Increases in exposure calls related to selected cleaners and disinfectants at the onset of the COVID-19 pandemic: data from Canadian poison centres

Little is known about the use or misuse of cleaning products during the COVID-19 pandemic. We compiled data from January to June in 2019 and 2020 from Canadian poison centres, and report on calls regarding selected cleaning products and present year-overyear percentage change. There were 3408 (42%) calls related to bleaches; 2015 (25%) to hand sanitizers; 1667 (21%) to disinfectants; 949 (12%) to chlorine gas; and 148 (2%) to chloramine gas. An increase in calls occurred in conjunction with the onset of COVID-19, with the largest increase occurring in March. Timely access to Canadian poison centre data facilitated early communication of safety messaging for dissemination to the public.

Auramine-o (Synthetic Yellow Cow Dung Powder) Poisoning: Rare but Fatal

INTRODUCTION

Cow dung known since long ago for its germicidal properties, used by Indian villagers to clean the house premises. As cow dung is not available easily, nowadays people have started using synthetic yellow coloured powder (Auramine-o) available easily in grocery shops locally known as "Morechap powder" in districts of Maharashtra. As the poisoning is rare, very few literatures are available mentioning the detailed mechanism of action, clinical presentation and complications.

AIM AND OBJECTIVE

To study the clinical features, treatment and outcomes of synthetic yellow cow dung powder poisoning.

MATERIAL AND METHODS

25 patients presenting with confirmed H/O consumption of (Auramine-o) synthetic yellow cow dung powder poisoning were studied. Patient's routine investigations BSL, RFT, LFT were done. CT brain was done whenever indicated.

RESULTS AND CONCLUSIONS

Synthetic yellow cow dung powder poisoning was common in young age group and females. Vomiting, respiratory depression were common symptoms. Synthetic yellow cow dung powder poisoning was needed only symptomatic treatment. It was very rare and mortality is low when treated promptly.

Pharyngeal cancer mortality among chemical plant workers exposed to formaldehyde

Objectives: To assess the possible relationship between formaldehyde exposure and mortality risk from pharyngeal cancer (PC), in particular nasopharyngeal cancer (NPC). Methods: Subjects were 7328 workers employed at a plastics-producing plant (1941-1984). Vital status for 98% of the cohort and cause of death for 95% of 2872 deaths were determined. Reconstructed exposures to formaldehyde, particulates and pigment were used to compute several exposure measures. Standardized mortality ratios (SMRs) were computed for several demographic, work history and formaldehyde exposure variables. In a nested case-control study, seven cases of NPC and 15 cases of other PC were matched on race, sex, age and year of birth to four controls from the cohort. Among interviewed subjects, lifetime smoking history was determined using respondents or proxies for all but one control subject. Results: Statistically significant 2.23-fold and fivefold excesses for PC and NPC, respectively, were observed. Fivefold range NPC excesses were observed for both short (B / 1 year) and long-term workers and were concentrated among workers hired during 1947-1956. Only three NPC cases were exposed to formaldehyde for longer than one year, and each had low average intensity of formaldehyde exposure (0.03-0.60 ppm). Only a few exposure measures revealed some evidence of an association with all PC or NPC. For all PC combined, adjustment for smoking and year-of-hire in the case-control study generally corroborated findings from the cohort study. Conclusions: Overall, the pattern of findings suggests that the large, persistent nasopharyngeal and other PC excesses observed among the Wallingford workforce are not associated with formaldehyde exposure, and may reflect the influence of nonoccupational risk factors or occupational risk factors associated with employment outside the Wallingford plant.

An unnatural death by propan-1-ol and propan-2-ol

A fatality of an inpatient ingesting a disinfectant containing ethanol, propan-1-ol, and propan-2-ol is reported. The alleged survival time was about 1 h. Major findings at autopsy were an extended hemorrhagic lung edema, an edematous brain, and shock kidneys. Concentrations of alcohols and acetone, a major metabolite of propan-2-ol, were determined from body fluids (blood from the heart and the femoral vein, urine, gastric contents) and tissues (brain, muscle, liver, kidneys, lungs) by headspace/gas chromatography using 2-methylpropan-2-ol as the internal standard. All samples investigated were positive for propan-1-ol, propan-2-ol, ethanol, and acetone except stomach contents, where acetone was not detectable. The low concentration of acetone compared to propan-2-ol likely supports the short survival time. The concentration ratios estimated from the results are in accordance with the physico-chemical properties of the particular alcohols, their different affinities towards alcohol dehydrogenase as well as their interdependence during biotransformation. Autopsy did not reveal the cause of death. According to the few published data, blood concentrations of 1.44 and 1.70 mg/g of propan-2-ol and propan-1-ol, respectively, are considered sufficient to have caused the death. This case also points to the need to restrict access to antiseptic solutions containing alcohols in wards with patients at risk.

