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Caustic Cocktail

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Other Names

  • Caustic Cocktail


  • 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




  • 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


  • 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[1]
  • 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[2]
    • Quantity and concentration of substance,
    • Duration of mucosal contact.

Risk Factors

  • Diving related
    • Closed circuit rebreather

Differential Diagnosis

Differential Diagnosis Dive Medicine

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




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


  • Not applicable




Rehab and Return to Play


  • Not applicable

Return to Play/ Work

Complications and Prognosis



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

See Also


  1. Howell JM. Alkaline ingestions. Ann Emerg Med 1986;15(7):820-5
  2. Wason S. The emergency management of caustic ingestions. J Emerg Med 1984;2:175-82.
Created by:
John Kiel on 12 July 2022 14:20:24
Last edited:
25 July 2022 20:51:19