# A 4-year-old child 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 and crying, with visible burns around the mouth and difficulty swallowing. What is the priority nursing intervention?

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> subject: Child Health

## 문제

A 4-year-old child 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 and crying, with visible burns around the mouth and difficulty swallowing. What is the priority nursing intervention?

## 보기

1. Induce vomiting immediately to remove the remaining poison from the stomach
2. Administer activated charcoal to absorb the remaining acid in the gastrointestinal tract
3. Give small sips of milk to neutralize the acid and soothe the burned tissues
4. Maintain airway patency and prepare for possible emergency intubation **✔ 정답**

**정답: 4**

## 해설

For caustic acid ingestion with visible burns and dysphagia, airway management is the priority due to risk of laryngeal edema. Dilution with milk is contraindicated as it can cause exothermic reaction and vomiting.

## 심화 해설

Priority Nursing Intervention for Caustic Ingestion

The child’s presentation—alert, crying, with visible burns around the mouth and difficulty swallowing—indicates acute injury from hydrochloric acid, a potent acidic corrosive. In the immediate post-ingestion phase, the airway is the most critical concern. The priority nursing intervention is to maintain airway patency and prepare for possible emergency intubation.

Why Airway Protection Is the Priority

Ingestion of caustic substances can rapidly lead to airway compromise. The pathophysiologic process involves direct tissue destruction: acids cause coagulation necrosis, forming an eschar that may initially limit deeper penetration but can still produce severe edema [1]. This edema can extend to the larynx and pharynx, causing progressive upper airway obstruction. Signs such as difficulty swallowing and visible oral burns are strong predictors of potential airway involvement. A patent airway must be secured before any other intervention, as loss of airway control can be fatal within minutes [2].

Why the Other Options Are Contraindicated

- Inducing vomiting (Option 1): This is strictly contraindicated. Vomiting re-exposes the esophageal and oropharyngeal mucosa to the corrosive agent, causing re-injury and potentially worsening burns. It also increases the risk of aspiration of gastric contents containing the acid, which can lead to chemical pneumonitis and further airway damage [1].

- Administering activated charcoal (Option 2): Activated charcoal is ineffective for binding acids and is not recommended in caustic ingestions. More importantly, the charcoal slurry obscures the endoscopic view if endoscopy is required later to assess the severity of injury. The black residue can coat the mucosa, making it difficult to accurately grade the extent of the burns [3].

- Giving milk (Option 3): While dilution with small amounts of milk or water has been historically suggested, its role is controversial and it is not the priority intervention. The primary concern is that any oral intake could induce vomiting, which must be avoided. Furthermore, the act of swallowing may be difficult and dangerous if the airway is not yet secure. Neutralization attempts are also discouraged because the resulting exothermic reaction can cause additional thermal injury [1,3].

Clinical Management Context

The initial management of caustic ingestion follows a systematic approach where airway, breathing, and circulation (ABCs) take precedence. After securing the airway, the focus shifts to hemodynamic stabilization and then to diagnostic evaluation, typically with endoscopy within the first 12–24 hours to assess the extent of esophageal and gastric injury [2]. The severity of injury on endoscopy guides further treatment, which may range from observation to interventions for strictures, a common long-term complication [3,4]. For this child, the immediate, life-saving action is ensuring the airway remains open and preparing for the possibility that the edema will progress to the point of requiring intubation.References (research sources)

- [1]Ingestion of foreign bodies and caustic substances in children: a narrative review on clinical evaluation and management update.Research articleRogalidou M. (2026) · DOI: 10.3345/cep.2025.01823

- [2]Evolving diagnostic and therapeutic methods in corrosive esophagitis: Evaluation of a diagnostic and therapeutic algorithm based on 26 years of experience.Research articlePirzirenli MG, İşevi C, Köksal Y, İşevi M, Taslak Şengül A, Çelik B, Gürz S, Büyükkarabacak Y. (2026) · DOI: 10.4274/tjtcs.2025.28277

- [3]Post-Caustic Esophagitis: Updated Clinical Insights and Practical Lessons from Case Illustrations.Research articleOprita B, Diaconu AE, Dinu B, Ghiorghiu AA, Oprita R. (2025) · DOI: 10.3390/jcm14238575

## 임상 시나리오

Caustic Ingestion: Airway FirstImmediate nursing priority in corrosive poisoning
After ingestion of a strong acid like hydrochloric acid, the airway is the absolute priority. Coagulation necrosis and severe edema can rapidly obstruct the larynx, making emergency intubation necessary.

Signs of airway threat include difficulty swallowing, drooling, stridor, and visible oral burns. Maintain NPO status and prepare for immediate endotracheal intubation if edema progresses.

CautionNever induce vomiting, administer activated charcoal, or give neutralizing fluids like milk. Vomiting causes re-injury and aspiration; charcoal obscures endoscopy; neutralization can cause a thermal burn from the exothermic reaction.

## 핵심 개념

- **Coagulation Necrosis** — A type of tissue death where acid denatures proteins, forming a protective eschar that limits deep penetration but can still cause severe edema.
- **Eschar** — A dry, dark scab or layer of dead tissue that forms over a chemical burn, potentially limiting deeper injury from acids.
- **Chemical Pneumonitis** — Inflammation of the lung tissue caused by aspiration of gastric contents or chemical agents, a major risk if vomiting is induced after caustic ingestion.

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