A 34-year-old male presents to the emergency department after ingesting strong hydrochloric acid in a suicidal attempt. He is conscious but visibly distressed. On examination, he complains of severe burning pain in his mouth and throat. His vital signs are stable, and there are no signs of respiratory distress. He is able to swallow liquids, and the time of ingestion was within the last 15 minutes. What is the first step in treatment?
A. Perform gastroscopy
B. Administer broad-spectrum antibiotics
C. Perform a barium meal examination
D. Administer oral liquids (e.g., water or milk) to dilute the acid
E. Administer IV proton pump inhibitors
Correct Answer:
D. Administer oral liquids (e.g., water or milk) to dilute the acid
Explanation: [1]
In the case of hydrochloric acid ingestion, the first step is to dilute the acid in the stomach to minimize its harmful effects. If the patient is conscious and able to swallow, oral liquids (such as water or milk) should be administered as soon as possible. This will help to reduce the concentration of the acid and protect the mucosal lining of the mouth, esophagus, and stomach from further damage. This is particularly important within the first 30 minutes after ingestion, as dilution is much less effective if delayed.
Why Other Options Are Incorrect:
A. Perform gastroscopy:
- Gastroscopy is an important diagnostic tool to assess the extent of injury caused by caustic substances like hydrochloric acid. However, it should not be the first step. The patient must first be stabilized and the acid diluted if possible before performing endoscopy. Gastroscopy is usually done 12–24 hours after ingestion to evaluate mucosal damage and guide further treatment decisions.
B. Administer broad-spectrum antibiotics:
- Antibiotics are used to prevent or treat infections, but they are not the first step after acid ingestion. Antibiotics are considered later in treatment if infection or perforation occurs. The immediate concern is stabilizing the patient and minimizing the acid’s harmful effects.
C. Perform a barium meal examination:
- Barium meal studies should be avoided in cases of caustic ingestion. If there is any esophageal or gastric perforation, the barium could exacerbate the injury. Gastroscopy is a safer method for diagnosing the extent of injury, as it provides a direct view of the mucosa without the risk of worsening damage.
E. Administer IV proton pump inhibitors (PPIs):
- IV PPIs are helpful in reducing stomach acid production and promoting healing of mucosal injuries. However, they are not the first step. PPIs are usually administered after gastroscopy to manage gastric ulcers or erosions caused by the acid and help with long-term healing. Immediate treatment focuses on dilution and stabilization, not on acid suppression.
Management Steps:
- Airway, Breathing, Circulation (ABC):
- Ensure the airway is clear, and the patient is breathing adequately. Stabilizing the patient should be the first priority.
- Dilution with Oral Liquids: [1]
- If the patient is alert and can swallow, oral liquids (water or milk) should be given to dilute the acid. This should be done immediately after ingestion, ideally within 30 minutes.
- Transport to a Medical Facility:
- After initial dilution and stabilization, transport the patient to a hospital for further evaluation and management.
- Gastroscopy:
- Once the patient is stable, gastroscopy is performed to assess the extent of mucosal damage. This helps guide further decisions about treatment, such as whether surgery is needed.
- Proton Pump Inhibitors (PPIs):
- IV PPIs may be administered after gastroscopy to help suppress stomach acid, promoting healing and preventing further damage.
Conclusion:
The first step in treating hydrochloric acid ingestion is to dilute the acid with oral liquids (water or milk) to minimize damage to the digestive tract. After stabilization, the patient should undergo gastroscopy to evaluate the extent of the injury, and then treatment with PPIs can be initiated for healing and acid suppression.