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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

HOUSEHOLD HAZARDS

Kent R. Olson, MD

Medical Director, SF Division

California Poison Control System

household poisons
Household Poisons
  • Medicine cabinet: Rx and OTC
  • Under the sink:
    • Drain cleaners
    • Soaps & detergents
    • Rat poison
  • In the garage:
    • Solvents
    • Antifreeze
    • Pesticides
slide3
More . . .
  • Living room:
    • Lamp oil
    • Record/CD cleaner
    • Leftover beer, wine, coke, speed, …
  • Outside:
    • Snail bait
    • Herbicides & fertilizers
    • Plants & mushrooms
slide4
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
citronella continued
Citronella, continued . . .
  • On the following day the CXR showed bilateral infiltrates
  • Child did fine, home on Day 3
hydrocarbon aspiration
Hydrocarbon aspiration
  • Common exposure in children:
    • Lighter fluid
    • Furniture polish
    • Lamp oil
  • Initial coughing, choking common
  • CXR findings may be delayed
slide7
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 = ?
coma continued
Coma, continued . . .
  • No response to naloxone
  • Several hours later:
    • BP 59/33
    • HR 70/min
  • After IV fluids:
    • BP 100/54
    • HR 90
coma continued1
Coma, continued . . .
  • Special toxcology study was positive for CLONIDINE

Household trivia question:

WHAT OTC PRODUCT(S) CAN PRODUCE TOXICITY IDENTICAL TO CLONIDINE?

answer
Answer:
  • Imidazolines
    • Visine™ (tetrahydrozoline)
    • Afrin™ (oxymetazoline)
  • All are alpha2 agonists:
    • CNS-mediated lethargy, hypotension, bradycardia, miosis
    • Peripheral alpha1 effects can cause hypertension (usually transient)
glass case
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 !!
glassman continued
Glassman, continued . . .
  • Admitted to ingesting several boxes of RAT POISON
superwarfarins
“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
rat poison continued
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!!
blue baby
Blue baby
  • 17 month old infant turned blue after eating crayons
  • Awake, alert but irritable
  • Pulse ox 89%
blue continued
Blue, continued . . .
  • Methemoglobin level 39%
  • Treated with methylene blue, 0.1 cc/kg IV and did well

BLUE CRAYONS = RED HERRINGS?

blue continued1
Blue, continued . . .
  • The mother found an open container of Oragel™
  • Missing ½ - ¾ teaspoon
  • Contents: benzocaine 20%
benzocaine
Benzocaine
  • Topical anesthetic, in a variety of OTC and Rx products
    • Orajel™
    • Lanacaine™
    • Hurricaine™
  • Benzocaine  aniline in some pts
  • Prilocaine can also induce Methgb
rub a dub dub
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
isopropyl alcohol
Isopropyl alcohol
  • 3-carbon alcohol
  • Potent intoxicant:
    • About 2:1 compared to EtOH
  • IPA may partially cross-react with EtOH assay
osmolar gap
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
slide24

METHANOL

ELEVATED

OSMOLAR GAP

FORMALDEHYDE

ANION GAP

ACIDOSIS

FORMIC ACID

slide25

METHANOL

CONVERSION CATALYZED

BY ALCOHOL DEHDROGENASE

CAN BE BLOCKED BY

ETHANOL or FOMEPIZOLE

FORMALDEHYDE

isopropyl continued
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
isopropyl baby continued
Isopropyl baby, continued . . .
  • Child’s BP responded to IV fluids
  • Extubated the next day
  • Full recovery with supportive care
bad bathroom cleaning idea
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
bad idea cont
Bad idea, cont. . .
  • Worsening respiratory distress, bronchospasm, pulse ox 80%
  • Required intubation, ICU care
  • Eventual recovery, but some persistent reactive airway disease
chlorine gas
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
health shake shakes
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
shake continued
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
cholinesterase inhibitors
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
op poisoning treatment
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
a final stumper
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
more info
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
and more
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
and the answer
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
common causes of seizures
Common causes of seizures
  • Amphetamines, cocaine
  • Tricyclic antidepressants
  • Diphenhydramine
  • Isoniazid
  • Camphor
  • . . . many others
the bottle contained
The bottle contained . . .
  • . . .ERYTHROMYCIN
  • The child had spontaneous improvement over several hours and eventually recovered fully
ok the answer is
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