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Chemical Pneumoni.s A1er Laundry Detergent Pod Inges.on
Background Discussion
Case Summary
Bronchoscopy/EGD
References
Suzanne VanValkenburgh MD, Marla Matar, MD Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine -‐ Los Angeles, CA, US
Single-‐use laundry detergent pods (LDPs) were released in the US in 2011, and their colorful, candy-‐like appearance has led to an increasing number of unintenQonal pediatric ingesQons.
In 2014, the American AssociaQon of Poison Control Centers received 11,711 reports of exposure to LDPs in children ≤ 5 years of age (up from 10,395 exposures in 2013). TradiQonal laundry detergent ingesQons are less common and associated with less severe effects, such as minor oral mucosal irritaQon and vomiQng. The ingesQon of highly concentrated LDPs is being associated with significantly increased morbidity, including esophageal injury, pulmonary toxicity, and CNS depression.
10 month old male brought to OSH aaer witnessed ingesQon of a Kirkland® detergent pod. NBNB emesis x 2, AAO, increased salivaQon.
PMH/PSH: Unremarkable Allergies: NKDA Meds: None Weight: 9.2 kg Ini.al VS: T 979, HR 166, RR 31, SpO2 99% on RA CXR: ø infiltrate Labs:
Aaer a period of unevenful observaQon, he developed hypersalivaQon, stridor, subcostal retracQons and intermigent SpO2 in the high 80s. He was treated with albuterol & ipratropium nebulizers, methylprednisolone 20mg IV, racemic epinephrine and O2 via high flow NC. Transferred to CHLA for further management, admiged to the PICU with a stable respiratory status.
CXR (8 hrs post-‐exposure): bilateral perihilar & RUL opaciQes CBG: pH 7.34/pCO2 28/pO2 63/HCO3 15/BE -‐9.6/O2 91%
Hospital Course
On Hospital Day (HD) #2 (~17 hrs post-‐exposure), the paQent was brought to the OR for Bronchoscopy/EGD under GETA. InducQon and intubaQon were unevenful.
Bronchoscopy: Superficial burns to epigloms/AE folds/posterior pharyngeal wall, normal vocal cords, mild erythema of distal trachea and mainstem bronchi.
EGD: Mucosal sloughing in oropharynx & circumferenQally for enQre extent of esophagus, scagered erosions in stomach body, 2 ulcers in the antrum.
§ HD #3 (~35 hrs post-‐exposure) – Intubated for respiratory distress. Prolonged expiratory Qme, capnography demonstraQng obstrucQve pagern.
§ Advised by Toxicology to avoid systemic corQcosteroids due to increased risk of esophageal rupture aaer causQc ingesQon with steroids.
§ ConQnued mechanical venQlaQon over the next week due to persistent obstrucQve breathing pagern. Stable CXR findings.
§ HD #10 – Weaned from ven.latory support & successfully extubated § HD #17 – Repeat EGD performed, showing completely normal esophagus,
gastroesophageal juncQon & stomach § HD #23 – Discharged home without event on regular diet
§ Valdez, AL, et al. Pediatric Exposure to Laundry Detergent Pods. Pediatrics. 2014;134: 1127-‐1135.
§ Beuhler MC, et al. Laundry Detergent “Pod” IngesQons: A Case Series and Discussion of recent Literature. Pediatr Emer Care. 2013;29: 743-‐747.
§ Centers for Disease Control and PrevenQon (CDC). Health hazards associated with laundry detergent pods – United States, May-‐June 2012. Morb Mortal Wkly Rep. 2012;61:825-‐829.
§ Heppner J, et al. Household “Hazmat”: A Pair of SUDSy Siblings. Pediatr Emer Care. 2013;29: 773-‐777.
Laundry detergent pods (LDPs) contain a highly concentrated detergent formula within a water soluble membrane. When held in a moist hand, or placed in the mouth, these pods can easily burst or dissolve, releasing their contents onto skin, into eyes and the mouth. While the majority of exposures develop only minor symptoms, recent studies have shown that exposure to LDPs result in a higher rate of symptoms and more severe outcomes when compared to tradiQonal laundry detergents.
Recent NPDS data from 2012-‐2013 shows: • 17,230 children (< 6 years) were exposed to LDPs • 35.4% received treatment at a health care facility • Majority of hospital admissions associated with an oral exposure • Children < 3 yrs old more likely to be hospitalized • Of all exposures, 50.3% experienced minor effects, 7.5% resulted in moderate or major clinical effects, including 1 confirmed death
ComplicaQons associated with LDP exposure include: • Ophthalmologic – conjuncQviQs, corneal abrasions/burns • GI – N/V, dysphagia, oral/esophageal/gastric burns • Pulmonary – coughing, choking, stridor, aspiraQon, airway
edema/burns, pneumoniQs, respiratory distress • Neurologic – CNS depression, seizures, coma
Clinicians should be aware of these potenQal complicaQons, and monitor paQents for clinical deterioraQon in neurologic or respiratory status. More research must be done to determine which chemical compound or ingredient is responsible for the significantly increased clinical findings in exposure to LDPs, however it is hypothesized that propylene glycol, ethoxylated alcohols, and the surfactants contained in the pods may play a role.