List the potential complications associated with the management of a patient after intentional corrosive ingestion.
College Answer
Potential complications of intentional corrosive ingestion include:
• Acute:Oral, oesophageal, gastric bums of varying thickness Laryngeal oedema and airway obstruction Oesophageal, gastric perforation
Shock Haemorrhage Mediastinitis Psychiatric problems
• Chronic/late:
Laryngopharyngo fibrosis with airway incompetence and chronic aspiration
Oesophageal fibrosis, stricture and stenosis
Psychosocial problems
Carcinoma
Discussion
This question would benefit from a systematic response.
- Airway:
- Airway burns, leading to airway compromise
- Potential acute tracheo-oesophageal fistula due to corrosive effect on oesophagus
- Assessment and immediate airway control is a priority
- Breathing:
- Potential aspiration of caustic gastric/oesophageal contents, thus acute lung injury
- Hypoxia may be present; supplemental oxygen may be required. NIV may be contraindicated in case of full-thickness oesophageal injury
- Circulation:
- Potential hypovolemic shock due to fluid loss into the corroded gut, or haemorrhage though ulcers
- Need for rapid fluid replacement or surgical haemostasis
- CVC access, as this patient is likely to require long-term TPN
- Neurological state:
- Potential for disorganised behaviour due to psychiatric condition, or obtundation due to shock
- Analgesia issues need to be addressed
- Electrolyte disturbance
- Absorption of corrosive agent may result in electrolyte and acid-base disturbance
- Fluid balance
- Likely, hypovolemia will exist and need correction
- renal impairment may be present, with implications on drug dosing
- Gastrointestinal problems:
- Extent of corrosive damage will need to be assessed by CT and/or direct endoscopy (earlier is better, before significant tissue softenting makes endoscopy risky)
- Perforation of hollow organs must be ruled out with CXR and/or CT
- Specific issues
- Decontamination by NG aspiration may be possible if it is safe to pass an NGT