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Household products
SPECIFIC SUBSTANCES
Household products
Talcum powders are occasionally inhaled by small children, and very rarely may cause severe pulmonary oedema and death. Nail polish, and nail polish remover contain a variety of solvents, including acetone (see Medicine 2012; 40(2): 88) and gamma butyrolactone. Both can cause coma and acetone may irritate mucous membranes, but few children who swallow it come to any harm and serious toxicity is rare. Perfumes contain ethanol, but quantities ingested usually cause no symptoms.
D Nicholas Bateman
Abstract Household products are generally accidentally ingested by children. In developing countries more toxic agents are available in a domestic setting, but in Western Europe serious toxicity is rare. Inappropriately aggressive interventions should be avoided.
Petroleum distillates Petroleum distillates, which include paraffin (kerosene) and white spirit, are among the most common causes of poisoning with household products. Aspiration is the major concern with these products. They are usually ingested and toxicity is low unless they are inhaled accidentally (as when siphoning petrol) or following vomiting. Occasionally the quantity taken may be sufficient to cause nausea, vomiting and diarrhoea. If large quantities are ingested, central nervous system (CNS) features occur: initial excitation followed by impaired consciousness, with its attendant hazards of aspiration. If petroleum distillates enter the respiratory tract they can spread widely because of their low surface tension. This may result in haemorrhagic pneumonitis, which causes breathlessness, wheezing and cyanosis. It is difficult to treat, and is occasionally fatal. Convulsions, intravascular haemolysis and pneumatoceles have been reported, but
Keywords batteries; bleach; detergent; household products; petroleum distillates
In the UK, poisoning with household products is usually accidental, and is most common among children aged between 9 months and 5 years. In this age group about a third of poisonings are caused by products listed in Table 1. Less commonly, alkalis such as sodium hydroxide and strong acids are involved. The exact amount ingested is seldom known. Container design and child-proof caps may make it difficult for children under 5 years of age to consume significant quantities. The morbidity from such episodes is low e less than 5% lead to symptoms. Children over 5 years old ingest household products less often, but are more likely to take medicines and alcohol or inhale the solvents in adhesives.
Some commonly ingested household products Bleach C Sodium hypochlorite C Hydrogen peroxide
Detergents and toiletries Details of the common ingredients of liquid detergents and toiletries can be obtained from TOXBASE or poisons information services, but the precise contents are of little clinical importance because almost none causes toxic effects other than nausea, vomiting and, perhaps, diarrhoea. Decontamination procedures such as charcoal are unnecessary and risks of gastric lavage far outweigh any potential benefit. No specific treatment is available, and symptomatic measures are not often required. Automatic dishwasher detergents and clothes washing liquid capsules are more toxic. Both are irritant, dishwasher products severely so, although most are difficult to swallow. Simple mouth and eye inspection is important, and often reassuring. ‘Liquitabs’ for dishwashers are attractive to children, more hazardous and may cause caustic injury, or drowsiness in young children.1 Other household items that may cause burns of the pharynx, larynx and oesophagus include sterilizing tablets containing dichloroisocyanurate, and some denture-cleaning tablets containing perborates, sulphates, carbonates and phosphates. These have corrosive effects if left in contact with mucosal surfaces.2,3 Corrosives are considered elsewhere in this issue (pages 118-120).4
Cosmetics and toiletries Cologne C Hair remover containing thioglycollate C Perfume C Aftershave lotion C Creams and lotions C Nail polish C Nail polish remover C
Detergents Washing-up liquid C Fabric conditioner C Soap C Automatic washing/dishwashing machine liquid/‘liquitabs’ C
Disinfectants Dichlorometaxylenol C Phenol C Cresol C
Petroleum distillates Paint thinner C Paintbrush cleaner C Paraffin C Turpentine substitute C Furniture and floor polish C
D Nicholas Bateman MD FRCP FRCPE FBPharmacolS FBTS FAACT is Professor in Clinical Toxicology and Director of the National Poisons Information Service (Edinburgh Unit) at the Royal Infirmary, Edinburgh, UK. He is a Past-President of the European Association of Poison Centres and Clinical Toxicologists. Competing interests: none declared.
