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DETERGENTS AND SOAPS-ANIONIC AND NONIONIC

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) NONIONIC SURFACTANTS: Many nonionic surfactants are condensation products of fatty alcohols with ethylene oxide. The general formula is H(CH2)n(OCH2CH2)m(OH).
    B) ANIONIC SURFACTANTS: Anionic surfactants are sodium, potassium, or ammonium salts of sulfonated or phosphorylated hydrocarbons. The general formula is RSO3(-)Na(+) and ROPO3(-)Na(+).
    C) SOAPS: Soaps are a subset of anionic surfactants. They are sodium or potassium salts of carboxylic acids. The general formula is RCO2(-)Na(+).

Specific Substances

    A) ANIONIC SURFACTANTS
    1) Alkyl sulfate
    2) Alkyl sulfonates
    3) Alkyl phosphate
    4) Alkylbenzene sulfonates
    5) Ammonium lauryl sulfate
    6) Aryl sulfonates
    7) Dialkyl sulfosuccinate
    8) Linear alkylate sulfonate
    9) Organocarbonates
    10) Organosilicates
    11) Phosphorylated hydrocarbons
    12) Sodium alkyl carbonates
    13) Sodium alkyl silicates
    14) Sodium lauryl sulfate (SLS)
    15) Sodium stearate
    16) Sulfated hydrocarbons
    17) Sulfonated hydrocarbons
    18) TEA-lauryl sulfate
    AMPHOTERIC (ZWITERIONIC) SURFACTANTS
    1) Alkyl betaines
    2) Alkyl glycinates
    3) Alkyldimethylamine oxides (ADAO)
    4) Cocobetaine
    5) Cocamidopropyl betaine
    NONIONIC SURFACTANTS
    1) Alkyl aryl polyether sulfates
    2) Alkyl phenol polyglycol
    3) Alkylphenyl polyethoxyethanol
    4) Alkylpolyethoxylates
    5) Chlorhexidine gluconate
    6) Ethoxylated alcohols
    7) Lauramide DEA
    8) Nonoxynol
    9) PEG alkyl aryl ethers
    10) PEG stearates
    11) Polyalkaline glycol, fatty acid alkanolamide amide
    12) Polysorbate 60
    13) Polysorbate 20
    14) Polyethylene glycol alkyl aryl ethers
    15) Polyoxyethylene alkyl ethers
    GENERAL TERMS
    1) ANIONIC SURFACTANTS
    2) WETTING AGENTS, ANIONIC AND NONIONIC
    3) SURFACTANTS, ANIONIC AND NONIONIC
    4) SOAPS, ANIONIC AND NONIONIC
    5) NONIONIC WETTING AGENTS
    6) NONIONIC SURFACTANTS
    7) ANIONIC DETERGENTS
    8) EMULSIFERS, ANIONIC AND NONIONIC
    9) ANIONIC SOAPS
    10) ANIONIC WETTING AGENTS
    11) DETERGENT (ANIONIC AND NONIONIC)
    12) NONIONIC EMULSIFIERS
    13) NONIONIC DETERGENTS
    14) ANIONIC EMULSIFIERS

Available Forms Sources

    A) FORMS
    1) DETERGENT: Non-soap surfactants in combination with inorganic ingredients (phosphates, silicates and carbonates).
    2) SOAP: Salt of a fatty acid made by the action of alkali on neutral fats and oils.
    B) USES
    1) GENERAL LAUNDRY DETERGENTS
    a) ANIONIC - alkylbenzene sulfonates, sodium lauryl sulfate
    2) LOW-SUDSING DETERGENTS/AUTOMATIC DISHWASHER DETERGENTS
    a) NONIONIC - polyoxyethylene alkyl ethers (also called ethoxylated alcohols)

