ALKALIS
Alkalis commonly encountered in poisoning include ammonia
(usually in the form of ammonium hydroxide),
carbonates of sodium and potassium, and
hydroxides of sodium, potassium, and calcium.
Sodium hypochlorite is also increasingly being implicated.
Physical Appearance
• Most of these occur as white powders or colourless solutions.
• Ammonia gas is colourless with a pungent, choking odour.
Uses
■ Ammonia gas—Smelling salts.*
■ Ammonium hydroxide (32.5% ammonia)—Paint, oil, and dirt remover,
refrigerant.
■ Sodium hydroxide (caustic soda)—Drain cleaner, oven cleaner.
■ Potassium hydroxide (caustic potash)—Drain cleaner, hearing aid batteries.
■ Sodium carbonate (washing soda)—Household cleaning agent, detergent.
■ Potassium carbonate—Household cleaning agent.
■ Sodium hypochlorite—Household bleach.
Usual Fatal Dose
■ About 10 to 15 gm for most alkalis.
■ About 15 to 20 ml for ammonia.
Mode of Action
Locally, alkalis produce liquefaction necrosis which results in extensive
penetrating damage because of saponification of fats and solubilisation of
proteins.
Production of ulcers is common which may persist for several weeks.
Oesophagus is more severely affected than the stomach in contrast to acids
Clinical Features
1. Corrosion of GI mucosa with greyish pseudomembrane formation.
Oesophagus is often severely affected resulting in dysphagia, vomiting,
drooling, and haematemesis. Stridor is an important indicator of severe
oesophageal injury.
2. There are four categories of alkali induced oesophagitis:
a. Non-ulcerative oesophagitis—from ingestion of mild irritants, resulting in 1st
degree burns.
b. Mild ulcerative oesophagitis—from ingestion of weak bases. 2nd degree burns
are produced. Strictures may develop.
c. Severe ulcerative oesophagitis—from ingestion of strong bases. There is severe
dysphagia with vomiting which may subside after 2 to 3 days only to reappear as
slowly progressive dysphagia after 4 to 6 weeks due to stricture formation. This
may lead to total obstruction.
d. Oesophagitis with complications—apart from oesophagitis, there are
complications such as mediastinitis, perforation, pericarditis, pulmonary oedema,
laryngeal obstruction, etc. It is important to perform oesophagoscopy and make
accurate assessment as to the extent of local injury
Contraindications to oesophagoscopy include upper airway obstruction and GI
perforation
3. Abdominal pain, diarrhoea, tenesmus.
4. Skin involvement results in greyish, soapy, necrotic areas without charring.
5. Eye involvement can produce serious complications, and constitutes an
ophthalmologic emergency.
6. Ammonia ingestion causes manifestations which are essentially similar to
those seen with other alkalis, but respiratory symptoms are commonly super-
added due to inhalation of fumes while swallowing.
Diagnosis
1. In stomach contents:
a. White, solid, slimy lumps, flakes, or granules.
b. Turns litmus paper blue.
c. Becomes warm on addition of water.
d. If exposed to air, becomes moist and gets dissolved.
e. Soapy or slimy feeling when touched with fingers.
f. Sharp penetrating odour in the case of ammonia.
2. Platinum wire flame test: Touch platinum wire to the unknown substance and
then place it in a flame. Sodium gives an intense persistent yellow flame.
Potassium gives a deep purple flame.
3. Fume test for ammonia: Place an open bottle of concentrate Hcl near a
sample of stomach contents, aspirate, or vomitus. Copious white fumes of
ammonium chloride will emanate if ammonia is present. The test can also be
done to detect the presence of ammonia in the atmosphere.
Treatment
1. Respiratory distress (especially in the case of ammonia) may require
endotracheal intubation, cricothyroidotomy, or tracheostomy, depending on
severity. Oxygen must be administered as necessary.
2. Diluents such as milk or water may be given as a first aid measure for alkali
ingestion (no more than one or two glasses for an adult). If more than one hour
has elapsed, this is usually not efficacious
3. The following are absolutely contraindicated : emesis, gastric lavage,
catharsis, and activated charcoal.
4. Withhold all oral feeds initially.
5. Assess fluid and electrolyte balance
6. Watch for development of complications and attend to them accordingly.
7. If circumferential 2nd degree or 3rd degree burns of the oesophagus are seen,
exploratory laparotomy should be undertaken followed by gastric resection and
oesophagectomy, in case gastric necrosis is evident at laparoscopy.
8. High dose corticosteroid therapy in caustic ingestion should be avoided.
9. Antibiotics should be administered only if there are signs of perforation or
secondary infection.
10. An oesophagogram should be done at 3 weeks to evaluate the formation of
strictures. Patients should be instructed to seek medical attention immediately
whenever they develop dysphagia.
12. Alkali injuries to the eye and skin should be irrigated copiously with water or
saline for at least 20 to 30 minutes. Ophthalmologic consultation is mandatory.
Topical antibiotics and steroids may help.
13. Patients who have suffered from stricture formation require long-term
endoscopic follow-up for the presence of neoplastic changes of the oesophagus
which may occur with a delay of several years or decades
Autopsy Features
1. Characteristic odour (in the case of ammonia).
2. Brownish or greyish staining of skin.
3. Inflammatory oedema with corrosion and sliminess of the tissues of the
oesophagus and stomach. The mucosa may be brownish owing to formation of
alkaline haematin.
4. Congestion of respiratory tract and pulmonary oedema (especially in the case
of ammonia).
Forensic Issues
■ Accidental poisoning occurs usually by mistaking an alkali solution for water,
lemonade, beer, etc., because of careless storage of these chemicals in
inadequately labeled, ordinary looking bottles or jars.
■ Industrial accidents involving these substances are reported from time to time.
■ Suicidal cases are occasionally encountered. Homicides are quite rare.
■ Ammonia may sometimes be sprayed or thrown on a victim to facilitate
robbery.
OTHER CAUSTICS
i. Potassium Permanganate Synonyms
Condy’s crystals;
Chameleon mineral;
Purple salt
ii. Iodine
iii. Hydrogen Peroxide Synonyms
Albone;
Carbamide peroxide;
Hydrogen dioxide;
Urea peroxide.
iv. Cetrimide (atrimonium bromide)