Phenol Toxicity Following Cutaneous Exposure to Creolin®: A Case Report

INTRODUCTION

Phenol is a caustic that may cause cutaneous or gastrointestinal burns depending on the route of exposure. Significant absorption may result in systemic toxicity. We present a case of topical phenol exposure resulting in cutaneous burns and systemic phenol toxicity.

CASE REPORT

A 9-year-old girl was exposed to Creolin(®), a general-purpose disinfectant containing phenol, when her mother applied this product to her head and upper torso. The patient required endotracheal intubation due to depressed mental status; she had cutaneous erythema in the distribution of contact with the cleanser. An initial EKG revealed sinus tachycardia with brief runs of monomorphic ventricular tachycardia. On hospital day (HD) 1, the area of erythema extended to both upper extremities and hyperpigmentation developed over the affected areas, which continued to darken during the hospital course. The patient was extubated late on HD 1. On HD 2, the patient's urine was noted to be a dark green color that resolved later that day. On HD 3, areas of desquamation and decreased sensation developed in skin areas of maximal contact with the cleanser. The patient developed a mild transaminitis with peak AST and ALT levels of 84 units/l and 99 units/l, respectively. The patient was discharged to home on HD 4.

DISCUSSION

Our patient presented with signs of cutaneous and systemic phenol toxicity characterized by dermal burns, depressed mental status, cardiac dysrhythmias, and elevated hepatic transaminases. Phenol exposure may cause systemic toxicity following limited dermal exposure.

Dettol poisoning and the need for airway intervention

OBJECTIVES. To (1) characterise the clinical features of Dettol poisoning on a territory-wide basis, (2) assess the need for airway intervention after such poisoning and its time frame after ingestion, and (3) identify predictors for such an intervention. DESIGN. Case series. SETTING. Sixteen accident and emergency departments in Hong Kong. PATIENTS. Patients with Dettol ingestion who presented within 48 hours of ingestion from July 2005 to June 2009, derived from the database of the Hong Kong Poison Information Centre. RESULTS. In all, 213 patient records were identified, of which 36 were excluded based on pre-defined criteria and 177 were analysed. Among the latter, the median age was 32 (range, 2-95) years and the male-to-female ratio was 1:2.7 (48:129). Intentional ingestion constituted the majority (95%) of cases. The most common symptoms were related to the local irritative/corrosive effects on the aero-digestive tract, such as gastro-intestinal upset and localised throat pain. Airway intervention was required in 14 (8%) patients. All interventions were performed within 12 hours of Dettol ingestion and three cases involved re-intubation after extubation. Univariate analysis showed that a Glasgow Coma Scale score of <8, older age, a larger amount ingested, lip swelling, lung crackles, and wheezing were all associated with airway intervention. In the multivariate analysis using forward stepwise logistic regression, only coma (Glasgow Coma Scale score of <8) remained statistically significant. CONCLUSIONS. Delayed airway obstruction (>12 hours after Dettol ingestion) is unlikely. For those who are intubated, careful assessment of airway adequacy before extubation is strongly recommended to avoid extubation failure and subsequent re-intubation. Patients in coma (Glasgow Coma Scale score of <8) should prompt airway intervention.

Centers for Disease Control and Prevention. Acute illness and injury from swimming pool disinfectants and other chemicals--United States, 2002-2008