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: Detergents are used in many cleaning products, as emulsifiers and in chemical manufacturing. The general structure is a hydrocarbon chain linked to an ionic group (anionic or cationic) or an alcohol group (nonionic). Soaps are salts of a fatty acid made by the action of alkali or natural fats and oils.
    B) EPIDEMIOLOGY: Exposures are very common, but significant effects are rare.
    C) TOXICOLOGY: Detergents dissolve lipid layers in tissue and produce local irritation and injury.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: The most common effects are skin, mucosal and eye irritation. Vomiting and diarrhea may occur, but are usually self-limited.
    2) SEVERE TOXICITY: Aspiration can cause upper airway irritation and respiratory distress, most often in young children. Rarely, ingestion can cause caustic injury to the GI tract. Significant corneal injury is rare, but has been reported after ocular exposure. LAUNDRY DETERGENT PACKETS: There have been reports of serious toxicity in young children after inadvertent ingestion of products containing concentrated laundry detergent packaged in small, single-use packets. There have been several cases in which young children rapidly developed profuse vomiting, CNS depression, aspiration and respiratory distress requiring endotracheal intubation and mechanical ventilation after swallowing or biting into these packets.
    0.2.20) REPRODUCTIVE
    A) Most studies examining the teratogenic potential of the maternal use of spermicides have shown no evidence of increased risk. In contrast, the use of nonoxynol-containing vaginal spermicides has been implicated in causing spontaneous abortion or congenital defects.

Laboratory Monitoring

    A) No specific lab work is needed in most patients. If patients have more than mild symptoms, testing should be directed at evaluation of other causes for the symptoms.
    B) Monitor serum electrolytes in patients with protracted vomiting or diarrhea.
    C) Obtain a chest radiograph and monitor pulse oximetry in patients with respiratory distress.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TOXICITY
    1) Primarily supportive care; wash affected skin and remove contaminated clothing. Irrigate exposed eyes copiously and check pH after irrigation. If the patient has oral irritation they should rinse their mouth. Patients with persistent vomiting may require IV fluids. Treat respiratory irritation or bronchospasm with inhaled beta agonists.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Eye exposure should be treated with irrigation until the conjunctival pH is normalized. Patients with persistent symptoms or evidence of corneal injury should have an ophthalmology evaluation (slit-lamp exam). Administer aerosolized beta agonists (albuterol) to patients with respiratory irritation. Airway swelling may necessitate intubation. Patients with significant pain suggesting GI tract injury (such as persistent vomiting, abdominal pain or inability to swallow) should have nothing by mouth and be evaluated by endoscopy.
    C) DECONTAMINATION
    1) PREHOSPITAL: Dermal exposures should be washed with water and contaminated clothing removed. Patients with an inhalation exposure should be taken to fresh air.
    2) HOSPITAL: Dermal exposures should be washed with water. Patients with respiratory irritation should be treated with oxygen. Patients with oral irritation should rinse their mouth with water. An eye exposure should be treated with irrigation until the conjunctival pH is normalized.
    D) AIRWAY MANAGEMENT
    1) Early orotracheal intubation in patients with signs of airway or pulmonary injury.
    E) ANTIDOTE
    1) None.
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients with mild mucosal, eye or skin irritation or self-limited GI symptoms after an inadvertent exposure may be observed at home.
    2) OBSERVATION CRITERIA: Patients with persistent GI, skin or eye irritation or self-harm ingestions should be referred to a healthcare facility for evaluation and treatment.
    3) ADMISSION CRITERIA: Patients with persistent respiratory, GI symptoms or evidence of caustic injury on endoscopy should be admitted.
    4) CONSULT CRITERIA: A toxicologist should be consulted if there is a question of possible systemic toxicity. Consult a gastroenterologist for endoscopy to evaluate for burns (ideally within 12 hours) for patients with persistent GI symptoms (ie, persistent pain, or vomiting, inability to swallow). Consult an ophthalmologist for a patient with evidence of corneal injury.
    G) DIFFERENTIAL DIAGNOSIS
    1) Differential diagnosis includes other causes of mucosal irritation such as caustics, hydrocarbons or other irritants.
    0.4.3) INHALATION EXPOSURE
    A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
    0.4.4) EYE EXPOSURE
    A) 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.
    B) CONJUNCTIVAL EPITHELIAL DEFECT: Six children aged 18 months to 3 years were treated for alkali eye injury following exposure to liquid laundry detergent tablets. The tablets contained 50 mL of concentrated alkaline detergent (pH 9). In each case, the tablets burst, spraying detergent over the face and eyes. Immediate eye irrigation was performed. At the time of presentation, corneal epithelial defects ranged from 20% to 80% of the corneal surface area, with bilateral injuries in 3 patients and corneal epithelial defects in 4 cases. All patients recovered (Horgan et al, 2005).
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and irrigate exposed areas with copious amounts of water. A physician may need to examine the area if irritation or pain persists.

