- Email: [email protected]
Household products
SPECIFIC SUBSTANCES
Household products
These capsules are easy to use, providing the exact unit dose of detergent per wash and are placed directly into the washing machine. The capsules are designed to release their contents when they come into contact with water, and this can happen prematurely if they come into contact with moisture, for example in the hands or mouth. As a result, there have been a substantial number of exposures reported in recent years, predominantly involving children <5 years of age.2,3e6 While the majority of patients remain asymptomatic or suffer only minor features (PSS 1), a small proportion develop features such as central nervous system (CNS) depression, stridor, pulmonary aspiration and/or airway burns following ingestion, and conjunctivitis leading to corneal ulceration from eye exposure.2,3
Allister Vale
Abstract Household products are generally ingested accidentally by children. In developing countries more toxic agents are available in a domestic setting, but in the developed world serious toxicity is rare.
Keywords Batteries; bleach; detergents; disinfectants; petroleum distillates; reed diffusers
Introduction Bleaches Household cleaning products account for some 10% of exposures reported to the UK National Poisons Information Service (NPIS) and 8% of exposures reported to the American Association of Poisons Control Centers National Poison Data System, which is not surprising considering their ubiquitous nature in a home. In a study reported by the UK NPIS, of 5939 enquiries regarding exposures to household products,1 exposures were most common among children <5 years of age (66.5% of exposures). The majority of exposures occurred at home (97.6%) and most were accidental (93.6%). Liquid laundry detergent capsules were most commonly involved (n ¼ 647), followed by bleaches (n ¼ 481), air fresheners (n ¼ 429), multipurpose cleaners (n ¼ 408), dishwasher products (n ¼ 399) and descalers (n ¼ 397). Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burns (skin contact). The majority of patients (70.5%) were asymptomatic (World Health Organization/ International Programme on Chemical Safety/European Commission/European Association of Poisons Centres and Clinical Toxicologists Poisoning Severity Score [PSS] 0), 28.0% developed minor features (PSS 1), 1.3% developed moderate features (PSS 2) and 0.15% (nine patients) developed serious features (PSS 3).
Bleaches are used to whiten clothes and remove stains (and as disinfectants e see below). Most household bleaches contain sodium hypochlorite, but others contain 6% hydrogen peroxide. Following the ingestion of weak concentrations of sodium hypochlorite (<5%), symptoms are usually mild. With stronger bleaches, particularly >10% hypochlorite, features are more severe. Small amounts cause a sensation of burning. The oropharynx can look mildly inflamed but burns are unlikely. Larger doses cause nausea, retching, vomiting, diarrhoea and rarely haematemesis. In severe cases, a hypernatraemic hyperchloraemic acidosis, hypotension, coma, convulsions and cardiorespiratory arrest can occur.7,8 The gastrointestinal mucosa can become haemorrhagic, ulcerated and perforated. Chlorine is not released from bleach solutions in appreciable amounts under normal use conditions. However, the mixing of hypochlorite with acids (e.g. when cleaning the toilet bowl) can result in a substantial release of chlorine and lung injury. Mixing bleach with ammonia produces chloramine compounds (mainly monochloramine), which can produce severe chemical pneumonitis.9 Hydrogen peroxide causes toxicity via three main mechanisms: corrosive damage, oxygen gas formation and lipid peroxidation.10 Ingestion can cause irritation of the gastrointestinal tract with nausea, vomiting, haematemesis and foaming at the mouth; the foam can obstruct the respiratory tract or result in pulmonary aspiration. Painful gastric distension and belching can be caused by the liberation of large volumes of oxygen in the stomach. Blistering of the mucosae and oropharyngeal burns are common following ingestion of more concentrated solutions. Most inhalational exposures cause little more than coughing and transient dyspnoea.
Detergents Liquid laundry detergent capsules (also called single-use detergent sacs, laundry pods) have become an increasingly popular household product over the last decade. The capsules are a pouch of concentrated liquid laundry detergent in a watersoluble polyvinyl alcohol membrane that can be placed directly in a washing machine. In Europe, these liquid detergents most commonly contain anionic surfactants (20e35% per capsule), non-ionic surfactants (10e20%), propylene glycol (8e20%) and ethanol (2e5%), and have a pH of 7e9.
