to ulcerations and erythema. Laryngeal damage can cause hoarseness or airway compromise. Esophageal damage can lead to dysphagia, odynophagia, and difficulty handling secretions (eg, heavy drooling). In patients with alkaline caustic ingestions, gastric damage (eg, abdominal pain) is less likely, probably due to partial neutralization of the alkali by stomach acids. Full-thickness necrosis of the esophagus can lead to perforation, resulting in either mediastinitis or peritonitis. Esophageal strictures are the most common complication and occur weeks to months after the ingestion. Many patients (approximately one-third) develop esophageal squamous cell carcinoma years after the initial ingestion. (Choices A and E) Anticholinergic toxicity would cause xerostomia (rather than drooling), altered mental status, tachycardia, and urinary retention. Tricyclic antidepressant toxicity often presents with anticholinergic effects, as well as mental status changes (eg, sedation or delirium), cardiac arrhythmias, and hypotension. (Choice C) Ingestion of methanol results in disinhibition (similar to ethanol) shortly after ingestion. Formate, a toxic substance formed after the metabolism of methanol via alcohol dehydrogenase and aldehyde dehydrogenase, is primarily responsible for the delayed (10-30 hr) symptoms of visual blurring, epigastric pain, and profound metabolic acidosis. (Choice D) Patients with organophosphate poisoning may have increased salivation (due to cholinergic excess rather than difficulty swallowing) but typically also have bradycardia, miosis, increased urination, and diarrhea. Educational objective: A caustic ingestion causes injury to the upper aerodigestive tract and most commonly presents with pain, dysphagia, and oropharyngeal erythema and ulcerations. It does not cause alterations in consciousness. References: Endoscopic findings and outcome in caustic ingestion of acidic and alkaline agents in adults: a retrospective analysis. (http://www.ncbi.nlm.nih.gov/pubmed/31464902)

A 34-Year-Old Man Is Brought to the Emergency Department by Paramedics