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HOUSEHOLD HAZARDS

HOUSEHOLD HAZARDS. Kent R. Olson, MD Medical Director, SF Division California Poison Control System. Household Poisons. Medicine cabinet: Rx and OTC Under the sink: Drain cleaners Soaps & detergents Rat poison In the garage: Solvents Antifreeze Pesticides. More. Living room:

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HOUSEHOLD HAZARDS

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  1. HOUSEHOLD HAZARDS Kent R. Olson, MD Medical Director, SF Division California Poison Control System

  2. Household Poisons • Medicine cabinet: Rx and OTC • Under the sink: • Drain cleaners • Soaps & detergents • Rat poison • In the garage: • Solvents • Antifreeze • Pesticides

  3. More . . . • Living room: • Lamp oil • Record/CD cleaner • Leftover beer, wine, coke, speed, … • Outside: • Snail bait • Herbicides & fertilizers • Plants & mushrooms

  4. Case • 18 month old child with an open container of citronella oil, coughing • In ER: still coughing • pulse ox 97% • CXR: normal • Admitted overnight. Next AM: • T max 39.1 C • pulse ox 98% • CXR remained normal

  5. Citronella, continued . . . • On the following day the CXR showed bilateral infiltrates • Child did fine, home on Day 3

  6. Hydrocarbon aspiration • Common exposure in children: • Lighter fluid • Furniture polish • Lamp oil • Initial coughing, choking common • CXR findings may be delayed

  7. Coma • A 10 month old child was brought to the ER lethargic • BP 150/115, HR 60-90/min • Pupils small • CT scan negative • Initial Treatment = ?

  8. Coma, continued . . . • No response to naloxone • Several hours later: • BP 59/33 • HR 70/min • After IV fluids: • BP 100/54 • HR 90

  9. Coma, continued . . . • Special toxcology study was positive for CLONIDINE Household trivia question: WHAT OTC PRODUCT(S) CAN PRODUCE TOXICITY IDENTICAL TO CLONIDINE?

  10. Answer: • Imidazolines • Visine™ (tetrahydrozoline) • Afrin™ (oxymetazoline) • All are alpha2 agonists: • CNS-mediated lethargy, hypotension, bradycardia, miosis • Peripheral alpha1 effects can cause hypertension (usually transient)

  11. Glass case • A young man was seen eating pieces of glass and was brought to the ER • Vital signs normal • Routine blood work normal • INR 37 !!

  12. Glassman, continued . . . • Admitted to ingesting several boxes of RAT POISON

  13. “Superwarfarins” • Warfarin-like compounds • Brodifacoum, Bromadiolone, Others • Ultra long-acting • Effects may last for weeks-months • Treatment: • PT/INR at 36-48 hrs • If elevated, give Vitamin K (PO) • FFP for significant bleeding • May need to Rx for months

  14. Rat poison, continued . . . • The man was admitted and started on oral Vitamin K1 • A dose of ~ 200 mg/day was required to normalize the PT • One month later he presented to the ER with gingival bleeding flank pain and gross hematuria. He had missed several doses of Vit K. INR 92!!

  15. Blue baby • 17 month old infant turned blue after eating crayons • Awake, alert but irritable • Pulse ox 89%

  16. Blue, continued . . . • Methemoglobin level 39% • Treated with methylene blue, 0.1 cc/kg IV and did well BLUE CRAYONS = RED HERRINGS?

  17. Blue, continued . . . • The mother found an open container of Oragel™ • Missing ½ - ¾ teaspoon • Contents: benzocaine 20%

  18. Benzocaine • Topical anesthetic, in a variety of OTC and Rx products • Orajel™ • Lanacaine™ • Hurricaine™ • Benzocaine  aniline in some pts • Prilocaine can also induce Methgb

  19. Rub a dub dub • A 2 yo was found with a bottle of rubbing alcohol • In ER: • Comatose, intubated • BP 69/25, HR 107/min • Osm gap 103 mOsm/L • EtOH = 68 mg/dL • Only mild metabolic acidosis

  20. Isopropyl alcohol • 3-carbon alcohol • Potent intoxicant: • About 2:1 compared to EtOH • IPA may partially cross-react with EtOH assay

