CAS RN: 51-28-5

Treatment Overview

  • A) EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
  • B) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
  • C) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.
    • 1) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
  • D) REDUCE FEVER - Control agitation with benzodiazepines. Monitor rectal temperature continuously. Remove patients clothing and enhance evaporative heat loss by spraying the skin with water and placing fans in the room. Use a hypothermia blanket. Immersion in ice water for patients unresponsive to other measures. Dantrolene may be effective. SALICYLATES ARE NOT RECOMMENDED - in the management of fever.
  • E) ADMINISTER OXYGEN - if needed. Monitor for dysrhythmias if vital signs not stable.
  • F) ADMINISTER INTRAVENOUS FLUIDS - and correct electrolyte, acid-base disturbances and to prevent dehydration associated with hyperthermia.
    • 1) Intravenous glucose solutions should be utilized to supply the requirements of increased metabolism.
    • 2) CAUTION - should be exercised in administering fluids to patients with cerebral edema.
    • 3) With significant exposure and impending coma, insert urinary catheters and a right heart catheter to measure output and pulmonary wedge pressure.
  • G) If intubation or any procedure that reduces respiratory drive (eg, sedation) is performed, monitor arterial blood gases carefully to avoid uncompensated metabolic acidosis and severe acidemia. CAUTION: Inability to intubate or ventilate due to widespread muscle rigidity (despite suxamethonium and vecuronium administration) has been reported after 2,4-dinitrophenol poisoning. Be prepared to perform a surgical airway if necessary.
  • H) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).
    • 1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
    • 2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
  • I) ENDOSCOPY: Early endoscopy allows patients without gastrointestinal injury to be medically cleared, and provides important prognostic information in patients who do have varying degrees of gastrointestinal burns. In addition, it facilitates the safe placement of enteral feeding tubes thereby shortening the period of time that patients with burns are without enteral nutritional support. Endoscopy should be performed within the first 24 hours post-ingestion, and should be avoided from 2 days to 2 weeks post-ingestion since wound tensile strength is lowest and the risk of perforation highest during this time. Endoscopy is indicated for all adults with deliberate ingestion or any signs or symptoms attributable to ingestion, and for children with stridor, vomiting, or drooling. Consider endoscopy in children with dysphagia, refusal to swallow, significant oral burns, or abdominal pain. If second or third degree burns are found, follow 10 to 20 days later with barium swallow or esophagram.
  • J) PHARMACOLOGIC TREATMENT: The use of corticosteroids is controversial. Patients with first degree burns generally do well and rarely develop strictures. Corticosteroids are generally not beneficial in these patients. Some authors have advocated the use of corticosteroids for second degree, deep-partial thickness burns within 48 hours of ingestion in patients without gastrointestinal bleeding or evidence of perforation. However, no well-controlled human study has documented efficacy. Corticosteroids are generally not beneficial in patients with second degree, superficial-partial thickness burns. Some authors have recommended steroids in patients with third degree burns. A high percentage of patients with third degree burns go on to develop strictures with or without corticosteroid therapy and the risk of infection and perforation may be increased by corticosteroid use. Most authors feel that the risk outweighs any potential benefit and routine use is not recommended. Antibiotics are indicated for suspected perforation or infection and in patients receiving corticosteroids.
  • K) SURGICAL OPTIONS: Initially, if severe esophageal burns are found a string may be placed in the stomach to facilitate later dilation. Insertion of a specialized nasogastric tube after confirmation of a circumferential burn may prevent strictures. Dilation is indicated after 2 to 4 weeks if strictures are confirmed; if unsuccessful, either colonic intraposition or gastric tube placement may be performed. Consider early laparotomy in patients with severe esophageal and/or gastric burns.
  • L) ACUTE LUNG INJURY: Maintain ventilation and oxygenation and evaluate with frequent arterial blood gases and/or pulse oximetry monitoring. Early use of PEEP and mechanical ventilation may be needed.
  • A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
  • A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    • 1) DECONTAMINATION - Wash affected areas of skin and hair vigorously with soap and water. Dermal exposure is usually accompanied by a yellowish discoloration which does not have to be removed completely to prevent absorption.
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