Disinfectants Disinfectants are antimicrobial agents. Previously, these solutions commonly contained phenol (carbolic acid) or cresol (cresylic acid), but these have largely been replaced by the less toxic chlorophenol or chloroxylenols (dichlorometaxylenol and parachlorometaxylenol). Quarternary ammonium compounds such as benzalkonium chloride, cetyl trimethylammonium bromide, cetylpyridinium chloride and benzethonium chloride are also used as disinfectants. Sodium hypochlorite and hydrogen peroxide (see above) are also effective disinfectants because they release chlorine and oxygen, respectively, which oxidizes the cell membrane of microorganisms.
Allister Vale MD FRCP FRCPE FRCPG FFOM FAACT FBTS FBPhS FEAPCCT is Director of the National Poisons Information Service (Birmingham Unit) at City Hospital, Birmingham, and Honorary Professor, University of Birmingham, UK. Competing interests: none declared.
MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Vale A, Household products, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2015.12.016
SPECIFIC SUBSTANCES
code through which it may be possible to identify the chemical composition. There are three potential hazards: Obstruction e batteries larger than about 20 millimetres in diameter can become stuck in the oesophagus, causing obstruction. A chest X-ray is therefore indicated in every case. Leakage e ingested batteries can break open and release their contents. Corrosive effects e batteries can cause local corrosive effects on the gut wall, with subsequent perforation. These effects result from leakage of sodium hydroxide or corrosive salts from the cells (particularly alkaline manganese types) and from local electrical discharges (possible only with batteries that retain much of their charge when swallowed). Disc batteries stuck in the oesophagus must be removed, preferably by endoscopic techniques with or without the use of magnets. However, most batteries pass into the stomach without difficulty and do not cause symptoms. In about 60% of cases, batteries transit the gut within 48 hours and no treatment is required. In the remainder, transit can take up to 1 week. This can be speeded by the aid of a laxative, or whole-bowel irrigation can be considered. There is controversy over whether batteries that are slow to clear the gut should be removed surgically, to eliminate the risk of complications should the battery case disintegrate. However, batteries whose casings are seen radiologically to be disintegrating should be removed.16,17
Chloroxylenols and chlorophenol These compounds can cause a burning sensation in the mouth and throat and vomiting. They can cause coma, hypothermia, hypotension and respiratory depression.11 If the product contains ethanol, this can exacerbate the CNS depression. Metabolic acidosis and bradycardia can occur and aspiration pneumonia and pulmonary oedema have been reported. These complications can arise following ingestion of a relatively small quantity. Ingestion of a large quantity of a phenolic disinfectant can cause renal impairment,12 which can be exacerbated by hypotension and fluid loss due to excessive vomiting.13 Quaternary ammonium compounds Concentrated solutions of these compounds (particularly those 10%) can cause immediate burning pain in the mouth, throat and abdomen, hypersalivation and ulceration of mucous membranes, followed by vomiting, haematemesis, diarrhoea and confusion.14 In severe cases, which are uncommon, there can be hypotension, shock, convulsions, respiratory paralysis and coma. Metabolic acidosis and increased liver enzyme activities can occur.15 Dermal burns have been reported with concentrated cetrimide, including solutions of 12% and 17%. Eye exposures can cause corneal damage.
Petroleum distillates Petroleum distillates, which include paraffin (kerosene) and white spirit, are among the most common exposures with household products worldwide. Nausea, vomiting and diarrhoea can follow ingestion. A double gastric fluid level may be visible on X-ray, the lower being the aqueous and the higher the hydrocarbon portion in the stomach. The greatest hazard from ingestion, however, is the associated risk of pulmonary aspiration, causing choking, coughing, wheeze, breathlessness and possibly cyanosis, hypoxia, fever and leucocytosis. The chest Xray may show shadowing in the mid or lower zones. These symptoms and signs may progress over 24e48 hours. Rarely, pleural effusions or pneumatocoeles develop. After substantial ingestion, systemic uptake can result in the features typical of the narcotic effects of more volatile hydrocarbons, with CNS depression, convulsions and cardiac arrhythmias. Prolonged contact with skin leads to defatting and acute inflammatory changes. In most cases, petroleum distillate ingestion requires no treatment. Emesis and lavage are absolutely contraindicated as they can lead to aspiration. However, if a large volume (probably more than 1 mL/kg body weight) has been ingested, gastric aspiration can be considered provided the lungs can be protected by insertion of a cuffed endotracheal tube. The value of gut decontamination has not been demonstrated in clinical trials. Activated charcoal is of no value. Supportive measures may be required in serious cases, but prophylactic corticosteroids and antibiotics are of no value. If the presence of secondary infection is proven, antibiotics should be used.