Swimming pools require disinfectants and other chemicals to maintain water quality and prevent swimmers from acquiring infections. When these chemicals are stored or used improperly or when they are handled or applied by persons not using appropriate personal protective equipment (PPE), illness or injury can result. To assess the frequency of illness and injury related to pool chemicals, CDC analyzed data for the period 2002--2008 from six states participating in the Sentinel Event Notification System for Occupational Risk (SENSOR)--Pesticides surveillance program and from the National Electronic Injury Surveillance System (NEISS). This report describes the results of that analysis, which identified 584 cases of illness or injury associated with pool chemicals in the six SENSOR-Pesticides states and indicated an estimated national total of 28,071 cases (based on 688 NEISS cases) during that period. For the 77% of state cases and 49% of NEISS cases that had sufficient information to determine factors contributing to illness or injury, the most common contributing factors included mixing incompatible products, spills and splashes of chemicals, lack of appropriate PPE use, and dust clouds or fumes generated by opening a chemical container. Adhering to existing CDC recommendations can prevent some of the reported illnesses and injuries, but additional measures (e.g., improving package design to limit the release of dust clouds and fumes when a container is opened, making containers child-proof, and making product labels easier to understand) might reduce them further.

Centers for Disease Control and Prevention (CDC). Chlorine gas exposure at a metal recycling facility--California, 2010

On June 8, 2010, chlorine gas was released from a ruptured, 1-ton, low-pressure tank being recycled at a California metal recycling facility. A total of 23 persons, including employees, customers, and workers at nearby businesses, were treated for the effects of the fumes at seven area hospitals. Chlorine is a corrosive, greenish-yellow gas that is heavier than air and can cause severe respiratory damage; it is used widely in water purification, sewage treatment, and disinfectant washes for foods. Following the incident, the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC collaborated with the California Department of Public Health (CDPH) on an Assessment of Chemical Exposures (ACE) to determine 1) the circumstances surrounding those exposed during the chlorine gas release, 2) health effects associated with exposures, and 3) recommendations for preventing recurrences. This report describes the chlorine gas release in California and summarizes the results of the ACE investigation. Of 29 persons potentially exposed to chlorine gas, 27 were interviewed to collect information regarding their exposures. In addition, information regarding acute health effects and symptoms was abstracted from medical records. At the time of the chlorine gas release, 15 persons were outdoors, and 13 were exposed for >30 minutes before they were decontaminated. Twenty-three persons reported experiencing one or more upper or lower respiratory tract symptoms within 24 hours of exposure; six persons were hospitalized for 1-11 days. Based on these findings, CDPH issued a statewide alert to all recycling facilities on how to handle containers with potential hazardous waste.

[System of biocide products control in Poland]

In this article we presented actual legislation concerning biocide products in Poland. Rules of reporting and archiving of biocide products exposure were discussed. We presented the first results of monitoring of biocide poisoning cases in Poland from July 2007 to June 2008.

[Case of serious renal failure induced by ingesting large volume of MAKIRON]

A 23-year-old male patient ingested 150 mL of MAKIRON in a suicide attempt and was transferred to the hospital emergency room approximately 30 hours after ingestion. Upon admission, components of MAKIRON, including naphazoline (1.4 microg/mL), chlorpheniramine (0.81 microg/mL), dibucaine (3.2 microg/mL) and benzethonium (5.5 microg/mL) were detected in the patient's plasma. Direct hemoperfusion and hemodiafiltration enforcement were carried out and the chemical components of MAKIRON were not detected the following day. At the time of hospitalization, the patient presented with serious hepatopathy, pneumonia and acute renal failure. The hepatopathy and pneumonia resolved several days later; however, the patient required continuation of dialysis three times per week for seventeen days due to persistence of anuria. Few case reports on renal failure induced by MAKIRON have been published, whereas there are occasional reports of MAKIRON poisoning. Serious renal dysfunction in this case is thought to be due to both the large volume of MAKIRON ingested and the time delay between ingestion and treatment.

The indirect detection of bleach (sodium hypochlorite) in beverages as evidence of product tampering

Bleach (sodium hypochlorite) has been identified as the adulterant in a relatively large number of product tamperings that have been investigated by the Forensic Chemistry Center (FCC) of the U.S. Food and Drug Administration. In this work, household bleach was added to 23 different beverages at each of three levels. The impact of sodium hypochlorite on these beverages over a 13-day study period was evaluated using the following techniques: diphenylamine spot test for oxidizing agents, potassium iodide-starch test paper for oxidizing agents, pH, iodometric titration for quantitating hypochlorite, ion chromatography for chloride and chlorate quantitation, automated headspace sampling with gas chromatography-flame ionization detection (GC-FID) for determination of chloroform, and visual and organoleptic observations. This study has shown that hypochlorite is fragile when added to most common beverages and typically breaks down either partially or completely over time. In cases where a beverage is suspected of being adulterated with bleach but tests for hypochlorite are negative, it is still possible to characterize the product to demonstrate that the results are consistent with the addition of bleach. An adulterated product will give a positive test for oxidizing agents using the diphenylamine spot test. It is likely that the pH of the adulterated product will be higher than a control of that product. Ion chromatographic analysis shows elevated chloride and chlorate as compared with a control. And, chloroform may also be detected by GC-FID especially if the beverage that was adulterated contains citric acid.

