# A 4-year-old child is brought to the emergency department after ingesting an unknown amount of liquid drain cleaner 30 minutes ago. The child is alert but drooling and complaining of mouth pain. What is the nurse's priority action?

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## 문제

A 4-year-old child is brought to the emergency department after ingesting an unknown amount of liquid drain cleaner 30 minutes ago. The child is alert but drooling and complaining of mouth pain. What is the nurse's priority action?

Emergency management of caustic ingestion in a pediatric patient

## 보기

1. Induce vomiting immediately to remove the caustic substance
2. Give the child milk to neutralize the caustic substance
3. Maintain the child's airway and assess for respiratory distress **✔ 정답**
4. Administer activated charcoal to absorb the poison

**정답: 3**

## 해설

For caustic ingestions, airway management is critical due to risk of laryngeal edema. Inducing vomiting, giving milk, or activated charcoal are contraindicated and can cause further damage.

## 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

Clinical Management Guide: Pediatric Caustic Ingestion

Immediate Priorities

- Assess and stabilize the airway, breathing, and circulation (ABCs) as the first action. Monitor for stridor, hoarseness, or respiratory distress indicating airway edema.

- Position the child upright to facilitate secretion management and reduce aspiration risk if drooling is present.

- Do not induce vomiting, perform gastric lavage, or administer neutralizing agents (e.g., milk, water, weak acids/bases) due to risk of re-injury, exothermic reactions, or aspiration.

- Activated charcoal is not recommended; it does not adsorb caustic agents and interferes with subsequent endoscopy.

Assessment Findings

- Presence of drooling, dysphagia, or refusal to swallow suggests significant esophageal injury.

- Stridor, hoarseness, or respiratory distress are critical signs of upper airway compromise requiring immediate intervention.

- Oral burns may be absent even with severe esophageal damage; do not rely on oropharyngeal inspection to rule out injury.

Diagnostic and Ongoing Care

- Prepare for early diagnostic endoscopy (ideally within 12-24 hours) to grade the severity of esophageal and gastric injury.

- Maintain NPO (nothing by mouth) status until the extent of injury is determined.

- Provide supportive care including intravenous fluids and pain management.

- Consult poison control and consider pediatric gastroenterology and surgery consultations for high-grade injuries.

## 핵심 개념

- **Caustic Ingestion** — Ingestion of corrosive substances. This occurs when strong acids or strong alkalis are swallowed, causing severe chemical burns to the mucosa of the digestive tract from the mouth to the stomach.
- **Airway Obstruction** — Airway obstruction. A condition where air entry into or exit from the lungs is blocked due to swelling, foreign bodies, secretions, etc. It is a life-threatening situation that can occur acutely due to laryngeal edema when ingesting corrosive substances.
- **Liquefaction Necrosis** — Liquefactive necrosis. This is a type of necrosis where strongly alkaline corrosive substances hydrolyze tissue proteins and saponify fats, causing the tissue to melt away. It is characterized by deep tissue penetration and damage.
- **Stridor** — Stridor. It is a harsh sound mainly heard during inhalation, suggesting obstruction of the larynx or upper trachea. It is a danger sign that must be reported immediately after ingestion of corrosive substances.
- **Prioritization** — Priority setting. It is a clinical judgment process of addressing the most urgent and important issues first among multiple nursing problems or interventions, based on the patient's condition. In this scenario, life support (airway) is the top priority.

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