A Case of Laundry Pod Ingestion
You are called to the low-acuity side of your department for a two year old child who was triaged three hours ago. The child was witnessed to eat a laundry pod at home, but was stable on arrival so sent to the back. Now, the child is wheezing, seems drowsy, and is tachycardic. When you approach the child, he begins to cry and you note the sound of a baby pterodactyl that you recognize as stridor.
Laundry pods are caustic substances that cause functional and histological damage due to direct contact with the body. Recently, these pods have gained a lot of media attention due to the “Tide Pod Challenge” in which people purposefully ingest the colorful, candy-appearing pods, and post videos online. These types of poisonings can be severe in some cases, given that the chemicals in pods are in very high concentration. As a result, it is crucial that those on the front line are familiar with how to handle these emergencies.1
Laundry pod ingestion can present in a variety of populations. These exposures are generally divided into: (1) intentional (in persons with suicidal ideation and more recently the “Tide Pod Challenge”), (2) accidental (in children or adults with dementia), and (3) incidental (due to occupational exposures). Most exposures are unintentional or incidental, however the intentional ingestion (with suicidal intent) are associated with higher grade of GI tract injury.
In the first fifteen days of 2018, the American Association of Poison Control Centers (AAPCC) reported 39 intentional cases of exposure to laundry pods. This number is highly worrisome, given that in 2016 there were 39 cases, and 2017 there were 53 cases.2
Laundry pods are composed of an external dissolvable polyvinyl alcohol membrane that dissolves with contact with water (or saliva). Inside the membrane is a proprietary alkaline mixture of chemicals, containing toxic alcohols (like propylene glycol), surfactants and long chain polymers. This mixture can cause damage through ocular and dermal contact, but ingestion is far more common, with 90% of exposures having ingestion as one of the routes. The toxic effects span a variety of systems, and are summarized below:
- Systemic and Metabolic: Propylene glycol is converted to lactic acid, causing a lactic acidosis.
- CNS: Ethanol and propylene glycol in the pods are hypothesized to contribute to altered mental status (1-8% of cases).
- GI: Pharyngeal and esophageal burns may occur due to caustic burn. These may lead to rupture from liquefaction necrosis in severe cases. GI irritation associated with vomiting, while the long chain polymers are associated with diarrhea.
- Renal: Dehydration secondary to vomiting and diarrhea, combined with propylene glycol thought to cause renal insufficiency and injury.
- Respiratory: Increased risk of aspiration due to altered mental status and vomiting. Coughing and stridor also possible due to direct irritation.
- Ocular: Keratitis
- Integumentary: 2nd and 3rd degree burns possible
CLINICAL EVALUATION AND DIAGNOSIS
The presentation after laundry pod ingestion can be varied in severity, and the absence of clinical signs is not always predictive of severity.3 Overall, intentional ingestion (with suicidal intent) are associated with higher grades of GI tract injury, with or without clinically obvious signs.4
A review of pediatric laundry pod ingestion cases found that common clinical features included vomiting (56%), coughing or choking (14.6%), drowsiness or lethargy (7.8%) and nausea (4.9%). Severe symptoms included seizures, respiratory arrest, gastric burns, and coma. The differential for laundry pod ingestion is broad, as patients can have increased or decreased temperature and respiratory rate. Common causes on the differentials for these presentations should be explored when reasonable.
History should focus on what was specifically ingested by the patient, time since ingestion, whether actions were intentional or unintentional, and whether there were other co-ingestants (e.g. salicylate and acetaminophen in suicide attempts). Physical exam should start by looking for signs of respiratory distress and circulatory shock first. After patients have been deemed stable, the clinician should looks for signs of pharyngeal injury (mucosal burns, drooling, cough, dysphagia), respiratory injury (coughing, wheezing, dysphonia), and gastric injury (vomiting, epigastric tenderness, diarrhea, hematemesis).5
For unintentional ingestions, additional workup is only required if severe symptoms are present (e.g. drooling, respiratory distress or vomiting). Intentional ingestions should always receive workup, due to the increased severity of injury. Testing is extensive due to the broad differential, and should include a venous blood gas, electrolyte panel, hepatic profile, CBC, coagulation profile, lactate, blood type and screen, and acetaminophen/salicylate levels (and other coingestants if sufficient concern). Patients should also undergo a chest x-ray if they have chest pain, dyspnoea, or vomiting, in order to check for peritoneal or mediastinal air.
