Corrosive and hydrocarbon ingestion

Management— do this, in order

• Nil by mouth from the moment of arrival: keep the patient strictly nil by mouth until objective assessment permits otherwise, and convert oral medication to intravenous equivalents.
• Secure the airway early and electively if there is hoarseness, stridor, drooling, inability to swallow saliva or supraglottic oedema — by the most experienced operator available, with a smaller tube than predicted and a surgical airway plan prepared in advance, since a burnt, oedematous, bleeding supraglottis is a difficult intubation; blind nasal intubation is contraindicated and a supraglottic device will neither pass nor seal. Keep continuous suction running for pooled blood, slough and saliva.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Nebulised adrenaline is a bridge, not a treatment: 1:1000, 5 mL in an adult, or 0.5 mL/kg of 1:1000 to a maximum of 5 mL in a child; the effect wears off within an hour, often with rebound.Doctor / Nurse
• Oxygen and bronchodilators: high-flow oxygen by reservoir mask for any symptomatic patient; in hydrocarbon aspiration oxygen and nebulised bronchodilators are the mainstay — salbutamol 5 mg nebulised in an adult, 2.5 mg in a child under 5 years, repeated for wheeze.
• Circulation: two large-bore cannulae with blood drawn on insertion; these patients lose fluid into an oedematous gut wall exactly as a burns patient loses it into skin, so give warmed 0.9% sodium chloride or Ringer's lactate 500 mL as a bolus in an adult, 10–20 mL/kg in a child, reassessing after each, targeting urine output above 0.5 mL/kg/hour in adults and 1 mL/kg/hour in children.Doctor / Nurse
• Continuous ECG monitoring is required for all hydrocarbon and hydrofluoric acid exposures — chlorinated and fluorinated hydrocarbons cause ventricular premature beats and ventricular tachycardia, and hydrofluoric acid causes QT prolongation.
• External decontamination: remove all contaminated clothing, cutting rather than pulling it over the face, and irrigate the skin with copious lukewarm water or saline, washing behind the ears, under the nails and in skin folds; for oily substances wash at least twice with soap and shampoo the hair.
• Brush off dry before any water: alkali metals (sodium, potassium, lithium), calcium oxide (quicklime) and elemental phosphorus are made worse by water — phosphorus burns are then immersed in water to extinguish combustion of residual phosphorus, with meticulous removal of fragments and dressings kept soaked to exclude oxygen.
• For the eye, act quickly: instil topical local anaesthetic if available (blepharospasm otherwise prevents adequate irrigation), remove contact lenses, lift the tarsal conjunctiva to look for undissolved particles, then flush with copious saline or water for at least 15 minutes or until each eye has received at least 1 litre, and for an acid or a base check the pH of the tears afterwards, continuing until it is between 7 and 7.4.
• Dilution is the one permitted oral intervention: water, another clear liquid or milk at 5 mL/kg — approximately 250–350 mL in an adult, sipped rather than gulped, and 75 mL in a 15 kg child — only after corrosive ingestion, only within minutes, and only in a fully conscious patient able to swallow on command, with no stridor or drooling, no vomiting and no evidence of perforation.
• Analgesia for an extremely painful injury: morphine 2 mg IV repeated every 5 minutes and titrated (typical total 5–10 mg), child 0.05–0.1 mg/kg IV titrated, monitoring respiratory rate and conscious level; fentanyl 1 microgram/kg IV in adult or child where morphine is unsuitable.Doctor / Nurse
• Stop the vomiting, because vomiting is genuinely harmful here: ondansetron 4–8 mg IV slowly, child 0.1 mg/kg IV to a maximum of 4 mg; metoclopramide 10 mg IV is an adult alternative but is avoided in children and young adults because of dystonic reactions.Doctor / Nurse
• Acid suppression to protect denuded mucosa: omeprazole 40 mg IV once daily, child 0.5–1 mg/kg IV once daily to a maximum of 40 mg; pantoprazole 40 mg IV twice daily is preferred after bleeding — neither heals a chemical burn.Doctor / Nurse
• Antibiotics only for suspected perforation, mediastinitis, peritonitis or secondary bacterial infection: ceftriaxone 2 g IV daily plus metronidazole 500 mg IV 8-hourly, child ceftriaxone 50–80 mg/kg IV daily plus metronidazole 7.5 mg/kg IV 8-hourly.Doctor / Nurse
• Hydrofluoric acid by any route: check calcium and magnesium urgently, monitor the ECG, and correct hypocalcaemia aggressively with calcium gluconate 10%, 10 mL IV over 10 minutes repeated according to ionised calcium and ECG (child 0.5 mL/kg IV slowly, maximum 20 mL, with cardiac monitoring); for dermal exposure, immediate copious water irrigation then prompt application of calcium gluconate gel.Doctor / Nurse
• Methaemoglobinaemia above 30% after copper sulphate or another oxidant is treated with methylthioninium chloride 1–2 mg/kg IV, adult and child — suspect it when cyanosis fails to correct with oxygen and arterial blood is chocolate-brown.Doctor / Nurse
• Assess severity objectively within 24 hours — ideally by upper gastrointestinal endoscopy, alternatively by contrast-enhanced CT of neck, chest and abdomen where endoscopy is unavailable or the patient is too unstable — and arrange prompt surgical intervention to remove necrotic tissue if indicated.Not available at your setup — CT scan.
• Observe by the clock: corrosive ingestion demands airway reassessment every 15–30 minutes for the first four hours and surveillance for perforation for at least 48 hours; hydrocarbon ingestion that is not certainly trivial requires observation for at least 6 hours from ingestion with hourly respiratory rate, saturation and auscultation, and a repeat chest radiograph before discharge.