MEDICINE 40:3
Table 1
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Ó 2011 Elsevier Ltd. All rights reserved.
SPECIFIC SUBSTANCES
Disc (button) batteries Disc batteries may be mercury, alkaline manganese or silver cells; mercury-containing batteries are now banned in the EU. They are widely available and are often swallowed by young children. There are three hazards. Obstruction batteries larger than about 20 mm in diameter may become stuck in the oesophagus, causing obstruction. A chest radiograph is therefore indicated in every case. Leakage ingested batteries may break open and release their contents. It is very rare for a potentially toxic amount of mercury to be absorbed from mercury cells. Corrosive effects batteries may 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 mercury and alkaline manganese types) and from local electrical discharges (possible only with batteries that retained much of their charge when swallowed).
Figure 1 Ingestion of 500e600 mL white spirit can lead to coma and diarrhoea. The skin appearances of defatting are seen in this patient.
are uncommon. Prolonged contact with skin leads to defatting (Figure 1) and acute inflammatory changes.5,6 Management In most cases, petroleum distillate ingestion requires no treatment. Emesis and lavage are absolutely contraindicated as they may lead to aspiration of the poison. However, if a large volume (probably more than 1 mL/kg body weight) has been ingested, gastric aspiration may 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 corticosteroids and antibiotics are probably of no value in the treatment of lipoid pneumonia unless the presence of secondary infection is proven, in which case antibiotics should be used.
Management Disc batteries stuck in the oesophagus must be removed, preferably by endoscopic techniques with or without the use of magnets. Most batteries pass into the stomach without difficulty, however, 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 may take up to 1 week. This may be speeded by the aid of a laxative. There is controversy whether batteries that are slow to clear the gut should be removed surgically, to eliminate the risk of complications should the battery case disintegrate. A universal rule is impossible. Batteries whose casings are seen radiologically to be disintegrating should be removed.9,10 A
Bleaches, disinfectants and drain cleaners Bleaches usually contain sodium hypochlorite. At weak concentrations (<5%) that used to be found in the home symptoms are usually mild. With stronger bleaches, particularly >10% hypochlorite, that are now available features are more severe. Small amounts cause a sensation of burning. The oropharynx may 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. The gastrointestinal mucosa may become haemorrhagic, ulcerated and perforated. Incorrect mixing of agents may result in release of chlorine gas, and lung injury may also be a feature of large ingestions. Disinfectants usually contain dichlorometaxylenol, but phenol and/or cresol may be the main ingredients. Although these substances are potentially corrosive, problems seldom arise after accidental ingestion, probably because the quantities ingested from household products are small.7,8 In contrast, deliberate ingestion, particularly of phenol or cresols (or accidental consumption of drain cleaners, which contain sodium hydroxide) may lead to death from corrosive effects on the upper alimentary tract and systemic toxicity.
MEDICINE 40:3
REFERENCES 1 Williams H, Bateman DN, Thomas SHL, Thompson JP, Vale JA. The toxicity of liquid detergent capsules (Fabric cleaning liquid tablets). Clin Tox 2011; 49: 254. Abstract 240. 2 Krenzelok EP. Liquid automatic dishwashing detergents: a profile of toxicity. Ann Emerg Med 1989; 18: 111e4. 3 Johannsen HG, Mikkelsen JB, Larsen CF. Poisoning with household chemicals in children. Acta Paediatr 1995; 83: 1317e8. 4 Bateman DN. Corrosives. Medicine 2007; 35: 609e11. 5 Seymour FK, Henry JA. Assessment and management of acute poisoning by petroleum products. Hum Exp Toxicol 2001; 20: 551e62. 6 Henry JA. Composition and toxicity of petroleum products and their additives. Hum Exp Toxicol 1998; 17: 111e23. 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 Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125: 1168e77. 10 Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics 2010; 125: 1178e83.
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Ó 2011 Elsevier Ltd. All rights reserved.
