Hot Seat #217: A Caustic Conundrum
Posted on: October 20, 2023, by : Brandon Ho
Case by Hannah Kotler MD, CNH PEM Fellow
You are carrying the transport phone when you receive a call for a destination decision:
15-year-old M ingested “half a bottle” of household bleach in a suicide attempt. Currently, he is c/o stomach and throat pain. His vital signs are as follows: HR 80, BP 118/78, SpO2 100% on RA. There is no report of respiratory distress. The nearest facility with (limited) pediatric capabilities is 20 minutes away by ground. Your facility is 90 minutes away.
You advise that the patient is stable for evaluation at the nearest facility, but they prefer that the patient be seen at the tertiary children’s hospital. Given the patient’s current stability, he is transferred by ground.
Just over an hour later, you get a call from the transporting EMS crew. The patient’s priority has been upgraded and they are being transported by lights/sirens, as he is newly complaining of SOB and anxiety. He desatted to low 90s on RA and is wheezing. They have given him a duoneb and initiated 2L NC. Updated VS are P100, RR 31, BP 152/94, EtCO2 41 with “shark fin” waveform. He is awake and alert. They are 20 minutes out from your facility, and they report feeling comfortable with the current level of management. The team wants to know if they should proceed the 20 mins to your facility, or divert to the nearest facility which has a 10 min ETA.
It would be very important to ascertain the contents of the bleach ingestion. Routine household bleaches are nontoxic if swallowed into the GI tract. Aspiration may set off reactive bronchospasm. On arrrival I would assess to assure the wheezes are from lower airway bronchospasm and not stridor from upper airway edema Remember homophynous vs. heterophynous wheezing?