Journal of Pediatric Surgery Case Reports 34 (2018) 30–34

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Journal of Pediatric Surgery Case Reports

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Simultaneous internal and external chemical injuries T

a,∗ b c,d a,b
Morgan Johnson , Jason W. Nielsen , Harish Yalamanchilli , Rajan K. Thakkar ,
Karen Diefenbacha,b, Brian Kenneya,b, Mark Hoganb, Renata Fabiaa,b
a
The Ohio State University College of Medicine, Columbus, OH, USA
b
Nationwide Children's Hospital, Department of Surgery, Columbus, OH, USA
c
Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
d
Mount Carmel Hospital, Columbus, OH, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Chemical injuries from household products cause significant morbidity and mortality annually in pediatric
Chemical burn patients. We present a rare case of a 21-month-old male with significant esophageal and cutaneous chemical
Non-accidental trauma burns secondary to non-accidental trauma. Given the unique challenges associated with multiple burn types we
Caustic ingestion describe this case and provide a current review of the literature on the management of these potentially de-
Pediatric burn
vastating injuries.

1. Introduction management. After initial assessment in the Emergency Department he

was immediately admitted to the Pediatric Intensive Care Unit for
Ingestion of caustic substances by pediatric patients comprises a stabilization and resuscitation.
major health concern as it can lead to devastating injuries. According to
the 2012 Annual Report of the American Association of Poison Control 2.1. Operative findings
Centers' National Poison Data System there were 111,148 instances of
exposure to household cleaning agents by children age five years and He was taken the operating room (OR) shortly after admission for
younger making this the third most common substance exposure in this bronchoscopy, esophagogastroduodenoscopy (EGD) and cutaneous
population [1]. We present a complex case of an ingested chemical burn wound care. On evaluation: both lips and his tongue had burns with
leading to a complex dermal injury. To our knowledge there have been ulcerations. The trachea was hyperemic but there was no evidence of
no previous similar reports. injury to the airway. EGD noted an edematous oropharynx with white
Since both chemical ingestion and cutaneous injuries present a plaques and marked edema of the proximal esophagus. A circumfer-
variety of dilemmas to the managing clinician, a discussion of the ential white, adherent plaque was noted throughout the remainder of
management of such injuries is provided based on literature review and the esophagus indicative of a significant mucosal injury. No evidence of
our own experience. perforation was identified. A portion of the greater curvature and
posterior wall of the stomach was also noted to be gray with an is-
2. Case report chemic appearance of the mucosa. According to the Zargar classifica-
tion system, this would classify as a combination of Grade 3 [16].
A 21 month old male child ingested an alkali drain cleaner at home Due to the extensive injuries, an 18-French Stamm gastrostomy tube
and his mother immediately induced emesis causing exposure of the (G-tube) with a trans-gastric-esophageal-nasal string was placed to aid
substance onto his left torso and left thigh. He was taken to a local in future dilations as necessary. Placement of the gastrostomy tube was
hospital via emergency medical services (EMS) and was found to have challenging given the cutaneous burns of the abdomen. The cutaneous
stridor and grunting in addition to significant burns on his torso and left burns were surgically debrided and Xeroform® with Neosporin® dres-
thigh totaling about 8% TBSA (total body surface area) full thickness sings were applied. Empiric antibiotic coverage was also initiated.
burns (Fig. 1). He was intubated and air-transported to an American He returned to the OR on hospital day three and underwent further
Burn Association (ABA) verified Pediatric Burn Center for further debridement of the cutaneous thermal wounds and a split-thickness

∗
Corresponding author. The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH, 43210, USA.
E-mail addresses: [email protected], [email protected] (M. Johnson), [email protected] (J.W. Nielsen), [email protected] (H. Yalamanchilli),
[email protected] (R.K. Thakkar), [email protected] (K. Diefenbach), [email protected] (B. Kenney),
[email protected] (M. Hogan), [email protected] (R. Fabia).

https://doi.org/10.1016/j.epsc.2018.04.014
Received 18 April 2018; Accepted 21 April 2018
Available online 30 April 2018
2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

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M. Johnson et al. Journal of Pediatric Surgery Case Reports 34 (2018) 30–34

Fig. 2. Upper gastrointestinal contrast study demonstrating the esophageal

strictures.

