Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Upcoming SlideShare
Toxicity of Corrosives
Next
Download to read offline and view in fullscreen.

96

Share

Download to read offline

Corrosive poisoning by Dr.Ashwin Menon

Download to read offline

Otorhinolaryngological aspect of corrosive poisoning.

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all

Corrosive poisoning by Dr.Ashwin Menon

  1. 1. CORROSIVE POISONING DR.ASHWIN MENON
  2. 2. • An average home contains a dozen different cleaning products. These are responsible for a large number of accidental and intentional poisoning. • Incidence :- 2.5 - 5% • Mortality :- 13% • Morbidity :- > 50% • About 80% of corrosive poisoning occurs in children < 5 yrs. INTRODUCTION
  3. 3. INTRODUCTION • The route of entry of corrosive substances in the body is: – ingestion – inhalation (rarely) • Adult exposure has more mortality & morbidity due to significant volume of exposure & possible co- ingestion.
  4. 4. CLASSIFICATION THREE TYPES ACIDS ALKALIS (Most dangerous) OXIDANTS
  5. 5. FACTORS DETERMINING CORROSIVENESS Factors that determine corrosiveness include: • Physical form: Solid/liquid • Duration of contact with tissue • Concentration of agent • Quantity of agent > 100 -150ml - Massive poisoning
  6. 6. FACTORS DETERMINING CORROSIVENESS • pH of agent: pH <2 and >11 are morevcorrosive • Food: Presence or absence of food in stomach • Titratable acid or alkali reserve (TAR): This quantifies the amount of neutralizing substance required to bring the pH of a caustic agent to physiological pH of the tissue.
  7. 7. EXAMPLES  ACIDS • SULPHURIC ACID - CAR BATTERIES • NITRIC ACID – METAL CLEANERS • HYDROCHLORIC ACID & ACETIC ACID -DESCALERS • PHENOL & BORIC ACID -DISINFECTANT • HYDROFLUORIC & OXALIC ACID – RUST REMOVERS  ALKALIS • AMMONIA – HOUSE HOLD CLEANERS & LAUNDARY DETERGENTS • BLEACH – DISINFECTANT • SODIUM HYDROXIDE - DRAIN CLEANERS
  8. 8. MECHANISM OF INJURY
  9. 9. ACIDS
  10. 10. ACIDS • They ppt protein → Coag.→ Necrosis • Coagulum forms a barrier and limits further damage. • Sq. epithelium of pharynx and oesophagus are resistant to acids. • Stomach (Antrum) is the most commonly involved organ. • Most common complication is perforation occurring on 3 or 4th day. • In the presence of food gastric injuries tend to be less severe and involve the lesser curve and pylorus.
  11. 11. ALKALIS
  12. 12. ALKALIS • They saponify fats & dissolve proteins → liquifactive necrosis & rapid injury. • Sq. epithelium of pharynx and oesophagus (lower half) are the most commonly affected parts. • Most common complication is stricture - 2 to 4 weeks. – Development of stricture depends on the depth of the burns. o Superficial (Superficial to muscularis mucosa) 1% o Deep - 70-100%
  13. 13. • Disk shaped batteries are easily swallowed but if they get lodged in the oesophagus, they cause injury by – – Leakage of alkali : direct caustic injury – Absorption of toxic substances – Pressure necrosis – Electrical discharge → Mucosal burns ALKALIS
  14. 14. Chest radiograph of a child who has ingested a coin-shaped battery
  15. 15. SEQUELAE • Lead to: – Oesophageal burn without perforation – Oesophageal burn with perforation – Tracheo oesophageal fistula – Aorto oesophageal fistula
  16. 16. HISTOPATHOLOGIC EVENTS ASSOCIATED WITH 10% SODIUM HYDROXIDE BURN OF OESOPHAGEAL MUCOSA • Oedema of submucosa • Inflammation of submucosa with thrombosis • Sloughing of the superficial layers • Necrosis of the muscular layer • Fibrosis of the deep layers • Delayed re-epithelialization
  17. 17. LUNG TISSUE
  18. 18. RENAL TUBULAR NECROSIS
  19. 19. CLINICAL FEATURES GIT • Severe pain of lips, mouth, throat, chest and abdomen • Excessive salivation • Dysphagia and odynophagia • Epigastric pain and hematemesis • Symptoms and signs of GI perforation
  20. 20. Respiratory system • Cough • Dyspnea • Bronchoconstriction • Pulmonary oedema • Chemical pneumonitis Eyes and skin • Pain at the site of exposure • Burns at the site of exposure • Erythema and vesicle formation
  21. 21. MANAGEMENT 1. Accurate history defining what and amount of ingestion occurred. 2. ABCs – Treat like a burn 3. Evaluate for hoarseness, stridor, drooling, odynophagia, refusal of food.
  22. 22. 4. Palpate for subcutaneous air 5. Rigidity and sub sternal chest pain 6. Assess for emesis. -Increased laryngeal/oesophageal exposure MANAGEMENT
  23. 23. INVESTIGATIONS 1. Test the pH of the saliva. Neutral pH does NOT mean caustic ingestion did not occur. 2. Labs -CBC -ABG -Urine
  24. 24. 3. CXR -Pneumomediastinum -Button battery 4. KUB -Pneumoperitoneum -Button battery 5. CT -Use water soluble contrast. 6. Technetium 99m–labeled sucralfate study INVESTIGATIONS
  25. 25. X ray neck- oesophageal perforation
  26. 26. Esophageal rupture with right pneumothorax with midline shift
  27. 27. Barium oesophagogram of a perforated esophagus. Arrow shows the extravasation of contrast into the left chest
  28. 28. CT scan of a perforated esophagus. Note the air and fluid in the mediastinum.
  29. 29. Lesion in the gastric antrum (arrows) demonstrated by x-ray Scintigraphy - Note retention in area of the lesion on both 1-hr and 2- hr images. Uptake in fundus of stomach is also persistent although no pathology existed in this area.
  30. 30. ENDOSCOPY
  31. 31.  When to perform? -Optimally performed 6 - 24 hrs.  Why? -Because if performed earlier the full extent of the injury may not be apparent. -If performed later the risk of the perforation is high (especially with rigid endoscopy) • First assess the cricopharynx and then larynx If burns are noted prophylactic ET. ENDOSCOPY
