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 = ?

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

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

11. Answer:  Imidazolines  Visine™ (tetrahydrozoline)  Afrin™ (oxymetazoline)  All are alpha 2 agonists:  CNS-mediated lethargy, hypotension, bradycardia, miosis  Peripheral alpha 1 effects can cause hypertension (usually transient)

13. 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 !!

14. Glassman, continued...  Admitted to ingesting several boxes of RAT POISON

15. “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

16. Rat poison, continued...  The man was admitted and started on oral Vitamin K 1  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!!

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

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

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

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

21. 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

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

23. 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

24. METHANOLMETHANOL FORMALDEHYDEFORMALDEHYDE FORMIC ACID ANION GAP ACIDOSIS ANION GAP ACIDOSIS ELEVATED OSMOLAR GAP ELEVATED OSMOLAR GAP

25. METHANOLMETHANOL FORMALDEHYDEFORMALDEHYDE CONVERSION CATALYZED BY ALCOHOL DEHDROGENASE CAN BE BLOCKED BY ETHANOL or FOMEPIZOLE CAN BE BLOCKED BY ETHANOL or FOMEPIZOLE

26. 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

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

28. 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

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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Common causes of seizures  Amphetamines, cocaine  Tricyclic antidepressants  Diphenhydramine  Isoniazid  Camphor ... many others

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

41. 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