Posted: July 4th, 2024

A critical pediatric emergency involving the ingestion of Clinitest® tablets by a 3-year-old child.

This case study presents a critical pediatric emergency involving the ingestion of Clinitest® tablets by a 3-year-old child. The situation requires prompt and appropriate medical intervention based on the child’s symptoms and the nature of the ingested substance.

Gastric Lavage
Gastric lavage is not recommended in this case. The ingestion occurred 20 minutes prior to arrival at the emergency department, and the child has already vomited twice. Current guidelines advise against routine use of gastric lavage in poisoning cases, especially when the time since ingestion exceeds one hour (Benson et al., 2019). The potential risks of aspiration and further injury to the already damaged oropharynx outweigh any potential benefits.

Signs of Esophageal Injury
The child exhibits clear signs suggestive of esophageal injury. These include difficulty swallowing, drooling, and refusal to drink. The physical examination revealed second-degree burns in the oropharynx, indicating caustic injury to the upper gastrointestinal tract. Clinitest® tablets contain sodium hydroxide, a strong alkali that can cause severe corrosive damage to the esophagus upon ingestion (Hoffman et al., 2022).

Further Testing
Given the severity of the case, further testing is essential to assess the extent of injury and guide treatment. The following tests should be considered:

1. Chest and abdominal X-rays to evaluate for potential perforation or mediastinitis.
2. Endoscopy within 24-48 hours to assess the extent of esophageal and gastric injury.
3. Complete blood count, electrolytes, and renal function tests to monitor for systemic effects.
4. Arterial blood gas analysis to assess for metabolic abnormalities.

Endoscopy is particularly crucial in this case, as it allows for direct visualization of the extent and depth of caustic injury, which is essential for determining prognosis and guiding further management (Thomson et al., 2020).

Steroid Administration
The use of steroids in caustic ingestions remains controversial. While some studies suggest potential benefits in preventing stricture formation, others have found no significant advantage. Current evidence does not support the routine use of steroids in all cases of caustic ingestion (Contini and Scarpignato, 2021).

In this specific case, steroid administration should be considered only if there is evidence of significant airway edema or if recommended by the endoscopist based on the severity and extent of injury observed during the procedure. The decision to administer steroids should be made on a case-by-case basis, weighing potential benefits against risks such as masking of perforation and increased susceptibility to infection.

The primary focus of treatment should be on supportive care, including airway management, pain control, and nutritional support. Close monitoring for complications such as perforation, mediastinitis, and stricture formation is essential in the acute and follow-up periods.

In conclusion, this case highlights the importance of prompt recognition and appropriate management of caustic ingestions in pediatric patients. While gastric lavage and routine steroid administration are not recommended, thorough evaluation including endoscopy and supportive care form the cornerstone of management.

References

Benson, B.E., Hoppu, K., Troutman, W.G., Bedry, R., Erdman, A., Höjer, J., Mégarbane, B., Thanacoody, R. and Caravati, E.M., 2019. Position paper update: gastric lavage for gastrointestinal decontamination. Clinical Toxicology, 57(6), pp.437-443.

Contini, S. and Scarpignato, C., 2021. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World Journal of Gastroenterology, 27(13), pp.1277-1296.

Hoffman, R.S., Howland, M.A., Lewin, N.A., Nelson, L.S. and Goldfrank, L.R., 2022. Goldfrank’s toxicologic emergencies. 12th ed. New York: McGraw-Hill Education.

Thomson, M., Tringali, A., Dumonceau, J.M., Tavares, M., Tabbers, M.M., Furlano, R., Spaander, M., Hassan, C., Tzvinikos, C., Ijsselstijn, H. and Viala, J., 2020. Paediatric gastrointestinal endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy guidelines. Journal of Pediatric Gastroenterology and Nutrition, 70(1), pp.138-161.

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History: A 3-year-old presents to your emergency department after he was noted
to have found two blue-green speckled white tablets and promptly ate
them before his grandmother could take them away. Grandmother
identified the pills as Clinitest® tablets. The ingestion occurred 20 minutes
prior to arrival in the ED. Grandma is a diabetic but denies that the child
ingested any other medications. The child vomited twice after the
ingestion and has been drooling and having difficulty swallowing. The
child refuses to drink, and when grandma looked in the mouth she saw red
and white spots.
PMH: None.
Physical Examination:
T: 99.4°F HR: 128 bpm RR: 31 breaths per minute BP: 100/65 mm Hg
General: He is pale, agitated and crying.
HEENT: Examination reveals second degree burns to the oropharynx.
Pulmonary: Clear to auscultation.
CV: Regular rate and rhythm without murmur.
Abdomen: Soft and nontender.
Neurologic: GCS = 15. Cranial nerves II-XII intact.
QUESTIONS CASE STUDY #10
1. Should gastric lavage be performed in this patient?
2. Does this child have signs and symptoms which suggest an esophageal injury?
3. What further testing does this child require?
4. Should this child be given steroids?

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