In this episode, I’ll discuss things a pharmacist should keep in mind when managing a patient with a caustic ingestion.
According to an article in Intensive Care Medicine, caustic or corrosive ingestion in adult patients is a rare but potentially life-threatening condition with a mortality of 10% among intensive care unit (ICU) patients. Common ingested caustic substances are sodium hydroxide, hydrochloric acid, bleach, ammonia, and sulfuric acid. The higher the concentration of the ingested substance, the worse the outcome generally is.
Rapid and precise management of these patients is essential, and there are several things a pharmacist can expect to occur that they may be able to help with.
1. The provider will likely consider early intubation of these patients, so make sure medications to facilitate this are available at the bedside. The patient’s airway needs to be protected from aspiration of a caustic substance, so at the slightest hint of a need for intubation, the provider will likely choose to do so. If there was airway obstruction due to the caustic substance, a course of corticosteroids similar to what is used for patients with stridor to prevent post-extubation respiratory failure.
2. No treatment that might result in vomiting should be used due to the risk of aspiration of the caustic ingestant. This means no activated charcoal or NG tube placement.
3. Consult your local poison control center early for treatment guidance, especially if the ingested substance is unknown. In the US calling 1-800-222-1222 will route you to your regional poison control center.
4. Symptomatic and supportive treatment is the best you’ll be able to do with medications – there are no antidotes for caustic ingestants and surgery is often required. Corticosteroids and proton pump inhibitors may be used but there is no evidence they improve clinically meaningful outcomes in adult patients.
5. There is a one in seven chance of a co-ingestant, so do an aggressive workup to make sure another toxic agent is not also onboard. Hemodynamic instability on presentation or early in the course of care and an altered level of consciousness are two signs that a co-ingestant is present.
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