# A 3-year-old child is brought to the emergency department after ingesting an unknown amount of household bleach 30 minutes ago. The child is alert and crying, with no visible burns around the mouth. What is the nurse's priority action?

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> subject: Child Health

## 문제

A 3-year-old child is brought to the emergency department after ingesting an unknown amount of household bleach 30 minutes ago. The child is alert and crying, with no visible burns around the mouth. What is the nurse's priority action?

## 보기

1. Induce vomiting immediately to remove the bleach from the stomach
2. Assess the child's airway, breathing, and circulation status **✔ 정답**
3. Give the child milk to neutralize the bleach
4. Perform gastric lavage to remove remaining bleach

**정답: 2**

## 해설

The priority is to assess ABCs as bleach can cause airway compromise and respiratory distress. Other options (inducing vomiting, giving milk, gastric lavage) are contraindicated and may worsen injury.

## 심화 해설

Correct Answer: 2. Assess the child's airway, breathing, and circulation status

The priority action for any pediatric patient presenting with a potential toxic ingestion is a rapid primary survey following the ABC (airway, breathing, circulation) framework. This foundational principle of emergency nursing care takes precedence over all other interventions. The ingested substance is household bleach, which is a caustic agent. Caustic ingestions represent a significant clinical concern in pediatric populations, particularly among children aged 1-5 years, and can result in acute, life-threatening emergencies [1]. Before any specific decontamination or dilution procedure can be considered, the nurse must first establish that the child's airway is patent, breathing is adequate, and circulation is stable. The child’s alertness and crying are positive clinical signs, but a structured, systematic assessment is mandatory to rule out impending respiratory compromise from airway edema or aspiration, which are immediate threats to life.

Why the Other Options Are Incorrect

Option 1: Induce vomiting immediately to remove the bleach from the stomach. This action is contraindicated. Inducing emesis after the ingestion of a caustic substance like bleach causes the corrosive agent to re-contact the esophageal mucosa and oropharynx, leading to re-injury and an increased risk of aspiration. The severity of injury from caustic substances is influenced by the material's chemical composition and its anatomical location, particularly when esophageal contact occurs [1]. Re-exposing the already damaged tissue to the chemical significantly worsens the clinical course and long-term morbidity.

Option 3: Give the child milk to neutralize the bleach. While dilution with a small amount of milk or water is sometimes considered in specific pre-hospital or emergency department protocols for caustic ingestions, it is not the priority action. The immediate nursing priority is the assessment of physiological stability. Furthermore, the concept of "neutralization" is dangerous; the chemical reaction between an alkali (bleach) and a weak acid can generate heat, causing an exothermic thermal burn in addition to the chemical burn. Any oral intake must be ordered by a physician after a full assessment, as it could induce vomiting or complicate subsequent airway management.

Option 4: Perform gastric lavage to remove remaining bleach. Gastric lavage is strictly contraindicated in caustic ingestions. Passing a nasogastric or orogastric tube in a patient with a potentially friable, burned esophagus carries a high risk of perforation. The management of caustic substance ingestion focuses on stabilizing the patient and assessing the extent of injury via endoscopy, not on mechanically removing the substance, which can cause more trauma than the initial insult [1]. The clinical course and severity are determined by the nature of the substance and its contact time, and instrumentation can dramatically worsen the outcome.

Clinical Reasoning and Pathophysiology

Household bleach is an alkaline caustic substance. Alkalis cause injury through a process called liquefactive necrosis, which involves deep penetration into tissues, saponification of fats, and protein dissolution. This pathophysiological mechanism can lead to rapid, severe, and deep tissue damage. The absence of visible burns around the mouth does not rule out significant esophageal or gastric injury; the severity is influenced by the amount, concentration, and contact time of the substance [1]. A child who is alert and crying demonstrates a currently patent airway and adequate ventilation, but the nurse must conduct a formal assessment to detect subtle signs of stridor, drooling, or respiratory distress, which indicate evolving airway edema. The ABC assessment is the critical first step that guides all subsequent interventions, including the decision to consult a gastroenterologist for endoscopic evaluation and to maintain NPO (nothing by mouth) status.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

## 임상 시나리오

Caustic Ingestion: Initial Triage & ContraindicationsPrioritizing the Primary Survey Over Decontamination
For any suspected toxic ingestion, the nurse's priority is a rapid primary survey assessing the ABCs. This must precede any decontamination or dilution attempts, even in an alert child.

Household bleach is an alkali caustic agent. While the child is alert, impending airway compromise from edema or aspiration remains a life-threatening risk that must be ruled out immediately.

Critical ContraindicationsNever induce vomiting or perform gastric lavage after a caustic ingestion. These actions cause re-injury to the esophagus and increase the risk of perforation and severe aspiration pneumonitis.

## 핵심 개념

- **Caustic Ingestion** — The swallowing of a corrosive substance (acid or alkali) that can cause immediate liquefactive or coagulative necrosis of the tissues in the oropharynx, esophagus, and stomach.
- **Primary Survey (ABC)** — A systematic, rapid assessment of Airway, Breathing, and Circulation to identify and manage immediate life-threatening conditions, taking precedence over all other interventions.
- **Gastric Lavage** — A gastrointestinal decontamination procedure involving the placement of a large-bore orogastric tube to irrigate and remove stomach contents, contraindicated in caustic ingestions.

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