He continued to receive IR dilations, which resumed one month

after perforation. Mitomycin® injections/application were added to the
dilations three months later (during the fifth dilatation and continued
Fig. 1. Image demonstrating the external caustic injury. for five consecutive dilatations). A total of 13 dilatations were per-
formed over an 11-month period after the injury. With time, the patient
skin graft was placed covering approximately 5% TBSA. Porcine began to regain complete oral food tolerance, which appeared to last for
Xenograft (EZ-Derm®) was applied to the remaining 3% TBSA partial increasingly longer intervals between dilations.
thickness burns. However, the patient's symptoms due to recurrences of strictures
persisted, and it was decided to perform an esophageal replacement
with colonic interposition. His esophageal replacement surgery was
2.2. Clinical course
performed successfully one year after injury and he is presently
symptom-free.
A jejunostomy tube (j-tube) was placed through his gastrostomy
His most recent follow up, 16 months after injury, showed complete
tube and tube feeds were initiated on hospital day three. On hospital
healing of the superficial burns and grafting sites. He developed hy-
day seven he underwent direct laryngoscopy and repeat bronchoscopy
pertrophic scarring which is improving after making adjustments to his
showing multiple soft palate and supra-glottic burn injuries, superficial
custom-made compression garments. The compression treatment has
bilateral vocal cord erythema with overlying bilateral vocal cord
had its own challenges due to the patient's g-tube position being ad-
granulation, however normal vocal cord mobility.
jacent to areas of the burns and the need to initially accommodate a
He was extubated on hospital day 8 and underwent upper gastro-
trans-gastric-esophageal-nasal string and then j-tube. Finally, the g tube
intestinal contrast study demonstrating a mild narrowing of the prox-
was removed and garment fitting was excellent. The need for surgical
imal and mid esophagus along with esophagitis. He was transferred out
scar revision in the future is still a possibility. He continues to grow
of the intensive care unit (ICU) on hospital day nine.
appropriately and is engaged in normal activities. Upon his most recent
An esophagram on post-operative day (POD) #24 showed nar-
visit he has no food or activity restriction and has full range of motion
rowing with a stricture in the cervical and distal esophagus (Fig. 2).
and no apparent contractures.
Several episodes of high-grade gastro-esophageal reflux were also
noted. Following this finding, esophageal dilation was conducted by
interventional radiology (IR). 3. Discussion
Unfortunately it was determined that his injuries were non-acci-
dental and the patient was discharged to a foster home on hospital day 3.1. Etiology and pathophysiology
33 with cycled tube feeds, pureed oral diet, and planned repeated di-
lations with IR. Ingestion of caustic substances and chemical burns in the pediatric
population is not an uncommon event and can lead to devastating re-
2.3. Readmission and complications sults mostly from significant scarring and stricture formation, but also
death. In the 2012 report of the American Association of Poison Control
Four days after his second dilatation, the patient was brought back Centers, there were nearly 2.4 million toxic exposures, 83.4% of which
into the emergency department for fevers and hematemesis. An eso- were exposure from ingestion and 7% were from dermal exposure [1].
phagram showed a contained leak at the mid-to distal esophagus. His Household cleaning substances were the third most offending agent and
oral feedings were stopped, broad-spectrum antibiotics were started were involved in over 193,000 exposures [1]. In children five years and
and j-tube feeds were advanced to goal. A repeat esophagram seven younger, household cleaners accounted for over 111,000 cases and 2
days later showed no further leak. He recovered quickly and was dis- out of 34 toxin related fatalities [1]. Of those exposures, acid drain
charged home on tube feeds. cleaners led to 53 incidents and alkali cleaners led to 441 incidents [1].

31

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M. Johnson et al. Journal of Pediatric Surgery Case Reports 34 (2018) 30–34

