Application of a new hyperbaric oxygen therapy protocol in patients with arterial and venous gas embolism due to hydrogen peroxide poisoning

Hydrogen peroxide (H2O2) ingestion can cause vascular gas embolism (GE). Hyperbaric oxygen therapy (HBO2) is known to improve neurological abnormalities in patients with arterial gas embolism (AGE). Previously, HBO2 based on the U.S. Navy Table 6 diving protocol has been adopted for treating AGE and preventing the progression of portal venous GE, caused by H2O2 ingestion, to AGE. However, the indication and protocol for HBO2 have not been established for GE related to H2O2 ingestion. Herein, we describe a case in which GE caused by H2O2 ingestion was treated using HBO2 with a short protocol. A 69-year-old female patient presented with abdominal pain, vomiting, and transient loss of consciousness after ingesting 35% H2O2. Computed tomography revealed gastric wall and portal venous gas. She was administered an HBO2 protocol with 2.8-atmosphere absolute (ATA) compression for 45 minutes. This was followed by a 2.0-ATA treatment for 60 minutes with a five-minute air break, after which all gas bubbles disappeared. After HBO2 treatment, brain magnetic resonance imaging revealed focal cytotoxic edema lesions; however, the patient was discharged without additional symptoms.

Ingestion of food grade hydrogen peroxide with resultant gastrointestinal and neurologic symptoms treated with hyperbaric oxygen therapy: case report and review with emphasis on the therapeutic value of HBO2 in vascular gas embolism

A 52-year-old male accidentally ingested approximately 100 mL of 35% hydrogen peroxide (H2O2), resulting in the sudden onset of gastrointestinal and neurologic symptoms. Non-contrast abdominal CT revealed extensive portal venous gas and gastric pneumatosis. The patient was treated with hyperbaric oxygen therapy which resulted in complete resolution of symptoms. The case highlights the therapeutic value of hyperbaric oxygen therapy in the treatment of vascular gas embolism and mitigation of concentrated H2O2 ingestion toxicity.

Acute kidney injury due to povidone-iodine ingestion: A case report

RATIONALE

Povidone-iodine is a broad-spectrum antiseptic applied topically to treat wounds and prevent their infection. There have been several case reports of acute kidney injury (AKI) in burn patients after povidone-iodine irrigation and in patients receiving the substance as a sclerotherapy agent for management of lymphocele after renal transplantation. However, biopsy-confirmed AKI after ingestion of povidone-iodine has not previously been described.

PATIENT CONCERNS

A 47-year-old man who had apparently ingested povidone-iodine solution and presented with nausea, vomiting, and reduced urine output. Laboratory data revealed blood urea nitrogen of 124 mg/dL, serum creatinine of 6.3 mg/dL, impaired liver function, and leukocytosis. Urine iodine/creatinine ratio was markedly elevated.

DIAGNOSES

Acute tubular necrosis and interstitial nephritis secondary to povidone-iodine ingestion.

INTERVENTIONS

The patient was admitted to the intensive care unit and underwent continuous venovenous hemodiafiltration. Kidney biopsy showed acute tubular necrosis and interstitial nephritis. Unstained sections showed tan objects in the tubular lumina that were suspected to be povidone-iodine casts. Corticosteroid therapy (1 mg/kg/day) was started after kidney biopsy.

OUTCOMES

Renal function recovered after hemodialysis and corticosteroid medication, but not completely.

LESSONS

We have reported the first case of biopsy-confirmed AKI accompanied by increased urine iodine concentration following povidone-iodine ingestion.

