HOUSEHOLD HAZARDSHOUSEHOLD HAZARDS

Kent R. Olson, MDKent R. Olson, MDMedical Director, SF DivisionMedical Director, SF Division

California Poison Control SystemCalifornia Poison Control System

Household PoisonsHousehold Poisons

Medicine cabinet: Medicine cabinet: Rx and OTCRx and OTC Under the sink: Under the sink:

Drain cleaners Drain cleaners Soaps & detergentsSoaps & detergents Rat poisonRat poison

In the garage:In the garage: SolventsSolvents AntifreezeAntifreeze PesticidesPesticides

More . . .More . . .

Living room:Living room: Lamp oilLamp oil Record/CD cleanerRecord/CD cleaner Leftover beer, wine, coke, speed, …Leftover beer, wine, coke, speed, …

Outside:Outside: Snail baitSnail bait Herbicides & fertilizersHerbicides & fertilizers Plants & mushroomsPlants & mushrooms

CaseCase

18 month old child with an open 18 month old child with an open container of citronella oil, coughingcontainer of citronella oil, coughing

In ER: still coughingIn ER: still coughing pulse ox 97%pulse ox 97% CXR: normalCXR: normal

Admitted overnight. Next AM:Admitted overnight. Next AM: T max 39.1 CT max 39.1 C pulse ox 98%pulse ox 98% CXR remained normalCXR remained normal

Citronella, continued . . .Citronella, continued . . .

On the On the followingfollowing day day the CXR showed the CXR showed bilateral infiltratesbilateral infiltrates

Child did fine, Child did fine, home on Day 3home on Day 3

Hydrocarbon aspirationHydrocarbon aspiration

Common exposure in children:Common exposure in children: Lighter fluidLighter fluid Furniture polishFurniture polish Lamp oilLamp oil

Initial coughing, choking commonInitial coughing, choking common CXR findings may be delayedCXR findings may be delayed

Coma Coma

A 10 month old child was brought to A 10 month old child was brought to the ER lethargicthe ER lethargic BP 150/115, HR 60-90/minBP 150/115, HR 60-90/min Pupils smallPupils small CT scan negative CT scan negative

Initial Treatment = ?Initial Treatment = ?

Coma, continued . . . Coma, continued . . .

No response to naloxoneNo response to naloxone

Several hours later:Several hours later: BP 59/33BP 59/33 HR 70/minHR 70/min

After IV fluids:After IV fluids: BP 100/54BP 100/54 HR 90HR 90

Coma, continued . . . Coma, continued . . .

Special toxcology study was positive Special toxcology study was positive for CLONIDINEfor CLONIDINE

Household trivia question:Household trivia question:

WHAT OTC PRODUCT(S) CAN PRODUCE TOXICITY IDENTICAL TO

CLONIDINE?

WHAT OTC PRODUCT(S) CAN PRODUCE TOXICITY IDENTICAL TO

CLONIDINE?

Answer:Answer:

ImidazolinesImidazolines VisineVisine™™ (tetrahydrozoline) (tetrahydrozoline) AfrinAfrin™™ (oxymetazoline) (oxymetazoline)

All are alphaAll are alpha22 agonists: agonists: CNS-mediated lethargy, hypotension, CNS-mediated lethargy, hypotension,

bradycardia, miosisbradycardia, miosis Peripheral alphaPeripheral alpha11 effects can cause effects can cause

hypertension (usually transient)hypertension (usually transient)

Glass caseGlass case

A young man was seen eating pieces A young man was seen eating pieces of glass and was brought to the ERof glass and was brought to the ER

Vital signs normalVital signs normal Routine blood work normalRoutine blood work normal

INR 37 !!INR 37 !!

Glassman, continued . . . Glassman, continued . . .

Admitted to ingesting several boxes Admitted to ingesting several boxes of RAT POISONof RAT POISON

““Superwarfarins”Superwarfarins”

Warfarin-like compoundsWarfarin-like compounds Brodifacoum, Bromadiolone, OthersBrodifacoum, Bromadiolone, Others Ultra long-actingUltra long-acting Effects may last for weeks-monthsEffects may last for weeks-months

Treatment:Treatment: PT/INR at 36-48 hrsPT/INR at 36-48 hrs If elevated, give Vitamin K (PO)If elevated, give Vitamin K (PO)

FFP for significant bleedingFFP for significant bleeding May need to Rx for monthsMay need to Rx for months

Rat poison, continued . . . Rat poison, continued . . .

The man was admitted and started The man was admitted and started on oral Vitamin Kon oral Vitamin K11

A dose of ~ 200 mg/day was required A dose of ~ 200 mg/day was required to normalize the PTto normalize the PT

One month later he presented to the One month later he presented to the ER with gingival bleeding flank pain ER with gingival bleeding flank pain and gross hematuria. He had missed and gross hematuria. He had missed several doses of Vit K. several doses of Vit K. INR 92!!INR 92!!