Chlorine-related inhalation injury from a swimming pool disinfectant in a 9-year-old girl

Chlorine is a potential respiratory hazard in both occupational and household settings. The clinical sequelae of inhalation are variable in severity and timing, and subacute presentation is a concern. We report the case of a 9-year-old girl who developed dyspnea, hypoxemia, and pneumonitis approximately 12 hours after exposure to chlorine released from aerosolized swimming pool purification tablets. Her course was characterized by improvement with supplemental oxygen and bronchodilator therapy. Follow-up pulmonary testing at 4 months after the episode revealed the presence of mild obstructive reactivity of the airways, but she was able to perform normal activities without requiring medications. We discuss the pathophysiology, symptoms, therapy, and long-term follow-up of chlorine inhalation injuries.

Ethyl Mercury Poisoning During a Protein A Immunoadsorption Treatment

We describe the case of a 38-year-old woman with Guillain-Barré syndrome who was accidentally intoxicated with thimerosal, a column disinfectant containing ethyl mercury, during a protein A immunoadsorption treatment. The 1-time overdose caused by an equipment handling error led to a maximum blood serum mercury level of 2,250 microg/L, thus exceeding the normal blood reference range by a factor of approximately 200. Although the patient did not show short-or long-term clinical signs of mercury intoxication, she was treated with chelation therapy, and we replaced thimerosal with a commercially available mercury-free disinfectant, suggesting that thimerosal is no longer indicated for preservation of protein A columns.

Considering risks to healthcare workers from glutaraldehyde alternatives in high-level disinfection

Due to concerns over glutaraldehyde's toxicity, two substitutes have recently been introduced; ortho-phthalaldehyde (OPA), and a mixture of hydrogen peroxide and peracetic acid. There is limited information about the health effects for employees from these products. This study assesses the current practices regarding the use of high-level disinfectants in British Columbian hospitals and predicts the relative toxicities of each product. Industry practices were compiled using a comprehensive survey of current practices and decision processes in all hospitals in British Columbia. Of 95 hospitals, 64 returned surveys; 80% of these used high-level disinfection. Among user hospitals, 49% used glutaraldehyde alone and 51% had introduced alternatives. Concern about staff health was the most common reason for substituting, but this was frequently not considered when choosing specific alternatives. Hospitals that involved occupational health, infection control or regional staff in high-level disinfectant decisions used glutaraldehyde alternatives less often. In most hospitals, it was difficult to find individuals who were knowledgeable about the use of disinfectants. Potential health effects associated with each type of high-level disinfectant were assessed by review of the published literature and available manufacturers' data along with qualitative structure-activity relationship analysis. Results indicated that although all products irritate the skin and respiratory tract, OPA is a potential dermal and respiratory sensitizer but hydrogen peroxide and peracetic acid do not cause allergic reactions. Despite little being known about the risks to employees from glutaraldehyde alternatives, their use is widespread. The potential risks of all high-level disinfectants are serious; thus regulators and users are faced with important risk management decisions before and after they have been introduced into the workplace.

Pulmonary epithelial integrity in children: relationship to ambient ozone exposure and swimming pool attendance

Airway irritants such as ozone are known to impair lung function and induce airway inflammation. Clara cell protein (CC16) is a small anti-inflammatory protein secreted by the nonciliated bronchiolar Clara cells. CC16 in serum has been proposed as a noninvasive and sensitive marker of lung epithelial injury. In this study, we used lung function and serum CC16 concentration to examine the pulmonary responses to ambient O3 exposure and swimming pool attendance. The measurements were made on 57 children 10-11 years of age before and after outdoor exercise for 2 hr. Individual O3 exposure was estimated as the total exposure dose between 0700 hr until the second blood sample was obtained (mean O3 concentration/m3 times symbol hours). The maximal 1-hr value was 118 microg/m3 (59 ppb), and the individual exposure dose ranged between 352 and 914 microg/m3hr. These O3 levels did not cause any significant changes in mean serum CC16 concentrations before or after outdoor exercise, nor was any decrease in lung function detected. However, children who regularly visited chlorinated indoor swimming pools had significantly lower CC16 levels in serum than did nonswimming children both before and after exercise (respectively, 57 +/- 2.4 and 53 +/- 1.7 microg/L vs. 8.2 +/- 2.8 and 8.0 +/- 2.6 microg/L; p < 0.002). These results indicate that repeated exposure to chlorination by-products in the air of indoor swimming pools has adverse effects on the Clara cell function in children. A possible relation between such damage to Clara cells and pulmonary morbidity (e.g., asthma) should be further investigated.