[Case of iodism complicated with severe airway stenosis due to pharyngolaryngeal edema]

A 22-year-old man was admitted to our hospital with dilute iodine tincture poisoning. He had ingested 150 mL in a suicide attempt. On arrival, he was in need of urgent airway management as he was repeatedly vomiting. Although we had difficulty with endotracheal intubation because of remarkable pharyngolaryngeal mucosal edema induced by dilute iodine tincture, we managed to secure the airway. On the 2nd day, laryngoscope showed severe mucosal erosion from the upper to middle pharynx and epiglottis. On the 4th day, we performed a tracheoctomy in anticipation of prolonged airway management. On the 16th day, laryngoscopy showed improvement in each of the 2nd day findings. On the 30th day, the patient was transferred to a psychiatric hospital. Generally, iodine poisoning induces multiple organ disorders and there have been several reports describing iatrogenic iodine poisoning. However, cases of severe airway stenosis due to ingestion of iodine are very rare. Presently, members of the public can easily purchase dilute iodine tincture in Japan, therefore emergency medical personnel should be aware of iodine poisoning as a method of suicide attempt.

A case of mixed intoxication with isopropyl alcohol and propanol-1 after ingestion of a topical antiseptic solution

We report a mixed intoxication with isopropyl alcohol and propanol-1 in a hospitalized patient who ingested, on two separate days, two 100 ml bottles of a topical antiseptic solution containing isopropyl alcohol and propanol-1. Eight hours after the second ingestion, plasma concentrations of isopropanol, propanol-1 and acetone were 37 mg/dL, <10 mg/dL, and 227 mg/dl, respectively. Despite a lack of severe toxicity, 4-methylpyrazole (fomepizole) was initiated. This case points out the need to limit access to alcohol-containing antiseptic solutions on wards where alcoholic and psychotic patients are hospitalized.

Camphor induced myocarditis: a case report

Availability of camphor containing products in households is not uncommon. In certain parts of the world, camphor is used in medicines intended for enteral intake and also used as a flavoring agent in edibles. Toxicity due to ingestion of camphor has been described and in severe forms it manifests as seizures, apnea, asystole, circulatory collapse and death. We report myocarditis associated with ingestion of a large dose of camphor. The electrocardiogram revealed prolonged QRS duration and QTc interval. 2D- Echo images revealed features of acute myocarditis. The changes were transient and resolved in a short time while the patient was on supportive therapy. The medicinal uses of camphor are unsupported by evidence and safer, more effective alternatives exist. Its use in household products and edibles should be discouraged.

A rare and preventable cause of respiratory insufficiency: ingestion of benzalkonium chloride

Caustic agents stored in ordinary containers can be ingested by children. These materials should be stored in soft distinctive bottles and in safe places. The probability of ingestion of a caustic agent is low in the newborn period, and caustic burns have been reported infrequently. In this case study, a newborn baby with severe respiratory insufficiency after ingestion of benzalkonium chloride is reported.

Silver dressings: their role in wound management

Dressings have a part to play in the management of wounds; whether they are sutured or open, usually chronic wounds of many aetiologies which are healing by secondary intention. They traditionally provide a moist wound environment, but this property has been extended through simple to complex, active dressings which can handle excessive exudate, aid in debridement, and promote disorganised, stalled healing. The control of infection remains a major challenge. Inappropriate antibiotic use risks allergy, toxicity and most importantly resistance, which is much reduced by the use of topical antiseptics (such as povidone iodine and chlorhexidine). The definition of what is an antimicrobial and the recognition of infection has proven difficult. Although silver has been recognised for centuries to inhibit infection its use in wound care is relatively recent. Evidence of the efficacy of the growing number of silver dressings in clinical trials, judged by the criteria of the Cochrane Collaboration, is lacking, but there are good indications for the use of silver dressings, to remove or reduce an increasing bioburden in burns and open wounds healing by secondary intention, or to act as a barrier against cross contamination of resistant organisms such as MRSA. More laboratory, and clinical data in particular, are needed to prove the value of the many silver dressings which are now available. Some confusion persists over the measurement of toxicity and antibacterial activity but all dressings provide an antibacterial action, involving several methods of delivery. Nanocrystalline technology appears to give the highest, sustained release of silver to a wound without clear risk of toxicity.

