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Common Household Poisoning
Nur Afni Amir
Drug & Poison Information Pharmacist
National Poison Centre, USM
What are common household poisoning? Which household item is dangerous? What are the sign and symptoms of the poisoning? What are the treatment ?
What can you do to avoid accidental household poisoning?
TOPIC OUTLINE
At the end of this lecture, you should be able to answer these question…
• Detergents (bleaching agents, floor cleaner,laundry detergents)
• Solvents (kerosene, thinner)
• Automotive products (petrol,brake fluid,battery water)
• Cosmetics and personal care(soaps,shampoo,nail polish)
• Other household product (mothball,dessicant)
What are common household poisoning?
HOUSEHOLD BLEACHES
1. Chlorine based bleaches - contain chlorine or hypochlorite - general disinfectant and bleaching agent. - The toxicity of bleach is related primarily to the
oxidizing capacity of the hypochlorite ion and the pH of the solution
2. Non-chlorine bleaches - used in numerous household products, including
disinfectants, chlorine free bleaches, fabric stain removers, contact lens disinfectants, hair dyes and tooth whitening products
- May contain hydrogen peroxide, sodium perborate, sodium percarbonate
1. Most household bleach solutions contain 3% - 5%hypochlorite. *swimming pool disinfectants &industrial bleach : up to 20% hypochlorite 2. Bleaches with a hypochlorite concentration greater than 10% are corrosive while those with a concentration of less than 10% are irritants (Kiristioglu et al, 1999). 3.Household bleach is a mild to moderate irritant which does not cause tissue damage unless ingested in large amounts. Systemic toxicity may occur after a large ingestion. 4.Ingestion of more than 100 mL in a child or 300 mL in an adult of a household bleach (<10% sodium hypochlorite) may cause significant toxicity.
HOUSEHOLD BLEACHES: CHLORINE BASED
CLINICAL EFFECTS HYPOCHLORITE
MILD TO MODERATE *dilute hypochlorite solutions (3%-5%) immediate burning in the
mouth & throat. GI upset no further injury
SEVERE *concentrated solution
significant esophageal & gastric burns
dysphagia, drooling, severe throat, chest & abdominal pain.
hematemesis & GI perforation
systemic toxicity:electrolyte disturbances, metabolic acidosis, mental status changes, cardiovascular effects and pulmonary edema
Hypochlorite + Acid (Toilet bowl /tile cleaner) = Chlorine gas
HOUSEHOLD BLEACHES
Hypochlorite + Ammonia = chloramine gas
INHALATION OF CHLORAMINE /CHLORINE GAS
• With normal use, household bleach
is NOT a respiratory hazard • Corrosive gases may be produced
when mixing bleach with other household cleaning products
• IRRITANT effects on the mucous membrane (eyes,nose,throat)
• May trigger wheezing and respiratory symptoms
• In serious exposures, which are rare with household products, upper airway edema may cause obstruction and chemical pneumonitis may also occur.
HOUSEHOLD BLEACHES:
CLINICAL EFFECTS
TREATMENT
INGESTION • Treatment is unlikely to be required if only small amounts have been
ingested
• Gastric lavage should NOT be undertaken : risk of aspiration
• Activated charcoal is CONTRAINDICATED
• Neutralization is CONTRAINDICATED: Administration of acids or basic substances for neutralization is contraindicated due to the possibility of exothermic reaction and subsequent burning.
• Dilution :small amount of milk or water as soon as possible after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
HOUSEHOLD BLEACHES
• ENDOSCOPY is indicated in a patient with any of the
following:
HOUSEHOLD BLEACHES
drooling, pain, dysphagia, evidence of oropharyngeal burns a history of intentional ingestion
of a substantial amount of corrosive material.
TREATMENT INHALATION EXPOSURE Leave the area of exposure immediately Supplemental oxygen, bronchodilators,and advanced airway
support(eg, intubation) as necessary EYE EXPOSURE Immediate copious eye irrigation
DERMAL EXPOSURE Remove all exposed clothing and wash exposed areas of the body twice
with water. Standard burn care (eg, dressings, antibiotic ointment) for corrosive
injuries. Wash all exposed clothes with soap and water. Complications are unlikely.
