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CYANOACRYLATES-SUPER GLUE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Cyanoacrylates are commonly used as adhesives for many home and commercial uses. Medically, they are primarily used as tissue adhesives for minor wound repair. The most commonly used tissue adhesive in the United States is octyl-2-cyanoacrylate, marketed under the brand name Dermabond ® (Ethicon).
    B) Cyanoacrylate tissue adhesives are liquid monomers that undergo an exothermic reaction upon exposure to moisture, forming a polymer.
    C) Commercial grade products, marketed as "super glues", usually contain methyl or ethyl monomers, plus plasticizers and thickening agents, and acidic stabilizers.

Specific Substances

    A) CONSTITUENTS OF THE GROUP
    1) Methyl 2-cyanoacrylate
    2) Ethyl 2-cyanoacrylate
    3) n-butyl 2-cyanoacrylate
    4) Isobutyl 2-cyanoacrylate
    5) Alkyl cyanoacrylate

Available Forms Sources

    A) FORMS
    1) Cyanoacrylates are found in many so called "Super Glue" glues available in small tubes, usually 1 to 3 grams under a wide variety of trade names: Methyl-2-Cyano-Acrylate monomer, Eastman 910, Super Glue, Ethyl-2-Cyano-Acrylate, Super Bonder, etc.
    2) Commercial grade products, marketed as "super glues", usually contain methyl or ethyl monomers, plus plasticizers and thickening agents, and acidic stabilizers (Mickey & Samson, 1981).
    3) Alkyl cyanoacrylate is the principal constituent of an adhesive compound called "Aron Alpha" (Nakazawa, 1990). Alkyl cyanoacrylates are less volatile and possess longer chains than methyl-, butyl-, and ethyl-type cyanoacrylates.
    B) USES
    1) Cyanoacrylates are commonly used as adhesives for many home and commercial uses. Medically, they are primarily used as tissue adhesives for minor wound repair. The most commonly used tissue adhesive in the United States is octyl-2-cyanoacrylate, marketed under the brand name Dermabond(R) (Ethicon).
    2) Cyanoacrylate tissue adhesives are liquid monomers that undergo an exothermic reaction upon exposure to moisture, forming a polymer.
    3) Cyanoacrylate monomers have been used in neurosurgery, ophthalmology, and ear surgery (Mickey & Samson, 1981; Carlson & Wilhelmus, 1987; Chen & Harner, 1986).
    4) Butyl-2-cyanoacrylate (Histoacryl) and isobutyl-2-cyanoacrylate are used as a tissue glue (Kamer & Joseph, 1989; Berenstein & Hieshima, 1987).
    5) The butyl monomers have been used medically because polymerization times, rate of degradation and histotoxicity tend to decrease as the length of the side chain increases (Mickey & Samson, 1981).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Cyanoacrylates are commonly used as adhesives for many home and commercial uses. Medically, they are primarily used as tissue adhesives for minor wound repair. The most commonly used tissue adhesive in the United States is octyl-2-cyanoacrylate, marketed under the brand name Dermabond(R) (Ethicon).
    B) PHARMACOLOGY: Cyanoacrylate tissue adhesives are liquid monomers that undergo an exothermic reaction upon exposure to moisture, forming a polymer.
    C) TOXICOLOGY: Cyanoacrylates degrade into the toxic by-products cyanoacetate and formaldehyde, which may cause an inflammatory response in the surrounding tissue. In addition, they may cause unwanted adhesive effects.
    D) EPIDEMIOLOGY: Exposures are very common; cyanoacrylate glues are by far the most commonly reported adhesives to poison centers and have very few serious complications.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: Adverse effects include unintended bonding of 2 surfaces, erythema, edema, pain, thermal discomfort, and infection.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Ingestion is very rare; these products are rarely available in large enough volumes to cause any significant clinical effects. In addition, the product would polymerize upon exposure to moisture, and thus local and foreign body effects are the most one would expect. This product is not inhaled. Dermal exposure is rarely an issue as this is the indicated route for treatment. Eye exposure may cause a local irritant effect.
    0.2.4) HEENT
    A) WITH POISONING/EXPOSURE
    1) OCULAR EXPOSURE: Eye exposure rapidly seals eyelids together. Corneal abrasions, loss of lashes, eyelid skin excoriation, or conjunctival inflammation may occur.
    2) ORAL EXPOSURE: Cyanoacrylates polymerize so rapidly that monomer will usually not pass beyond the oropharynx without polymerization, making pharyngeal or esophageal adhesions unlikely. Polymerized materials adhere to the mouth and tongue producing a greyish-white plaque that may be left alone to wear off.