[Acute intoxication with hydrogen peroxide with air emboli in central nervous system--a case report]

54-year-old woman with brain gas emboli after an accidental ingestion of concentrated hydrogen peroxide was described. Hydrogen peroxide (H2O2) is a water-soluble, caustic liquid. Exposure to concentrated (> 30-35%) hydrogen peroxide may cause cardiorespiratory insufficiency, shock, convulsions, coma, and chemical burns of skin and mucous membranes. Arterial gas embolization in central nervous system is a relatively rare complication. There are three possible mechanisms of gas embolization: persisting patent foramen ovale, pulmonary gas emboli caused by aspiration of hydrogen peroxide to the lower respiratory tract, formation of gas emboli after reaching the brain. Absence of gas emboli and cerebral infarction in CT does not exclude intoxication. Hyperbaric therapy is most effective for brain air embolism complicating hydrogen peroxide poisoning in acute phase. Some authors suggested that this therapy is also effective if administered during the subacute phase.

CONCLUSIONS

Neurologic symptoms after ingestion of hydrogen peroxide may suggest gas embolism of the cerebral vasculature. The absence of atrial septal defect does not exclude the possibility of cerebral air embolism. The absence of gas and cerebral infarction in CT scans does not exclude brain gas embolism. The use of hyperbaric therapy should be considered in treating severe cases of hydrogen peroxide poisoning.

Methemoglobinemia by cerium nitrate poisoning

Cerium nitrate is a topical antiseptic used with silver sulfadiazine (Flammacerium) for the treatment of serious burns. This topical agent can induce methemoglobinemia, but no cases have been reported in the recent literature. In this article, we present the case of a 16-year old girl, with third-degree burns over 95% of her body. After daily dressings of Flammacerium, on the sixth day she developed a bluish skin coloring. When tested for methemoglobinemia, levels of 31.8% were found. These returned to normal after classic treatment with Methylene blue.

Acute ethanol toxicity from ingesting mouthwash in children younger than age 6, 1989-2003

PURPOSE

The purpose of this study was to analyze American Association of Poison Control Centers (AAPCC) reports of suspected overingestion of mouthwash by children under age 6 and examine the effect of a 1995 Consumer Product Safety Commission (CPSC) rule requiring child-resistant packaging for mouthwashes containing at least 3 g (0.11 oz) of ethanol per package.

METHODS

The volume of ethanol ingested per kg of body weight was computed for children at the 5th, 50th, and 95th percentiles. The potentially toxic and potentially lethal volumes of 100% ethanol at each weight were also determined. The authors used segmented regression to test the difference in slopes between 1989 to 1996 (preintervention) and 1996 to 2003 (postintervention).

RESULTS

Incidence of overingestion rose from a low of 12.7 per 100,000 (1991) to 20.7 (1996). The increase ended with the adoption of the CPSC rule, declining to 16.8 per 100,000 in 2001 and rising to 17.9 in 2003.

CONCLUSIONS

This study's analysis suggests that the CPSC rule requiring child-resistant packaging on containers of mouthwash containing 3 g or more of ethanol has been successful in reducing AAPCC's reports of mouthwash overingestion. Health care providers should take a more active role by informing parents of the dangers associated with accidental ingestion of ethanol-containing mouthwash. Manufacturers should print warnings about the potential hazard of high ethanol concentrations on labels more prominent and they should stop producing mouthwashes with such high concentrations of ethanol. Moreover, they should also consider discontinuing packaging mouthwash in large containers.