HOUSEHOLD BLEACHES
Colourless, odourless, acidic oxidizing agent available in a variety of concentrations from 3 to 90%
General purpose disinfectants 3%
Hair bleach and hair dyes 6%
Contact lens disinfectants 3%
Chlorine free bleach 6%
Fabric stain removers 5-15%
Industrial strength up to 90%
HOUSEHOLD BLEACHES: HYDROGEN PEROXIDE
INGESTION
vomiting,
mild gastrointestinal irritation
gastric distension
gastrointestinal erosions
HOUSEHOLD BLEACHES: HYDROGEN PEROXIDE
MILD TO MODERATE TOXICITY
INHALATION & OCULAR household strength hydrogen peroxide (3%) can cause respiratory irritation and mild ocular irritation
Hydrogen peroxide's toxicity is mainly due to the release of oxygen
gas causing venous or arterial gas embolism. Each mL of 3%
hydrogen peroxide releases 10 mL of oxygen gas
INGESTION:
Ingestion of higher (greater than 10%) concentration products.
caustic injuries to the gastrointestinal tract, leading to hemorrhagic gastritis, burns in the mouth, throat, esophagus, and stomach, ulcerating colitis, intestinal gangrene, and gas embolization.
Systemic gas embolization can involve any organ, resulting in seizure, cerebral infarction, cerebral edema, spinal cord infarction, acute myocardial infarction, hypotension, cardiac arrest, and death.
INHALATION: Inhalation of vapors from concentrated (greater than 10%) solutions may result in severe pulmonary irritation. Acute lung injury and respiratory arrest
OCULAR: Eye exposure to high concentrations can cause corneal ulceration and perforation. DERMAL: Dermal exposure to concentrated solutions has resulted in burns and gangrene
HOUSEHOLD BLEACHES:
HYDROGEN PEROXIDE
SEVERE TOXICITY
Used in many cleaning products. Mainly contain surface active agents consist of:
ANIONIC, NONIONIC CATIONIC
Mildly irritating Hazardous
DETERGENTS
Most common surfactant in bath soap,shampoo, general laundry detergents
Common in heavy duty laundry detergent
Disinfectants,industrial products, fabric softener,swimming pool algicides
DETERGENTS
Anionic Surfactant
• Alkyl sulfate • Alkyl sulfonates • Alkyl phosphate • Alkylbenzene sulfonates • Ammonium lauryl sulfate • Sodium lauryl sulfate • Sodium stearate
Irritants effect
Nonionic Surfactant
•Alkylpolyethoxylates •Chlorhexidine gluconate • Ethoxylated alcohols •Lauramide DEA •Nonoxynol •PEG alkyl aryl ethers •PEG stearates •Polysorbate 60 • Polysorbate 20 • Polyethylene glycol
Produce less local irritation than anionic
Cationic Surfactant
• 10-15% : caustic • 0.1-0.5% : significant mucosal irritation • Esophageal or gastrointestinal tract
burns are possible with ingestion of just a few mL of concentrated solution.
• CNS depression progressing to coma and shock (rare)
• benzalkonium /benzethonium chlorides
• cetylpyridinium,cetrimonium • dequalinium chloride
• Proteolytic/amylolytic enzymes used in laundry detergents and presoaks to loosen soil & remove stain
• Products contain enzyme,detergents and builders which have irritating and sensitizing properties
• Ingestion: likely to cause emesis
DETERGENTS
ORAL INGESTION: - Immediate spontaneous vomiting - Intractable vomiting, diarrhea & hematemesis with large ingestion EYE EXPOSURE: - Mild to serious corrosive injury depending on products SKIN EXPOSURE: - Mild erythema or rash
DETERGENTS:
CLINICAL EFFECTS
DECONTAMINATION Dilution Do NOT induce emesis Activated charcoal CONTRAINDICATED Irrigation with copious amount of water in cases of eye exposure EMERGENCY/SUPPORTIVE MEASURES IV fluids to correct dehydration and electrolyte imbalance due to protracted vomiting or diarrhea MONITORING Most exposures do not require specific testing Endoscopy:within 24 hours in patients whom GI burns are a concern (patients with stridor, drooling of saliva,dysphagia, or severe throat and abdominal pain)
DETERGENTS:TREATMENT
THESE ARE CHEMICALS THAT IRRITATE,
BURN OR DAMAGE SKIN AND OTHER LIVING CELLS.