Range Of Toxicity

    A) TOXICITY: Inadvertent exposures usually result in mild, transient irritation. Massive ingestion of these products may cause systemic toxicity. Low phosphate detergents are more alkaline and may cause more caustic injury. Intravenous injection of 40 mL of bath detergent caused life-threatening toxicity. LAUNDRY DETERGENT PACKETS: Children who have ingested small amounts of the concentrated laundry detergents from single-use packets (each containing 30 to 35 mL of detergents) have experienced severe symptoms, such as profuse vomiting, CNS depression, aspiration and respiratory distress.

Clinical Effects

Summary Of Exposure

    A) USES: Detergents are used in many cleaning products, as emulsifiers and in chemical manufacturing. The general structure is a hydrocarbon chain linked to an ionic group (anionic or cationic) or an alcohol group (nonionic). Soaps are salts of a fatty acid made by the action of alkali or natural fats and oils.
    B) EPIDEMIOLOGY: Exposures are very common, but significant effects are rare.
    C) TOXICOLOGY: Detergents dissolve lipid layers in tissue and produce local irritation and injury.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: The most common effects are skin, mucosal and eye irritation. Vomiting and diarrhea may occur, but are usually self-limited.
    2) SEVERE TOXICITY: Aspiration can cause upper airway irritation and respiratory distress, most often in young children. Rarely, ingestion can cause caustic injury to the GI tract. Significant corneal injury is rare, but has been reported after ocular exposure. LAUNDRY DETERGENT PACKETS: There have been reports of serious toxicity in young children after inadvertent ingestion of products containing concentrated laundry detergent packaged in small, single-use packets. There have been several cases in which young children rapidly developed profuse vomiting, CNS depression, aspiration and respiratory distress requiring endotracheal intubation and mechanical ventilation after swallowing or biting into these packets.