Endoscopy is the gold standard for grading injury, and should be done in all intentional cases, and unintentional cases with severe symptoms (stridor, significant oropharyngeal burns, and/or vomiting, drooling, or food refusal with or without oropharyngeal burns). Prompt endoscopy is required, and should be done in <12 hours, and not >24 hours due to risk of iatrogenic perforation.
Decontamination takes priority. Staff should wear appropriate PPE as required, and should remove soiled clothing from patient to prevent dermal burns. Staff may be exposed to the caustic agent through vomit, and careful care should be taken around this.
The first line of management is to stabilize the patient’s ABCs. Emergency airway management may be required, due to altered mental status, vomiting, and oropharyngeal swelling. The first choice for management is oral intubation with direct visualization. Blind nasotracheal intubation is contraindicated; LMAs, combination tubes with pharyngeal or tracheal balloons, retrograde intubation and bougies can increase tissue damage or cause perforation, and should be avoided.3
Activated charcoal and ipecac syrup are contraindicated in caustic agents alone. However in situations where co-ingestants serve as a risk of systemic toxicity, charcoal may be considered. There is no benefit to neutralization and dilution therapy in the pre-hospital or ED setting.3
Careful care should be taken to ensure patients are adequately fluid resuscitated. Large bore IV access should be established for crystalloids to prevent shock. In some cases, central venous access may be required. Currently systemic steroids and prophylactic antibiotics are not recommended in the ED setting for caustic ingestion.
Known laundry pod ingestion should be reported to poison control center as soon as possible.
The disposition of patients can vary greatly, and should be evaluated appropriately. All patients with symptomatic caustic ingestions should be admitted. Grading from endoscopic evaluation should be used to guide disposition in appropriate cases.
|Grade of Injury||Disposition|
|1||Home (if asymptomatic)|
|2A||Hospitalization to ensure symptoms do not progress|
Close monitoring is important in severe cases, due to systemic concerns from metabolic acidosis (due to propylene glycol acidosis), fluid depletion (due to diarrhea/vomiting), and altered mental status. Standard critical care principles should be applied to optimize hemodynamics.2–4,6
Emergency surgery may be required in cases of GI perforation or extensive necrosis. Laparotomy is preferred as it provides posterior gastric visualization. Indications for surgery include esophageal perforation, peritoneal signs and free intraperitoneal air. Relative indications include large volume (>150 mL) ingestions, signs of shock, respiratory distress, persistent lactic acidosis, ascites and pleural fluid.
Overall, short term prognosis is worst with Grade 3 (severe) GI injury, systemic complications, and age >65 years. Long term complications include esophageal strictures, which can form from scar tissue after mucosal remodeling. These strictures can lead to dysphagia, odynophagia and malnutrition. In patients with grade 3 injury, there is an increased risk (1000x) for squamous cell cancer of the esophagus (decades after ingestion). In these cases, total removal of the esophagus may be recommended. 7,8
This post was copyedited and uploaded by Jesse Leontowicz @jleontow
Reviewing with the Staff
LDPs (like any other household chemicals) have been an exposure threat since its invention. Started with accidental toddlers’ bite and ingestion to current “Tide pod challenge” wave. Which, emphasizes the weight of peers pressure in certain age group. The review shed light on all of the important and clinically relevant toxicological aspects. Using Activated Charcoal should be sought carefully and may be avoided if upper endoscope is part of the management plan for those patients. Increasing public awareness and better prevention measures by manufacturers are warranted.