A 4-year-old boy is seen 1 h after ingestion of a lye drain cleaner. No oropharyngeal burns are noted, but the patient's voice is hoarse. Chest x-ray is normal. Of the following, which is the most appropriate therapy?
Corrosive injuries of the esophagus most frequently occur in young children due to accidental ingestion of strong alkaline cleaning agents. Significant esophageal injury occurs in 15% of patients with no oropharyngeal injury, while 70% of patients with oropharyngeal injury have no esophageal damage. Signs of airway injury or imminent obstruction warrant close observation and possibly tracheostomy. The risk of adding injury, particularly in a child, makes esophagoscopy contraindicated in the opinion of most surgeons. Administration of oral "antidotes" is ineffective unless given within moments of ingestion; even then, the additional damage potentially caused by the chemical reactions of neutralization often makes use of them unwise. A barium esophagogram is usually done within 24 h unless evidence of perforation is present. In most reports, steroids in conjunction with antibiotics reduce the incidence of formation of strictures from about 70% to about 15%. Vomiting should be avoided, if possible, to prevent further corrosive injury and possible aspiration. It is probably wise to avoid all oral intake until the full extent of injury is ascertained.The most helpful ECG finding is the presence of a new right bundle branch block, which occurs because of damage to the anterior portion of the interventricular septum; ST-segment and T-wave changes and even the development of new Q waves may be seen. CPK-MB fractions are useful if they are positive; however, frequent false negatives may be seen because of the release of CPK-MM from other contused organs, such as the pectoralis muscles, which can dilute the cardiac CPK-MB to nondiagnostic levels. Echocardiography may be helpful, but the right ventricle is often poorly visualized. Radionuclide angiography is most useful because it suggests the degree of myocardial impairment caused by decreased compliance.Therapy of myocardial contusion is directed at inotropic support of the ventricle; usually, the coronary arteries are intact after the injury and so there is little role for coronary vasodilators and less for coronary artery bypass grafting.
Immediate esophagoscopy
Parenteral steroids and antibiotics
Administration of an oral neutralizing agent
Induction of vomiting
Heart & Pericardium