PEM

Tough on Stains... and on Bodies

The Case

Figure 1: :Laundry Detergent Pod  By  Soulbust  - Own work, CC BY-SA 4.0,

Figure 1: :Laundry Detergent Pod

By Soulbust - Own work, CC BY-SA 4.0,

A previously healthy 12-month-old male was brought to the Emergency Department by his parents 20 minutes after ingesting a laundry detergent pod. The patient’s mother reported finding the child with pieces of the lining of an ALL Mighty Pacs detergent pod in his mouth. She removed the pieces and noted the packet was empty of liquid. At that point, the child started gagging and vomiting “almost immediately.” En route to the ED the patient had 2-3 more episodes of clear emesis. On arrival, he continued to have non-bloody, non-bilious emesis and dry heaves. Vitals were within normal limits with oxygen saturations in the mid 90s. On exam, the child was noted to have a hoarse voice and was mildly somnolent but easily arousable. He was drooling and crying in pain with swallowing, but his oropharynx was otherwise clear. Stridor was noted as well as suprasternal, substernal and supraclavicular retractions. The child was given Zofran, a 20cc/kg fluid bolus and decadron. ENT was consulted for increasing stridor and upper airway symptoms. The patient underwent nasopharyngeal scope at beside and was found to have mild vocal cord edema. He was taken emergently to the OR for definitive airway and bronchoscope. GI was also consulted for endoscopy. 

Findings

In the OR the child was intubated and underwent formal bronchoscopy and endoscopy. Significant findings included:

  1. Watery edema of the supraglottic structures
  2. Mild mucosal changes in the proximal esophagus
  3. Somewhat nodular proximal esophagus with patchy edema and mild sloughing of the mucosa (Fig 1. a, b, c)
  4. Mild patchy sloughing and nodularity distally
  5. One small erosion in the stomach
  6. Normal duodenum
  7. Congenital laryngomalacia and elliptical cricoid consistent with congenital subglottic stenosis

Detergent Pods

Laundry detergent “pods” or “packets” are small, often colorful, dissolvable packs containing concentrated laundry detergent. These laundry capsules have been in Europe since 2001, but were introduced to United States markets in 2010. [1] Laundry pods have been identified as a threat to pediatric patients who are often attracted to the candy-like appearance of the pods. The most common route of toxicity is via ingestion in patients younger than 5 years of age.[2] Recently, however, teenagers have become a significant percentage of the patient population via the “Tide Pod Challenge,” a viral, social-media campaign that dares teens to eat the pods. Detergent pods are often packaged in soft linings that consist of a water-soluble polyvinyl alcohol membrane that easily dissolves when exposed to saliva or moist skin.[3] The liquid mixture inside is usually composed of an anionic and a nonionic detergent as well as a cationic surfactant. All contain irritants and some brands also contain alkaline substances.[4] The alkaline nature of detergent pods can cause inflammation and mucosal destruction in the oropharynx, larynx and esophagus.[5]

Ingestion of detergent pods is associated with more severe symptoms than traditional laundry detergent.[6] One explanation for this is the concentrated nature of the detergent pack and the ingredients, which may include propylene glycol and ethoxylated alcohols.[7] Propylene glycol is found in great proportion in detergent packets than in typical detergent formulations.[8] It is not clear exactly how detergent pods cause injury, but there are several explanations.[9] When ingested, propylene glycol is metabolized by the liver to form lactate, acetate and pyruvate. The increased lactate results in a metabolic acidosis. The drug is excreted in the urine, but at higher doses of propylene glycol the renal tubules ability to secrete the drug is impaired. In children, propylene glycol remains in the blood longer than in adults, which results in more toxic effects, such as renal failure and CNS depression. Another important ingredient in laundry pods is ethoxylated alcohols, which can cause sedative effects. Lethargy is a unique feature of pod ingestion that is not seen with less concentrated detergent formulations.[10]

Ingredient Proposed Effect Clinical Manifestation
Alkalinity Inflammation and damage to oral, laryngeal and esophageal mucosa Hoarse Voice, Dysphagia, Drooling, Stridor, Respiratory Distress
Multiple Noxious response Nausea, vomiting, diarrhea
Propylene glycol Conversion to lactic acid and impaired renal clearance CNS Depression, Metabolic acidosis, Renal insufficiency
Phosphates Caustic Rash, Burns

Management

In the case of any suspected ingestion local poison control should be contacted for advice. Management efforts should initially focus on stabilizing airway, breathing and circulation. If eyes are involved, copious irrigation should begin as soon as possible, as delayed irrigation may be associated with increased morbidity, including burns.[11] Any contaminated clothing should be removed. Activated charcoal, whole bowel irrigation, or gastric lavage is not indicated in the treatment of alkaline ingestions such as detergents.[12] Charcoal and whole bowel irrigation has not been shown to have an effect. Gastric lavage is contraindicated due to risk of perforation and aspiration.[13]