Laboratory Monitoring

    A) Specific laboratory determination for cyanoacrylates is not indicated.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) The most common effect is inadvertent bonding of skin. Manufacturers recommend acetone-based solvents to assist with dissolving the glue, but these are often not effective. The glue bond will eventually release the skin. Pharyngeal or esophageal adhesions are unlikely since the monomer rapidly polymerizes in the mouth. Mouth, tongue, and oral mucous membrane adhesions are best managed without mechanical manipulation. These may be left alone to wear off or the process may be hastened by gentle abrasion with a toothbrush. Do not apply solvents to the oropharynx.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Severe toxicity from this agent is not expected. Aspiration, resulting in polymerized material in the trachea and mainstem bronchi, has occurred but is rare. Administer humidified oxygen, corticosteroids and inhaled beta agonists as necessary for respiratory distress, and refer for bronchoscopy if aspiration is suspected. Esophageal or gastric injury or obstruction can develop after deliberate ingestion, endoscopic evaluation is recommended in symptomatic patients.
    C) DECONTAMINATION
    1) PREHOSPITAL: The majority of these exposures can be managed at home as above.
    2) HOSPITAL: Similar management as home exposure.
    D) ANTIDOTE
    1) The easiest way to remove the agent is to use a hydrocarbon solvent. However, washing with other liquids and mechanical removal (e.g. rolling eyelashes between fingers) may be just as efficacious.
    E) PATIENT DISPOSITION
    1) HOME CRITERIA: Most patients can be managed at home.
    2) OBSERVATION CRITERIA: Patients with changes in vision or persistent eye or skin irritation should be referred to a health care facility for examination.
    3) ADMISSION CRITERIA: Patients, in general, do not need to be admitted for these exposures.
    4) CONSULT CRITERIA: Ophthalmology consult may be indicated for any changes in vision or severe inflammation of the eyes.
    F) PITFALLS
    1) Agents such as water, saline, iodine solutions, soap, or chlorhexidine gluconate are not expected to immediately loosen the bonds formed via polymerization of the cyanoacrylate glue and thus should not be used as first-line agents for removal. Patients should recover without treatment and thus aggressive intervention may cause more problems (e.g. corneal abrasions in trying to remove glue from eyeball).
    G) PHARMACOKINETICS
    1) Onset of action is immediate upon exposure to a moisture-containing surface (e.g. skin). Duration of action depends on the specific formulation and site of action, but the film formed usually remains in place for 5 to 10 days. Cyanoacrylate glues are not systemically absorbed.
    H) DIFFERENTIAL DIAGNOSIS
    1) Other types of glue adhesives should be considered in the exposure, including epoxy and toluene/xylene formulations.
    0.4.4) EYE EXPOSURE
    A) As the bond will eventually release, most experts recommend conservative management and allowing the glue to release. The process can be accelerated by gently rolling the eyelashes between fingers. Take care not to pull out the eyelashes. Solvents should not be used around the eye.
    B) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    C) Usually simple protection with a dry gauze patch will suffice, with spontaneous resolution occurring in 1-4 days. Gauze soaked in mineral oil, ophthalmic antibiotic ointments, and tap water may speed this process. Solvents may be used as a LAST RESORT ONLY. Occasionally surgical separation is required. Do not use acetone or alcohol in or near the eye.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) Treatment is as above. Use a hydrocarbon solvent for removal but use care around the eye and mucous membranes.
    2) ACETONE-BASED SOLVENTS: Manufacturers recommend acetone-based solvents to assist with dissolving the glue, but these are often not effective. The glue bond will eventually release the skin. Prolonged soaking in warm water and/or ethanol water mixtures may result in sufficient softening of the bond to separate tissue surfaces. This may take several hours to accomplish. CAUTION: Do not burn skin with hot water and do not use acetone or alcohol on or near the eyes.
    3) MINERAL OIL, vegetable oil, or vaseline jelly aids in the removal of cyanoacrylates from tender dermal areas and about the eyes.
    4) SURGICAL INTERVENTION: Generally not required. The affected tissue surfaces usually separate of their own accord over a few days.

Range Of Toxicity

    A) TOXICITY: No known information concerning a toxic dose is available. Tracheal and bronchial obstruction have occurred in a child following ingestion of approximately 7 mL of a cyanoacrylate and subsequent aspiration of the product.

Clinical Effects

Summary Of Exposure

    A) USES: Cyanoacrylates are commonly used as adhesives for many home and commercial uses. Medically, they are primarily used as tissue adhesives for minor wound repair. The most commonly used tissue adhesive in the United States is octyl-2-cyanoacrylate, marketed under the brand name Dermabond(R) (Ethicon).
    B) PHARMACOLOGY: Cyanoacrylate tissue adhesives are liquid monomers that undergo an exothermic reaction upon exposure to moisture, forming a polymer.
    C) TOXICOLOGY: Cyanoacrylates degrade into the toxic by-products cyanoacetate and formaldehyde, which may cause an inflammatory response in the surrounding tissue. In addition, they may cause unwanted adhesive effects.
    D) EPIDEMIOLOGY: Exposures are very common; cyanoacrylate glues are by far the most commonly reported adhesives to poison centers and have very few serious complications.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: Adverse effects include unintended bonding of 2 surfaces, erythema, edema, pain, thermal discomfort, and infection.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Ingestion is very rare; these products are rarely available in large enough volumes to cause any significant clinical effects. In addition, the product would polymerize upon exposure to moisture, and thus local and foreign body effects are the most one would expect. This product is not inhaled. Dermal exposure is rarely an issue as this is the indicated route for treatment. Eye exposure may cause a local irritant effect.

