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

CAMPHOR

MOTHBALL

NAPHTHALENE

PARADICHLORO- BENZENE (PDB)

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

OTHER HOUSEHOLD PRODUCTS

CONTAINING ETHYLENE GLYCOL

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

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

What can you do to avoid accidental household poisoning?

Thank You

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