Mortality from solid cancers among workers in formaldehyde industries

In industrial workers, formaldehyde exposure has been associated with cancer of the nasal cavities, nasopharynx, prostate, lung, and pancreas; however, these associations are inconsistent and remain controversial. Animals exposed to formaldehyde show excesses of nasal cancer. In an extended follow-up of a large cohort of formaldehyde-exposed workers, the authors evaluated mortality from solid cancers (1,921 deaths) among 25,619 workers (865,708 person-years) employed in 10 US formaldehyde-producing or -using facilities through 1994. Exposure assessment included quantitative estimates of formaldehyde exposure. Standardized mortality ratios and relative risks were calculated. Compared with that for the US population, mortality from solid cancers was significantly lower than expected among subjects exposed and nonexposed to formaldehyde (standardized mortality ratios = 0.91 and 0.78, respectively). Relative risks for nasopharyngeal cancer (nine deaths) increased with average exposure intensity, cumulative exposure, highest peak exposure, and duration of exposure to formaldehyde (p-trend = 0.066, 0.025, <0.001, and 0.147, respectively). Formaldehyde exposure did not appear to be associated with lung (744 deaths), pancreas (93 deaths), or brain (62 deaths) cancer. Although relative risks for prostate cancer (145 deaths) were elevated for some measures of formaldehyde exposure, the trend was inconsistent. In this cohort of formaldehyde-industry workers, some evidence was found of an exposure-response relation with mortality from nasopharyngeal cancer (based on small numbers) but not for cancers of the pancreas, brain, lung, or prostate.

A case report of occupational asthma due to gluteraldehyde exposure

INTRODUCTION

We report the first case of occupational asthma due to gluteraldehyde exposure in Singapore and also describe the use of a specific inhalational challenge (SIC) test in confirming the diagnosis.

CLINICAL PICTURE

A 32-year-old laboratory technician presented with adult-onset asthma 2 years after daily exposure to gluteraldehyde which was used to sterilise the mouthpieces used for lung function testing. SIC testing showed a 25% drop in FEV1 after exposure to gluteraldehyde but not after exposure to a control, thus confirming the diagnosis.

TREATMENT

Alternative arrangements were made for sterilisation of the mouthpieces so that gluteraldehyde could be removed from the workplace. There was a marked improvement in her asthmatic control thereafter.

CONCLUSIONS

This case illustrates the use of a SIC test in the diagnosis of occupational asthma. Gluteraldehyde is a known cause of occupational asthma and should be kept in mind when evaluating asthmatic patients in at-risk occupations. Effective ventilation and proper storage should be ensured to minimise exposure to gluteraldehyde where its use is necessary.

Measurements of carbonyls in a 13-story building

BACKGROUND, AIM AND SCOPE

Formaldehyde and acetaldehyde are emitted by many mobile and stationary sources and secondary aldehydes are intermediates in the photo-oxidation of organic compounds in the atmosphere. These aldehydes are emitted indoors by many materials such as furniture, carpets, heating and cooling systems, an by smoking. Carbonyls, mainly formaldehyde and acetaldehyde, have been studied because of their adverse health effects. In addition, formaldehyde is a suspected carcinogen. Therefore, the concentrations of formaldehyde and acetaldehyde were determined to assess the inhalation exposure doses to carbonyls for people who work in a 13-story building and in order to evaluate the cancer hazard.

METHODS

Carbonyl compounds in indoor and outdoor air were measured at a 13-story building located in Mexico City. The mezzanine, fifth and tenth floors, and the third level-parking garage were selected for sampling. Samples were collected in two sampling periods, the first from April 20 to 29, 1998 and the second from December 1 to 20, 1998. Carbonyls were sampled by means of DNHP-coated cartridges at a flow rate of 1 l min(-1) from 9:00 to 19:00 hours, during 2-hour time intervals and analyzed by HPLC with hours, during 2-hour time intervals and analyzed by HPLC with UV/VIS detection.