The most important aspects of management are supportive care and symptom control. It is necessary to monitor for respiratory failure and depressed mental status, which may lead to the need for mechanical ventilation. Steroids have been used to mitigate airway edema, but studies have not confirmed their utility.[14] Zofran and other anti-emetics are useful for nausea and vomiting. Fluids should be administered for metabolic derangements or losses secondary to emesis. Endoscopy is important for injury staging and can help to risk stratify patients, however, many complications are delayed. Esophageal stricture is a rare, but possible, long-term sequela.[15]

Case Conclusion

The patient was admitted to the pediatric ICU for further care and management. On hospital day 1 frothy secretions were noted to be draining from his endotracheal tube. He was treated with Lasix for pulmonary edema and had improvement. Decadron was continued for a total of 4 doses of 0.5mg/kg. Feeds were given via NG tube. On hospital day 2 the child underwent repeat endoscopy to monitor for possible progression of mucosal damage. On hospital day 3 he was successfully extubated. Prior to discharge the patient was tolerating a regular pediatric diet with instructions to avoid acidic foods and juices. On hospital day 4 the child was discharged with ENT and GI follow-up. He was instructed to take omeprazole daily for 4-6 weeks

Faculty Reviewer: Dr. Jane Preotle

References

[1] Celentano A, Sesana F, Settimi L, Milanesi G, Assisi F, Bissoli M, Borghini R, Della Puppa T, Dimasi V. Accidental exposures to liquid detergent capsules. SKIN. 2012 May 25;5:0-9.

[2] Stromberg PE, Burt MH, Rose SR, Cumpston KL, Emswiler MP, Wills BK. Airway compromise in children exposed to single-use laundry detergent pods: a poison center observational case series. The American journal of emergency medicine. 2015 Mar 1;33(3):349-51.

[3] Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian family physician. 2013 Dec 1;59(12):1295-6.

[4] Fraser L, Wynne D, Clement WA, Davidson M, Kubba H. Liquid detergent capsule ingestion in children: an increasing trend. Archives of disease in childhood. 2012 Aug 1:archdischild-2012.

[5] Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. American Journal of Gastroenterology. 1992 Mar 1;87(3).

[6] Valdez AL, Casavant MJ, Spiller HA, Chounthirath T, Xiang H, Smith GA. Pediatric exposure to laundry detergent pods. Pediatrics. 2014 Nov 10:peds-2014.

[7] Beuhler MC, Gala PK, Wolfe HA, Meaney PA, Henretig FM. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatric emergency care. 2013 Jun 1;29(6):743-7.

[8] Shah LW. Ingestion of Laundry Detergent Packets in Children. Critical care nurse. 2016 Aug 1;36(4):70-5.

[9] Huntington S, Heppner J, Vohra R, Mallios R, Geller RJ. Serious adverse effects from single-use detergent sacs: Report from a US statewide poison control system. Clinical toxicology. 2014 Mar 1;52(3):220-5.

[10] Shah LW. Ingestion of Laundry Detergent Packets in Children. Critical care nurse. 2016 Aug 1;36(4):70-5.

[11] Haring RS, Sheffield ID, Frattaroli S. Detergent Pod–Related Eye Injuries Among Preschool-Aged Children. JAMA ophthalmology. 2017 Mar 1;135(3):283-4.

[12] Riordan M, Rylance G, Berry K. Poisoning in children 4: household products, plants, and mushrooms. Archives of disease in childhood. 2002 Nov 1;87(5):403-6.

[13] McGregor T, Parkar M, Rao S. Evaluation and management of common childhood poisonings. American family physician. 2009 Mar 1;79(5).

[14] Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. New England Journal of Medicine. 1990 Sep 6;323(10):637-40.

[15] Smith E, Liebelt E, Nogueira J. Laundry detergent pod ingestions: is there a need for endoscopy?. Journal of medical toxicology. 2014 Sep 1;10(3):286-91.

AEM Early Access 12: Behavioral Changes in Children after ED Procedural Sedation

Welcome to the twelfth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing: (click title for full text; open access through March 31, 2018.)

Behavioral Changes in Children After Emergency Department Procedural Sedation. Jean I. Pearce, David C. Brousseau, Ke Yan, Keri R. Hainsworth , Raymond G. Hoffmann, Amy L. Drendel. Academic Emergency Medicine 2018, in press. 

LISTEN NOW: 

PearceFirstAuthorPhoto.jpg

Jean Pearce, M.D., M.S.
Assistant Professor, Pediatric Emergency Medicine
Medical College of Wisconsin

ARTICLE SUMMARY:

Objectives:
Post-anesthesia negative behavioral changes in children are well documented in surgical and anesthesia literature, and these changes can last for days to weeks. It is not known if this is true for children receiving procedural sedation in the emergency department. The objective of this study was to evaluate the proportion of pediatric patients who experience negative post-discharge behaviors in the 1-2 weeks after procedural sedation for fracture reduction in the emergency department, and to determine predictors of negative post-discharge behaviors among study subjects. 