Chemical burns can be caused by acids or bases that come into endoscopic evaluation. Attempts at dilution by large volumes of oral
contact with tissue. Acids result in coagulation necrosis by denaturing liquid may induce vomiting and re-exposure.
proteins and their penetration may be limited to the superficial layer of In regards to chemical burns on the skin, all contaminated clothing
the tissue due to forming of a coagulum (e.g. eschar). Bases/strong should be removed as soon as possible and burn areas should be irri-
alkalis typically produce a more severe injury by causing liquefaction gated with large volumes of water. Care must be taken to avoid hy-
necrosis. This process includes denaturing of proteins, forming soluble pothermia while performing irrigation. No consensus exists on the
alkaline proteinases containing hydroxyl ion (OHe), which causes duration of irrigation but some providers recommend 2 h or more if
further chemical reactions initiating deeper injury of the tissue. In ad- small zones are affected [4]. With alkali burns where penetration of
dition, saponification of fats, an exothermic reaction itself, causes se- tissues is deep, water will not be able to eliminate all of the chemical
vere tissue injury. Destruction of fat allows further tissue penetration by present. When the patient is clinically stable they should be taken for
alkali agents. Hydroscopic nature of alkali causes extraction of water burn wound debridement with placement of skin grafts or other ap-
from cells resulting in extensive cell death. Blood vessel thrombosis propriate dressings as was the case with our patient.
may also occur and thereby limit flow to affected tissue [2–4].
The severity of the burn is related to a number of factors, including
the pH of the agent, the concentration and quantity of the agent, the 3.4. Assessing the extent of the esophageal injury
length of the contact time, and the physical form of the agent. The
sequelae of an alkali burn consists of three phases. The first phase lasts The severity of chemical injury does not correlate with clinical signs
1–4 days after injury and results in cell necrosis from coagulation da- or laboratory values. However, leukocytosis (> 20,000 cells/mm3), an
mage; the second phase begins 3–5 days after injury and results in the elevated serum C-reactive protein (CRP), as well as age, and the pre-
sloughing of the necrotic tissue resulting in ulceration and subsequent sence of an esophageal ulcer can predict mortality [15].
granulation, and the third and most important phase results in con- Imaging including neck and chest x-rays can reveal air in the
tracture and stricture formation. The esophagus is the weakest in this mediastinum or under the diaphragm indicating perforation [6]. This
last phase that typically lasts about 10 days [3]. can be confirmed by performing an esophagram with a water-soluble
agent although performing such study should not delay an EGD. CT
3.2. Clinical presentation and assessment scans can be an excellent modality to assess the transmural injury,
necrosis, and perforation. The World Society of Emergency Surgery
For chemical ingestion, rapid assessment of severity of injury is Consensus conference now supports the use of emergency CT in the
important. Signs of caustic ingestion may include nausea, vomiting, management of corrosive ingestion [16]. CT imaging in select patients
drooling, chest and abdominal pain, dysphagia, odynophagia, or with these types of injuries can improve patient survival and decrease
stridor. Although presence of these symptoms should alert the physician cost [16].
for possible upper digestive injury, they do not always correlate to the Esophagogastroduodenoscopy is crucial and needs to be performed
severity of injury [5–7] Solids and powders usually cause orophar- within the first 24–48 h. Endoscopic grading can predict multiple sys-