RESULTS

Mean carbonyl concentrations were highest in the 3rd level-parking garage, with the formaldehyde concentration being the highest ranging from 108 to 418 microg m(-3). In working areas, the highest carbonyl arithmetic mean concentrations (AM) were observed on the 5th floor. Acetone and formaldehyde concentrations were highest in April ranging from 161 to 348 microg m(-3) (AM = 226) and from 157 to 270 microg m(-3) (AM = 221), respectively. Propionaldehyde and butyraldehyde were present in smaller concentrations ranging from 2 to 25 and 1 to 28 microg m(-3), respectively, considering all the samples. Mean indoor/outdoor ratios of carbonyls ranged from 1.8 to 9.6. A reduction of inhalation exposure doses of 41% and 45% was observed in the fifth floor air after the air conditioning systems had been repaired. Formaldehyde and acetaldehyde concentrations were higher in smoking environments.

CONCLUSION

Indoor carbonyl concentrations were significantly greater than outdoor concentrations. Tobacco smoke seems to be the main indoor source of formaldehyde. After the air conditioning system was maintained and repaired (as was recommended), an important reduction in the emission of formaldehyde and acetaldehyde was achieved on all floors, except for the 3rd level parking garage, thereby reducing the inhalation exposure doses.

RECOMMENDATION

The results obtained in this research demonstrated that maintenance of air conditioning systems must be carried out regularly in order to avoid possible adverse effects on health. Additionally, it is mandatory that isolated smoking areas, with air extraction systems, be installed in every public building.

Association between lung function and exposure to smoke among firefighters at prescribed burns

We investigated the short-term effects of exposures to PM3.5, acrolein, formaldehyde, and carbon monoxide on lung function in a group of firefighters performing prescribed burns. Spirometric measurements were made on 65 firefighters at the beginning, midpoint, and end of their work shift, while exposure was measured over the entire day. The interquartile range (IQR) of daily personal PM3.5 exposures was 235 micrograms/m3 to 1317 micrograms/m3, with an average daily exposure of 882 micrograms/m3. Concentrations of acrolein (IQR: [0.002, 0.018] ppm), formaldehyde (IQR: [0.008, 0.085] ppm), and carbon monoxide (IQR: [2.10, 10.48] ppm) were similarly elevated. In this group of firefighters, FEV1 changed by -0.125 L from preshift to postshift (p < .001). We examined the association between this cross-shift lung function decrement and smoke exposure. A 1000 micrograms/m3 increase in PM3.5 was associated with a -0.030 L change in the cross-shift FEV1 (95% CI [-0.087, 0.026]). Acrolein, formaldehyde, and carbon monoxide exposure were also not significantly associated with changes in FEV1, FVC, or FEF25-75. We concluded that while firefighters' lung function significantly decreased from preshift to postshift, firefighters exposed to greater concentrations of respiratory irritants did not experience greater lung function decrements. We could not establish a significant link to any of the individual toxic components of smoke we measured.

Determination of phenol and o-cresol by GC/MS in a fatal poisoning case

A fatality due to the ingestion of solution containing phenol and o-cresol is described. The pathological findings were typical of acute substantial poisoning. Blood, urine and stomach content were obtained during post mortem examinations. Phenol and o-cresol were identified using GC/MS. The extractions from autopsy materials were obtained as follows: by gel permeation with cyclohexane/dichloromethane from stomach content, by solid phase extraction (SPE) from urine and by deproteinization with acetonitrile from blood. The phenol and o-cresol concentrations in the samples were found, respectively, as follows: 115.0 and 5.0 microg/g in the stomach contents, 58.3 and 1.9 microg/ml in the blood, 3.3 and 20.5 microg/ml in the urine. Distributions of phenol in fatal poisonings have been reported, but, usually, colorimetry was used as the analytical method and it cannot exclude the interference of other phenolic compounds.

[Ototoxic study spiral ganglion neurons in the pig guinea with ethylene oxide remained in absorbable gelatin sponge]

OBJECTIVE

To measure ethylene oxide remained in absorbable gelatin sponge, and to observe change of ultrastructure in spiral ganglion neurons after deposited in otic vesicle of pig guinea with ethylene oxide sterilized absorbable gelatin sponge.