Methods:
The study was conducted among a prospective cohort of pediatric patients receiving ketamine for procedural sedation during emergency department fracture reduction. Subjects between 2 and 18 years of age were enrolled at single pediatric emergency department between October 2014 and September 2015. A baseline measure of the subjects’ anxiety as perceived by treating physicians was measured using the Modified Yale Preoperative Anxiety Scale, and negative behavioral changes were measured by parents who completed the Post-Hospitalization Behavior Questionnaire both prior to, and again in the 1-2 weeks after discharge. A variety of statistical methods including descriptive statistics, odds ratios and multivariable logistic regression models were used to analyze the data.


Results:
Of the 82 of 97 patients who completed follow-up, 33 (40%) were perceived to be highly anxious prior to sedation, and 18 (22%) had significant negative discharge behaviors after ED discharge. Predictors of negative postdischarge behaviors were high anxiety (OR 9.0, 95% confidence interval 2.3 - 35.7) and nonwhite race (OR 6.5, 95% confidence interval 1.7 - 25.0).


Conclusion:
Two of five children who undergo procedural sedation in the emergency department are observed to be highly anxious prior to procedural sedation, and almost one in four experience negative discharge behaviors after procedural sedation. Highly anxious and nonwhite children are particularly more likely to experience negative discharge behaviors compared to their peers.


Further Reading:
Brodzinski, Holly, and Srikant Iyer. "Behavior changes after minor emergency procedures." Pediatric emergency care 29.10 (2013): 1098-1101.

Madati, P. J. "Ketamine: Procedural Pediatric Sedation In The Emergency Department." Pediatric Emergency Medicine Practice 8.1 (2010).

MacLaren, Jill E., et al. "Prediction of preoperative anxiety in children: who is most accurate?." Anesthesia and analgesia 108.6 (2009): 1777.
 

 

Asynchrony PEM: Pediatric Gonadal Emergencies

Today, we’re talking gonads! Specifically, painful pediatric gonadal emergencies.  

Gonadal emergencies present in the pediatric emergency department so many different ways; it's not as straightforward as kids complaining of testicular swelling or 'my ovaries hurt'. They usually present as pediatric abdominal pain.  And because both that chief complaint and gonadal emergencies in general can cause you and your patient to cry, here's this week's theme song:

 

Kicking things off: Twist and Shout?

From our friends in Cincinnati, some key history and physical tips for your pediatric patients complaining of testicular pain.  Important questions that our urology colleagues will ask about the physical exam include symmetry, testicular lie, and, most importantly, is there a cremasteric reflex? This was found to be 83.3% accurate in a 2004 study by Paul et al.

Patients with the bell-clapper deformity (a horizontal lie due to a defect in posterior attachment) are at an increased risk for torsion, based on the testicular lie.

What is your differential for pediatric testicular pain? More from our friends in Cincinnati: The emergency, the painful, and the treat or not to treat? And if you want more info on appendix testis torsion, or epididymitis PEDS EM Morsels has some brief input to check out.

But what if your patient has ovaries and not testicles?

These patients will present with acute onset abdominal pain, unilateral, and constant. Depending on how long the ovary has been twisted, pain can subside and become dull and mimic many different abdominal presentations, which is why it is often missed!

Ultrasound is not 100% in diagnosis and if you have high clinical suspicion, please call the urologists.  Remember to ask our radiology colleagues to comment on the spermatic cord and flow in their report. And ask nicely!

Testicular torsion can even happy perinatally (no age is safe!).  Check half way down the page for some quick tidbits on perinatal torsion. Check here for more information, but, in summary, testicular torsion can happen any time prenatally after the 6th week of gestation (when gonads form) to just before, during and after birth.  Depending on when the torsion occurs, the infant might present with just a dusky hemiscrotum, firm hemiscrotum, or may just be an inconsolable infant.

But the gonads can do more that just twist, right? You betcha.

For the auditory learners listen to this quick (<10 minutes) podcast on ruptured ovarian cysts. (Note, we will not do transvaginal ultrasounds at Hasbro hospital, our home institution.)

Teenagers are also sexually active.  Make sure to talk to patients about pregnancy, get a urine or serum b-HCG, and screen for PID. The American Academy of Pediatrics has guidelines for screening for STIs in adolescents.  Basically: screen for gonorrhea, chlamydia, trichomoniasis, and syphilis as indicated. Don’t forget oral and anal swabs, as teens will have oral, vaginal, or anal sex.

And finally some Y chromosome specifics for when your patient gets their penis caught in a zipper or suffers from summer penile syndrome (for audio learners and readers).

That's it! Now you're ready to grab any gonadal emergency by the...horns.

See you next time in Asynchrony PEM!