  32. 32. • Where Oesophagoscopy should not be performed? – haemodynamically unstable patients. – evidence of GI perforation. – Patients with significant airway oedema. • If the patient presents >48 hours after initial ingestion, barium swallow may be considered instead of Oesophagoscopy.
  33. 33. • Anatomical areas of narrowing oftentimes receive the most damage- -Cricopharyngeal area (UE) -Aortic arch -LES -Antrum/body of stomach • These are also the most common sites of stricture formation.
  34. 34. Endoscopic view of the epiglottis and vocal cords 4 days after ingestion. Endoscopic view of the epiglottis and vocal cords 11 days after ingestion.
  35. 35. ENDOSCOPIC GRADING- KIKENDALL CLASSIFICATION  I GRADE: Oedema and erythema of the mucosa  II A GRADE: Haemorrhage, erosions, blisters, superficial ulcers  II B GRADE: Circumferential lesions  III GRADE: Deep grey or brownish-black ulcers  IV GRADE: Perforation.
  36. 36. ENDOSCOPIC GRADING - ZARGAR’S CLASSIFICATION GRADE 1 Erythema GRADE 2(a) Superficial localized ulcer, Friable Erosion, Haemorrhage, Exudate. GRADE 2(b)* 2(a) + Localized deep, discrete or circumferential ulcers GRADE 3(a)* Small Scattered areas of necrosis GRADE 3(b)* Extensive circumferential necrosis * Lead to Strictures
  37. 37. Oesophagoscopy A. Grade 2A. B Grade 2B of stomach B. C 3A of stomach D. 3B of stomach
  38. 38. FOUR STAGES OF OESOPHAGEAL BURNS
  39. 39. VIDEO 1
  40. 40. CINE - OESOPHAGOGRAPHY • Detects motility disorders • Atonic rigid oesophagus • Atonic dilated oesophagus • Abnormal un co-ordinated contractions *Cine Oesophagram is a video version of Barium Swallow. Later Develop into Strictures
  41. 41. TREATMENT TO DO:  IMM. DILUTION WITH PLAIN WATER 5ml/kg.  SECURE AIRWAY  I.V.FLUID  PROPHYLACTIC AB’S  H2 BLOCKERS  SUCRALFATE 1gm/6hrs.  MONITOR ACID BASE & ELECTROLYTES STATUS. NOT TO DO:  GASTRIC LAVAGE  EMESIS  NEUTRILIZATION  ACTIVATED CHARCOAL  CARBONATED DRINKS
  42. 42. WHY – NOT TO DO? GASTRIC LAVAGE : Risk of perforation (Immediate lavage within 1-2 hrs. after large volume of ingestion is beneficial) EMESIS : Leads to new exposure and risk of aspiration. NEUTRILIZATION : Leads to heat production more injury. ACTIVATED CHARCOAL : Obscures endoscopic view.
  43. 43. STEROIDS? Role of steroids controversial. • Animal studies have proven to be beneficial, but human evidence lacking. Local injection of TRIAMCINOLONE is also beneficial. • Steroids definitely have a role in preventing laryngeal oedema. - Prednisolone 1 - 2mg/kg/6 hrly. for 2 weeks. - Contraindicated if perforation.
  44. 44. PHARMACOLOGIC THERAPY C A L M S Corticosteroid Antibiotics Lathyrogenic agents-β-aminopropionitrile, N- acetylcysteine, and penicillamine Mitomycin Sucralfate
  45. 45. MECHANICAL THERAPY • The simplest mechanical method for maintaining a lumen in a third degree oesophageal burn is to place a nasogastric tube at the time of initial endoscopy.
  46. 46. • Other types of stents used are polymeric silicone tubes in the oesophagus. • The important type of stents that are available on the market are 1. Polyflex 2. Ultraflex 3. Z stent 4. Bonastent
  47. 47. SELF EXPANDING STENT
  48. 48. VIDEO 2
  49. 49. • Mild strictures can be serially dilated in a prograde fashion through an oesophagoscope with filiform dilators.
  50. 50. • Fluoroscopic guided balloon catheter dilation for acquired strictures has shown little success.
  51. 51. VIDEO 3
  52. 52. ENDOSCOPIC LUMEN RESTORATION (ELR) • Multiple strictures are managed most safely with retrograde dilators, popularized by Tucker. • ELR is best accomplished by a multidisciplinary approach including an experienced gastroenterologist/endoscopist, an otolaryngologist, and a swallowing therapist (speech pathologist).
  53. 53. A) Barium swallow shows mid-oesophageal stricture after alkaly ingestion in an adolescent 4 weeks after ingestion and at the beginning of retrograde dilations. B) Same patient 5 years later, after 4 years of repetitive dilations; the patient has a stable stricture and is generally non symptomatic. A B
  54. 54. • Esophageal replacement with gastric tubes, right colon, transverse colon, or descending colon has been described. • The right colon has been reported to be the most useful conduit.
  55. 55. • Gastric outlet obstruction as a complication of acid ingestion is well known. • Presenting symptoms include – frequent non-bilious emesis – secondary marked weight loss. Treatment is surgical and includes -Gastro-jejunostomy or Billroth I for complete obstruction -The Finney or Heineke Mikulicz pyloroplasty for partial obstruction.
  56. 56. BILLROTH 1
  57. 57. Heineke-Mikulicz Pyloroplasty
  58. 58. ORAL FEEDING, WHEN TO START?  GRADE-1 INJURIES ON ENDOSCOPY - DAY 1  GRADE-2 INJURIES ON ENDOSCOPY - LIQUID FOODS AFTER 48-72 Hrs.  GRADE-3 INJURIES - NIL ORAL - FEEDING JEJUNOSTOMY /TPM
  59. 59. TREAMENTALGORITHM
  60. 60. CONCLUSION • With corrosive poisoning the injury ranges from minimal mucosal erythema to frank transmural necrosis of the oesophagus and stomach with viscous perforation. • Full length oesophageal endoscopy is the most accurate initial method of examination, and is indicated after any ingestion of a strong liquid alkali.
  61. 61. • Oesophageal stricture formation is the chief long- term complication with a potential devastating impact on quality of life. Although repetitive stricture dilations are the mainstay of management, prevention or reduction in the severity of this complication is promising. CONCLUSION
  62. 62. THANK YOU …
  • krunalpandav33

