A 2-year-old female was brought in by EMS after mom heard a scream and found her daughter had gotten into the laundry detergent packs approximately 30 minutes ago. Mom arrives with a half-eaten Tide Pod in hand and tells us that she immediately induced vomiting and called emergency services. On initial exam, the toddler is playful and interactive and has Mountain Breeze on her breath. You vaguely remember kids on the internet eating Tide Pods as a challenge several years ago, but you’re just an intern and are not sure how to move forward otherwise. Luckily, the toxicology fellow just so happens to also be one of your attendings tonight, and they fill you in with more than you ever wanted to know about this potentially fatal ingestion.
What is it:
Laundry detergent pods (LDPs) are commercially available packets of proprietary mixtures generally composed of propylene glycol, surfactants, and other hydrocarbons/toxic alcohols housed in a water-soluble polyvinyl alcohol membrane. Their popularity has increased due to their convenience, ease of use and low storage requirements. They are brightly colored, soft and easily dissolvable. Most importantly, these mixtures are highly concentrated. In comparison to packet and non-packet laundry and dishwasher detergent, LDPs are associated with as much as a 5 times greater odds of hospital admission and 8 times greater odds of serious medical outcome 1–3.
Despite their composition, LDPs tend to be less alkaline than their non-packeted counterparts. Tide is the least alkaline with pH ranges between 7.2-7.7, followed by All with a pH of 7.8, and the most alkaline brand, Purex with pH range 8.0-114–6.
Epidemiology:
Three types of exposure history:
Accidental (children, elderly adults)
Intentional (suicide, peer pressure)
Incidental (work exposure)
From 2013-2015, LDPs accounted for 74% of all detergent related poison center calls requiring medical management 77. The vast majority of cases are accidental exposures in children under 5, which have been steadily decreasing in incidence over the last decade with an 8-year low of 7082 reported in 20218,9. Nonetheless, cases have been reported in all age groups, and should especially be considered in cognitively impaired older adults7,10. Intentional exposure appears to have reached a peak incidence in 2018 with popularization of the “tide pod challenge”, with no data reported since8.
Pathophysiology:
Three main routes of exposure:
Ingestion (>90% of cases)
Ocular
Dermal
Though the mechanisms are not fully understood, once exposed, the corrosive ingredients in LDPs are thought to cause caustic injury primarily via non-ionic surfactants and can cause serious, multi-system toxicity by a variety of other mechanisms 3,11. Notably, LDPs have been associated with esophageal injury, delayed pneumonitis, altered mental status, and lactic acidosis 1,10,12,13.
GI Injury
Caustic burn injury of the pharyngeal and esophageal epithelium rupture may lead to esophageal rupture secondary to liquefactive necrosis.
Tract irritation causes vomiting.
Long chain polymers may cause diarrhea.
Respiratory injury
Delayed pneumonitis
Cough and stridor secondary to irritation
Aspiration risk due to coughing and AMS
CNS Effects
Ethanol and propylene glycol thought to cause AMS
Seizures have been reported
Metabolic dysfunction:
Propylene glycol is converted (via alcohol dehydrogenase and aldehyde dehydrogenase) to lactic acid causing lactic acidosis.
Integumentary injury
Caustic mechanism causing chemical irritation and burns.
Rash
Ocular injury
Caustic mechanism causing irritation and keratitis.
Renal injury
Vomiting and diarrhea can cause prerenal acute kidney injury that is exacerbated by propylene glycol toxicity leading to renal insufficiency.
Clinical History:
Initial presentation can vary widely as clinically significant symptoms may not manifest until hours following ingestion. One’s clinical suspicion for severe injury should be high in cases ofself-harm, though intentional ingestion of any kind is associated with more severe injury of the GI tract. EMS and the parent/guardian will be key in many cases to piecing together your history, especially in pediatric patients.
GI symptoms will generally occur within one 30 minutes to 1 hour, while respiratory and CNS symptoms may be delayed anywhere from 1 to 4 hours after ingestion.
Key questions:
What product was ingested and was it witnessed? (ask if someone is home to snap a picture of the culprit agent or if they can bring it in!)
When was it ingested?
Co-ingestion or other exposure?
Interventions at home? (some savvy parents may attempt to illicit vomiting or may irrigate at home)
Intentional or unintentional?
The most common review of systems findings are vomiting, coughing, and CNS depression, other common complaints are nausea, and drowsiness1,10,12. Severe features of the clinical history include seizure, coma, and respiratory depression/arrest1414.
Physical Exam:
While most patients will be asymptomatic1,12, a head-to-toe exam is warranted given the potential for multi-system injury paying particular attention to the GI, respiratory, ocular, and integumentary systems.