yngeal injury with minimal esophageal injury due to decreased travel temic complications and long-term survival [16]. The initial endoscopy
down the digestive tract whereas liquid substances increase the in- can be utilized to predict future stricture formation due to the grading
cidence of esophageal injury [6,8]. of the stricture [16]. The Zargar classification is the widely accepted
system for endoscopic injuries [16]. It is not necessary to stop the en-
3.3. Immediate interventions doscope when a circumferential second or third degree burn is en-
countered [2,3,6] A grading system for esophageal injuries has been
All attempts at establishing the causative agent must be undertaken established (Table 1). Contraindications to endoscopy include radi-
since the treatment protocols may be directed towards specific agents. ologic suspicion of perforation, glottic burns, and a third degree burn to
Emergency interventions should follow advanced trauma life support the hypopharynx [3].
protocols and maintain ventilation with intubation if necessary. Initial treatment and immediate complications
Intubation is indicated if obvious injury to the upper airway is noted Up to 90% of patients can be initially managed with a non-surgical
[9,10]. Oropharyngeal intubation is mostly preferred and it is re- approach [16]. Medical therapy recommendations include acid sup-
commended to avoid cricothyroidotomy in children younger than 12 pression using proton-pump inhibitors or H2 blockers [15]. Corticos-
years of age. Large bore intravenous (IV) access should be obtained to teroid usage is controversial in relation to stricture formation but may
begin fluid resuscitation. The Parkland or other resuscitation formulas have some utility in helping with airway edema [17,18]. Steroids may
may be used, however under and overestimation of burn size and fluid also increase the risk of perforation in cases of full thickness necrosis of
resuscitation may occur, as it is difficult to assess the degree of internal the esophagus. Antibiotic therapy is recommended especially in the
body surface area involvement [11,12]. It has been suggested that presence of steroids although once again, controversy exists regarding
formulas, which account for body composition changes in pediatric dosage and duration [3,4]. Deterioration of clinical sings or laboratory
patients such as Galveston Du Bois (Galveston–DB) Formula and Gal- results should trigger a reevaluation of the need for surgical
veston ¾ power model (Galveston 3/4 p.m.) Formula for children 2–23
months better predict volume requirements [13]. Addition of devices Table 1
such as the transcardiopulmonary thermodilution monitoring device Injury grade description (Zargar Classification).
(pulse contour cardiac output [PiCCO]; Pulsion Medical Systems, Mu- Injury Findings
nich, Germany) to monitor fluid input may even further improve ap-
propriate resuscitation measures [14]. Target urine output in children Grade 0 Normal mucosa
Grade 1 (superficial) Mucosal edema and hyperemia
under 30 kg is 1 ml/kg/h and this should increase to 2 ml/kg/h if
Grade 2 (transmucosal) Friability, hemorrhages, erosions, blisters, whitish
myoglobinuria is present. membranes, and superficial ulcerations
It is critical to note that gastric lavage and induced emesis need to Grade 2A No deep focal or circumferential ulcers
be avoided as these measures may increase the re-exposure to the Grade 2B Deep focal or circumferential ulcers
caustic substance. Our case shows clearly that induced emesis not only Grade 3 Areas of multiple ulceration and areas of brown-black
or greyish discoloration suggesting necrosis
increased the severity of the esophageal injury, but also caused sec-
Grade 3A Small scattered areas of focal necrosis
ondary deep cutaneous injuries from chemicals still active in vomited Grade 3B Extensive necrosis
content. Activated charcoal and milk are not effective and may obscure