    Sep. 10, 2021
  • SurbhiNarayan2

    Aug. 21, 2021
  • ChaudharyAsad2

    Aug. 8, 2021
  • vishnuvardhan614

    Jun. 29, 2021
  • MernaMahrous1

    Jun. 15, 2021
  • HkpDrEaMs

    May. 10, 2021
  • MsNagaSaiSudha

    Apr. 20, 2021
  • DeepshikhaMishra14

    Apr. 16, 2021
  • RemyaN5

    Mar. 23, 2021
  • ssuser5c668f1

    Mar. 17, 2021
  • MutharasuSanthanam

    Feb. 24, 2021
  • MahanteshBJ

    Feb. 13, 2021
  • DebapriyoSaha

    Feb. 12, 2021
  • marepallykarthikvenk

    Feb. 11, 2021
  • TamilSelvi182

    Feb. 9, 2021
  • ShivaTripathi13

    Feb. 4, 2021
  • NakiburJaman

    Jan. 31, 2021
  • AhirDuva

    Jan. 31, 2021
  • SuganyaSekar9

    Jan. 28, 2021
  • Shivram126

    Jan. 28, 2021

Otorhinolaryngological aspect of corrosive poisoning.

Views

Total views

12,872

On Slideshare

0

From embeds

0

Number of embeds

16

Actions

Downloads

466

Shares

0

Comments

0

Likes

96

×