Reed diffusers Reed diffusers are popular household air fresheners and comprise vessels or jars made of glass, containing fragrance liquid and ‘wicking’ reeds, which act to diffuse the scent of the liquid. In addition to essential oils, the liquid commonly contains glycol ethers (propylene glycol monobutyl ether, dipropylene glycol monomethyl ether, dipropylene glycol n-butyl ether, dipropylene glycol methyl ether acetate); other ingredients and/ or alternatives are 3-methoxy-3-methyl-1-butanol, petroleum distillates (see above), ethanol and isopropanol. Experimentally, dipropylene glycol monomethyl ether causes CNS, respiratory and cardiac toxicity18,19 and dipropylene glycol n-butyl ether produces CNS toxicity.20 3-Methoxy-3-methyl-1butanol has caused CNS toxicity and oesophageal injury in children.21,22 The ingestion of ethanol and/or isopropanol can also induce CNS depression. The features of essential oil ingestion include dysaesthesia inside the mouth, nausea, vomiting, tachycardia, drowsiness and, in severe cases, convulsions and coma. Hence the chemicals present in reed diffusers are potentially very toxic, especially as they are often present in high concentrations. Despite the presence of chemicals known to cause CNS, respiratory, cardiac and ophthalmic toxicity, few patients with severe symptoms have been reported.23 A
Batteries
REFERENCES 1 Williams H, Moyns E, Bateman DN, et al. Hazard of household cleaning products: a study undertaken by the UK National Poisons Information Service. Clin Toxicol 2012; 50: 770e5.
These are mainly alkaline (nickel, lithium, cadmium, manganese dioxide, zinc, silver); mercuric oxide batteries are now banned in the European Union. Disc (button) batteries are imprinted with a
MEDICINE --:-
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Vale A, Household products, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2015.12.016
SPECIFIC SUBSTANCES
13 Chan TY, Critchley JA. Is chloroxylenol nephrotoxic like phenol? A study of patients with Dettol poisoning. Vet Hum Toxicol 1994; 36: 250e1. 14 Hitosugi M, Maruyama K, Takatsu A. A case of fatal benzalkonium chloride poisoning. Int J Legal Med 1998; 111: 265e6. 15 van Berkel M, de Wolff FA. Survival after acute benzalkonium chloride poisoning. Hum Toxicol 1988; 7: 191e3. 16 Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125: 1168e77. 17 Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics 2010; 125: 1178e83. 18 Shideman FE, Procita L. The pharmacology of the mono methyl ethers of mono-, di-, and tripropylene glycol in the dog with observations on the auricular fibrillation produced by these compounds. J Pharmacol Exp Ther 1951; 102: 79e87. 19 Rowe VK. Toxicology of mono-, di- and tripropylene glycol methyl ethers. Arch Ind Hyg Occup Med 1954; 9: 509e25. 20 Myers RC, Tyler TR. Acute toxicologic evaluation of dipropylene glycol monobutyl ether. J Am Coll Toxicol Part B 1992; 1: 172. 21 Staton-Growcock ST, Sztajnkrycer MD. First reported human oral exposure to a reed diffuser air freshener containing 3-methoxy-3methyl-1-butanol (MMB). Clin Toxicol 2007; 45: 612. 22 Strickland SS, Whitlow KS. Toxic effects from human oral exposure to 3-methoxy-3-methyl-1-butanol (MMB). Clin Toxicol 2008; 46: 643. 23 Panchal B, Eddleston M, Thomas SHL, et al. 754 exposures to reed diffusers reported to the United Kingdom National Poisons Information Service 2010-2014. Clin Toxicol 2016; online early: http://dx.doi.org/10.3109/15563650.2016.1140772.