Heent

    3.4.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) OCULAR EXPOSURE: Eye exposure rapidly seals eyelids together. Corneal abrasions, loss of lashes, eyelid skin excoriation, or conjunctival inflammation may occur.
    2) ORAL EXPOSURE: Cyanoacrylates polymerize so rapidly that monomer will usually not pass beyond the oropharynx without polymerization, making pharyngeal or esophageal adhesions unlikely. Polymerized materials adhere to the mouth and tongue producing a greyish-white plaque that may be left alone to wear off.
    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) SUMMARY: The glue may be mistaken for eyedrops and instilled directly into the eye. Eyelids are rapidly sealed together following exposure, and usually the bond lasts for 1 to 4 days. Significant irritation, with pain, corneal abrasions, keratoconjunctivitis, and punctate epitheliopathy may occur; eyelash loss is common. Chronic exposure may cause giant papillary conjunctivitis.
    2) ADHESION: The eyelids seal together rapidly following exposure and remain sealed for 1 to 4 days (DeRespinis, 1990; Blinder et al, 1987; Margo & Trobe, 1982).
    3) PAIN: Intense burning or stinging may occur immediately after exposure (Lyons et al, 1990).
    4) CORNEAL ABRASION is common following accidental or intentional exposure; may persist for 4 to 5 days (DeRespinis, 1990; Lyons et al, 1990; Dean & Krenzelok, 1989; Silverman, 1988).
    a) CASE SERIES: Fifteen of 34 patients suffered corneal abrasion in one 12-month prospective study (Dean & Krenzelok, 1989).
    1) Corneal and conjunctival abrasions resolved within 5 days in 4 of 6 patients with (Lyons et al, 1990).
    b) CASE SERIES: In a review of 14 ocular superglue injuries, no permanent complications occurred from any injury. Injuries consisted mainly of conjunctivitis, corneal abrasions, or eyelashes glued together. In 50% of the patients, glue was splashed into the eye while the glue container was being opened; in 2 patients glue was mistaken for eyedrops (McLean, 1997).
    5) KERATOCONJUNCTIVITIS may occur transiently after exposure (DeRespinis, 1990; Blinder et al, 1987; Margo & Trobe, 1982).
    a) Allar (1987) suggests that the longer the cyanoacrylate is in contact with the cornea the greater the risk of keratopathy and endothelial cell death. This author also noted that the shorter the side chain, the greater the tissue toxicity (Allar, 1987).
    6) PUNCTATE EPITHELIOPATHY has been reported following ocular exposures.
    a) CASE SERIES: Punctate epitheliopathy was reported in 2 of 6 patients with exposure; it resolved within 5 days (Lyons et al, 1990).
    7) GIANT PAPILLARY CONJUNCTIVITIS may occur after prolonged exposure (Carlson & Wilhelmus, 1987).
    8) Endophthalmitis with a Lecythophora mutabilis fungal infection developed in a patient who had long-term adherence of a cyanoacrylate tissue eye patch post surgery (Marcus et al, 1999).
    3.4.4) EARS
    A) WITH POISONING/EXPOSURE
    1) SUPERGLUE EAR: Blockage of the external auditory canal may occur after instillation into the ear (Wight & Bull, 1987).
    2) OTITIS EXTERNA was reported following instillation into the ear.
    a) CASE REPORT: An adult male developed otitis externa despite treatment with prophylactic antibiotic otic suspension several weeks after his son had placed cyanoacrylate glue in his ear canal, forming an acrylic cast of his external auditory canal. Surgical removal of the cast was required (Pollock, 1988).
    3) CASE REPORT: A 35-year-old man mistakenly administered a cyanoacrylate glue into his ear which he had assumed was ear drops. Following administration, the patient experienced a burning sensation and a loss of hearing. Examination revealed complete obstruction of the ear canal by the glue which was removed without analgesia (O'Donnell et al, 1997).
    4) CASE REPORTS: Ear pain and hearing loss were reported in 3 patients following topical application of cyanoacrylate glue to the external auditory canal (EAC). The first patient, a 54-year-old man, also experienced fever approximately 3 days after laceration of his left earlobe was repaired using cyanoacrylate glue. Initial examination of the ear revealed occlusion of the EAC. A procedure was performed to remove the glue plug, resulting in perforation of the tympanic membrane; however, a second procedure completely removed the plug and the perforation spontaneously healed. The second patient, a 78-year-old man, inadvertently applied cyanoacrylate glue into his ear instead of topical antibiotic drops. After an unsuccessful attempt to remove the glue plug manually, it gradually became detached from the EAC over the next several months, and the glue cast was removed. The third patient, a 25-year-old man, developed headaches, tinnitus, dizziness, left-sided deafness, and bloody otorrhoea after friends topically applied cyanoacrylate glue into his left ear. Examination of his ear revealed polypoid granulations at the lateral end of the glue cast in the EAC. The cast was removed surgically and the granulation tissue was cauterized, resulting in clinical improvement of the patient (Dimitriadis et al, 2013).
