Pediatric emergency medicine trisk 4081 4081
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ingested should be identified, as this information may be useful in guiding further
management. Clinicians should contact their regional Poison Control Center; this
is often very helpful in determining active ingredients and the degree of concern
for a given substance (see Chapter 102 Toxicologic Emergencies ). The airway
should be assessed and secured if necessary. Stridor should raise concern for
laryngeal edema and orotracheal intubation is indicated in its presence. The
airway should be visualized during this maneuver and tubes should not be passed
blindly. One exception to this is in the case of ingested hydrofluoric acid, which
requires immediate evacuation, best achieved by nasogastric decompression of
the stomach.
Patients presenting to the ED following a caustic ingestion may become
critically ill and should be closely monitored with this in mind. They should
remain nil per os and large-bore intravenous lines should be placed for fluid
administration. Measures to dilute or neutralize the ingested agent may cause
further complications, and activated charcoal and emetic agents should be
avoided. Two view radiographs of the chest and abdomen should be performed
and reviewed carefully for evidence of pneumomediastinum, pneumoperitoneum,
and pleural effusion. These findings raise concern for full-thickness esophageal or
gastric injury.
Patients with suspected esophageal or gastric injury should receive prompt
gastroenterology and/or surgical evaluation, as early endoscopy is the gold
standard for the assessment of caustic injuries and should be performed within the
first 12 to 24 hours after ingestion. Patients with any concerning history or
findings should be admitted to the appropriate inpatient ward for close monitoring
thereafter, and patients with obvious perforation should receive broad-spectrum
antibiotics and will likely require urgent operative management.
PLEURAL DISEASES
The lung is covered by the densely adherent visceral pleura, which moves
smoothly over the parietal pleura of the chest wall. A thin fluid film and the
friction created by apposition of the pleural layers (like two plates of glass held
together by a film of water) contribute to the full expansion of the lung
mechanically. When air, excess fluid, or purulent material comes between the two
layers of the pleura, the lung may collapse or become significantly compressed
and consideration needs to be given to drainage of the pleural space.
Pneumothorax
PEARLS AND PITFALLS