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) LAUNDRY DETERGENT PACKETS
    a) CASE SERIES: Between August 2010 and October 2011, the Milan Poison Control Center received 578 calls related to inadvertent exposure to laundry detergent packets (each packet contained 30 to 35 mL of concentrated liquid laundry detergent), with most cases (n=474; 81%) occurring in children under 4 years of age. Symptoms included ocular hyperaemia (n=70; 15.9%) and corneal lesion (n=8; 1.8%) (Celentano et al, 2012).
    b) CASE SERIES: Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures (96.1%) occurring in children 5 years of age or less. Ocular symptoms included conjunctivitis with or without eye pain (n=64), eye pain alone (n=13), and keratitis (n=4) (Williams et al, 2011).
    c) CASE SERIES: Six children aged 18 months to 3 years were treated for alkali eye injury following exposure to liquid laundry detergent tablets. The tablets contained 50 mL concentrated alkaline detergent (pH 9). In each case, the tablets burst, spraying detergent over the face and eyes. Immediate eye irrigation was performed. However, at the time of presentation, corneal epithelial defects ranged from 20% to 80% of the corneal surface area, with bilateral injuries in 3 patients and corneal epithelial defects in 4 cases. Each patient required hospitalization (length of stay ranged from 2 to 5 days). All patients recovered with normal corneal epithelium (Horgan et al, 2005).
    d) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ocular contact was the sole route of exposure in 110 cases (7.4%) with 93 cases involving children less than 5 years of age. The primary clinical effects were conjunctivitis and corneal ulceration, reported in 68.4% (n=145) and 2.8% (n=6) of patients, respectively (Williams et al, 2014).
    2) OTHER LAUNDRY PRODUCTS
    a) EYE IRRITATION: No permanent damage or symptoms persisting longer than 3 to 4 days were reported after ocular exposure to household soaps, detergents, or cleaners in 184 cases of exposure (Temple, 1978).
    b) Exposure to products with high corrosive contents may result in severe eye irritation. For more information on the degree of eye injury caused by various agents, see Range of Toxicity section.
    c) CONJUNCTIVAL ISCHEMIA/NECROSIS: A 20-year-old man developed conjunctival necrosis after having soft brown soap, also called floor soap, splashed into his right eye. The chemical burn caused damage extending over a large portion of the limbus and denuded the corneal epithelium. Initial therapy consisted of vitamin C 10%, atropine 1%, Timoptol 0.5%, and Predmycin-P eyedrops, as well as vitamin C orally. Despite these measures, cornea erosion persisted and visual acuity diminished. Stem cell transplantation was done approximately 10 weeks after exposure; measurable improvement in the patient's vision was noted within weeks (Maudgal, 1996).
    d) CORNEAL ENDOTHELIUM TOXICITY: Corneal toxicity was reported in 18 patients after unintentional injection of a detergent residue containing a nonionic ethoxylated fatty alcohol (6% vol/vol) into the anterior eye chamber during ocular surgery (Nuyts et al, 1990).
    3.4.6) THROAT
    A) WITH POISONING/EXPOSURE
    1) LAUNDRY DETERGENT PACKETS
    a) LARYNGEAL SPASM: Between August 2010 and October 2011, the Milan Poison Control Center received 578 calls related to inadvertent exposure to laundry detergent packets (each packet contained 30 to 35 mL of concentrated liquid laundry detergent), with most cases (n=474; 81%) occurring in children under 4 years of age. Laryngospasm was reported in 3 cases (Celentano et al, 2012).
    b) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Foaming at the mouth, sore tongue/mouth/throat, increased saliva, and stridor were reported in 47 (3.9%), 8 (0.7%), 14 (1.2%), and 10 (0.8%) patients, respectively (Williams et al, 2014).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) BRONCHOSPASM
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Asthma developed in a 38-year-old laboratory technician working in a detergent manufacturing plant after exposure to a newly developed detergent ingredient (ie, sodium iso-nonanoyl oxybenzene sulphonate). Symptoms included cough, wheezing, chest tightness, and breathlessness (Hendrick et al, 1988).
    b) LAUNDRY DETERGENT PACKETS
    1) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Bronchospasm was reported in 6 patients (0.5%) (Williams et al, 2014).
    B) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) LAUNDRY DETERGENT PACKETS
    1) SUMMARY: There have been reports to US Poison Centers of toxicity in young children associated with swallowing or biting into highly concentrated laundry detergent packets. Symptoms have included wheezing, gasping, and coughing. One toddler aspirated and was placed on a ventilator after biting into a packet (American Association of Poison Control Centers, 2012).
