Name: Caustic ingestion — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Caustics are an airway problem first and an endoscopy problem second — and the mouth lies about what's downstream. The defensible chart documents the airway assessment, that the harmful "old reflexes" (neutralize, induce emesis, blind NG) were withheld, and the endoscopy/disposition decision.

01What's at stake

Alkalis cause deep liquefactive necrosis (esophagus); acids cause coagulative necrosis (often the stomach) and can be absorbed systemically. The can't-miss complications — airway edema, perforation/mediastinitis, and delayed strictures — can be present even when the oropharynx looks normal. Every intentional ingestion gets endoscopy, and intervening the wrong way (neutralizing, inducing emesis) makes the injury worse.

02Can't-miss complications

Airway compromise / edema — drooling, stridor, dysphonia, dyspnea; deteriorates fast.
Perforation → mediastinitis/peritonitis; hemorrhage from vascular erosion.
Delayed strictures (up to ~70% of grade 2b, nearly all grade 3) and, long-term, esophageal cancer.
Hydrofluoric acid — severe pain with little visible injury; systemic hypocalcemia/hyperkalemia and dysrhythmias.
Laundry detergent pods (children) — mental-status depression and delayed respiratory distress.

03Assessment — and what NOT to do

Airway first. Danger signs (drooling, stridor, dysphonia, dyspnea) → early/prophylactic intubation; a stable initial SpO₂ is falsely reassuring. → secure the airway early
No induced emesis, no neutralization (exothermic), no charcoal, no blind gastric lavage — all worsen injury or aspiration risk. Make the patient NPO with IV access.
Oral findings do not predict distal injury — their absence doesn't exclude it.
Cautious water/milk dilution only within minutes, asymptomatic patient handling secretions.

Skip the typing

Work the case in the Overdose / Ingestion Workup — it records the ECG, poison-control contact, and observation, and assembles an MDM you can adapt to document the airway assessment, the withheld interventions, and the endoscopy/disposition plan.

04Workup & management

Endoscopy for all intentional ingestions (regardless of symptoms) and symptomatic unintentional ones — ideally within 12–24h; avoid days 2–3 and 48h–2 weeks (perforation risk). Grading predicts strictures.
Imaging — upright chest/abdomen films (low sensitivity), CT for suspected perforation; contact poison control/toxicology.
Disposition by grade/symptoms — asymptomatic child with a known household-alkali unintentional ingestion may discharge after 4–6h tolerating PO; intentional ingestions admit; grade 2b/3 → ICU; perforation → surgery.
Hydrofluoric acid — calcium (topical gel, then intradermal/IV/intra-arterial per toxicology), continuous cardiac monitoring and serial calcium/magnesium/potassium; treat dysrhythmias.
Ocular/dermal caustic — copious irrigation, recheck pH toward neutral, urgent ophthalmology for the eye.

05What to document

▼ weak

"Drank some drain cleaner, mouth looks fine, gave milk to neutralize, observed and discharged."

▲ defensible

"Intentional drain-cleaner (alkali) ingestion. Airway assessed — no drooling/stridor/dysphonia, monitored closely with early-intubation readiness. Oropharynx normal, but noted this does not exclude distal injury. No emesis induced, no neutralization, no charcoal/blind NG; NPO with IV access. Poison control contacted; GI consulted for endoscopy within 24h; admitted. Co-ingestants screened; self-harm intent addressed."

06Where charts fail

Using a normal-looking mouth to forgo endoscopy/admission.
Neutralizing, inducing emesis, or giving charcoal/blind NG.
Deferring intubation in a patient with airway symptoms because the SpO₂ is "fine."
Sending an intentional ingestion to psychiatry without endoscopy, or doing endoscopy on days 2–3.
Underestimating hydrofluoric acid (pain without visible injury; missed hypocalcemia).

07Sources

Wightman RS, Read KB, Hoffman RS. Evidence-based management of caustic exposures in the emergency department. Emergency Medicine Practice (EB Medicine). 2016;18(5).
Crain EF, Gershel JC, Mezey AP. Caustic ingestions: symptoms as predictors of esophageal injury. Am J Dis Child. 1984;138(9):863-865.
Usta M, Erkan T, Cokugras FC, et al. High doses of methylprednisolone in the management of caustic esophageal burns. Pediatrics. 2014;133(6):e1518-e1524.
Ryu HH, Jeung KW, Lee BK, et al. Caustic injury: can a CT grading system predict esophageal stricture? Clin Toxicol (Phila). 2010;48(2):137-142.

Caustic ingestion: documentation that holds up