    3.4.5) NOSE
    A) ALLERGIC RHINITIS has been reported after occupational exposure (Lindstrom et al, 2013; Nakazawa, 1990; Lozewicz et al, 1985; Kopp et al, 1985).
    B) ADHESION/CASE REPORT: A 9-year-old boy experienced complete obstruction of his right nostril after another boy intentionally applied cyanoacrylate adhesive into the nostril. The patient subsequently rubbed his nose, resulting in adherence of the nasal mucosa to the septum. The patient presented to the hospital several hours later with no pain or respiratory compromise. Following administration of general anesthesia, a Freer elevator was used to carefully remove the adhesive in pieces. The patient recovered without sequelae (Sira et al, 2011).
    3.4.6) THROAT
    A) PLAQUES: Polymerized materials adhere to the mouth and tongue producing a grayish white plaque. These may be left alone to wear off or the process may be hastened by gentle abrasion with a toothbrush.
    1) No cases of esophageal adhesion or other gastrointestinal problems have been reported to the manufacturer. Eastman Kodak notes their studies indicate that free monomer could not get past the mouth without polymerization, making pharyngeal or esophageal adhesions unlikely.
    2) CASE REPORT: A 2.5-year-old boy bit into a tube of cyanoacrylate glue. Glue covered both lips and many of the lower teeth, fixing the lips rigidly about 1 centimeter apart and sticking the tongue to the floor of the mouth. The use of swabs soaked in normal saline for 30 minutes allowed removal of the glue. (Cousin, 1990).
    B) CASE REPORT: A 72-year-old woman presented to the emergency department with a red and swollen throat approximately 7 hours after she ingested 30 mL (3 bottles) of cyanoacrylate glue. Endoscopy of the esophagus showed lacerated mucosal lesions of the upper esophagus and large foreign bodies causing esophageal impaction. Endoscopic removal of the foreign bodies was unsuccessful. The patient refused surgical removal and was subsequently discharged. A follow-up 2 months later showed that her esophagus was healing without complications (Park et al, 2012).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) INJURY OF UPPER RESPIRATORY TRACT
    1) WITH POISONING/EXPOSURE
    a) IRRITATION: Heating cyanoacrylate glues increases their volatility and creates increased respiratory and eye irritation. Cyanide is not released. Intraoral use of cyanoacrylates may cause respiratory irritation and allergic reactions (Gordon, 1987).
    B) BRONCHOSPASM
    1) WITH POISONING/EXPOSURE
    a) Occupational asthma and allergic rhinitis may occur after inhalational exposure (Lindstrom et al, 2013; Nakazawa, 1990; Kopp et al, 1985; Lozewicz et al, 1985).
    C) BRONCHITIS
    1) WITH POISONING/EXPOSURE
    a) Occupational eosinophilic bronchitis without asthma was described in a 50-year-old woman using glue containing cyanoacrylate and methacrylate at a company that produced weather strips for vehicles. She experienced shortness of breath, chest tightness, wheezing, persistent dry cough, and runny and stuffy nose when at work; however, her symptoms improved substantially on weekends. Although she had symptoms of asthma, she had no variable airflow limitation (Lemiere et al, 1997).
    D) RESPIRATORY OBSTRUCTION
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: ADULT: A 62-year-old man intentionally ingested an unknown amount of cyanoacrylate glue and presented to the emergency department gasping and cyanotic 15 minutes after ingestion. Upon exam it was noted that his mouth and throat were full of hardened glue. The glue formed a cast of his upper airway and was removed in one piece with Magill forceps under direct laryngoscopy. A rigid bronchoscopy was performed to remove residual glue and he was discharged 7 days later with mild mucositis (Chang et al, 2011).
    b) CASE REPORT: CHILD: A 19-month-old child ingested approximately 7 mL of a cyanoacrylate-containing product, aspirated some of the ingested product, and subsequently developed a severe, persistent cough. Rigid bronchoscopy showed large amounts of adhered glue in a cast that nearly obstructed the trachea, along with adhered glue in both mainstem bronchi and some material in the more distant bronchioles. The patient recovered following removal of the cyanoacrylate material from the trachea and main stem bronchi and with supportive treatment, including administration of intravenous steroids, inhaled beta-agonists, and prophylactic antibiotics (Vitale et al, 2008).
    E) PULMONARY EMBOLISM
