a b s t r a c t

Introduction: Single-use laundry detergent pods (LDPs) were introduced to the United States in 2010 but had been available in Europe as early as 2001. Case reports of unintentional exposures noted vomiting, ocular injuries, respiratory depression, and Central nervous system depression. We summarize clinical effects from unintentional LDP exposures reported to a single poison center over 15 months.

Methods: Electronic poison center records were searched using verbatim field and both product and generic codes to identify laundry pod exposures from January 1, 2012, through April 9, 2013. Clinical effects were ab- stracted to a database and summarized using descriptive statistics.

Results: We identified 131 cases between March 2012 and April 2013. Median (interquartile range) age was 2.0 (1.5) years with 4 adult cases; all were coded as unintentional. The most common route was ingestion (120) followed by ocular (14) and dermal (6). Some patients had multiple routes of exposure. Of ingestion exposures, 79 (66%) were managed at home; and 41 (34%) were evaluated in a hospital, of which 9 patients were admitted. The median (interquartile range) age of admitted patients was 1.4 (1.1) years. Relevant findings in these admit- ted children included emesis (78%), central nervous system depression (22%), upper airway effects (56%), lower respiratory symptoms (33%), seizure (n = 1), and intubation (67%). One child with emesis initially managed at home was subsequently intubated for respiratory distress.

Discussion: Exposure to LDP can cause significant toxicity, particularly in infants and toddlers. Compared to tra- ditional detergents, clinicians should be aware of the potential for airway compromise following exposure to LDP.

(C) 2014

Introduction

Single-use laundry detergent pods (LDPs) were introduced to the United States in 2010 but had been available in Europe as early as 2001. The pods contain concentrated liquid detergent in a water- soluble polyvinyl alcohol membrane. Case reports of exposures have noted vomiting, ocular injuries, respiratory depression, and central ner- vous system (CNS) depression [1]. The aim of this investigation was to summarize clinical effects from detergent pod exposures reported to a single poison center over 15 months.

Methods

Study design

This was a retrospective cross-sectional chart review using electronic poison center data evaluating clinical outcomes from

? An abstract of these data was presented at the North American Congress of Clinical Toxicology annual meeting held in Atlanta, GA, 2013.

* Corresponding author.

E-mail address: [email protected] (B.K. Wills).

single-use detergent pods. Institutional Review Board approval was obtained.

Setting and population

The Virginia Poison Center provides toxicology consultation in the central and eastern Virginia regions, with an annual call volume of ap- proximately 27 000. The poison center electronic database Toxicall was queried from January 1, 2012, to April 9, 2013, by 2 investigators (MB and PES) using temporary substance code and specific xenobiotic codes established in April 2012 by the American Association of Poison control centers. Chart acquisition was performed by specialists in poison information and abstracted into a database with no patient identifiers.

Study protocol

A data collection spreadsheet was created a priori. Data were ab- stracted from each case by 2 investigators (MB and PES); all cases and abstractions were re-reviewed by 1 investigator for accuracy (PES). No ? score between abstractors was calculated because of a single

http://dx.doi.org/10.1016/j.ajem.2014.11.044

0735-6757/(C) 2014

350 P.E. Stromberg et al. / American Journal of Emergency Medicine 33 (2015) 349–351

abstractor for a small number of hospitalized patients and relatively objective data.

Demographic information was collected from each case including age and sex. Exposure-specific data were obtained including name of product involved, route of exposure, and location where exposure oc- curred (home, work, or other). Symptoms at time of call were recorded. The initial site of the call, whether treatment at a health care facility was sought before contacting the poison center, and whether referral to health care facility was recommended or required were recorded. Vital signs of patients treated at health care facilities were recorded. Cat- egories of clinical effects included gastrointestinal (eg, emesis), upper respiratory signs (eg, drooling, stridor), lower respiratory signs (eg, ab- normal lung examination result, retractions, or respiratory distress), and CNS (eg, CNS depression, seizures). Any interventions provided at a health care facility were recorded (eg, intubation, irrigation of eyes). Length of stay for hospitalizations was recorded when available.