2 Williams H, Bateman DN, Thomas SHL, et al. Exposure to liquid detergent capsules: a study undertaken by the UK National Poisons Information Service. Clin Toxicol 2012; 50: 776e80. 3 Williams H, Jones S, Wood K, et al. Reported toxicity in 1486 liquid detergent capsule exposures to the UK National Poisons Information Service 2009e2012, including their ophthalmic and CNS effects. Clin Toxicol 2014; 52: 136e40. 4 Huntington S, Heppner J, Vohra R, et al. Serious adverse effects from single-use detergent sacs: report from a U.S. statewide poison control system. Clin Toxicol 2014; 52: 220e5. 5 Forrester MB. Referral of pediatric laundry detergent pack exposure reported to poison centers. J Emerg Med 2014; 47: 532e8. 6 Valdez AL, Casavant MJ, Spiller HA, et al. Pediatric exposure to laundry detergent pods. Pediatrics 2014; 134: 1127e35. 7 Racioppi F, Daskaleros PA, Besbelli N, et al. Household bleaches based on sodium hypochlorite: review of acute toxicology and Poison Control Center experience. Food Chem Toxicol 1994; 32: 845e61. 8 Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope 1997; 107: 122e5. 9 Reisz GR, Gammon S. Toxic pneumonitis from mixing household cleaners. Chest 1986; 89: 49e52. 10 Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide poisoning. Toxicol Rev 2004; 23: 5157. 11 Bradberry SM, Vale JA. Common chemical poisonings: phenol and related compounds. In: Bateman DN, Jefferson RD, Thomas SHL, et al., eds. Oxford desk reference: toxicology. Oxford: Oxford University Press, 2014; 257e9. 12 Watson ID, McBride D, Paterson K. Fatal xylenol self-poisoning. Postgrad Med J 1986; 62: 411e2.
MEDICINE --:-
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Vale A, Household products, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2015.12.016
Household products
These capsules are easy to use, providing the exact unit dose of detergent per wash and are placed directly into the washing machine. The capsules are designed to release their contents when they come into contact with water, and this can happen prematurely if they come into contact with moisture, for example in the hands or mouth. As a result, there have been a substantial number of exposures reported in recent years, predominantly involving children <5 years of age.2,3e6 While the majority of patients remain asymptomatic or suffer only minor features (PSS 1), a small proportion develop features such as central nervous system (CNS) depression, stridor, pulmonary aspiration and/or airway burns following ingestion, and conjunctivitis leading to corneal ulceration from eye exposure.2,3
Allister Vale
Abstract Household products are generally ingested accidentally by children. In developing countries more toxic agents are available in a domestic setting, but in the developed world serious toxicity is rare.
Keywords Batteries; bleach; detergents; disinfectants; petroleum distillates; reed diffusers
Introduction Bleaches Household cleaning products account for some 10% of exposures reported to the UK National Poisons Information Service (NPIS) and 8% of exposures reported to the American Association of Poisons Control Centers National Poison Data System, which is not surprising considering their ubiquitous nature in a home. In a study reported by the UK NPIS, of 5939 enquiries regarding exposures to household products,1 exposures were most common among children <5 years of age (66.5% of exposures). The majority of exposures occurred at home (97.6%) and most were accidental (93.6%). Liquid laundry detergent capsules were most commonly involved (n ¼ 647), followed by bleaches (n ¼ 481), air fresheners (n ¼ 429), multipurpose cleaners (n ¼ 408), dishwasher products (n ¼ 399) and descalers (n ¼ 397). Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burns (skin contact). The majority of patients (70.5%) were asymptomatic (World Health Organization/ International Programme on Chemical Safety/European Commission/European Association of Poisons Centres and Clinical Toxicologists Poisoning Severity Score [PSS] 0), 28.0% developed minor features (PSS 1), 1.3% developed moderate features (PSS 2) and 0.15% (nine patients) developed serious features (PSS 3).
