Level 1 of 6Core
Corrosive and hydrocarbon ingestion
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Suspect it from the bottle, not the mouth: a corrosive (acid/alkali — drain and toilet cleaners, battery fluid, oven cleaner, industrial bleach) or a hydrocarbon (kerosene/paraffin, white spirit, petrol, lamp oil) swallowed from a decanted drinks bottle — the commonest single circumstance at any age. Accidental child ingestion is a small mouthful usually spat out; deliberate adult ingestion of a concentrated industrial product is the kind that perforates and kills.
- Airway first after a corrosive: hoarseness or muffled voice, stridor, drooling, difficulty handling secretions, supraglottic oedema or blistering — progressive laryngeal oedema that alters management within minutes. The full corrosive complex: immediate severe pain, oropharyngeal burning, inability to swallow saliva, odynophagia, retrosternal/epigastric pain, vomiting, haematemesis.
- Lung first after a hydrocarbon: coughing, choking or gagging at the moment of swallowing signifies aspiration and predicts chemical pneumonitis. Respiratory signs (cough, tachypnoea, wheeze, crackles, cyanosis, falling SpO2) often take hours to appear, and low-grade fever with leucocytosis in the first 24–48 hours is part of the pneumonitis, not bacterial infection.
- Triage rule: three or more of stridor, drooling, dysphagia, vomiting and abdominal pain predicts severe (grade 2b or 3) oesophageal injury — an aid, not a substitute for assessment after deliberate ingestion.
- Signs of perforation, at the outset or evolving over days: new chest or interscapular pain, subcutaneous emphysema in the neck, guarding and rigidity with absent bowel sounds, fever, tachycardia, hypotension. Metabolic acidosis or a rising lactate after corrosive ingestion means tissue necrosis, perforation or shock until proved otherwise — a reason for surgical assessment, not a number to correct with bicarbonate.Not available at your setup — Arterial blood gas.
- Two traps: an unremarkable mouth does not mean an unremarkable oesophagus (and florid oral burns do not establish the depth of the distal burn); a normal early chest radiograph does not exclude hydrocarbon aspiration — radiographic change lags by several hours.
Manage now— do this, in order
- Nil by mouth from the moment of arrival, strictly, until objective assessment permits otherwise; convert oral medication to intravenous equivalents.
- Secure the airway early and electively for hoarseness, stridor, drooling, inability to swallow saliva or supraglottic oedema — most experienced operator, a smaller tube than predicted, surgical airway plan prepared in advance; blind nasal intubation is contraindicated and a supraglottic device will neither pass nor seal. Nebulised adrenaline 1:1000 (adult 5 mL; child 0.5 mL/kg, maximum 5 mL) is a bridge only — it wears off within an hour, often with rebound.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
- 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; fluid is lost into an oedematous gut wall exactly as a burns patient loses it into skin — warmed 0.9% sodium chloride or Ringer's lactate 500 mL bolus in an adult, 10–20 mL/kg in a child, reassessing after each; target urine output above 0.5 mL/kg/h (adult) and 1 mL/kg/h (child). Continuous ECG monitoring for all hydrocarbon and hydrofluoric acid exposures.Doctor / Nurse
- Dilution is the ONE permitted oral intervention: water, another clear liquid or milk at 5 mL/kg (adult ~250–350 mL sipped, 75 mL in a 15 kg child) — only after a corrosive, only within minutes, only in a fully conscious patient able to swallow on command, with no stridor or drooling, no vomiting, no evidence of perforation. Never after hydrocarbon ingestion, never for tablets or capsules, never more than 5 mL/kg.
- Analgesia and antiemesis: morphine 2 mg IV every 5 minutes titrated (typical total 5–10 mg; child 0.05–0.1 mg/kg IV titrated), monitoring respiratory rate and conscious level; ondansetron 4–8 mg IV slowly (child 0.1 mg/kg, maximum 4 mg) — vomiting is genuinely harmful here. Omeprazole 40 mg IV once daily (child 0.5–1 mg/kg, maximum 40 mg) to protect denuded mucosa.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). Avoid routine corticosteroids and routine prophylactic antibiotics.Doctor / Nurse
- NEVER: gastric lavage, induced emesis, activated charcoal, cathartics, chemical neutralisation, blind nasogastric tube, or barium acutely. The harm is done by contact, not absorption — a corrosive burns the oesophagus a second time on the way up, a hydrocarbon goes into the lung, neutralisation is exothermic, and a blind tube perforates a necrotic oesophagus.
- Observe by the clock: corrosive — airway reassessment every 15–30 minutes for the first 4 hours, perforation surveillance for at least 48 hours, and objective severity assessment (endoscopy, or contrast CT if unavailable/unstable) within 24 hours. Hydrocarbon — observe at least 6 hours from ingestion with hourly respiratory rate, SpO2 and auscultation, and a repeat chest radiograph before discharge.
| Never do | Why |
|---|---|
| Gastric lavage | Perforation (corrosive) / aspiration pneumonitis (hydrocarbon) |
| Induced emesis | Burns the oesophagus a second time; hydrocarbon goes into the lung |
| Activated charcoal | Obscures endoscopy; acids/alkalis poorly adsorbed; useless for distillates |
| Chemical neutralisation | Exothermic — adds a thermal burn; gas distends a damaged stomach |
| Blind nasogastric tube | Perforates a necrotic oesophagus — place any tube under direct vision |
Refer / escalate
Refer or transfer urgently for any airway sign (hoarseness, stridor, drooling, supraglottic oedema), perforation or peritonism, subcutaneous emphysema, shock, acidosis or rising lactate, haematemesis, deliberate ingestion of a concentrated industrial product, a button battery at or above the diaphragm, hydrofluoric acid by any route, or hydrocarbon aspiration with hypoxaemia — early, to a centre with endoscopy, CT and surgery, since severity must be graded within 24 hours.
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