Measures

The primary end points were to (1) describe proportion of detergent pod exposure cases evaluated at home, referred to the emergency department and discharged, or hospitalized and (2) summarize clinical effects in hospitalized patients.

Data analysis

Data were summarized using Excel (Microsoft; Redmond, WA) including proportions for nominal data and mean or median for continuous data.

Results

We identified 131 cases between January 2012 and April 2013. Me- dian (interquartile range [IQR]) age was 2.0 (1.5) years, with 4 adult cases; all were coded as unintentional. The most common route was in- gestion (120) followed by ocular (14) and dermal (6). Some patients had multiple routes of exposure. Of ingestion exposures, 79 (66%) were managed at home; and 41 (34%) were evaluated in a hospital, of which 9 were admitted (Table 1). The median (IQR) age of admitted pa- tients was 1.4 (1.1) years. Relevant findings in the 9 hospitalized chil- dren included emesis (7/9, 78%), CNS depression (2/9, 22%), upper airway effects (5/9, 56%), lower respiratory symptoms (3/9, 33%), seizure (1/9, 11%), and intubation (6/9, 67%) (Table 2). One child with emesis initially managed at home was subsequently intubated for respi- ratory distress. Available clinical information for the 6 intubated patients is listed in Table 3.

Discussion

The findings reported in these patients are consistent with published reports of exposures to LDP. Exposures predominantly occur in children younger than 5 years. Common routes of exposure include ingestion, ocular, and dermal exposure; but multiple routes of exposure may occur simultaneously [2]. In several large series, CNS depression was re- ported in 1.7% to 7.8% of ingestions, with no cases undergoing intuba- tion and mechanical ventilation [2-4]. Cases of children exposed to LDP who required intubation for airway protection have been reported

Table 1

Summary demographic and outcome data of 131 cases

Table 2

Clinical data of 9 admitted patients

[3,5,6]. In these cases, it appears that airway intervention was per- formed because of a combination of significant CNS depression, hypoventilation, and respiratory distress. The largest series of LDP expo- sures from the National Poison Data System to date reported intubation in 82 (0.6%) of all 13730 oral ingestions [3]. Caustic effects of LDP have also been reported [7,8], which could potentially contribute to upper airway compromise. Although ingestion of powder laundry detergent has been recognized for many years as a cause of severe respiratory symptoms in children [9], the LDP described in this study have only been available in the United States since 2010.

The mechanism causing CNS depression following LDP exposure re- mains unclear. These pods contain varying concentrations of nonionic surfactants and propylene glycol, although no component has been clearly attributed to the observed clinical effects [2,5]. The majority of reported exposures in our case series were managed at home with min- imal symptoms, whereas hospitalized children exhibited significant clinical effects soon after exposure. Hospitalized patients often exhibit- ed Gastrointestinal symptoms (ie, vomiting) followed by respiratory symptoms and CNS depression. Among the children hospitalized in this series, a disproportionally high number (67%) were intubated be- cause of either CNS depression and/or concerns for upper airway injury (eg, drooling). Clinical effects appear to be self-limited, with the major- ity of patients being successfully extubated and discharged within a few days. Of the patients observed at home, only one had subsequent deterioration.

Limitations

Retrospective poison center chart reviews have inherent limitations in the quality of data. Information contained in poison center charts is generated passively through voluntary discussions with health care providers by poison center specialists, sometimes by providers only pe- ripherally involved in patient care. This process undoubtedly results in documentation of incomplete vital signs, physical examination findings, signs, symptoms, and laboratory data. Based on these limitations, it is difficult to completely understand the clinical circumstances leading to the decision to intubate. Underlying medical history or comorbidities of admitted patients were not known and could confound the severity of outcomes observed. Additionally, these data cannot be used to esti- mate prevalence of serious clinical outcomes given the passive nature of reporting to regional poison centers.

Conclusion

Exposure to LDP can cause significant toxicity in infants and tod- dlers. Compared to traditional detergents, clinicians should be aware of the potential for airway compromise following exposure to LDP. This could be due to a combination of CNS depression and/or upper airway effects.

P.E. Stromberg et al. / American Journal of Emergency Medicine 33 (2015) 349–351 351

Table 3

Clinical data for 6 intubated patients

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