    2) CASE SERIES: Between August 2010 and October 2011, the Milan Poison Control Center received 578 calls related to inadvertent exposure to laundry detergent packets (each packet contained 30 to 35 mL of concentrated liquid laundry detergent), with most cases (n=474; 81%) occurring in children under 4 years of age. Coughing was reported in 72 (16.3%) cases (Celentano et al, 2012).
    3) CASE SERIES: Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures occurring in children 5 years of age or less. Most exposures (n=518) occurred as a result of ingestion. Coughing was observed in 21 cases following ingestion (Williams et al, 2011).
    4) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Coughing was reported in 53 patients (4.4%). Other reported respiratory effects included difficulty in breathing (n=4), pulmonary aspiration (n=3), hypoxia (n=3), choking (n=3), and respiratory depression (n=2) (Williams et al, 2014).
    b) OTHER LAUNDRY PRODUCTS
    1) CASE SERIES (PEDIATRIC): LAUNDRY DETERGENTS: Unintentional ingestion of a sodium carbonate/sodium silicate-based nonphosphate laundry detergent produced respiratory distress in 5 of 6 children, aged 1 to 2.5 years, with an onset between 1 and 2 hours. All but one of the symptomatic children had edema of the upper respiratory tract, in most cases involving the epiglottis and/or vocal cords, which resulted in substantial airway compromise. Signs and symptoms included stridor, retractions, and coughing.
    a) Two additional children with a history of inhalation of laundry detergent, with or without ingestion, developed a more rapid onset (one immediately and the other within 1 hour) of symptoms, which included hoarseness, retractions, fever, tachypnea, and respiratory distress.
    b) All children improved within 12 hours of admission, were extubated within 48 hours, and were asymptomatic at 72 hours (Einhorn et al, 1989).
    C) OBSTRUCTION OF TRACHEA
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT (PEDIATRIC): A 15-month-old girl died of tracheal obstruction 6 days after inhaling nonphosphate laundry detergent powder (Foote, 1973).
    D) BRONCHITIS
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 54-year-old man with a history of alcohol abuse presented with tachypnea and wheezing after ingesting and partially aspirating detergent. A chest x-ray demonstrated left lower lobe opacities, and a bronchoscopy showed inflammation of both the larynx and tracheobronchial tree. The diagnosis of laryngo-tracheo-bronchitis with aspiration pneumonia was made, and the patient made a full recovery following steroid and antibiotic treatment (Walter et al, 1999).
    3.6.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) RESPIRATORY DISORDER
    a) GUINEA PIGS: Difficulty in breathing and histological pulmonary changes were seen in guinea pigs after inhalation of 5000 and 10,000 parts per million of 4 different anionic surfactants (Hall, 1950).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) UNRESPONSIVE
    1) WITH POISONING/EXPOSURE
    a) LAUNDRY DETERGENT PACKETS: Poison Centers have received reports of pediatric exposures to highly concentrated laundry detergent packaged in small, single-use packets. In one case, a toddler developed a rapid onset of profuse vomiting, wheezing, and gasping followed by unresponsiveness even to painful stimuli (American Association of Poison Control Centers, 2012).
    B) DROWSY
    1) WITH POISONING/EXPOSURE
    a) LAUNDRY DETERGENT PACKETS
    1) SUMMARY: Poison Centers have received reports of pediatric exposures to highly concentrated laundry detergent packaged in small, single-use packets. In one case, a toddler rapidly became drowsy, vomited and then aspirated. Ventilator support was necessary (American Association of Poison Control Centers, 2012; Williams et al, 2011; Wood & Thompson, 2009).
    2) CASE SERIES: Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures occurring in children 5 years of age or less. Most exposures (n=518; 80.1%) occurred as a result of ingestion. Drowsiness occurred in 9 cases (Williams et al, 2011).
    3) CASE REPORTS: In a review of calls to the United Kingdom National Poisons Information Service (NPIS) during October 2007 to October 2008, 472 calls were received regarding liquid laundry detergent packets (liquitabs). Of these exposures, 10 (2.1%) children 2 years of age or less developed CNS symptoms that included drowsiness, hyporesponsiveness, lethargy and a decreasing Glasgow Coma Scale rating (Wood & Thompson, 2009).
    4) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Drowsiness/CNS depression was reported in 49 patients (children 2 years of age or less (n=42), children 3-years-old (n=5), adults 86-years-old (n=2)) (Williams et al, 2014).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) VOMITING
    1) WITH POISONING/EXPOSURE
    a) SUMMARY