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 34-year-old man with hepatitis B cirrhosis presented to the emergency department with lethargy and multiple episodes of hematemesis. He was also hypotensive and tachycardic. An upper GI endoscopy demonstrated several esophageal varices, blood in the stomach, and a fundal gastric varix. In addition to banding ligation to his esophageal varices, he underwent further endoscopy and received cyanoacrylate injection (4 mL of a 1:1 (with lipiodol) cyanoacrylate glue mix) into 2 sites in the gastric varix. He appeared to be hemodynamically stable following the procedure, but continued to remain intubated and ventilated due to severe hepatic encephalopathy. Approximately 10 days post-procedure, the patient developed a fever, tachycardia, a decrease in his oxygen saturation (98% to 94%) and an increase in his FiO2, from 0.4 to 0.7. Blood stained secretions appeared in his tracheostomy tube and ventilatory circuit, crepitations were audible on pulmonary examination, and a chest radiograph revealed diffuse, bilateral opacity. A non-contrast CT scan showed multiple pulmonary emboli from the injected cyanoacrylate glue in the gastric varix, with parenchymal changes that suggested either pulmonary edema or acute lung injury. With supportive care, including administration of IV diuretics and antibiotics for possible ventilator-associated pneumonia, the patient gradually improved with a decrease in oxygen requirements and resolution of the parenchymal changes as evidenced by a repeat chest radiograph. Following successful weaning off the ventilator and extubation, a repeat endoscopy showed no further bleeding and he was discharged home. At follow-up, he remained asymptomatic (Chew et al, 2014).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) FOREIGN BODY
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 72-year-old woman presented to the emergency department (ED) with a red and swollen throat approximately 7 hours after she ingested 30 mL (3 bottles) of cyanoacrylate glue. Endoscopy of the esophagus showed lacerated mucosal lesions of the upper esophagus and large foreign bodies causing esophageal impaction. Endoscopy of the stomach revealed several large foreign bodies with diffuse scarlet mucosal congestion. Endoscopic removal of the foreign bodies was unsuccessful. The patient refused surgical removal and was subsequently discharged. A follow-up 2 months later showed that the esophagus was healing without complications; however, the large foreign bodies and diffuse congestion in the stomach were still present. The patient presented to the ED 10 months later with severe abdominal pain. Abdominal radiography demonstrated high-density foreign bodies in the stomach and distal ileum that resulted in intestinal obstruction. The patient again refused surgical removal, and her symptoms seemed to improve without surgery (Park et al, 2012).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) URETHRAL FINDING
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 7 cm cast of super glue was removed from the penile urethra and a 2 cm cast of super glue was removed from the posterior urethra in a 22-year-old man following instillation of super glue into his urethra, believing it to be lignocaine gel (Turner, 1990).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) Primary irritation of the skin occurs where bonded surfaces are pulled apart mechanically.
    B) CHEMICAL BURN
    1) WITH POISONING/EXPOSURE
    a) The solidification reaction is exothermic and exposure to a large volume of adhesive increases the risk of burns.
    b) CASE REPORT: A 2-year-old child developed a full thickness skin burn to his right lower leg after inadvertent contact with cyanoacrylate glue. Upon arrival at the emergency department, the pyjama bottoms that were glued to the child’s leg were peeled off directly, removing a layer of skin with the clothing. A 10 by 3 cm area of full thickness burn was observed on the postero-medial aspect of the right lower leg. On day 2, a split thickness skin graft was performed to resurface the burn. Examination 2 days after surgery showed that the graft had adhered 100% in all areas. Wound care with mepitel, gauze, and pressure dressings were performed and an examination after 2 more days showed 100% graft adherence and no signs of infection (Clarke, 2011).
    C) CONTACT DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) Contact dermatitis has been reported after chronic dermal exposure (Bruze et al, 1995; Fitzgerald et al, 1995; Jacobs & Rycroft, 1995; Belsito, 1987; Pigatto et al, 1986; Shelley & Shelley, 1984). There is no cross-reactivity between cyanoacrylates and methyl methacrylate monomer in patients who are sensitive to the latter (Fisher, 1987).
    b) CASE REPORT: A case of allergic contact dermatitis is reported with occupational exposure to ethyl cyanoacrylate adhesives. A female hairstylist presented with acute periorbital eczema and marked edema of the eyelids as well as erythematous and scaly lip commissures and dry eczema of the fingertips (Tomb et al, 1993).
    D) NAIL FINDING
    1) WITH POISONING/EXPOSURE
    a) Nail dystrophy and periungual dermatitis, and paronychias have been reported.
    b) CASE REPORT: Nail dystrophy and periungual dermatitis, with erythema, scaling, and fissuring of the paronychial skin was described in a 25-year-old woman who had used a cyanoacrylate nail adhesive. The nails were rough, split, and deformed. Patch testing with the glue showed a delayed positive reaction after 72 hours (Shelley & Shelley, 1988).
    c) Fingernail discoloration, dystrophy, and paronychia have also been described (Fisher, 1987).

