# A 2-year-old toddler is brought to the emergency department after ingesting an unknown amount of toilet bowl cleaner containing hydrochloric acid 30 minutes ago. The child is alert but drooling and complaining of mouth pain. What is the most appropriate immediate nursing intervention?

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> subject: Child Health

## 문제

A 2-year-old toddler is brought to the emergency department after ingesting an unknown amount of toilet bowl cleaner containing hydrochloric acid 30 minutes ago. The child is alert but drooling and complaining of mouth pain. What is the most appropriate immediate nursing intervention?

## 보기

1. Induce vomiting immediately to remove the toxic substance
2. Administer activated charcoal to absorb the poison
3. Give small sips of milk or water to dilute the acid **✔ 정답**
4. Insert a nasogastric tube for gastric lavage

**정답: 3**

## 해설

For corrosive acid ingestion, diluting with small sips of milk or water helps dilute the acid and reduce tissue damage. Inducing vomiting or gastric lavage can worsen injury by re-exposing the esophagus to the corrosive substance.

## 심화 해설

Understanding Corrosive Acid Ingestion

When a toddler ingests a strong acid like hydrochloric acid found in toilet bowl cleaner, the primary injury is a liquefactive necrosis of the tissues it contacts. This means the acid immediately begins to burn and dissolve the mucosa of the mouth, esophagus, and stomach upon contact. The child’s symptoms of drooling and mouth pain are classic signs of this localized corrosive injury. The depth and severity of the injury are determined by the concentration of the acid, the volume ingested, and the duration of tissue contact [1]. The immediate priority in nursing care is to halt this progressive contact injury without causing additional trauma.

Analyzing the Options and Selecting the Safest Intervention

The management of acute corrosive poisoning is fraught with controversy, but there is a firm consensus on what *not* to do. The correct intervention is to give small sips of milk or water.

- Why Option 3 is Correct (Give small sips of milk or water): The goal of administering a small volume of a diluent is to wash the corrosive agent off the oral and esophageal mucosa and dilute the acid remaining in the stomach. This can help limit the ongoing contact injury to deep tissues, which is a major concern in the acute phase of poisoning [1]. Water or milk serves this purpose effectively. It is critical that the volume is small to avoid inducing vomiting, which would re-expose the delicate tissues to the caustic agent.

- Why Option 1 is Incorrect (Induce vomiting): Inducing vomiting is strictly contraindicated. The act of vomiting would bring the corrosive acid back up through the esophagus, causing a second chemical burn to tissues already damaged. This re-exposure dramatically worsens the injury and increases the risk of esophageal perforation.

- Why Option 2 is Incorrect (Administer activated charcoal): Activated charcoal is ineffective for absorbing strong acids. More importantly, its administration is contraindicated in corrosive ingestions. The charcoal slurry coats the esophageal and gastric mucosa, which can obscure the visualization of burn injuries during a subsequent endoscopy, a key diagnostic procedure for assessing the extent of damage.

- Why Option 4 is Incorrect (Insert a nasogastric tube for gastric lavage): Blind insertion of a nasogastric tube in a patient with a corrosive esophageal burn carries a high risk of perforating the weakened, friable tissue. Gastric lavage is also contraindicated as it can provoke vomiting and cause further tissue trauma without reliably removing the adherent corrosive agent.

Clinical Reasoning and Safety Priority

The clinical presentation of the toddler—alert but with drooling and mouth pain—indicates a patent airway but confirms a corrosive injury to the upper aerodigestive tract. The immediate nursing action must adhere to the principle of "first, do no harm." The risk of accidental poisoning with household cleaning products is a significant concern, and unsafe storage practices by caregivers are a known risk factor for these events . In the emergency department, the most common routes of pediatric poisoning are ingestion, and the immediate pre-hospital or nursing response must prioritize dilution over removal for corrosive substances . Attempting to remove the agent through emesis or lavage converts a controlled clinical situation into a high-risk one for aspiration, perforation, and further tissue destruction. The safe, evidence-based first step is gentle dilution with small sips of a clear liquid.References (research sources)

- [1]Severe Intentional Corrosive (Nitric Acid) Acute Poisoning: A Case Report and Literature Review.Case reportStoica A, Lionte C, Palaghia MM, Gîrleanu I, Şorodoc V, Ceasovschih A, Sîrbu O, Haliga RE, Bologa C, Petriş OR, Nuţu V, Trofin AM, Bălan GG, Catana AN, Coman AE, Constantin M, Puha G, Morăraşu BC, Şorodoc L. (2023) · DOI: 10.3390/jpm13060987

## 임상 시나리오

Corrosive Ingestion: Immediate Nursing ResponsePrioritizing airway protection and limiting tissue injury
The priority for a child with drooling and mouth pain after ingesting hydrochloric acid is to dilute the agent and wash it from the mucosa. Administer small sips of water or milk to limit ongoing liquefactive necrosis.

Strictly avoid interventions that risk re-exposure or perforation. Inducing vomiting, performing gastric lavage, or administering activated charcoal are all contraindicated. These actions can cause additional burns, esophageal perforation, or obscure airway and endoscopic assessment.

CautionEnsure the volume of diluent is small (under 15 mL/kg). Large volumes can distend the stomach and trigger vomiting, which re-exposes the esophagus to the corrosive agent and worsens the injury.

## 핵심 개념

- **Liquefactive Necrosis** — A type of tissue death where the affected tissue is transformed into a liquid viscous mass, characteristic of corrosive acid ingestion injuries.
- **Dilution Therapy** — The administration of small volumes of water or milk to reduce the concentration of an ingested corrosive agent and wash it from tissue surfaces.
- **Contraindication** — A specific situation in which a drug, procedure, or intervention should not be used because it may be harmful to the patient.
- **Gastric Lavage** — A medical procedure involving the passage of a tube into the stomach to wash out its contents, contraindicated in corrosive ingestions due to perforation risk.

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