    1) Nausea and vomiting are very common, though vomiting with blood is rare. Intractable vomiting may result in fluid and electrolyte depletion, leading to hypochloremic alkalosis.
    b) LAUNDRY DETERGENT PACKETS
    1) CASE SERIES: Between August 2010 and October 2011, the Milan Poison Control Center received 578 calls related to inadvertent exposure to laundry detergent packets (each packet contained 30 to 35 mL of concentrated liquid laundry detergent), with most cases (n=474; 81%) occurring in children under 4 years of age. Vomiting (n=308; 69.8%) was the most common systemic symptom (Celentano et al, 2012). In a few cases reported to US Poison Centers, profuse vomiting has occurred in young children after swallowing or biting into highly concentrated laundry detergent packets (American Association of Poison Control Centers, 2012).
    2) CASE SERIES: Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures (96.1%) occurring in young children 5 years of age or less. Most cases (n=518; 80.1%) occurred as a result of ingestion. Vomiting (n=124) was the most common symptom reported.
    3) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Nausea and vomiting were the most commonly reported effects, occurring in 721 patients (59.3%) (Williams et al, 2014).
    c) OTHER LAUNDRY PRODUCTS
    1) Nausea or vomiting was reported in 99 of 545 ingestions of soaps, detergents, and cleaners in one survey and was more common with granular formulations (Temple, 1978). Five of 8 children, aged 1 to 2.5 years, vomited after ingesting nonphosphate laundry detergent powder (Einhorn et al, 1989).
    2) CASE REPORT (PEDIATRIC): A 15-month-old child vomited spontaneously after ingesting a low-phosphate granular laundry detergent containing anionic/nonionic detergents with alkaline builders (Herrington et al, 1998).
    B) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) Diarrhea was reported in 73 of 545 patients who ingested soaps, detergents, or household cleaners. It was most common with liquid detergents and persisted longer than 24 hours in some cases (Temple, 1978).
    b) LAUNDRY DETERGENT PACKETS
    1) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Diarrhea was reported in 25 patients (2.1%) (Williams et al, 2014).
    C) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) LAUNDRY DETERGENT PACKETS/CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Abdominal pain was reported in 6 patients (0.5%) (Williams et al, 2014).
    D) COLITIS
    1) WITH POISONING/EXPOSURE
    a) Administration of soap enemas and nonionic detergent enemas (eg, chlorhexidine gluconate) have resulted in acute colitis, serious serosanguineous fluid loss, rectal irritation, and rectal gangrene (Schmelzer et al, 2004; Rousseau, 1988; Hardin & Tedesco, 1986; Orchard & Lawson, 1986; Pike et al, 1971; Bendit, 1945; Barker, 1945) .
    E) INFLAMMATORY DISEASE OF MUCOUS MEMBRANE
    1) WITH POISONING/EXPOSURE
    a) Mucous membrane irritation of the mouth was reported in 63 of 545 patients who ingested household detergents. Two cases involving highly alkaline automatic dishwashing detergents required hospitalization for esophagoscopy (Temple, 1978).
    F) STRICTURE OF ESOPHAGUS
    1) WITH POISONING/EXPOSURE
    a) Ingestion of products with a high corrosive content may result in esophageal stricture. Lack of burns to the mouth does not necessarily mean there will not be esophageal burns.
    G) GASTRIC ULCER
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT (PEDIATRIC): A 15-month-old child ingested a low-phosphate granular laundry detergent containing anionic/nonionic detergent with alkaline builders and vomited spontaneously. One hour after ingestion, the patient was listless and drooling with perioral edema. A gastroesophageal endoscopy showed gastric erythema and ulceration, but without hypopharyngeal or esophageal injury. The patient was discharged with cimetidine and sucralfate and was asymptomatic 2 months later (Herrington et al, 1998).
    b) LACK OF EFFECT
    1) Chronic ingestion of detergent from washed, but poorly rinsed, dishes has been postulated. No cases of gastrointestinal injury have been reported in humans with this type of chronic ingestion (Mercurius-Taylor et al, 1984).
    3.8.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) INTESTINAL NECROSIS
    a) RATS given 100 mg/kg/day of synthetic detergents showed irreversible abnormalities of the gastrointestinal tract, including villous and glandular atrophy (Mercurius-Taylor et al, 1984).
    2) GASTRIC ULCER
    a) CATS: Nine of 11 cats given 10 mL of a 30% (vol/vol) solution of nonphosphate detergent incurred corrosive gastric or esophageal injuries. These injuries killed 4 of the cats (Lee et al, 1972).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) KIDNEY FINDING
    1) WITH POISONING/EXPOSURE
    a) LACK OF EFFECT
    1) Ingestion of 100 mg/day of an alkyl aryl sulfonate for 4 months had no demonstrable effect on the kidney function of human volunteers (Freeman et al, 1945a).