Bleaches are used to whiten clothes and remove stains (and as disinfectants e see below). Most household bleaches contain sodium hypochlorite, but others contain 6% hydrogen peroxide. Following the ingestion of weak concentrations of sodium hypochlorite (<5%), symptoms are usually mild. With stronger bleaches, particularly >10% hypochlorite, features are more severe. Small amounts cause a sensation of burning. The oropharynx can look mildly inflamed but burns are unlikely. Larger doses cause nausea, retching, vomiting, diarrhoea and rarely haematemesis. In severe cases, a hypernatraemic hyperchloraemic acidosis, hypotension, coma, convulsions and cardiorespiratory arrest can occur.7,8 The gastrointestinal mucosa can become haemorrhagic, ulcerated and perforated. Chlorine is not released from bleach solutions in appreciable amounts under normal use conditions. However, the mixing of hypochlorite with acids (e.g. when cleaning the toilet bowl) can result in a substantial release of chlorine and lung injury. Mixing bleach with ammonia produces chloramine compounds (mainly monochloramine), which can produce severe chemical pneumonitis.9 Hydrogen peroxide causes toxicity via three main mechanisms: corrosive damage, oxygen gas formation and lipid peroxidation.10 Ingestion can cause irritation of the gastrointestinal tract with nausea, vomiting, haematemesis and foaming at the mouth; the foam can obstruct the respiratory tract or result in pulmonary aspiration. Painful gastric distension and belching can be caused by the liberation of large volumes of oxygen in the stomach. Blistering of the mucosae and oropharyngeal burns are common following ingestion of more concentrated solutions. Most inhalational exposures cause little more than coughing and transient dyspnoea.
Detergents Liquid laundry detergent capsules (also called single-use detergent sacs, laundry pods) have become an increasingly popular household product over the last decade. The capsules are a pouch of concentrated liquid laundry detergent in a watersoluble polyvinyl alcohol membrane that can be placed directly in a washing machine. In Europe, these liquid detergents most commonly contain anionic surfactants (20e35% per capsule), non-ionic surfactants (10e20%), propylene glycol (8e20%) and ethanol (2e5%), and have a pH of 7e9.
Disinfectants Disinfectants are antimicrobial agents. Previously, these solutions commonly contained phenol (carbolic acid) or cresol (cresylic acid), but these have largely been replaced by the less toxic chlorophenol or chloroxylenols (dichlorometaxylenol and parachlorometaxylenol). Quarternary ammonium compounds such as benzalkonium chloride, cetyl trimethylammonium bromide, cetylpyridinium chloride and benzethonium chloride are also used as disinfectants. Sodium hypochlorite and hydrogen peroxide (see above) are also effective disinfectants because they release chlorine and oxygen, respectively, which oxidizes the cell membrane of microorganisms.
Allister Vale MD FRCP FRCPE FRCPG FFOM FAACT FBTS FBPhS FEAPCCT is Director of the National Poisons Information Service (Birmingham Unit) at City Hospital, Birmingham, and Honorary Professor, University of Birmingham, UK. Competing interests: none declared.
MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Vale A, Household products, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2015.12.016
SPECIFIC SUBSTANCES
code through which it may be possible to identify the chemical composition. There are three potential hazards: Obstruction e batteries larger than about 20 millimetres in diameter can become stuck in the oesophagus, causing obstruction. A chest X-ray is therefore indicated in every case. Leakage e ingested batteries can break open and release their contents. Corrosive effects e batteries can cause local corrosive effects on the gut wall, with subsequent perforation. These effects result from leakage of sodium hydroxide or corrosive salts from the cells (particularly alkaline manganese types) and from local electrical discharges (possible only with batteries that retain much of their charge when swallowed). Disc batteries stuck in the oesophagus must be removed, preferably by endoscopic techniques with or without the use of magnets. However, most batteries pass into the stomach without difficulty and do not cause symptoms. In about 60% of cases, batteries transit the gut within 48 hours and no treatment is required. In the remainder, transit can take up to 1 week. This can be speeded by the aid of a laxative, or whole-bowel irrigation can be considered. There is controversy over whether batteries that are slow to clear the gut should be removed surgically, to eliminate the risk of complications should the battery case disintegrate. However, batteries whose casings are seen radiologically to be disintegrating should be removed.16,17
Chloroxylenols and chlorophenol These compounds can cause a burning sensation in the mouth and throat and vomiting. They can cause coma, hypothermia, hypotension and respiratory depression.11 If the product contains ethanol, this can exacerbate the CNS depression. Metabolic acidosis and bradycardia can occur and aspiration pneumonia and pulmonary oedema have been reported. These complications can arise following ingestion of a relatively small quantity. Ingestion of a large quantity of a phenolic disinfectant can cause renal impairment,12 which can be exacerbated by hypotension and fluid loss due to excessive vomiting.13 Quaternary ammonium compounds Concentrated solutions of these compounds (particularly those 10%) can cause immediate burning pain in the mouth, throat and abdomen, hypersalivation and ulceration of mucous membranes, followed by vomiting, haematemesis, diarrhoea and confusion.14 In severe cases, which are uncommon, there can be hypotension, shock, convulsions, respiratory paralysis and coma. Metabolic acidosis and increased liver enzyme activities can occur.15 Dermal burns have been reported with concentrated cetrimide, including solutions of 12% and 17%. Eye exposures can cause corneal damage.
Petroleum distillates Petroleum distillates, which include paraffin (kerosene) and white spirit, are among the most common exposures with household products worldwide. Nausea, vomiting and diarrhoea can follow ingestion. A double gastric fluid level may be visible on X-ray, the lower being the aqueous and the higher the hydrocarbon portion in the stomach. The greatest hazard from ingestion, however, is the associated risk of pulmonary aspiration, causing choking, coughing, wheeze, breathlessness and possibly cyanosis, hypoxia, fever and leucocytosis. The chest Xray may show shadowing in the mid or lower zones. These symptoms and signs may progress over 24e48 hours. Rarely, pleural effusions or pneumatocoeles develop. After substantial ingestion, systemic uptake can result in the features typical of the narcotic effects of more volatile hydrocarbons, with CNS depression, convulsions and cardiac arrhythmias. Prolonged contact with skin leads to defatting and acute inflammatory changes. In most cases, petroleum distillate ingestion requires no treatment. Emesis and lavage are absolutely contraindicated as they can lead to aspiration. However, if a large volume (probably more than 1 mL/kg body weight) has been ingested, gastric aspiration can be considered provided the lungs can be protected by insertion of a cuffed endotracheal tube. The value of gut decontamination has not been demonstrated in clinical trials. Activated charcoal is of no value. Supportive measures may be required in serious cases, but prophylactic corticosteroids and antibiotics are of no value. If the presence of secondary infection is proven, antibiotics should be used.
Reed diffusers Reed diffusers are popular household air fresheners and comprise vessels or jars made of glass, containing fragrance liquid and ‘wicking’ reeds, which act to diffuse the scent of the liquid. In addition to essential oils, the liquid commonly contains glycol ethers (propylene glycol monobutyl ether, dipropylene glycol monomethyl ether, dipropylene glycol n-butyl ether, dipropylene glycol methyl ether acetate); other ingredients and/ or alternatives are 3-methoxy-3-methyl-1-butanol, petroleum distillates (see above), ethanol and isopropanol. Experimentally, dipropylene glycol monomethyl ether causes CNS, respiratory and cardiac toxicity18,19 and dipropylene glycol n-butyl ether produces CNS toxicity.20 3-Methoxy-3-methyl-1butanol has caused CNS toxicity and oesophageal injury in children.21,22 The ingestion of ethanol and/or isopropanol can also induce CNS depression. The features of essential oil ingestion include dysaesthesia inside the mouth, nausea, vomiting, tachycardia, drowsiness and, in severe cases, convulsions and coma. Hence the chemicals present in reed diffusers are potentially very toxic, especially as they are often present in high concentrations. Despite the presence of chemicals known to cause CNS, respiratory, cardiac and ophthalmic toxicity, few patients with severe symptoms have been reported.23 A
Batteries
REFERENCES 1 Williams H, Moyns E, Bateman DN, et al. Hazard of household cleaning products: a study undertaken by the UK National Poisons Information Service. Clin Toxicol 2012; 50: 770e5.
