Caustic Cocktail

Other Names

• Caustic Cocktail

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Background

• This page refers to 'caustic cocktail', a disease in which inhalation of water into a closed-circuit rebreather creates a highly basic and caustic vapor

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Pathophysiology

• General
  • Caustic cocktail occurs when water enters the closed circuit, mixing with sodasorb and becoming highly basic
  • Inspiration can result in significant injury to pharynx, esophagus and tracheobronchial tree

Etiology

• Sodasorb (soda lime)
  • Used in closed-circuit rebreathers to remove expired carbon dioxide (CO2)
  • Composed of calcium hydroxide (75%), sodium hydroxide (3%), potassium hydroxide (1%)
  • Normally, CO2 reacts with the soda lime and CO2-free gas is recirculated for breathing
  • All 3 components are strong bases that ionize in water
• Pathology
  • If it comes in contact with water, i.e. water entering closed circuit, it becomes highly basic and caustic
  • If inhaled, results in mucosal lesions that are typically deep, liquefactive necrotic burns
  • Burns can occur in the oropharynx, esophagus, stomach, and small bowel
• Esophagus
  • Initial burn is characterized by erythema and ulceration with 24 hours
  • Microscopy demonstrates fatty saponification, blood vessel thrombosis, and cellular necrosis within 2 to 3 days
  • Subsequently, deposition of scar tissue and stricture formation within 4 to 6 weeks after severe injury
• Factors which influence the extent of injury
  • pH
    • Alkaline chemicals with a pH greater than 12.5 more frequency result in gastrointestinal burns leading to strictures
  • Quantity and concentration of substance,
  • Duration of mucosal contact.

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Risk Factors

• Diving related
  • Closed circuit rebreather

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Differential Diagnosis

Differential Diagnosis Dive Medicine

• Barotrauma of descent
  • Otic Barotrauma: "ear squeeze"
  • Sinus Barotrauma: "sinus squeeze"
  • Mask Squeeze: air in the mask decreases in volume during a dive, creating negative pressure
  • Barodentalgia: trapped dental air causing squeeze
• At depth injuries
  • Oxygen Toxicity: harmful effects of breathing oxygen at higher partial pressures than normal
  • Nitrogen Narcosis: toxic effects of breathing nitrogen-containing gases while at depth
  • Hypothermia: decrease core temperature with prolonged exposure to cold water
  • Carbon Monoxide Toxicity: CO toxicity typically results from a faulty air compressor
  • Caustic Cocktail: Inhalation of absorbent material used to scrub CO2 mixes with water
• Barotrauma of ascent
  • Pulmonary Barotrauma: occurs when diver breathing compressed air ascends too rapidly
  • Decompression Sickness: Dissolved nitrogen comes out of solution, forms bubbles in blood and tissue ("the bends")
  • Arterial Gas Embolism
  • Alternobaric vertigo
  • Facial baroparesis (Bells Palsy)
• Other
  • Immersion Pulmonary Edema: also termed swimming induced pulmonary edema
  • Salt water aspiration
  • Submersion Injury: includes drowning, near drowning

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Clinical Features

• History
  • Patients may endorse throat and chest pain
  • Worse with swallowing, deep inspiration
  • Abdominal pain may be present
• Physical Exam
  • May be spitting out their sputum due to odynophagia
  • Stridor may or may not be present
  • Breath sounds can be course
• Special Tests

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Evaluation

Radiographs

• Standard Chest Radiograph
  • May show airspace opacities

Endoscopy

• Esophagogastroduodenoscopy
  • May show erosions in the stomach
  • Overlying black eschars
• Bronchoscopy
  • May demonstrate erosions, inflammation, secretions
  • Along arytenoids, tracheobronchial tree

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Classification

• Not applicable

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Management

Prevention

• See: Dive Medicine Prevention

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Rehab and Return to Play

Rehabilitation

• Not applicable

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Complications and Prognosis

Complications

• Early
  • Perforation
  • Gastrointestinal bleeding
  • Pulmonary aspiration
  • Adult respiratory distress syndrome,
  • Tracheoesophageal and aortoenteric fistulas
• Late
  • Esophageal strictures
  • Esophageal carcinoma
  • Esophageal achalasia
  • Obstruction

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See Also

• Internal
  • Dive Medicine Main
  • Environmental Main

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