Carcinogenicity

    3.21.3) HUMAN STUDIES
    A) CARCINOMA
    1) A study of chronic intraperitoneal implantation of isobutyl-2-cyanoacrylate in the rat suggests a dose-related carcinogenic potential (Samson & Marshall, 1986).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Specific laboratory determination for cyanoacrylates is not indicated.

Methods

    A) OTHER
    1) No assistance is provided by laboratory means in diagnosis.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients, in general, do not need to be admitted for these exposures.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Most patients can be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Ophthalmology consult may be indicated for any changes in vision or severe inflammation of the eyes.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with changes in vision or persistent eye or skin irritation should be referred to a health care facility for examination.

Monitoring

    A) Specific laboratory determination for cyanoacrylates is not indicated.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Treatment is generally symptomatic and supportive. The majority of these exposures can be managed at home. The most common effect is inadvertent bonding of skin. Manufacturers recommend acetone-based solvents to assist with dissolving the glue, but these are often not effective. The glue bond will eventually release the skin.
    2) Pharyngeal or esophageal adhesions are unlikely since the monomer rapidly polymerizes in the mouth. Mouth, tongue, and oral mucous membrane adhesions are best managed without mechanical manipulation. These may be left alone to wear off or the process may be hastened by gentle abrasion with a toothbrush. DO NOT APPLY SOLVENTS TO THE OROPHARYNX.
    6.5.3) TREATMENT
    A) SUPPORT
    1) Polymerized materials adhere to the mouth and tongue producing a grayish white plaque. These may be left alone to wear off or the process may be hastened by gentle abrasion with a toothbrush.
    2) CASE REPORT: A 2.5-year-old boy bit into a tube of cyanoacrylate glue (Cousin, 1990). Glue covered both lips and many of the lower teeth, fixing the lips rigidly about 1 centimeter apart and sticking the tongue to the floor of the mouth. The use of swabs soaked in normal saline for 30 minutes allowed removal of the glue.
    3) LIPS
    a) Apply water and encourage salivation. Peel or roll lips apart but do not pull. Saliva will remove the glue within 12 to 48 hours (Fisher, 1985).
    B) RESPIRATORY OBSTRUCTION
    1) CASE REPORT: Tracheal and bronchial obstruction occurred in a 19-month-old boy who aspirated a cyanoacrylate-containing product following ingestion. A rigid bronchoscope was used to remove material from the trachea and main stem bronchi. The patient was intubated, maintained on 50% inspired oxygen, and was treated with intravenous steroids, inhaled beta agonists, and prophylactic antibiotics. The toddler remained intubated for 8 days and was discharged to home on day 10 (Vitale et al, 2008).
    C) ESOPHAGEAL INJURY
    1) Deliberate ingestion has caused esophageal impaction, erosions and lacerations, gastric erosions, and bowel obstruction (Park et al, 2012). Endoscopy is recommended in patients with abdominal pain or dysphagia, or large deliberate ingestions both to assess for injury and attempt removal. Cyanoacrylate casts may be noted on radiographs but are not always visible