  21. Osmolar gap Osm = 2 (Na) + BUN/2.8 + Glucose/18 Osm “Gap” = Measured - Calculated Osm (normal gap = 0 + 5) • Causes of Osm Gap: • Ethanol • Isopropyl alcohol & Acetone • Methanol & Ethylene glycol • Other alcohols & glycols

  22. METHANOL ELEVATED OSMOLAR GAP FORMALDEHYDE ANION GAP ACIDOSIS FORMIC ACID

  23. METHANOL CONVERSION CATALYZED BY ALCOHOL DEHDROGENASE CAN BE BLOCKED BY ETHANOL or FOMEPIZOLE FORMALDEHYDE

  24. Isopropyl, continued . . . • Metabolized to ACETONE • Nail polish remover • Sweet smelling intoxicant • NOT an acid • Treatment: supportive • No need for EtOH, fomepizole • Dialysis might hasten awakening but not needed in most cases

  25. Isopropyl baby, continued . . . • Child’s BP responded to IV fluids • Extubated the next day • Full recovery with supportive care

  26. Bad bathroom cleaning idea • A 62 year old man developed acute coughing and dyspnea after mixing liquid bleach with toilet bowl cleaner to scrub the bathroom

  27. Bad idea, cont. . . • Worsening respiratory distress, bronchospasm, pulse ox 80% • Required intubation, ICU care • Eventual recovery, but some persistent reactive airway disease

  28. Chlorine gas • Original “war gas” • Highly irritating to mucous membranes • Eye, nose & throat irritation • Cough, bronchospasm • Pulmonary edema can occur with large exposure • Persistent pulmonary Sx in a few cases • Hypochlorite + acid  Cl gas

  29. Health shake shakes • A woman gave her husband a “health shake” • 30 min later he developed vomiting, abdominal cramps • Admitted to hospital with muscle twitching, weakness, sweating • Respiratory arrest  intubated

  30. Shake, continued . . . • An opened bottle of Sevin™ (containing carbaryl) was found at the home • The wife fled to Mexico • Captured 8 years later, convicted to attempted murder

  31. Cholinesterase inhibitors • Organophosphates and carbamates • Inhibit enzyme acetylcholinesterase • Buildup of excess Ach at nerve endings • Muscarinic effects: • Abdominal cramps, diarrhea, vomiting • Excessive salivation, sweating • Miosis • Nicotinic effects: • Muscle fasciculations  weakness

  32. OP Poisoning - Treatment • Decontaminate skin, discard clothing • Antidotes: • Atropine for muscarinic Sx • 2-PAM (pralidoxime) for muscle weakness • Not needed for carbamate poisoning • Prolonged Rx needed for some highly lipid-soluble OP’s

  33. A final stumper . . . • A 5 year old Laotian immigrant girl was brought to the ER at 3 AM very lethargic • She had started vomiting at 1 AM • BP 89/42, HR 103/min, R 16, T 97 • Pupils 4 mm

  34. More info . . . • According to the father, at 6 pm the previous evening the family had eaten a meal of steamed wild root • They collected it near the Berkeley Marina and considered it a tasty substitute for bamboo shoots • At 1 AM all 5 family members experienced nausea and vomiting; the 5 yo also had diarrhea

  35. And more . . . • Shortly after admission, the child’s pupils were noted to be dilated and poorly reactive • ABG: pH 6.8, pCO2 21, pO2 220 • Shortly after the blood gases were drawn, the child had a grand-mal seizure

  36. And the answer . . . ? • Additional Hx: one of the child’s siblings had recently been given a medicine for some type of lung infection, but they could not recall the name • A family member was sent home to retrieve the bottle

  37. Common causes of seizures • Amphetamines, cocaine • Tricyclic antidepressants • Diphenhydramine • Isoniazid • Camphor • . . . many others

  38. The bottle contained . . . • . . .ERYTHROMYCIN • The child had spontaneous improvement over several hours and eventually recovered fully

  39. OK, the answer is . . . • A blood CYANIDE level was 6 mg/L • Wild root was identified as PAMPAS GRASS • Usually nontoxic • At certain times of the year, it can produce cyanogenic glycosides

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