Household products
Talcum powders are occasionally inhaled by small children, and very rarely may cause severe pulmonary oedema and death. Nail polish, and nail polish remover contain a variety of solvents, including acetone (see Medicine 2012; 40(2): 88) and gamma butyrolactone. Both can cause coma and acetone may irritate mucous membranes, but few children who swallow it come to any harm and serious toxicity is rare. Perfumes contain ethanol, but quantities ingested usually cause no symptoms.
D Nicholas Bateman
Abstract Household products are generally accidentally ingested by children. In developing countries more toxic agents are available in a domestic setting, but in Western Europe serious toxicity is rare. Inappropriately aggressive interventions should be avoided.
Petroleum distillates Petroleum distillates, which include paraffin (kerosene) and white spirit, are among the most common causes of poisoning with household products. Aspiration is the major concern with these products. They are usually ingested and toxicity is low unless they are inhaled accidentally (as when siphoning petrol) or following vomiting. Occasionally the quantity taken may be sufficient to cause nausea, vomiting and diarrhoea. If large quantities are ingested, central nervous system (CNS) features occur: initial excitation followed by impaired consciousness, with its attendant hazards of aspiration. If petroleum distillates enter the respiratory tract they can spread widely because of their low surface tension. This may result in haemorrhagic pneumonitis, which causes breathlessness, wheezing and cyanosis. It is difficult to treat, and is occasionally fatal. Convulsions, intravascular haemolysis and pneumatoceles have been reported, but
Keywords batteries; bleach; detergent; household products; petroleum distillates
In the UK, poisoning with household products is usually accidental, and is most common among children aged between 9 months and 5 years. In this age group about a third of poisonings are caused by products listed in Table 1. Less commonly, alkalis such as sodium hydroxide and strong acids are involved. The exact amount ingested is seldom known. Container design and child-proof caps may make it difficult for children under 5 years of age to consume significant quantities. The morbidity from such episodes is low e less than 5% lead to symptoms. Children over 5 years old ingest household products less often, but are more likely to take medicines and alcohol or inhale the solvents in adhesives.
Some commonly ingested household products Bleach C Sodium hypochlorite C Hydrogen peroxide
Detergents and toiletries Details of the common ingredients of liquid detergents and toiletries can be obtained from TOXBASE or poisons information services, but the precise contents are of little clinical importance because almost none causes toxic effects other than nausea, vomiting and, perhaps, diarrhoea. Decontamination procedures such as charcoal are unnecessary and risks of gastric lavage far outweigh any potential benefit. No specific treatment is available, and symptomatic measures are not often required. Automatic dishwasher detergents and clothes washing liquid capsules are more toxic. Both are irritant, dishwasher products severely so, although most are difficult to swallow. Simple mouth and eye inspection is important, and often reassuring. ‘Liquitabs’ for dishwashers are attractive to children, more hazardous and may cause caustic injury, or drowsiness in young children.1 Other household items that may cause burns of the pharynx, larynx and oesophagus include sterilizing tablets containing dichloroisocyanurate, and some denture-cleaning tablets containing perborates, sulphates, carbonates and phosphates. These have corrosive effects if left in contact with mucosal surfaces.2,3 Corrosives are considered elsewhere in this issue (pages 118-120).4
Cosmetics and toiletries Cologne C Hair remover containing thioglycollate C Perfume C Aftershave lotion C Creams and lotions C Nail polish C Nail polish remover C
Detergents Washing-up liquid C Fabric conditioner C Soap C Automatic washing/dishwashing machine liquid/‘liquitabs’ C
Disinfectants Dichlorometaxylenol C Phenol C Cresol C
Petroleum distillates Paint thinner C Paintbrush cleaner C Paraffin C Turpentine substitute C Furniture and floor polish C
D Nicholas Bateman MD FRCP FRCPE FBPharmacolS FBTS FAACT is Professor in Clinical Toxicology and Director of the National Poisons Information Service (Edinburgh Unit) at the Royal Infirmary, Edinburgh, UK. He is a Past-President of the European Association of Poison Centres and Clinical Toxicologists. Competing interests: none declared.