Inhalation Exposure

    6.7.2) TREATMENT
    A) FOREIGN BODY IN TRACHEA, BRONCHUS AND LUNG
    1) If cyanoacrylate inhalation is suspected, the following treatment strategy for managing nasal cyanoacrylate injuries has been proposed (Sira et al, 2011):
    a) If there is no respiratory compromise, consider a chest x-ray or without bronchoscopy, and remove the adhesive under general anesthesia.
    b) If there is respiratory compromise, treat as an airway foreign body, and remove the adhesive under general anesthesia.
    2) CASE REPORT: A 9-year-old boy experienced complete obstruction of his right nostril after another boy intentionally applied cyanoacrylate adhesive into the nostril. The patient subsequently rubbed his nose, resulting in adherence of the nasal mucosa to the septum. The patient presented to the hospital several hours later with no pain or respiratory compromise. Following administration of general anesthesia, a Freer elevator was used to carefully remove the adhesive in pieces. The patient recovered without sequelae (Sira et al, 2011).
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) IRRIGATION
    1) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    2) Dean & Krenzelok (1989) found that individuals reporting complete resolution following ocular exposure to cyanoacrylates were irrigated within 20 minutes of exposure (Dean & Krenzelok, 1989).
    6.8.2) TREATMENT
    A) SOLVENT
    1) Do not use acetone or alcohol.
    B) ADHESION
    1) SUMMARY
    a) Usually simple protection with a dry gauze patch will suffice, with spontaneous resolution occurring in 1-4 days. Gauze soaked in mineral oil, ophthalmic antibiotic ointments, and tap water may speed this process. Solvents may be used as a LAST RESORT ONLY. Occasionally surgical separation is required.
    2) CONSERVATIVE TECHNIQUE
    a) Apply a gauze patch after irrigation. The eye will open without further action, usually within 1 to 4 days. Do not try to force the eye open (Fisher, 1985).
    3) MINERAL OIL/ANTIBIOTIC OINTMENT
    a) Continuous application of gauze pads saturated with mineral oil (Bock, 1984) and antibiotic ophthalmic ointment (Kimbrough et al, 1986) have also been used successfully.
    4) TAP WATER
    a) Three sterile eye pads saturated with tap water were used to apply a tight pressure patch to the eye over night. The next morning the lids were easily separated after the patch was removed. There was little discomfort associated with this procedure (Raynor, 1988).
    5) SURGICAL SEPARATION
    a) In one report a 12-year-old boy, after irrigation and 2 days of moist gauze patches, developed cellulitis of the lids, conjunctivitis, and corneal irritation. He recovered fully after surgical separation of the eyelashes and antibiotic treatment (Henderson et al, 1989).
    6) SOLVENT
    a) As a last resort, a solvent may be used to soften hardened glue from eyelids (Technical Information, 1987).
    b) CAUTION: Before using a solvent in the eye, check to make sure it is the eye epidermis that is glued together and not just the eyelashes. Sometimes cutting the eyelashes will open the eyes without solvent application (Chalfin, 1988; Donnenfeld et al, 1987).
    C) IRRITATION SYMPTOM
    1) Hardened dried glue in the inside lid margins or fornix should be removed to prevent mechanical irritation (Technical Information, 1987).
    2) The glue will dissociate over several hours. Weeping, double vision, and lacrimation may occur until the process is complete.
    3) Allar (1987) suggests that the longer the cyanoacrylate is in contact with the cornea, the greater the risk of keratopathy and endothelial cell death. This author also noted that the shorter the side chain, the greater the tissue toxicity (Allar, 1987).
    D) CORNEAL ABRASION
    1) After removal of adhesive, antibiotic ointments, cycloplegics, and eye patching may be indicated if fluorescein staining reveals epithelial damage (Technical Information, 1987).
    E) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Dermal Exposure

    6.9.2) TREATMENT
    A) ACETONE
    1) Application of acetone, prolonged soaking in warm soapy water and/or ethanol water mixtures may result in sufficient softening of the bond to separate tissue surfaces. This may take several hours to accomplish. One manufacturer also recommends soaking in nitromethane for 3 to 5 minutes (Technical Information, 1987).
    2) CAUTION
    a) Do not burn skin with hot water and do not use acetone or alcohol on or near eye.
    B) LUBRICATION
    1) Mineral oil, vegetable oil or vaseline jelly aids in the removal of cyanoacrylates from tender dermal areas and about the eyes (Bock, 1984).
    C) SURGICAL PROCEDURE
    1) Surgical separation of tissue surfaces may be necessary, but should not be done unless absolutely necessary. The tissue surfaces affected will usually separate of their own accord over a few days.
    D) ETHER
    1) One case study found that ether separated a palmar surface adhesion that did not respond to warm soak, 70% isopropyl alcohol or acetone. Care should be taken NOT to use diethyl ether around spark, flame, wounds, mouth or eyes (Woodcock & Goldberg, 1985).
    E) FOREIGN BODY IN NOSE
    1) The following treatment strategy for nasal cyanoacrylate injuries has been proposed (Sira et al, 2011):
    a) If cyanoacrylate inhalation is not suspected and the patient is not comfortable, the adhesive should be removed under general anesthesia, using a surgical instrument such as a Freer elevator. If there is no mucosal damage, no further follow-up is needed. If there is mucosal damage, administer saline douching with or without a topical steroid.
    b) If cyanoacrylate inhalation is not suspected and the patient is comfortable, administer saline soaks with or without lubrication. If the adhesive has been removed and there is no mucosal damage, no further follow-up is needed. If there is mucosal damage, administer saline douching with or without topical steroids. If the adhesive is not removed, administer a local anesthetic with or without epinephrine to mobilize the cast. If that does not remove the adhesive, place the patient under general anesthesia and carefully remove the adhesive using a surgical instrument, such as a Freer elevator.
    2) CASE REPORT: A 9-year-old boy experienced complete obstruction of his right nostril after another boy intentionally applied cyanoacrylate adhesive into the nostril. The patient subsequently rubbed his nose, resulting in adherence of the nasal mucosa to the septum. The patient presented to the hospital several hours later with no pain or respiratory compromise. Following administration of general anesthesia, a Freer elevator was used to carefully remove the adhesive in pieces. The patient recovered without sequelae (Sira et al, 2011).
    F) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Abstracts

