Vinegar poisoning is a chemical lesion provoked by the ingestion of concentrated acetic acid (CH3COOH) inside and /or arising from intoxication with vapors of this substance. The main clinical manifestations are visible burn marks on the face and mouth, swelling of the larynx, vomiting of blood, severe soreness, shock, kidney failure. The diagnosis is established on the basis of the clinical picture, endoscopic and laboratory examination methods. First aid and treatment includes massive infusions, decongestant and broncholytic therapy, analgesics, antibiotics, hormones, antispasmodics.
ICD 10
T54.2 Toxic effect of caustic acids and acid-like substances
General information
Chemical burns caused by ingestion of concentrated vinegar are common among people suffering from alcohol addiction. In addition, the risk group includes patients with a tendency to suicide. The defeat of vapors of the substance occurs in employees of industrial enterprises using CH3SOON in their work, housewives who use acid for canning. Vinegar poisoning accounts for 8.5-14.7% of the total number of cases of damage by poisons of cauterizing effect. The mortality rate reaches 19-22.5%. Ingestion of 12-15 g is considered fatal . 96% acid, 20-40 ml essence or 200 ml table solution (3-4%).
Causes
The most common reason is the unintentional use of a toxicant by people with chronic alcoholism. Such people, being in a state of abstinence and experiencing an overwhelming need for alcohol, often confuse bottles and drink concentrated acid. Due to weakened taste and olfactory sensations, they do not immediately realize that they have taken poison, they manage to take a few sips. Vinegar poisoning of this kind is one of the most severe. Other possible reasons:
- Suicide. The second most common mechanism of pathology development. It accounts for 35-40% of the total number of victims. The symptoms are expressed as much as possible, since a person purposefully strives to drink as much of the toxic substance as possible. The maximum number of cases is associated with the consumption of 80% of the essence.
- Taking vinegar by children. Occurs when the rules for the storage of dangerous liquids are violated, when CH3COON is in the refrigerator or directly on the table. The risk group is children 3-7 years old. Usually, the damage is limited to burns of the mouth and oropharynx, since the child stops drinking after the first sip.
- Third-party packaging. Poisoning with vinegar is possible if it is in bottles of mineral water, lemonades. Children, elderly people with impaired sense of smell, adult family members are at risk. As in the above case, extremely severe damage is rarely realized. The victim quickly realizes that he is not drinking a food product.
- Accidents at work. Pathology develops when a large amount of a damaging agent is spilled. The severity depends on the time spent in the infected area and the level of ventilation. The most difficult cases are noted when the disaster occurs indoors. The victims have symptoms of inhalation poisoning.
- Canning. A slight lesion with CH3COON vapors occurs in women engaged in canning or cooking dishes that require the use of vinegar. Such conditions do not pose a threat to life and are almost never an indication for medical care. They pass independently after a few hours from the moment of termination of contact with the toxic substance.
Pathogenesis
It is based on the mutual aggravating effect of burns of the gastrointestinal tract and intravascular hemolysis of erythrocytes. Local tissue damage develops according to the type of coagulation necrosis, which reaches its limit by the end of the first day. At the initial stage, bleeding is possible, sometimes profuse. There is a violation of the gastrointestinal tract, swelling of the larynx, esophagus. When splitting dying tissue sites, toxic necrolysis products enter the bloodstream. At 1-2 weeks, the risk of perforation of the burned area is especially high.
Under the influence of CH3COON, red blood cells are destroyed. Their membranes clog the renal tubules. This leads to oliguria, toxic nephropathy, the development of hemoglobinuria nephrosis, acute renal failure. The latter often becomes the main cause of death of the victim. In addition, the systemic effects of acetic acid include hypovolemia, increased hematocrit, hypercoagulation, decreased circulating blood volume, weakening of the pumping function of the heart.
Classification
Poisoning with vinegar or its vapors is divided by reasons (accidental, suicidal, industrial), the level of hemolysis (I-III degree), stage (toxicogenic, somatogenic). The classification by severity developed by E.A. Luzhnikov and L.G. Kostomarova in 1989 has the greatest clinical significance. According to this principle of division, pathology can have the following varieties:
- Easy. General symptoms are not clearly expressed. There is a lesion of the oral cavity, esophagus, pharynx. The level of hemolysis does not exceed 5 g/l. There are no changes on the part of the liver, the work of the kidneys is slightly impaired. The nature of inflammation is catarrhal-fibrinous. The shock does not develop. With inhalation penetration of the damaging agent, edema and hyperemia of the mucous membranes of the upper respiratory tract occur.
- Medium. There are esophageal burns, injuries to the mouth, pharynx, stomach. Hemolysis — 5-10 g / l. Moderate nephropathy, mild hepatopathy. The type of inflammation is catarrhal-serous. The phenomena of exotoxic shock are determined. Vapor poisoning leads to significant edema of the VDP, bronchospasm. It is possible to form small necrotic foci on the mucous membranes.