Acid-Base

    3.11.2) CLINICAL EFFECTS
    A) ALKALOSIS
    1) WITH POISONING/EXPOSURE
    a) Intractable vomiting may result in fluid and electrolyte depletion, leading to hypochloremic alkalosis.

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) CONTACT DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) SKIN IRRITATION has been reported after repeated exposure and prolonged occupational dermal contact with detergents (Celentano et al, 2012; Dooms-Goossens & Blockeel, 1996; Effendy & Maibach, 1996; Dihoom et al, 1996; Sakabe, 1962).
    b) Skin dryness and irritation are associated with the use of soaps and synthetic detergent bars. The irritant potential of a product generally rises as the soap concentration increases (Strube & Nicoll, 1987).
    c) CASE SERIES (PEDIATRIC): Liquid detergent with an acid pH used as a baby wash was associated with diaper dermatitis in 15 infants and toddlers. The dermatitis presented with inflammation and a peculiar brownish discoloration of the skin folds. The rash and discoloration improved with fewer washings and discontinuation of the liquid detergent (Patrizi et al, 1996).
    d) Perfumes added to soap products may have contributed to skin irritation or hypersensitivity reactions in presensitized subjects (Benke & Larsen, 1984).
    e) The dyes and perfumes added to soap products are in such small concentrations that they probably do not increase the toxicity of the products (Lawrence & Haggerty, 1971).
    f) ALLERGIC CONTACT DERMATITIS: The nonionic surfactants cocamide diethanolamine and lauramide diethanolamine reportedly caused a case of allergic contact dermatitis (DeGroot et al, 1987).
    g) LAUNDRY DETERGENT PACKETS
    1) Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures (96.1%) occurring in young children. Seven children aged 3 years or less experienced rash (n=4), irritation (n=2), chemical burn (n=2) and one child developed paraesthesia after dermal contact alone (Williams et al, 2011).
    2) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, dermal contact was the sole route of exposure in 20 cases (1.3%) with 18 of those cases involving children less than 5 years of age. Signs and symptoms following dermal exposure were as follows: erythema (n=9), rash (n=6), burn (n=3), and blistering (n=2) (Williams et al, 2014).
    B) ECZEMA
    1) WITH POISONING/EXPOSURE
    a) Exposure to ethoxylated phenol and phosphated ethoxylated phenol, two surfactants in a plate-developing solution, caused unilateral hand eczema in a patient who worked as a lithoprinter (Ashworth & White, 1991).
    b) An anionic surfactant in a hand cleanser, a sodium ricinoleic monoethanolamido sulfosuccinate derivative, caused an eczematous rash (Reynolds & Peachey, 1990).
    C) SUPERFICIAL PARTIAL THICKNESS BURN OF THIGH
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT (PEDIATRIC): A 10-month-old child presented with a superficial partial thickness burn on the medial thigh. The parents reported that liquid biological laundry detergent had been accidentally spilled onto the child's pants approximately 48 hours prior, but that the clothing had not been changed after the exposure. The child received antibiotic therapy and regular dressing changes, and the burn healed successfully.
    1) The authors experimented with a similar biological detergent to confirm the burn reaction seen in this child. Exposure to a biological detergent for 2 hours produced no effect, but 12 hours of contact resulted in a superficial partial thickness burn to the arm. A nonbiological detergent was applied to the other arm with only mild erythema and dryness seen after 12 hours. The authors concluded that prolonged exposure to biological detergents can lead to serious epithelial damage (Howieson et al, 2007).
    D) ERUPTION
    1) WITH POISONING/EXPOSURE
    a) LAUNDRY DETERGENT PACKETS
    1) CASE SERIES: The United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 1486 cases, from 2009 to 2012, that involved exposures to liquid detergent capsules. Of the 1486 cases, ingestion was the sole route of exposure in 1215 cases (81.8%) with 1168 cases involving children less than 5 years of age. Following ingestion suspected as the only route of exposure, rashes were reported in 22 patients (children 2 years of age or less (n=19), 3-year-old child (n=2), 11-year-old child (n=1)). Onset of symptoms were reported to occur between 3 and 12 hours postingestion, and in many instances, appeared to be generalized, involving the trunk and arms (Williams et al, 2014).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ANAPHYLACTOID REACTION
    1) WITH POISONING/EXPOSURE
    a) An anaphylactoid reaction was reported after administration of a soap enema (Smith, 1967).