METHOD

To use comparative colour technique measuring ethylene oxide remained in absorbable gelatin sponge, by means of transmission electron microscope to observe change of ultrastructure in spiral ganglion neurons after 3 months deposited in otic vesicle of pig guinea with ethylene oxide sterilized absorbable gelatin sponge.

RESULT

The mean value of ethylene oxide remained in absorbable gelatin sponge were 438.32 mg, while nation standard are less 10 mg, FDA standard(1978) less 25 mg. ultrastructural appearance showed condensed matric electron dense of spiral ganglion mitochondria and dark crista of mitochondria, vacuolated cytoplasm. Ultrastructural observation also demonstrated dissolution or necrosis of ganglion cells, satellite cells, and vacuolated myelin. These changes were near Donson reported(1997) intracochlear perfusion with aminoglycosides.

CONCLUSION

The mean value of ethylene oxide remained in absorbable gelatin sponge were 40 times nation standard. Toxic changes of ethylene oxide remained in absorbable gelatin sponge in spiral ganglion neurons were similar to intracochlear perfusion with aminoglycosides.

Acute mercuric chloride poisoning: effect of co-ingested milk on outcome and continued hyperamylasemia

Thirty-six h after intentionally ingesting 25 g of mercuric chloride powder mixed with 5O mL of milk, an elderly woman presented to the emergency department with diffuse upper gastrointestinal erosions and acute renal failure. The patient was treated with dimercaprol and hemodialysis, and was discharged from the hospital without clinically apparent sequelae. However, elevated serum concentrations of amylase and proteases persisted for several months despite normal findings by computed tomography including contrast administration. Delayed absorption and weakened corrosive effect may have resulted from the binding of mercuric chloride to thiol-containing proteins in milk, improving the clinical outcome.

Factors associated with seeking emergency treatment following suspected chemical contamination of a leisure pool

A leisure pool was evacuated when children complained of breathing difficulties, cough, and eye irritation subsequently thought to be due to high chloramine levels. The duration of the suspected contamination before the evacuation was unknown: it was suggested that some subsequent attendances at accident and emergency (A&E) departments had been prompted by news reports of the incident. The extent and nature of symptoms, the cause of the incident, and the impact of media reporting were investigated with the help of a postal questionnaire. One hundred and thirty-seven people (all but six under 20 years of age) attended A&E departments after the incident, most commonly with sore eyes (79%), cough (76%), and sore throat (71%). The number of different symptoms was associated with the length of time spent at the pool, but not with being present at the time of the evacuation or with having heard about the incident on radio or television.

Acute respiratory distress syndrome following cutaneous exposure to Lysol: a case report

Lysol (mixed cresols) is a brand of popular detergent commonly used to disinfect toilets and floors in Taiwan. We report a patient with acute respiratory failure immediately following chemical burns caused by skin contact with Lysol solution. On admission, chest radiography showed bilateral diffuse pulmonary infiltrates and an arterial blood gas analysis disclosed hypoxemia refractory to a high concentration of oxygen by inhalation. Under the impression of acute respiratory distress syndrome, our patient was admitted to the intensive care unit for respiratory care. Poor clinical improvement was noted, despite aggressive respiratory therapy. High-dose steroid therapy (hydrocortisone 30 mg/kg/day) was administered from the seventh day after mechanical ventilation began and the ratio of arterial partial pressure of oxygen to fractional concentration of oxygen in inspired gas improved thereafter. The amount of steroid was gradually tapered to the maintenance dose and the patient was successfully weaned from the ventilator after a 93-day course of mechanical ventilation.

[Acute, oral poisoning with hydrogen peroxide (concentrated peracetic acid) with neurologic sequelae]

The case of accidental, acute oral poisoning with concentrated hydrogen peroxide with peracetic acid components of disinfectant using in food industry (Steridial P) is presented. Neurological sequelae as a result of gas embolisation and supportive and symptomatic treatment are described.