Case Reports

    A) ROUTE OF EXPOSURE
    1) OCULAR: Three patients mistakenly instilled cyanoacrylate adhesives into their eyes because the plastic container resembled those used for ophthalmic medications. Each patient developed a tarsorrhaphy and transient keratoconjunctivitis (Margo & Trobe, 1982).
    2) OCULAR: Traumatic tarsorrhaphy from the intentional application of cyanoacrylate as an act of child abuse was reported in a 9-year-old who developed a keratoconjunctivitis also (Blinder et al, 1987).
    3) OCULAR: Giant papillary conjunctivitis occurred in a 75-year-old patient due to mechanical irritation from cyanoacrylate glue during treatment of a corneal perforation secondary to suppurative keratitis (Carlson & Wilhelmus, 1987).
    4) OCULAR: In one report a 12-year-old boy, after irrigation and 2 days of moist gauze patches, developed cellulitis of the lids, conjunctivitis and corneal irritation. He recovered fully after surgical separation of the eyelashes and antibiotic treatment (Henderson et al, 1989).
    5) OTHER: EXTERNAL AUDITORY BLOCKAGE -
    a) Traumatic instillation of cyanoacrylate glue to the ear of a 24-year-old man resulted in an adherent cast of the external auditory meatus surrounded by mucopurulent discharge. Surgical intervention was required to remove the blockage, but recovery was uneventful (Wight & Bull, 1987).
    6) INHALATION: Five cases of asthma occurring after on-the-job exposure to cyanoacrylate adhesives were reported in previously asymptomatic patients. In each case, subsequent inhalation testing with cyanoacrylates produced an asthmatic reaction (Lozewicz et al, 1985).
    7) INHALATION: Allergic rhinitis and asthma occurred in a previously well 32-year-old man after exposure to ethyl cyanoacrylate glue used in building model airplanes. Provocation testing with inhaled glue vapors resulted in an asthmatic response. Asthma symptoms resolved with avoidance of exposure (Kopp et al, 1985).
    8) INHALATION: A previously asymptomatic 33-year-old man developed panic attacks temporally related to the accidental inhalation of cyanoacrylate fumes. These attacks decreased in severity and frequency during 6 months' follow-up (Yeragani et al, 1988).
    9) DERMAL: A 2-year-old child required surgical skin grafting for a full thickness burn to his right lower leg after inadvertent contact with cyanoacrylate glue (Clarke, 2011).
    10) DERMAL: A 14-year-old boy developed a dermatitis behind both ears after applying a cyanoacrylate adhesive daily for 20 days to correct flapping ears. Standard patch tests were negative; a positive test occurred after rapid application of the adhesive resin (Pigatto et al, 1986).
    11) DERMAL: A 66-year-old woman developed a pruritic rash on breasts, scapular areas, abdomen, and thighs after using ethyl cyanoacrylates on her nails. Patch tests with standard allergens were negative, but dried ethyl cyanoacrylate produced a positive reaction. The eruption cleared after the patient discontinued use of cyanoacrylates (Shelley & Shelley, 1984).
    12) DERMAL: Three patients developed contact dermatitis of the hands after exposure to ethyl cyanoacrylates used in nail wrapping, a process where fine silk or linen is used to create an artificial nail. All 3 patients were negative to standard patch tests, but all 3 were positive to patch testing with ethyl cyanoacrylate. The rash resolved in all cases when patients avoided contact with the glue (Belsito, 1987).

Range Of Toxicity

Summary

    A) TOXICITY: No known information concerning a toxic dose is available. Tracheal and bronchial obstruction have occurred in a child following ingestion of approximately 7 mL of a cyanoacrylate and subsequent aspiration of the product.

Pharmacology Toxicology

Toxicologic Mechanism

    A) There is probably little difference physiologically between the ethyl-2-cyano-acrylates and the methyl-2-cyano-acrylates. Other components of Eastman 910 adhesive include thickeners, plasticizers, and stabilizers usually resulting in a thick liquid. There are no specific solvents. The main effect is rapid adhesion between any two surfaces or onto any surface. This includes mucous membranes, which are either wet or dry, steel, rubber, wood, etc. The adhesive action occurs rapidly on exposure to air, pressure or slight moisture as the acrylate monomer polymerizes to the polymer form producing adhesion.
    B) The toxicity of the cyanoacrylate esters decreases with the length of the alkyl side chain (Mickey & Samson, 1981).

References

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