MEDICINE 40:3
Table 1
125
Ó 2011 Elsevier Ltd. All rights reserved.
SPECIFIC SUBSTANCES
Disc (button) batteries Disc batteries may be mercury, alkaline manganese or silver cells; mercury-containing batteries are now banned in the EU. They are widely available and are often swallowed by young children. There are three hazards. Obstruction batteries larger than about 20 mm in diameter may become stuck in the oesophagus, causing obstruction. A chest radiograph is therefore indicated in every case. Leakage ingested batteries may break open and release their contents. It is very rare for a potentially toxic amount of mercury to be absorbed from mercury cells. Corrosive effects batteries may 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 mercury and alkaline manganese types) and from local electrical discharges (possible only with batteries that retained much of their charge when swallowed).
Figure 1 Ingestion of 500e600 mL white spirit can lead to coma and diarrhoea. The skin appearances of defatting are seen in this patient.
are uncommon. Prolonged contact with skin leads to defatting (Figure 1) and acute inflammatory changes.5,6 Management In most cases, petroleum distillate ingestion requires no treatment. Emesis and lavage are absolutely contraindicated as they may lead to aspiration of the poison. However, if a large volume (probably more than 1 mL/kg body weight) has been ingested, gastric aspiration may 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 corticosteroids and antibiotics are probably of no value in the treatment of lipoid pneumonia unless the presence of secondary infection is proven, in which case antibiotics should be used.
Management Disc batteries stuck in the oesophagus must be removed, preferably by endoscopic techniques with or without the use of magnets. Most batteries pass into the stomach without difficulty, however, 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 may take up to 1 week. This may be speeded by the aid of a laxative. There is controversy whether batteries that are slow to clear the gut should be removed surgically, to eliminate the risk of complications should the battery case disintegrate. A universal rule is impossible. Batteries whose casings are seen radiologically to be disintegrating should be removed.9,10 A
Bleaches, disinfectants and drain cleaners Bleaches usually contain sodium hypochlorite. At weak concentrations (<5%) that used to be found in the home symptoms are usually mild. With stronger bleaches, particularly >10% hypochlorite, that are now available features are more severe. Small amounts cause a sensation of burning. The oropharynx may 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. The gastrointestinal mucosa may become haemorrhagic, ulcerated and perforated. Incorrect mixing of agents may result in release of chlorine gas, and lung injury may also be a feature of large ingestions. Disinfectants usually contain dichlorometaxylenol, but phenol and/or cresol may be the main ingredients. Although these substances are potentially corrosive, problems seldom arise after accidental ingestion, probably because the quantities ingested from household products are small.7,8 In contrast, deliberate ingestion, particularly of phenol or cresols (or accidental consumption of drain cleaners, which contain sodium hydroxide) may lead to death from corrosive effects on the upper alimentary tract and systemic toxicity.
MEDICINE 40:3
REFERENCES 1 Williams H, Bateman DN, Thomas SHL, Thompson JP, Vale JA. The toxicity of liquid detergent capsules (Fabric cleaning liquid tablets). Clin Tox 2011; 49: 254. Abstract 240. 2 Krenzelok EP. Liquid automatic dishwashing detergents: a profile of toxicity. Ann Emerg Med 1989; 18: 111e4. 3 Johannsen HG, Mikkelsen JB, Larsen CF. Poisoning with household chemicals in children. Acta Paediatr 1995; 83: 1317e8. 4 Bateman DN. Corrosives. Medicine 2007; 35: 609e11. 5 Seymour FK, Henry JA. Assessment and management of acute poisoning by petroleum products. Hum Exp Toxicol 2001; 20: 551e62. 6 Henry JA. Composition and toxicity of petroleum products and their additives. Hum Exp Toxicol 1998; 17: 111e23. 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 Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125: 1168e77. 10 Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics 2010; 125: 1178e83.
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Ó 2011 Elsevier Ltd. All rights reserved.