38-17: Alkalies Poisoning

The strong alkalies are common ingredients of some household cleaning compounds and may be suspected by their “soapy” texture. Those with alkalinity above pH 12.0 are particularly corrosive. Disk (or “button”) batteries are also a source. Alkalies cause liquefactive necrosis, which is deeply penetrating. Symptoms include burning pain in the upper GI tract, nausea, vomiting, and difficulty in swallowing and breathing. Examination reveals destruction and edema of the affected skin and mucous membranes and bloody vomitus and stools. Radiographs may reveal evidence of perforation or the presence of radiopaque disk batteries in the esophagus or lower GI tract.

TREATMENT

A. Ingestion

Dilute immediately with a glass of water. Do not induce emesis. Some gastroenterologists recommend immediate cautious placement of a small flexible gastric tube and removal of stomach contents followed by gastric lavage after ingestion of liquid caustic substances, to remove residual material. However, others argue that passage of a gastric tube is contraindicated due to the risk of perforation or re-exposure of the esophagus to the corrosive material from vomiting around the tube.

Prompt endoscopy is recommended in symptomatic patients to evaluate the extent of damage; CT scanning may also aid in assessment. If a radiograph reveals ingested disk batteries lodged in the esophagus, immediate endoscopic removal is mandatory.

The use of corticosteroids to prevent stricture formation is controversial but may be indicated in select patient populations.

B. Skin Contact

Wash with running water until the skin no longer feels soapy. Relieve pain and treat shock.

C. Eye Contact

Anesthetize the conjunctival and corneal surfaces with topical anesthetic (eg, proparacaine). Irrigate with water or saline continuously for 20–30 minutes, holding the lids open. Amphoteric solutions may be more effective than water or saline and some are available in Europe (Diphoterine, Prevor). Check pH with pH test paper and repeat irrigation for additional 30-minute periods until the pH is near 7.0. Check for corneal damage with fluorescein and slit-lamp examination; consult an ophthalmologist for further treatment.