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M. Johnson et al. Journal of Pediatric Surgery Case Reports 34 (2018) 30–34

management [16]. Adequate nutritional support following these types success after a single dilation and 14% of patients requiring 5 or more
of injuries is critical for the acute phase of injury [16]. dilations. The average patient is reported to require 2 dilations [21]. In
With all burn injuries, appropriate burn management strategies in- order to increase the effectiveness of dilation, we used Mitomycin C® in
cluding early introduction with high calorie diets are important given our patient. Mitomycin C® is a chemotherapy agent that can be injected
the increased metabolic demands associated with burns. Early in- or topically applied to the esophagus and has been useful in preventing
vestigation of the esophagus should be performed with endoscopy with strictures. Indications for Mitomycin C® can be due to a symptomatic
some authors advocating for endoscopy in the first 24 h [19]. With stricture leading to effects such as dysphagia, vomiting, and malnutri-
significant esophageal injuries the establishment of a gastric access by tion. A recent systematic review indicated encouraging results in the
surgical gastrostomy tube or by naso/oro-gastric tube placement is re- long term [22]. However, specifics of use such as dosing and frequency
commended to allow for enteral access as well as medication and ali- still need more research and clarification. In addition, the possibility of
mentation delivery. an increase risk of malignancy is something to be considered when
As caustic injuries of the esophagus carry significant risk of eso- utilizing this technique [15]. The timing is controversial but most
phageal stricture, several strategies have been employed to attempt to commonly is performed when the patient is symptomatic.
alleviate stricture formation and to provide appropriate esophageal Esophageal replacement
access if strictures arise. Some literature has advocated the early pla- If patients exhibit continued symptoms despite dilatation or failed
cement of nasogastric tubes with endoscopic guidance. Others advocate dilatation, esophageal replacement may be considered. Some factors
the use of esophageal stents with concurrent gastrostomy tube insertion including long strictures and esophageal perforation may be predictive
and transgastric jejunal tube placement. The stent is left in place until of failure of dilatations [23,24]. Successful replacement of the eso-
healing is complete and is followed by weekly endoscopy. phagus has been reported by multiple techniques including colonic
In our patient, an esophageal string was placed which is brought out interposition and gastric conduit. Retrosternal coloplasty is considered
of a gastrostomy tube and through the nose creating a continuous loop. the gold standard after caustic injury [25]. Our patient underwent co-
The string allows for esophageal rest with less irritation but maintains lonic interposition with an excellent outcome.
access for future dilation of the esophagus by either retro or prograde Carcinoma risk
methods. The string is also more secure and not likely to be pulled out There is a long known association between corrosive strictures and
like an nasogastric tube (NG tube). carcinoma of the esophagus (squamous cell carcinoma and adeno-
Gastrostomy tube placement in our patient was difficult given cu- carcinoma) and can be associated with up to a 100 fold increase risk
taneous burns over the upper abdomen. The g-tube had to be placed [24,26]. An increase risk of cancer has been reported especially in re-
more medially than its standard position. The g-tube made normal gions of narrowing [15]. It has been reported that the time between the
surgical debridement, grafting, wound care, and dressing changes more exposure and carcinoma development is most likely between 25 and 40
difficult and may have contributed to some hypertrophic scar formation years [26]. However, the development of esophageal cancer has been
given the difficultly with placing compression garments over the burn reported in as low as 1 year after ingestion [15]. It was reported in a
area with the g-tube in the field. The burn dressing compression gar- single large series that 4 patients out of 239 ended up with esophageal
ments were modified with our physical and occupational therapist cancer over a 37 year period [26]. In addition to the risk of esophageal
colleagues to allow for access to the g-tube without compromising cancer, caustic ingestion may also present an increased risk of gastric
compression. This was accomplished by appropriately placed cut-outs. cancer [26]. Although the true increase in risk of cancer following
The proximity of the g-tube to the graft areas was problematic given caustic ingestion is debated, long term follow-up especially with en-
concern for leakage from the g-tube leading to contamination and ir- doscopic screening is advisable and necessary for both stricture for-
ritation of the burn and graft sites. Constant vigilance and appropriate mation and malignancy identification.
dressings as well as robust patient care giver education efforts were Conclusion
utilized. This case described an infant with ingestion of a caustic substance
Treatment of long term complications and subsequent induced vomiting leading to significant esophageal
Certain factors increase the risk of negative long-term complica- burns and strictures as well as significant cutaneous burns. The com-
tions. These include advanced age, tracheobronchial injuries, emer- bination of both burns as well as the non-accidental trauma of this case
gency esophageal resection, and need for extended resections [16]. Late led to significant management challenges. The patient's esophageal
complications need to be immediately addressed as they can be life injury progressed and esophageal replacement was necessary despite
threatening [16]. Bleeding can occur in 3% of the patients and usually excellent follow up care and multiple stricture dilations. Eventual re-
occurs 3–4 weeks post injury [16]. Fistula formation can occur at any placement was carried out with a colonic interposition leading to an
time and ingestion of highly corrosive agents increase the risk [16]. adequate functional outcome. Initial cutaneous burn and nutrition
Aspiration pneumonia can occur in 4.2% of patients after caustic in- management was also difficult given the location of the burns at normal
gestion and mortality can be up to 60% [16]. g-tube site with subsequent development of hypertrophic scarring.
Stricture formation after caustic ingestions is reported to occur in Successful management of simultaneous cutaneous and esophageal
3–57% of patients. Most patients with esophageal injury with grade 2B burns is possible with appropriate planning and the utilization of a
or higher will develop strictures and surveillance with an esophagram multi-disciplinary care team.
starting about 3 weeks after the injury is warranted in patients with
grade 2A or higher injuries (Table 1). The rate of stricture formation is Ethics approval and consent to participate
related to the grade of esophageal injury [15,20].
EGD is not recommended from 2 to 3 days up to 2 weeks after Consent Obtained from Legal Guardian of Minor Child and is on file.
caustic ingestion as a result of wound softening [20].
Multiple treatment methods have been described for managing
strictures. Our patient's dilatations were performed by esophageal bal- Consent for publication
loon dilatation either in the operating room or under fluoroscopic
guidance. Obtained from Legal Guardian of Minor Child.
Esophageal dilatation and Mitomycin C
Currently balloon dilatation (fluoroscopic or endoscopic) is the Availability of data and materials
preferred primary treatment method for esophageal strictures. The
success rate has been reported to be as high as 80–90% with 43% Not applicable.

33

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M. Johnson et al. Journal of Pediatric Surgery Case Reports 34 (2018) 30–34

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