Blue babyBlue baby

17 month old infant turned blue after 17 month old infant turned blue after eating crayonseating crayons

Awake, alert Awake, alert but irritablebut irritable

Pulse ox 89%Pulse ox 89%

Blue, continued . . .Blue, continued . . .

Methemoglobin level 39%Methemoglobin level 39%

Treated with methylene blue, 0.1 Treated with methylene blue, 0.1 cc/kg IV and did wellcc/kg IV and did well

BLUEBLUE CRAYONS = CRAYONS = REDRED HERRINGS? HERRINGS?BLUEBLUE CRAYONS = CRAYONS = REDRED HERRINGS? HERRINGS?

Blue, continued . . . Blue, continued . . .

The mother found an The mother found an open container of Oragelopen container of Oragel™™

Missing ½ - ¾ teaspoonMissing ½ - ¾ teaspoon

Contents: Contents: benzocaine 20%benzocaine 20%

BenzocaineBenzocaine

Topical anesthetic, in a variety of Topical anesthetic, in a variety of OTC and Rx productsOTC and Rx products OrajelOrajel™™ LanacaineLanacaine™™ HurricaineHurricaine™™

Benzocaine Benzocaine aniline in some ptsaniline in some pts Prilocaine can also induce MethgbPrilocaine can also induce Methgb

Rub a dub dubRub a dub dub

A 2 yo was found with a A 2 yo was found with a bottle of rubbing alcoholbottle of rubbing alcohol

In ER:In ER: Comatose, intubatedComatose, intubated BP 69/25, HR 107/minBP 69/25, HR 107/min Osm gap 103 mOsm/LOsm gap 103 mOsm/L EtOH = 68 mg/dLEtOH = 68 mg/dL Only mild metabolic acidosisOnly mild metabolic acidosis

Isopropyl alcoholIsopropyl alcohol

3-carbon alcohol3-carbon alcohol Potent intoxicant:Potent intoxicant:

About 2:1 compared About 2:1 compared to EtOHto EtOH

IPA may partially cross-react with IPA may partially cross-react with EtOH assayEtOH assay

Osmolar gapOsmolar gap

Osm = 2 (Na) + BUN/2.8 + Glucose/18Osm = 2 (Na) + BUN/2.8 + Glucose/18

Osm “Gap” = Measured - Calculated OsmOsm “Gap” = Measured - Calculated Osm

(normal gap = 0 (normal gap = 0 ++ 5) 5)

Causes of Osm Gap:Causes of Osm Gap: EthanolEthanol Isopropyl alcohol & AcetoneIsopropyl alcohol & Acetone Methanol & Ethylene glycolMethanol & Ethylene glycol Other alcohols & glycolsOther alcohols & glycols

METHANOLMETHANOLMETHANOLMETHANOL

FORMALDEHYDEFORMALDEHYDEFORMALDEHYDEFORMALDEHYDE

FORMIC ACIDFORMIC ACIDFORMIC ACIDFORMIC ACIDANION GAPACIDOSIS

ANION GAPACIDOSIS

ELEVATEDOSMOLAR GAP

ELEVATEDOSMOLAR GAP

METHANOLMETHANOLMETHANOLMETHANOL

FORMALDEHYDEFORMALDEHYDEFORMALDEHYDEFORMALDEHYDE

CONVERSION CATALYZEDCONVERSION CATALYZEDBY ALCOHOL DEHDROGENASEBY ALCOHOL DEHDROGENASE

CAN BE BLOCKED BYETHANOL or FOMEPIZOLE

CAN BE BLOCKED BYETHANOL or FOMEPIZOLE

Isopropyl, continued . . . Isopropyl, continued . . .

Metabolized to ACETONEMetabolized to ACETONE Nail polish removerNail polish remover Sweet smelling intoxicantSweet smelling intoxicant NOT an acidNOT an acid

Treatment: supportiveTreatment: supportive No need for EtOH, fomepizoleNo need for EtOH, fomepizole Dialysis might hasten awakening but Dialysis might hasten awakening but

not needed in most casesnot needed in most cases

Isopropyl baby, continued . . . Isopropyl baby, continued . . .

Child’s BP responded to IV fluidsChild’s BP responded to IV fluids Extubated the next dayExtubated the next day Full recovery with supportive careFull recovery with supportive care

Bad bathroom cleaning ideaBad bathroom cleaning idea

A 62 year old man developed acute A 62 year old man developed acute coughing and dyspnea after mixing coughing and dyspnea after mixing liquid bleach with toilet bowl cleaner liquid bleach with toilet bowl cleaner to scrub the bathroomto scrub the bathroom

Bad idea, cont. . .Bad idea, cont. . .