GI and Respiratory
Gastric injury can be indicated by vomiting, epigastric tenderness, chest pain, generalized abdominal pain, and hematemesis. Respiratory injury will be evidenced by coughing, wheezing, and dysphonia; and pharyngeal injury by mucosal burn, drooling, cough, and dysphagia. Further, while evaluating the mouth - bear with me - take a moment to try and appreciate the scent of the detergent which can help narrow down your differential if the ingestion is uncertain 1,10,12.
Ocular
The most common ocular finding will be conjunctivitis or eye irritation, though cases of patients experiencing keratitis or corneal damage have been reported12,15–17. Other findings reported include lacrimation, photophobia, corneal abrasion, and ptosis11.
Integumentary
Skin involvement is generally limited to dermatitis and rash, though 2nd or 3rd degree burns have been reported1,10,18,19.
Severe findings on physical exam:
Respiratory distress, vomiting/hematemesis, drooling, seizure, CNS depression, severe abdominal pain or chest pain, food refusal.
Work-Up:
A broad work-up is indicated in cases of intentional or undifferentiated ingestions/exposures. Other fantastic EM resources have suggested including VBGs, CBCs, CMPs, coags, lactic acids, type and screen, and ASA/APAP levels for laboratory work-up, and we certainly agree with that while narrowing for your specific case.
A chest X-ray is indicated for patients with chest pain, epigastric pain, vomiting/hematemesis, dyspnea, drooling, or other signs or symptoms concerning for acute esophageal, gastric, or pulmonary injury.
Ocular exposures should be evaluated with ocular pH and a fluorescein examination should be performed to evaluate for corneal defects.
All cases of intentional ingestion and unintentional ingestions with severe symptoms should undergo endoscopy for grading of injury within 24 hours of ingestion20. GI should additionally be consulted for any symptomatic case that is suspicious for corrosive ingestion in any time frame to determine the need for endoscopy and facilitate further management, as endoscopy performed 24 hours after ingestion may portend an increased risk of iatrogenic perforation20. [YB6]
Management:
ABCs. – Airway Management
An emergent intubation may be required in the setting of intractable vomiting, irreversible bronchospasm, oropharyngeal swelling/edema, and/or CNS depression. Ideally, the airway will be secured by fiberoptic visualization when possible 21.
In the setting of potential caustic injury to the esophageal tissue, blind nasotracheal intubation is strictly contraindicated due to risk of perforation. Similarly, the use of LMAs, combination tubes, bougies, and retrograde intubations are relatively contraindicated.
Decontamination
Removal of soiled garments and copious irrigation of exposed surfaces, especially Morgan Lens for ocular exposure. Pre-hospital, ingested alkali substances should be immediately diluted by drinking water21. Care takers should dawn appropriate PPE including face shields, gowns, and gloves while decontaminating due to risk of exposure from vomiting, clothing, or otherwise.
If no co-ingestion suspected, there is no role for charcoal in the management of solely caustic agents as it may obscure field visualization during endoscopy or intubation and may cause vomiting, re-exposing upper GI tissues21.
Monitoring
All symptomatic patients should be admitted and observed for 4-6 hours to evaluate for appearance of respiratory or neurological damage. Patients presenting at night should be monitored overnight.
Disposition
For patients who do not require endoscopy, they may be discharged home after appropriate monitoring as above. Otherwise, endoscopic findings will dictate their disposition.
Grade I: Home if asymptomatic or monitoring for continued symptoms
Grade IIa: Hospitalization for monitoring as above.
Grade IIb: Admission to the ICU and initiation of IV dexamethasone20.
Grade III: ICU admission.
Perforation: Emergency surgery.
Consultants
Even in the absence of oral erythema, ulcers, or swelling, patients may develop some form of esophageal injury. Providers should have a low threshold for GI consultation for endoscopy13. Further, endoscopic grading can help guide your disposition in complex cases21. Immediately involve your Poison Control center for all ingestions for both reporting and recommendations on management and disposition. Support from neurology, respiratory, dermatology, and ophthalmology may also be needed depending on the nature of exposure and the severity of injury to these systems.