Consists of:
• Mineral and organic acids • Alkalis
CAUSTIC & CORROSIVES
AGENTS
EXAMPLES OF ACIDS
WEAK IRRITANTS
Acetic acid 5-10% Aluminium sulfate 5-20%
Hydrochloric acid <5% Phosporic acid 15-35%
CORROSIVE (DANGER)
Acetic acid>/=50% Glycolic acid >10%
Hydrochloric acid >10% Oxalic acid >10%
Phosphoric acid >60% Sulfuric acid >10% Zinc sulfate >50%
STRONG IRRITANTS
Acetic acid 10-50% Boric acid
Hydrochloric acid 5-10% Oxalic acid <10%
Phosphoric acid 35-60% Sulfuric acid <10 % Zinc sulfate 5-50%
Automobile battery - Sulphuric acid 25-30% Toilet Bowl Cleaner (liquid) - Hydrochloric acid 10-25% - Sulfuric acid 80% Toilet Bowl Cleaner (granular) - sodium bisulphate 70-100% Metal cleaners and antirust - Phosphoric acid 5-80% - Oxalic acid 1% - Hydrochloric acid 5-25% - Chromic acid 5-20% Drain cleaners - Sulfuric acid 95-99%
PRODUCTS CONTAINING ACIDS
• Ammonia • Calcium oxide • Calcium hydroxide • Potassium carbonate • Potassium hydroxide (caustic potash) • Potassium polyphosphate • Sodium carbonate • Sodium hydroxide (caustic soda, lye) • Sodium phosphate • Sodium polyphosphate
EXAMPLES OF ALKALIS
PRODUCTS CONTAINING ALKALIS
• Detergents - Sodium tripolyphosphate • Drain cleaners - Sodium hydroxide • Ammonia compounds - Ammonium hydroxide
PRODUCTS CONTAINING
ALKALIS
Alkalis burn more severely. They dissolve tissues & penetrate deeper below the surface of the skin or lining of the gut ** the lower part of the
esophagus may be severely affected even when there are no burns in the mouth & throat.
DIFFERENCE BETWEEN ACID
AND ALKALI BURNS
Acids burn less severely than alkalis. They cause more severe injury to the stomach than to the mouth & throat Systemic poisoning can occur, but only when ingested in large amount.
MILD TO MODERATE ORAL TOXICITY Mild : irritation or grade I burns (superficial hyperemia and edema) burns of the oropharynx, esophagus or stomach Moderate toxicity: grade II burns (superficial blisters, erosions and ulcerations) are at risk for subsequent stricture formation, particularly esophageal. Some patients (particularly young children) may develop upper airway edema
SEVERE ORAL TOXICITY deep burns and necrosis of the gastrointestinal mucosa. complications often include perforation (esophageal, gastric, rarely duodenal), gastrointestinal bleeding. Hypotension, tachycardia, tachypnea and, rarely, fever Stricture formation (esophageal, less often oral or gastric) is likely to develop long term Upper airway edema is common and often life threatening.
CAUSTIC & CORROSIVES
CLINICAL EFFECTS:
INHALATION EXPOSURE: Mild exposure:cough and bronchospasm. Severe inhalation : upper airway edema and burns, stridor, acute lung injury (rare) OCULAR EXPOSURE: severe conjunctival irritation and chemosis, corneal epithelial defects, permanent visual loss and in severe cases perforation. DERMAL EXPOSURE: Mild exposure :irritation and partial thickness burns. Metabolic in patients with severe burns or shock.
CAUSTIC & CORROSIVES
CLINICAL EFFECTS:
Dilute with 4 to 8 ounces of water may be useful if it can be performed shortly after ingestion in patients who are able to swallow, with no vomiting or respiratory distress, then the patient should be NBM until assessed for the need for endoscopy.
Neutralization, activated charcoal, and gastric lavage are all
contraindicated. Symptomatic and supportive management
CAUSTIC & CORROSIVES
AGENTS:TREATMENT
HYDROCARBON SOLVENTS
• Hydrocarbons are a diverse group of organic compounds that are made up of primarily carbon and hydrogen atoms.
• PETROLEUM DISTILLATE : Hydrocarbon that are refined
form crude oils (kerosene, gasoline,mineral seal oil) • Hydrocarbon used as fuels and solvents, and are found
in many household and commercial products.
COMMON HYDROCARBON POISONING
1. Thinner
2. Kerosene *
3. Gasoline/Petrol
4. Turpentine
*common terms used by public :
minyak tanah/gasoline/minyak gas
HYDROCARBON SOLVENTS
Composition Examples Volatility Viscosity / Surface Tension
Risk of Aspiration
Risk of CNS Toxicity
Heavier fractions
motor oil, petroleum jelly
Lower Higher Lower Lower
Lighter fractions
Kerosene, gasoline white spirit
Higher Lower Higher Higher
The toxicity that results from exposure to a petroleum distillate will depend both on its composition and the route of exposure.
Poorly absorbed from the GI tract
Mainly aspiration hazards
Do not cause any appreciable systemic toxicity unless aspiration has occurred
HYDROCARBON SOLVENTS :COMPOSITION
OTHER TYPES OF
HYDROCARBON
TYPES EXAMPLES CLINICAL EFFECTS
TERPENES turpentine oil,pine oil Mild CNS depression
AROMATICS Benzene, xylene, toluene
CNS depression. Small risk of aspiration
HALOGENATED-CHLORINATED
Chloroform, carbon tetrachloride, trichloroethane
CNS effects, dysrhythmias, renal and hepatic effects.Small risk of aspiration
OTHER ALIPHATIC HYDROCARBONS
Butane, propane, hexane, methane
Asphyxiation if exposed in poorly ventilated spaces
Maintain a clear airway and ensure adequate ventilation.