- Heavy. The concentration of hemolysed hemoglobin is >10 g/liter. Liver and kidney damage is observed up to multiple organ failure. Burns spread to the deep parts of the digestive system with the involvement of the small intestine. Tissue changes of ulcerative-necrotic type. Severe exotoxic shock. Inhalation of vapors is accompanied by irritation of the nasopharynx, trachea, bronchi, lungs.
It should be noted that when affected by vapors, the symptoms differ significantly from oral administration of a poisonous substance. Signs of damage to the respiratory tract (bronchospasm, shortness of breath, respiratory failure, pulmonary edema) come to the fore. At the same time, hemolysis indicators do not correspond to the severity of the pathology. Thus, with life-threatening inhalation poisoning, the content of free hemoglobin may not exceed the norms established for the mild stage of intoxication.
Symptoms
When examining the victim, brown smudges are found on the lips, chin, neck and other places in contact with the traumatic agent. Patients complain of sharp pain behind the sternum, in the epigastric zone, in the mouth. There is hoarseness of the voice or complete aphonia caused by swelling of the glottis. There may be phenomena of mechanical asphyxia: diffuse cyanosis, the participation of auxiliary muscles in the process of breathing, sweating, a feeling of lack of air.
A few hours after the poisoning, there is a symptom such as vomiting with an admixture of scarlet blood or “coffee grounds”. The latter indicates the presence of gastric bleeding. The appearance of melena is possible — a black tar-like stool that occurs with hemorrhages in the upper intestine. Mental status changed. The patient is excited, scared. Tachycardia and increased blood pressure are detected. All of the above corresponds to the erectile phase of traumatic shock.
Severe vinegar poisoning is accompanied by a rapid change of the erectile stage to the torpid one. The patient’s blood pressure is critically reduced, blood circulation is centralized, and symptoms of cardiovascular and respiratory insufficiency are increasing. Breathing is noisy, stenotic. There may be the appearance of wet wheezing, indicating the development of alveolar pulmonary edema. With vomiting, diarrhea, and the release of a large amount of sputum, fluid loss occurs. Dehydration, increased hematocrit, decreased blood flow are determined.
The resorptive toxic effect of acetic acid is manifested mainly by hemolysis of erythrocytes, kidney damage. The concentration of nitrogen metabolism products increases, general toxic effects increase. Oliguria is observed, which should be taken into account when providing first aid using infusion solutions. Liver damage is characterized by the appearance of small foci of necrosis and a decrease in its absorption function. The process is reversible, the work of the organ is restored after 7-30 days.
Poisoning with fumes of table vinegar provokes the appearance of discomfort or sore throat. Possible cough, subjective feeling of lack of air, slight swelling and redness of the mucous membranes, headache. Inhalation of concentrated xenobiotic fumes causes chemical burns of the respiratory tract. At the same time, massive edema occurs, blocking the lumen of the trachea, bronchi. Symptoms: severe cyanosis of the skin, sweating, psychomotor agitation, the patient scratches his throat. Later there is a loss of consciousness.
Complications
The most common complication of chemical burns is the addition of a secondary infection. In the absence of preventive antibiotic therapy, this happens in 70% of cases. Septic processes of the pharynx and esophagus most often develop, purulent tracheobronchitis and pneumonia occur. The second most common occurrence can be considered bleeding, sometimes profuse. The risk of hemorrhage reaches a maximum by the end of 2-3 weeks, when the burn scab begins to separate. Usually, a complication is observed with a violation of the diet, the use of hot and hard dishes.
Severe vinegar poisoning is characterized by the development of liver and kidney failure in 40-45% of cases. This creates the highest possible risk to life. About half of patients with multiple organ dysfunction die. Perforations of the stomach and duodenum are diagnosed somewhat less frequently, which are accompanied by the appearance of peritonitis and require emergency surgery. They are detected from 5-7 to 10-12 days, when the rejection of necrotic masses occurs.
A delayed complication of chemical burns is the formation of strictures and stenoses. They are usually found in several places in the areas of greatest damage, formed 2-6 months after injury. There are cases when narrowing appeared 10-20 years after discharge from the hospital. Strictures cause partial obstruction of the esophagus. Patients are forced to eat only liquid and semi-liquid dishes. Against the background of cicatricial changes, the development of chronic esophagitis is possible.
Diagnostics
The primary diagnosis of vinegar poisoning is made on the basis of anamnesis and characteristic clinical symptoms. The SMP doctor, before providing first aid, assesses the presence of visible burns of the oral cavity, the mucous membrane of the lips and the skin of the face, if possible, determines what liquid the victim consumed, its name and concentration. Differentiation is carried out with poisoning by other acids, alkalis, oxidants. In the hospital, the patient is prescribed consultations with a gastroenterologist, an intensive care specialist and a surgeon, an examination by a specialist in endoscopic methods. The following diagnostic methods are used:
- Physical. There are signs characteristic of this type of poisoning. Blood pressure is higher than normal by 10-20 mm Hg, with torpid shock significantly lower than the usual indicators. The skin color is bluish or pale, marbled. The tones of the heart are muffled, wet wheezing may be present in the lungs. There is a slight hyperthermia up to 37-37.5 ° C.