Worsening respiratory distress, Worsening respiratory distress, bronchospasm, pulse ox 80%bronchospasm, pulse ox 80%

Required intubation, ICU careRequired intubation, ICU care

Eventual recovery, but some Eventual recovery, but some persistent reactive airway diseasepersistent reactive airway disease

Chlorine gasChlorine gas

Original “war gas”Original “war gas” Highly irritating to mucous Highly irritating to mucous

membranesmembranes Eye, nose & throat irritationEye, nose & throat irritation Cough, bronchospasmCough, bronchospasm Pulmonary edema can occur with large Pulmonary edema can occur with large

exposureexposure Persistent pulmonary Sx in a few casesPersistent pulmonary Sx in a few cases

Hypochlorite + acid Hypochlorite + acid Cl gas Cl gas

Health shake shakesHealth shake shakes

A woman gave her A woman gave her husband a “health shake” husband a “health shake”

30 min later he developed 30 min later he developed vomiting, abdominal crampsvomiting, abdominal cramps

Admitted to hospital with muscle Admitted to hospital with muscle twitching, weakness, sweatingtwitching, weakness, sweating

Respiratory arrest Respiratory arrest intubated intubated

Shake, continued . . . Shake, continued . . .

An opened bottle of An opened bottle of SevinSevin™ (containing ™ (containing carbaryl) was found carbaryl) was found at the homeat the home

The wife fled to MexicoThe wife fled to Mexico Captured 8 years later, convicted to Captured 8 years later, convicted to

attempted murderattempted murder

Cholinesterase inhibitorsCholinesterase inhibitors

Organophosphates and carbamatesOrganophosphates and carbamates Inhibit enzyme acetylcholinesteraseInhibit enzyme acetylcholinesterase

Buildup of excess Ach at nerve endingsBuildup of excess Ach at nerve endings Muscarinic effects:Muscarinic effects:

Abdominal cramps, diarrhea, vomitingAbdominal cramps, diarrhea, vomiting Excessive salivation, sweatingExcessive salivation, sweating MiosisMiosis

Nicotinic effects:Nicotinic effects: Muscle fasciculations Muscle fasciculations weakness weakness

OP Poisoning - TreatmentOP Poisoning - Treatment

Decontaminate skin, discard clothingDecontaminate skin, discard clothing Antidotes:Antidotes:

AtropineAtropine for muscarinic Sx for muscarinic Sx 2-PAM2-PAM (pralidoxime) for muscle (pralidoxime) for muscle

weaknessweakness Not needed for carbamate poisoningNot needed for carbamate poisoning Prolonged Rx needed for some highly lipid-Prolonged Rx needed for some highly lipid-

soluble OP’ssoluble OP’s

A final stumper . . .A final stumper . . .

A 5 year old Laotian immigrant girl A 5 year old Laotian immigrant girl was brought to the ER at 3 AM very was brought to the ER at 3 AM very lethargiclethargic

She had started vomiting at 1 AMShe had started vomiting at 1 AM BP 89/42, HR 103/min, R 16, T 97BP 89/42, HR 103/min, R 16, T 97 Pupils 4 mmPupils 4 mm

More info . . .More info . . .

According to the father, at 6 pm the According to the father, at 6 pm the previous evening the family had previous evening the family had eaten a meal of steamed wild rooteaten a meal of steamed wild root

They collected it near the Berkeley They collected it near the Berkeley Marina and considered it a tasty Marina and considered it a tasty substitute for bamboo shoots substitute for bamboo shoots

At 1 AM all 5 family members At 1 AM all 5 family members experienced nausea and vomiting; experienced nausea and vomiting; the 5 yo also had diarrheathe 5 yo also had diarrhea

And more . . .And more . . .

Shortly after admission, the child’s Shortly after admission, the child’s pupils were noted to be dilated and pupils were noted to be dilated and poorly reactivepoorly reactive

ABG: pH 6.8, pCO2 21, pO2 220ABG: pH 6.8, pCO2 21, pO2 220 Shortly after the blood gases were Shortly after the blood gases were

drawn, the child had a grand-mal drawn, the child had a grand-mal seizureseizure

And the answer . . . ?And the answer . . . ?

Additional Hx: one of the child’s Additional Hx: one of the child’s siblings had recently been given a siblings had recently been given a medicine for some type of lung medicine for some type of lung infection, but they could not recall infection, but they could not recall the namethe name

A family member was sent home to A family member was sent home to retrieve the bottleretrieve the bottle

Common causes of seizuresCommon causes of seizures

Amphetamines, cocaineAmphetamines, cocaine Tricyclic antidepressantsTricyclic antidepressants DiphenhydramineDiphenhydramine IsoniazidIsoniazid CamphorCamphor . . . many others. . . many others

The bottle contained . . . The bottle contained . . .

. . .. . . ERYTHROMYCINERYTHROMYCIN

The child had spontaneous The child had spontaneous improvement over several hours and improvement over several hours and eventually recovered fullyeventually recovered fully

OK, the answer is . . .OK, the answer is . . .

A blood CYANIDE level was 6 mg/LA blood CYANIDE level was 6 mg/L

Wild root was Wild root was identified as identified as PAMPAS GRASSPAMPAS GRASS Usually nontoxicUsually nontoxic At certain times At certain times

of the year, of the year, it can produce cyanogenic glycosidesit can produce cyanogenic glycosides