Systemic toxicity following ingestion of the chlorhexidine gluconate solution: a case report

The purpose of this article is to discuss possible adverse effects and emergency treatments following the ingestion of chlorhexidine (CHX). In this case a dental student (age 25, male) accidentally swallowed one shot of 20% CHX solution, which is equal to 100 shots of the standard 0.2% CHX mouthwash. Clinical emergency treatment included: washing the oral cavity with 30 g of toothpaste, drinking 100 ml of 5% (w/v) alginate syrup and ingestion of 5 g of cork. The following adverse effects were experienced: headache, euphoria, giddiness, blurred vision (duration = 12 h), stomachache, gastric lavage with demulcents (duration = 24 h) and complete loss of taste sensation (duration = 8 h), which recurred during the next 48 h. No change in plasma aminotransferase level was seen. We used basic chemical information about the incompatibilities of CHX for clinical management of unintentional ingestion. It is known that CHX is a cation, and, therefore, first aid in case of intoxication with CHX involves using anionic materials.

[Retrospective analysis of toxicity of eardrops, topical nasal and oropharyngeal medicines, documented in São Paulo, Brazil]

BACKGROUND

Retrospective analysis of human toxicity files involving topical medicines for treatment of upper airways diseases (eardrops, topical nasal medicines, lozenges, drops and sprays for oropharyngeal affections).

METHODS

Thirty-four brands of eardrops, 48 of topical nasal medicines and 22 of tablets, lozenges and sprays for oropharyngeal affections were selected, from a total of 104 products available in Brazil. We analyzed the registries in the electronic database from the Poison Control Centre of São Paulo (CCI-Jabaquara), Brazil, for the period from January 1996 through December 2000. The cases related to selected pharmaceuticals were collected.

RESULTS

10,823 cases of human toxicity caused by medicines were voluntarily reported to CCI-Jabaquara. Topical medicines for treatment of upper airways diseases accounted for 291 cases (2.68%), from which 240 (82.5%) represented poisoning; 12 (4.1%) involved ear drops, 268 (92%), topical nasal medicines and 11 (3.9%), topical medicines for oropharyngeal affections. Among topical nasal medicines, vasoconstrictors predominated (233 cases), and among medicines for oropharyngeal affections, it was tetracaine (four cases). Considering age distribution, toxicity predominated significantly in children aged from 1 to 4 years (p=0.0003). The main causes of toxicity were: accidental intake of medicines (43%) and error in drug administration (14.8%). Hypereflexia and vomiting were the most frequent symptoms related to toxicity.

CONCLUSIONS

There was significant incidence of systemic toxicity due to eardrops, topical nasal and oropharyngeal medicines in children 1 to 4 years-old, whose main cause was accidental intake of these medicines.

Fatal large-volume mouthwash ingestion in an adult: a review and the possible role of phenolic compound toxicity

OBJECTIVE

To describe a case of fatal mouthwash ingestion and review possible sources of toxicity.

DESIGN

Case report.

SETTING

Veterans Administration Medical Center.

PATIENT

Single patient with massive mouthwash ingestion.

MAIN RESULTS

This patient was a 45-year-old man who developed cardiovascular collapse and multiorgan system failure following a massive ingestion of mouthwash (almost 3 liters). His presentation was remarkable for a profound anion-gap metabolic acidosis and a significant osmolar gap. No other co-ingestants were identified, and he expired despite full supportive care including dialysis and mechanical ventilation. An autopsy failed to identify any other cause of death. Nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure in the reported toxic range of these ingredients.

CONCLUSIONS

When ingested in large quantities, the phenolic compounds in mouthwash may contribute to a severe anion-gap metabolic acidosis and osmolar gap, multiorgan system failure, and death. These compounds, in addition to alcohol, may account for the adverse effects associated with massive mouthwash ingestion.

