[Caustic injuries of the eye, skin and the gastrointestinal tract]

Caustic injuries of the eye usually occur accidentally and can result in minor eye irritations to total loss of vision. All chemical exposures to the eye require immediate decontamination by copious irrigation with an aqueous solution for at least 15-30 minutes up to two hours in single cases of massive exposure. Tap water is readily available, safe, and effective and, thus, the preferred irrigation fluid. Warmed lactated Ringer's solution is theoretically preferable to normal saline as an ocular irrigant because it has a more physiologic pH and osmolarity. Immediate ophthalmologic referral is recommended for all but the most trivial chemical burns to the eye. Specific treatments for decontamination depend on the underlying agent. Chemical burns of the skin usually occur accidentally. Initial treatment consists of copious water lavage commencing at the scene and removal of particles. While most caustic injuries are treated symptomatically, exposures to hydrofluoric acid (HFA) frequently necessitate specific topic, subcutaneous, intralesional, intravenous or intraarterial injections of calcium gluconate to bind fluoride ions until analgesia. A burn from HFA that involves more than 5% of total body-surface area, or more than 1% of total body-surface area if the concentration of HFA is greater than 50%, requires admission to an ICU for electrocardiographic monitoring and serial measurements of calcium levels, since life-threatening arrhythmias and hypocalcemia can occur. Caustic injuries of the gastrointestinal tract can occur due to inadvertent ingestion of mislabelled fluids or as a suicidal attempt. Ingestion of alkalis is generally thought to result in more severe injuries than ingestion of acids. The oropharynx needs to be first examined by laryngoscopy. A supraglottic or epiglottic burn with erythema and edema formation may be a harbinger of airway obstruction and should be seen as an indication of early endotracheal intubation or tracheostomy. Endoscopy should be performed preferably within 12 hours and generally not later than 24 hours and can serve as a prognostic tool to manage patients appropriately. The risk of procedure related perforation is generally accepted to be negligible. Existing data fail to support the routine use of steroids and antibiotics to prevent esophageal stricture formation and may mask signs of peritonitis. Esophageal strictures, stenosis or gastric outlet obstruction are formidably long-term complications. There is a 1000- to 3000-fold increase in the incidence of esophageal carcinoma after lye-ingestion with a latent period between the time of ingestion and the development of carcinoma as long as 60 years. Endoscopic dilatation or insertion of intraluminal stents should not be performed within the first 6 weeks. Patients with grade 3b injuries may underwent prompt surgical resection in single cases, even if no perforation is confirmed. Perforation, evolution of a mediastinitis or peritonitis with multi-organ failure are devastating complications with extremely high mortality and warrants immediate surgical treatment.