Warn parents: often missed home toxins.
These substances range from salicylate preparations, such as Pepto-Bismol, Ben Gay ointment, and oil of wintergreen flavoring, to lamp oil, bug repellant, lighter fluid and other fuels, air freshener, spray deodorant, hair spray, cooking spray, and ethanol, said Dr. Anderson, an attending physician and toxicologist at Hasbro Children's Hospital in Providence, R.I.
Given that "children will eat anything" and "'teens will try anything," the challenge for pediatricians is to consider sources of toxins that might not be on their immediate radar screen, she said.
For example, 9 ounces of Pepto-Bismol can be deadly for a toddler who weighs 10 kg, or 20 pounds (a toxic dose of salicylate is 150 mg/kg). One ounce of Ben Gay and 1 teaspoon of oil of wintergreen each contain the equivalent of 21 aspirin, or 7,000 mg of salicylate.
"You can kill a whole nursery school with 1 teaspoon of oil of wintergreen," said Dr. Anderson, who estimated that 60% of salicylate overdoses are misdiagnosed. One reason is that salicylate symptoms--high temperature, perspiration, increased heart and respiratory rates, hyperventilation, vomiting, and agitation--might suggest diabetic ketoacidosis or meningitis instead.
For salicylates and products like acetaminophen, a key factor in treatment is in knowing the length of time since ingestion, Dr. Anderson said.
Generally, if more than 1 hour has gone by, it's best not to try to remove what was ingested because the liquid or solid toxin is likely to have been absorbed. In any case, lavage or ipecac will empty only about 30% of stomach contents. Administering activated charcoal may be the most effective way to expel the remaining 70%, she said.
A second category of potentially deadly substances is aliphatic hydrocarbons--oil of citronella insect repellant, lamp oil, hair oil, gasoline, kerosene, lighter fluid, and the like--which can cause aspiration pneumonitis.
Dr. Anderson said few parents may be aware of citronella's toxicity--the liquid smells good and comes in an attractive bottle--so they wouldn't think to keep it out of children's reach during a picnic or barbecue.
She said patients with aliphatic hydrocarbon poisoning should be observed for 4-6 hours and sent home if there aren't any respiratory symptoms, if pulse oximetry produces normal findings, and if a chest x-ray doesn't detect abnormalities.
One of the more disturbing trends in this type of poisoning, according to Dr. Anderson, is the number of children and teens who inhale aerosolized hydrocarbons to get high. Products containing hydrocarbons, such as air freshener, butane cigarette lighters, gasoline, propane, spray deodorant, hair spray, and cooking spray, are widely available, legal, inexpensive, and provide a rapid high of short duration.
Dr. Anderson has recently witnessed five deaths that were a result of inhaling air freshener and four deaths from butane lighters.
"You can get up in the morning, do this before going to school, and look perfectly normal at school--and not get caught," she said.
The physiological effects of inhaled hydrocarbons can be devastating: degeneration of white matter in the brain and "sudden sniffing death syndrome," wherein the myocardium becomes oversensitized to catecholamines and the heart suddenly stops due to a frightful stimulus. Other symptoms include high myelin and neuronal concentrations, and bradycardia.
Dr. Anderson said pediatricians should suspect inhalant use if a patient recurrently complains of nasal irritation, chronic cough, or hemoptysis, or has red eyes.
Last on her list of common household toxins is ethanol. She cited the case of 2-year-old twins from a family in Rhode Island who one morning got into the liquor their parents had served at a party the previous night. Young children tend to become hypoglycemic after they ingest ethanol because their small livers can't metabolize it, Dr. Anderson explained.
An even greater concern, however, may be the variety of readily accessible but lesser-known ethanol sources aside from beer (6% ethanol), wine (12%), and spirits such as Jack Daniel's whiskey (45%). They include Listerine (28% ethanol), vanilla extract (35%), and Chanel No. 5 (90%).
"These are all in your house," Dr. Anderson said. "Do you hide your Chanel No. 5 from Junior? No, you don't, probably. So if a child comes in seizing and smelling pretty, think about ethanol."
PAUL ENGSTROM Contributing Writer
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|Title Annotation:||Clinical Rounds|
|Date:||Jan 1, 2006|
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