Toxicological analysis of chlorhexidine in human serum using HPLC on a polymer-coated ODS column

A simple and reliable high-performance liquid chromatographic (HPLC) method for analyzing chlorhexidine in human serum was developed. After the addition of an internal standard, levomepromazine, 0.2 mL serum was deproteinized with 10% perchloric acid. The acidic supernatant was neutralized with 1M potassium carbonate solution, and the insoluble salt was removed by centrifugation. An aliquot of the supernatant was applied to HPLC with UV detection (260 nm). HPLC separation was achieved on a polymer-coated ODS column equilibrated with acetonitrile/water containing 0.05% trifluoroacetic acid, 0.05% heptafluorobutyric acid, and 0.1% triethylamine (40:60, v/v). The calibration curve was linear in the concentration range from 0.05 to 50.0 microg/mL, and the lower limit of detection was 0.05 microg/mL. The accuracy and precision of the method were evaluated at concentrations of 0.5 microg/mL and 5.0 microg/mL. The coefficients of variation ranged from 4.0 to 4.5%. The concentration of chlorhexidine in the serum of a patient who died after a suspected intravenous injection of chlorhexidine gluconate was determined.

[Accidental oral mercurochrome poisoning]

Neonatal mercury poisoning, especially that due to merbromin ingestion, is uncommon. We describe the case of a 10 day old newborn infant who was given mercurochrome orally for 7 days due to misunderstanding of medical instructions. Initial symptoms included loss of appetite and low weight increase. Elevated blood mercury concentrations were found. Chelating therapy with dimercaprol was initiated and the patient's evolution was good. We discuss the potential toxicity of mercury and emphasise the importance of the transmission of information by physicians, especially to the immigrant population.

A case of fatal benzalkonium chloride poisoning

Five elderly persons with senile dementia accidentally ingested Hoesmin, a 10% aqueous solution of benzalkonium chloride (BAC). The condition of one patient, an 84-year-old woman whose lips and oral cavity became erythematous, gradually deteriorated. Although gastric lavage was performed, the patient died 3 h after ingestion of Hoesmin. Autopsy revealed corrosive changes of the mucosal surfaces of the tongue, pharynx, larynx, esophagus and stomach which may have come in contact with BAC. In addition, BAC was detected in the serum. We conclude that the patient died of BAC poisoning. Fatal BAC poisoning is rare and autopsy findings in only a few cases of BAC poisoning have been reported. Our findings emphasize the risk of oral ingestion of BAC.

Acute cerebral gas embolism from hydrogen peroxide ingestion successfully treated with hyperbaric oxygen

CASE REPORT

We present a case of an adult who suffered an apparent stroke shortly after an accidental ingestion of concentrated hydrogen peroxide. Complete neurologic recovery occurred quickly with hyperbaric therapy. Hydrogen peroxide can produce acute gas embolism. Hyperbaric therapy is the definitive treatment for gas embolism from hydrogen peroxide ingestion as it is for all other causes of acute gas embolism. This is the first case reported in the literature of hyperbaric therapy used successfully to treat cerebral gas embolism caused by hydrogen peroxide.

Acute ethanol toxicity from ingesting mouthwash in children younger than 6-years of age

The purpose of our study was to analyze reports of the American Association of Poison Control Centers (AAPCC) of suspected overingestion of ethanol from mouthrinses by children younger than 6 years of age between 1989 and 1994. Annual incidence rates of reported ethanol exposures attributed to mouthrinses were calculated. Lethal and toxic amounts of several mouthrinses were calculated using peak blood ethanol concentrations of 500 and 50 mg per 100 mL, respectively. In 1994, there were 2937 calls reported by poison control centers related to ethanol-containing mouthrinses, an estimated incidence of 168 reported exposures per 100,000 children younger than 6 years of age. A 15-kg child who ingests 212 mL (7.2 oz.) of Listerine (26.9% ethanol) ingests 57 mL (1.9 oz.) of ethanol, which is potentially lethal. Approximately one-tenth that amount of ethanol can produce a toxic reaction. Physicians, dentists, and other health care providers should inform parents of the dangers associated with accidental ingestion of mouthrinse and encourage them to keep mouthrinse out of the reach of children. The Food and Drug Administration (FDA) should require readily visible warning labels and child-resistant caps for containers with potentially toxic volumes of ethanol. The American Dental Association (ADA) should re-evaluate its acceptance criteria for advertising cosmetic mouthrinses in its publications and consider including child-resistant caps and warning labeling.