Give oxygen if indicated
Gastric lavage and Activated charcoal should NOT be given due to the increased risk of aspiration.
Observe patients for at least 6 hours after exposure. Monitor pulse, respiratory rate, oxygen saturation, conscious level and temperature.
The need for x-ray is dependant on likelihood of aspiration.
Patients may be considered for discharge 6 hours after ingestion if asymptomatic, if there are no signs in the chest and a chest x-ray is normal, with advice to return if symptoms develop.
HYDROCARBON SOLVENTS: TREATMENT
1. Colognes, perfumes, aftershave lotions, oral hygiene products and face toner
- alcohol; effects depend on the concentration. - often asymptomatic but may develop slurred speech & ataxia with large ingestion 2. Deodorants - contains aluminium and zinc: low toxicity 3. Nail polish / nail polish remover - contains acetates, acetone, toluene & aromatic hydrocarbons - large ingestion can cause CNS depression
COSMETICS & PERSONAL CARE
COSMETICS
4. Hair products - dyes and bleaches containing hydrogen peroxide (<3%) have low toxicity profile 5. Creams and lotions, lipstick, toothpaste - unlikely to be harmful - may cause laxative effects due to emollient content 6. Skin whiteners - hydroquinone; in large amount may cause cyanosis and
convulsions
COSMETICS & PERSONAL CARE
• First aid measures • Decontamination generally is not necessary • Symptomatic & Supportive
TREATMENT COSMETICS & PERSONAL CARE
TREATMENT
OTHER HOUSEHOLD
PRODUCTS:MOTHBALL
TTest to differentiate mothball ingredientst to differentiate mothball ingredients
N P C
Place the mothball in the glass of water
C
N P Place the mothball in the saturated salt solution by adding 3 tablespoonfuls of table salt into half a glass of water and stirring it vigorously until the salt does not dissolve any more
P
N
Plain water Salt solution
NAPHTHALENE MILD TO MODERATE : nausea, vomiting, diarrhea, headache, restlessness SEVERE: lethargy, hemolysis, hemolytic anemia, methemoglobinemia, hyperkalemia, dysuria, hematuria,seizures, coma, metabolic acidosis, renal failure, and acute lung injury *high risk to G6PD deficiency patient
PARADICHLORO-BENZENE
MILD TO MODERATE: Most inadvertent ingestions are asymptomatic. Inhalation can cause nausea, headache and vomiting. It can also cause irritation to the eyes and nose. SEVERE : Hepatotoxicity, hemolytic anemia, and methemoglobinemia (rare)
CAMPHOR MILD TO MODERATE : nausea and vomiting.
Seizures
SEVERE : delirium, visual
hallucinations, cerebral edema, and status
epilepticus, hypotension, tachycardia, respiratory
failure and death.
CLINICAL EFFECTS:MOTHBALL
DECONTAMINATION: Naphthalene: Consider administration of activated charcoal after a potentially toxic ingestion .Most effective when administered within one hour of ingestion.
Paradichlorobenzene :Consider administration of activated charcoal after large ingestion. Avoid fatty foods,oil and milk to minimize absorption
Camphor : Generally not recommended due to the fast onset of action and risk of seizure
TREATMENT
No ANTIDOTE
Symptomatic and supportive treatment
MANAGEMENT: MOTHBALL
OTHER HOUSEHOLD PRODUCTS:
ETHYLENE GLYCOL
Used as engine coolant ( eg: entifreeze used in car
radiator)
Primary concern is the severe metabolic acidosis
and nephrotoxicity from metabolites.
Toxic metabolites : Glycoaldehyde, glycolic
acid,oxalic acid
Antidotes : Fomepizole / Ethanol
INDICATION FOR ANTIDOTE
• Plasma ethylene glycol concentration greater than 3.2 mmol/L
(20 mg/dL) or;
• Recent ingestion of greater than 0.2 mL/kg ethylene glycol and
presence of osmolal gap greater than 10 mosm/L or;
• History or clinical suspicion of ethylene glycol poisoning and at
least two of the following
-Arterial pH < 7.3
-Serum bicarbonate < 20 mmol/L (20 mEq/L)
-Osmolal gap > 10 mosm/L
-Presence of urinary oxalate crystals
OTHER HOUSEHOLD PRODUCTS
CONTAINING ETHYLENE GLYCOL
OTHER HOUSEHOLD
PRODUCTS:DESSICANTS
A desiccant is a hygroscopic substance that induces or sustains a state of dryness (desiccation) in its vicinity. Commonly composed of
non-toxic chemicals such as silica gel
Be AWARE of other dessicants that contain Quick lime (calcium oxide) Calcium chloride Oxygen absorber (powdered iron/iron salts)
OTHER HOUSEHOLD
PRODUCTS:DESSICANTS
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