Chemical)Pneumoni.s)Aer)Laundry… · Chemical)Pneumoni.s)Aer)Laundry)Detergent)Pod)Inges.on)...

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.