An alleged poisoning with methanol and formaldehyde

It was alleged that a defendant added an unspecified amount of undyed formalin solution, containing formaldehyde and methanol, to the victim's bottle of ice and drinking water. The medical report indicated that except for a slight elevation of total creatine kinase, all other chemistry profiles were within normal ranges. The elevation of creatine kinase suggested muscle injury and inflammation; however, the significance of this elevation was not clear. Toxicological evaluations were made by conducting risk assessments. Based upon the medical report and risk assessments, the following conclusions were made: The calculated exposure doses of methanol and formaldehyde were too low to cause appreciable adverse effects; however, formaldehyde may have irritated the gastrointestinal tract causing smooth muscle and mucosal inflammation. The doses of methanol and formaldehyde were too low to cause death. The exposure scenario (a single oral exposure to formaldehyde) would not likely increase the cancer risk in the victim. The risk assessments provided resulted in a reduction in charge from attempted murder to felony.

Accidental intranasal administration of phenol

A 79-y-old man developed erythema and superficial sloughing of the turbinate following accidental intranasal administration of 89.2% phenol solution. Previous documented reports of phenol exposure include exposures via dermal and oral routes, but no reports of nasal phenol administration were found.

Delayed upper airway obstruction. A life-threatening complication of Dettol poisoning

Dettol liquid is a commonly used household disinfectant and although it is labelled nonpoisonous, serious respiratory complications have been reported in up to 8% of cases of Dettol ingestion. We report a case in which the delayed onset of upper airway obstruction was treated with emergency awake, fibreoptic guided nasotracheal intubation. Based on information available in published cases and on our own experience, we suggest that patients who have ingested large volumes of Dettol, have a history of vomiting or unprotected lavage, or have evidence of ongoing oropharyngeal inflammation, are at high risk of this complication. They should be closely observed for at least 48 h after ingestion and the facilities and staff required for emergency airway management should be immediately available.

Another hot tub hazard. Toxicity secondary to bromine and hydrobromic acid exposure

We describe the clinical course of two patients who developed acute pneumonitis followed by reactive airways dysfunction syndrome after bathing in a hot tub. Additional findings were present and suggested that exposure to a corrosive agent was responsible. Bromine and hydrobromic acid generated from a widely used water disinfectant were implicated as the underlying cause. Physicians should be alert to the possibility that such exposures may initiate or exacerbate inflammatory pulmonary disease.

Pulmonary aspiration following Dettol poisoning: the scope for prevention

1. After ingestion, Dettol liquid (4.8% chloroxylenol, pine oil, isopropyl, alcohol), a common household disinfectant, can cause central nervous system depression and corrosion of the oral mucosa, larynx and the gastrointestinal tract. The main risk from Dettol poisoning is pulmonary aspiration, leading to pneumonia, adult respiratory distress syndrome (ARDS) and/or sudden cardiorespiratory arrest. 2. To determine to what extent pulmonary aspiration in Dettol poisoning could be prevented, 13 patients treated in a general teaching hospital in Hong Kong were studied. Their clinical details were compared with those of control Dettol poisoning cases without pulmonary aspiration in order to identify possible risk factors for this complication. 3. At presentation, evidence of pulmonary aspiration was present in eight of the 13 patients prior to gastric emptying, but the use of gastric lavage without adequate protection of the airways could have aggravated the problem in three. In two other patients, evidence of aspiration was only present after gastric lavage was performed. The consequences of pulmonary aspiration were pneumonia (n = 10), ARDS (n = 2), acute exacerbation of asthma or chronic obstructive airway disease (n = 2) and sudden cardiorespiratory arrest (n = 1). Three patients with aspiration pneumonia (n = 2), ARDS (n = 1) and/or sudden cardiorespiratory arrest (n = 1) died. 4. Compared with the controls, the median amount of Dettol ingested was considerably larger (400 vs 150 ml), vomiting (100% vs 72.6%) and drowsiness/ confusion (60.2% vs 19.4%) occurred more often. 5. Amongst the 13 patients with Dettol poisoning and pulmonary aspiration, gastric lavage using the nasogastric tube technique without adequate production of the airways had been responsible for the occurrence or worsening of aspiration in two and three patients, respectively. Thus, gastric lavage particularly when using a nasogastric tube appeared to carry more harm than benefits in patients with Dettol poisoning. If the procedure is considered necessary, say because of the concomitant ingestion of the other poisons, the airways must first be well protected and the oropharyngeal aspiration and lavage technique using a wide bore Jacques tube is recommended. 6. Comparison with a control group has identified other risk factors for pulmonary aspiration: the amount of Dettol ingested, the occurrence of vomiting, drowsiness or confusion.