- Instrumental. The main method of instrumental examination is gastroscopy. During the procedure, chemical burns of varying severity, swelling of the mucous membranes, areas of ulceration are detected. Sometimes foci of capillary bleeding are detected. During repeated examinations, there is a visible burn scab, the initial stages of scarring.
- Blood test. The victim’s blood contains a large amount of free hemoglobin, the volume of which increases in proportion to the severity of the pathology (the exception is intoxication by vapors). The concentration of urea and creatinine increases, the activity of liver enzymes increases. There are shifts in the acidic side of the ABB, an increase in hematocrit due to water loss.
Treatment
Therapy of poisoning with cauterizing fluids includes several stages: first aid, inpatient treatment, resuscitation and surgical methods of correction, rehabilitation. Of particular importance is the diet, the refusal to comply with which makes all of the above methods ineffective. Hospitalization of the patient is recommended to be carried out in specialized toxicological centers.
First aid
First aid for poisoning with cauterizing poisons consists in probe gastric lavage. The probe should be installed with extreme care to avoid perforation of the esophagus. The device must be treated with lidocaine paste or vaseline oil. The procedure is carried out using pure water or 2% magnesium oxide, which neutralizes vinegar without causing gas formation. The use of soda and non-probe washing methods is strictly contraindicated, since it aggravates the severity of the injury.
Before starting the procedure, anesthesia should be provided. Intramuscular administration of narcotic analgesics is indicated, the use of neuroleptanalgesia is possible. In addition, the victim is prescribed glucocorticosteroids, antispasmodics. After the end of the manipulation, the patient is allowed to dissolve ice cubes, such a measure allows to narrow the vessels and reduce swelling. With the development of mechanical obstruction of the respiratory tract, an emergency conicotomy is performed.
Inpatient treatment
After first aid, the patient is taken to a hospital, where preventive antibiotic therapy is prescribed with the use of cephalosporin-type drugs. The therapeutic regimen includes antispasmodics, non-absorbable antacids, hormones, adsorbents, analgesics, proton pump blockers. Gelatinous topical agents are used to stimulate regenerative processes. In order to correct the water-salt balance, infusion solutions are administered. Their infusion requires strict control of the daily amount of urine.
Resuscitation allowance
In the ICU, the patient undergoes massive infusion therapy, the volume of which can reach 15 liters per day. This is necessary to reduce the risk of kidney damage. Water balance monitoring is mandatory. If necessary, hemodialysis or hemosorption is used. The condition is monitored around the clock. According to the indications, a tracheostomy is applied to the victim, transferred to a ventilator, and pressor amines are titrated. With the development of shock, anti-shock measures are indicated.
Surgical treatment
Vinegar poisoning can cause bleeding. Hemostasis is performed endoscopically, sometimes directly in the intensive care unit. With the help of a manipulator equipped with a needle, the doctor pricks the affected area with a solution of adrenaline with antibiotics or treats it with silver nitrate. Open interventions are required for perforation of the digestive tract, massive hemorrhages. If esophageal strictures are formed at a remote stage, surgical plastic surgery is performed.
Rehabilitation
Recovery from chemical burns takes from 1 to 3-6 months. During this period, physical activity is contraindicated for the patient. If the cause of the injury was suicide, the patient is consulted by a psychiatrist, hospitalization to a specialized clinic is often required. Psychological peace and absence of stress are recommended. The victim is observed on an outpatient basis by a gastroenterologist for 6-12 months.
Diet
In the first 1-2 days, hunger is shown. The patient is given pieces of ice, cold water in small sips. If necessary, nutrition is carried out parenterally. Next, liquid chilled food is used. These restrictions are observed throughout the first week. Semi-liquid sparing porridges at room temperature, broths, mashed potatoes diluted in milk are allowed for another 1-2 weeks. The return to a normal diet is carried out gradually over the course of six months. For the longest time, it is forbidden to eat bread, whole meat, fish, hot, drink alcoholic and carbonated drinks.
Prognosis and prevention
Mild to moderate vinegar poisoning has a fairly favorable prognosis. Timely first aid can save the vast majority of victims. With severe intoxication, the situation deteriorates dramatically. About a quarter of patients die from multiple organ failure, shock, sepsis. In case of poisoning with acetic acid vapors, the mortality rate is significantly lower. Symptoms of airway obstruction and pulmonary edema, which occur in 10-15% of patients, pose a threat to life.
Prevention consists in storing concentrated vinegar in places inaccessible to children, the elderly, people with unstable mentality. It is forbidden to pour the substance into containers from other products, especially clear lemonades, drinking water and vodka. It is dangerous to put the essence on the shelves of the refrigerator. Employees of enterprises dealing with acetic acid should be provided with personal respiratory protection equipment. In case of accidents, you should immediately leave the area of suspected infection. If an injury occurs, the victim must be provided with first aid, transportation to a medical facility.