These are mainly alkaline (nickel, lithium, cadmium, manganese dioxide, zinc, silver); mercuric oxide batteries are now banned in the European Union. Disc (button) batteries are imprinted with a
MEDICINE --:-
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Vale A, Household products, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2015.12.016
SPECIFIC SUBSTANCES
13 Chan TY, Critchley JA. Is chloroxylenol nephrotoxic like phenol? A study of patients with Dettol poisoning. Vet Hum Toxicol 1994; 36: 250e1. 14 Hitosugi M, Maruyama K, Takatsu A. A case of fatal benzalkonium chloride poisoning. Int J Legal Med 1998; 111: 265e6. 15 van Berkel M, de Wolff FA. Survival after acute benzalkonium chloride poisoning. Hum Toxicol 1988; 7: 191e3. 16 Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125: 1168e77. 17 Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics 2010; 125: 1178e83. 18 Shideman FE, Procita L. The pharmacology of the mono methyl ethers of mono-, di-, and tripropylene glycol in the dog with observations on the auricular fibrillation produced by these compounds. J Pharmacol Exp Ther 1951; 102: 79e87. 19 Rowe VK. Toxicology of mono-, di- and tripropylene glycol methyl ethers. Arch Ind Hyg Occup Med 1954; 9: 509e25. 20 Myers RC, Tyler TR. Acute toxicologic evaluation of dipropylene glycol monobutyl ether. J Am Coll Toxicol Part B 1992; 1: 172. 21 Staton-Growcock ST, Sztajnkrycer MD. First reported human oral exposure to a reed diffuser air freshener containing 3-methoxy-3methyl-1-butanol (MMB). Clin Toxicol 2007; 45: 612. 22 Strickland SS, Whitlow KS. Toxic effects from human oral exposure to 3-methoxy-3-methyl-1-butanol (MMB). Clin Toxicol 2008; 46: 643. 23 Panchal B, Eddleston M, Thomas SHL, et al. 754 exposures to reed diffusers reported to the United Kingdom National Poisons Information Service 2010-2014. Clin Toxicol 2016; online early: http://dx.doi.org/10.3109/15563650.2016.1140772.
2 Williams H, Bateman DN, Thomas SHL, et al. Exposure to liquid detergent capsules: a study undertaken by the UK National Poisons Information Service. Clin Toxicol 2012; 50: 776e80. 3 Williams H, Jones S, Wood K, et al. Reported toxicity in 1486 liquid detergent capsule exposures to the UK National Poisons Information Service 2009e2012, including their ophthalmic and CNS effects. Clin Toxicol 2014; 52: 136e40. 4 Huntington S, Heppner J, Vohra R, et al. Serious adverse effects from single-use detergent sacs: report from a U.S. statewide poison control system. Clin Toxicol 2014; 52: 220e5. 5 Forrester MB. Referral of pediatric laundry detergent pack exposure reported to poison centers. J Emerg Med 2014; 47: 532e8. 6 Valdez AL, Casavant MJ, Spiller HA, et al. Pediatric exposure to laundry detergent pods. Pediatrics 2014; 134: 1127e35. 7 Racioppi F, Daskaleros PA, Besbelli N, et al. Household bleaches based on sodium hypochlorite: review of acute toxicology and Poison Control Center experience. Food Chem Toxicol 1994; 32: 845e61. 8 Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope 1997; 107: 122e5. 9 Reisz GR, Gammon S. Toxic pneumonitis from mixing household cleaners. Chest 1986; 89: 49e52. 10 Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide poisoning. Toxicol Rev 2004; 23: 5157. 11 Bradberry SM, Vale JA. Common chemical poisonings: phenol and related compounds. In: Bateman DN, Jefferson RD, Thomas SHL, et al., eds. Oxford desk reference: toxicology. Oxford: Oxford University Press, 2014; 257e9. 12 Watson ID, McBride D, Paterson K. Fatal xylenol self-poisoning. Postgrad Med J 1986; 62: 411e2.
MEDICINE --:-
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Vale A, Household products, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2015.12.016