Campho-Phenique ingestion: an intentional overdose

We report a suicide attempt with the camphorated phenol preparation Campho-Phenique. The total dose ingested was 68 mg/kg of camphor and 28.9 mg/kg of phenol. The patient had grand mal seizures minutes after ingestion. Supportive medical care and intubation resulted in full recovery within 12 hours. Although Campho-Phenique has been discussed extensively in the pediatric literature and its accidental ingestion by adults has occasionally been reported, intentional ingestion of the preparation has not been reported. We discuss our unusual case and review the literature.

Unusual cause of seizure

INTRODUCTION

This case report of camphor ingestion in a 15-month-old child illustrates the potential toxicity of a common household product. Details of the patient presentation are reported along with a review of the literature.

METHODS

Patient information was collected using the records of Poison Control, the Emergency Department, and the Health Records at the Hospital for Sick Children in Toronto, Ontario, Canada. A comprehensive review of the literature was conducted using the MEDLINE database for the time period 1966 to April 1995.

DISCUSSION

Oral ingestion of camphor is unusual, given that these products have both unpleasant taste and texture. This patient ingested 70 ml of an over-the-counter medicated ointment containing 4.73% camphor, 2.6% menthol, and 1.2% eucalyptus oil. While the concentration of camphor in this product is low, an estimated 280 mg/kg of camphor was consumed. With significant ingestion of camphor (> 50 mg/kg), neurologic toxicity is common. In this patient, prolonged generalized tonic-clonic seizure activity was noted approximately two hours post single acute ingestion of camphor. This delay in onset of seizure activity is atypical, as seizures have previously been noted to occur in the 90 minutes following ingestion.

CONCLUSION

Readily available medicated ointments containing camphor have potential for serious or fatal consequences when ingested by children.

Fatal iatrogenic iodine toxicity in a nine-week old infant

BACKGROUND

Povidone-iodine has been used since the 1950s for various labelled uses as a topical antiseptic. The toxicity of an excessive dose in internal use is described in this case report.

CASE REPORT

A 9-week old infant was treated for colic by a pediatric gastroenterologist with loperamide and the elimination of nonhuman milk. Without improvement he was hospitalized and given an enema of 50 mL of povidone-iodine diluted in 250 mL of a bowel irrigant. The enema was promptly expelled and 50 mL of the described solution was given hourly for three doses by nasogastric tube. The infant was found lifeless three hours after the last dose and resuscitation was unsuccessful. Autopsy showed a corroded and necrotic intestinal tract, serous fluid in body cavities, a blood total iodine of 14,600 micrograms/dL, protein-bound iodine of 3,400 micrograms/dL and inorganic iodine of 11,700 micrograms/dL.

Clinical course of severe poisoning with thiomersal

CASE REPORT

A 44-year-old man ingested 83 mg/kg Thiomersal. He developed gastritis, renal tubular failure, dermatitis, gingivitis, delirium, coma, polyneuropathy and respiratory failure. Treatment was symptomatic plus gastric lavage and the oral chelating agents dimercaptopropane sulfonate and dimercaptosuccinic acid. The patient recovered completely. Maximum mercury concentrations were blood 14 mg/L, serum 1.7 mg/L, urine 10.7 mg/L, and cerebrospinal fluid 0.025 mg/L. Mercury concentration in blood declined with two velocities: first with half-time 2.2 days, then with half-time 40.5 days. The decline of mercury concentration in blood, urinary mercury excretion, and renal mercury clearance were not substantially influenced by chelation therapy.

Melaleuca oil poisoning in a 17-month-old

Ingestion of significant quantities of Melaleuca oil or Australian tea tree oil has been described only once in the medical literature. This report describes a 17-mo-old male who ingested less than 10 ml of the oil and developed ataxia and drowsiness. Emergency physicians, poison control personnel and pediatricians should be aware of potential toxicity from this product.