Written by:
Dr. Adam Roussas, MD
Emergency Medicine, PGY-1
Cook County Health
Reviewed by:
Dr. Brian Bush, MD
Toxicology Fellow
Cook County Health
Works Cited
1. Settimi L, Giordano F, Lauria L, Celentano A, Sesana F, Davanzo F. Surveillance of paediatric exposures to liquid laundry detergent pods in Italy. Injury Prevention. 2018;24(1):5. doi:10.1136/INJURYPREV-2016-042263
2. MG D, MJ C, HA S, T C, GA S. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014. Pediatrics. 2016;137(5). doi:10.1542/PEDS.2015-4529
3. I C, R H, A C, E G, N F. [Pediatric exposures to laundry pods or capsules: more toxic than traditional laundry products?]. Archives de pediatrie : organe officiel de la Societe francaise de pediatrie. 2014;21(6):601-607. doi:10.1016/J.ARCPED.2014.03.020
4. Ultrapacks P. Material Safety Data Sheet G-113 SECTION 1: PRODUCT AND COMPANY IDENTIFICATION. Accessed September 28, 2021. https://images-na.ssl-images-amazon.com/images/I/71tCHvvBR5S.pdf
5. SAFETY DATA SHEET. Accessed September 28, 2021. https://content.oppictures.com/Master_Images/Master_PDF_Files/PGC50978_SDS.PDF
6. All Stainlifter Might Pacs Safety Data Sheet. Published online 2018. Accessed September 9, 2021. https://images-na.ssl-images-amazon.com/images/I/71tCHvvBR5S.pdf
7. Laundry Pods Pose Lethal Risk for Adults With Dementia - Consumer Reports. Accessed September 28, 2021. https://www.consumerreports.org/laundry-cleaning/liquid-laundry-detergent-pods-pose-lethal-risk/
8. American Association of Poison Control Centers - Laundry Detergent Packets. Accessed September 28, 2021. https://www.aapcc.org/track/laundry-detergent-packets
9. Gaw CE, Spiller HA, Casavant MJ, Chounthirath T, Smith GA. Safety Interventions and Liquid Laundry Detergent Packet Exposures. Pediatrics. 2019;144(1). doi:10.1542/PEDS.2018-3117
10. Health Hazards Associated with Laundry Detergent Pods — United States, May–June 2012. Accessed September 28, 2021. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6141a1.htm#tab1
11. R D, SM B, SHL T, JA V. Liquid laundry detergent capsules (PODS): a review of their composition and mechanisms of toxicity, and of the circumstances, routes, features, and management of exposure. Clinical toxicology (Philadelphia, Pa). 2019;57(11):1053-1063. doi:10.1080/15563650.2019.1618466
12. R D, SM B, G J, et al. A review of 4652 exposures to liquid laundry detergent capsules reported to the United Kingdom National Poisons Information Service 2008-2018. Clinical toxicology (Philadelphia, Pa). 2019;57(12):1146-1153. doi:10.1080/15563650.2019.1590586
13. E S, E L, J N. Laundry detergent pod ingestions: is there a need for endoscopy? Journal of medical toxicology : official journal of the American College of Medical Toxicology. 2014;10(3):286-291. doi:10.1007/S13181-014-0414-3
14. S H, J H, R V, R M, RJ G. Serious adverse effects from single-use detergent sacs: report from a U.S. statewide poison control system. Clinical toxicology (Philadelphia, Pa). 2014;52(3):220-225. doi:10.3109/15563650.2014.892122
15. MP B, HR D, S T, U T. Prospective analysis of pediatric ocular chemical burns: laundry detergent pods. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 2018;22(6):426-428. doi:10.1016/J.JAAPOS.2018.07.349
16. ME G, CE W. Corneal injuries from liquid detergent pods. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 2014;18(5):494-495. doi:10.1016/J.JAAPOS.2014.05.006
17. RE W, CR B, PL A. Diffuse corneal abrasion after ocular exposure to laundry detergent pod. Pediatric emergency care. 2015;31(2):127-128. doi:10.1097/PEC.0000000000000244
18. Russell JL, Wiles DA, Kenney B, Spiller HA. Significant Chemical Burns Associated with Dermal Exposure to Laundry Pod Detergent. Journal of Medical Toxicology. 2014;10(3):292. doi:10.1007/S13181-014-0387-2
19. TA S, G M, R G. Laundry pod and non-pod detergent related emergency department visits occurring in children in the USA. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention. 2016;22(6):396-399. doi:10.1136/INJURYPREV-2016-041997
20. Thomson M, Tringali A, Dumonceau JM, et al. Paediatric gastrointestinal endoscopy: European society for paediatric gastroenterology hepatology and nutrition and European society of gastrointestinal endoscopy guidelines. Journal of Pediatric Gastroenterology and Nutrition. 2017;64(1):133-153. doi:10.1097/MPG.0000000000001408
21. Judkins DG, McTeer A v. Alkali Toxicity. StatPearls. Published online June 23, 2021. Accessed September 28, 2021. https://www.ncbi.nlm.nih.gov/books/NBK544235/
Tags: laundry detergent pods, liquid laundry packets, tide pod challenge, tide pods, single use detergent sacs