Reproductive

    3.20.1) SUMMARY
    A) Most studies examining the teratogenic potential of the maternal use of spermicides have shown no evidence of increased risk. In contrast, the use of nonoxynol-containing vaginal spermicides has been implicated in causing spontaneous abortion or congenital defects.
    3.20.2) TERATOGENICITY
    A) LACK OF EFFECT
    1) NONOXYNOL
    a) Most studies examining the teratogenic potential of the maternal use of spermicides have shown no evidence of increased risk (Einarson et al, 1990).
    b) A study conducted with pregnant Long-Evans hooded rats showed no evidence of teratogenicity. The rats were treated with 2 or 20 times the normal adult dosage on days 6 through 15 of gestation. There were no significant differences between the control group and those treated with nonoxynol-9 in relation to the vagina, maternal reproductive organs, fetal toxicity, or the incidence of visceral and skeletal malformations (Abrutyn, 1982).
    3.20.3) EFFECTS IN PREGNANCY
    A) ABORTION
    1) In contrast, the use of nonoxynol-containing vaginal spermicides has been implicated in causing spontaneous abortion or congenital defects (Jick, 1981).
    B) LACK OF EFFECT
    1) NONOXYNOL: No increased risk has been demonstrated (Einarson et al, 1990; Huggins, 1982; Mills, 1982; Shapiro, 1982; Polednak, 1982) .

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No specific lab work is needed in most patients. If patients have more than mild symptoms, testing should be directed at evaluation of other causes for the symptoms.
    B) Monitor serum electrolytes in patients with protracted vomiting or diarrhea.
    C) Obtain a chest radiograph and monitor pulse oximetry in patients with respiratory distress.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Monitor fluid status and serum electrolytes in patients with persistent vomiting or diarrhea.

Radiographic Studies

    A) Obtain a chest radiograph and monitor pulse oximetry in patients with respiratory distress.

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 with persistent respiratory, GI symptoms (ie, persistent pain, or vomiting, inability to swallow) or evidence of caustic injury on endoscopy should be admitted.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients with mild mucosal, eye or skin irritation or self-limited GI symptoms after an inadvertent exposure may be observed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) A toxicologist should be consulted if there is a question of possible systemic toxicity. Consult a gastroenterologist for endoscopy to evaluate for burns (ideally within 12 hours) for patients with persistent GI symptoms (ie, persistent pain, or vomiting, inability to swallow). Consult an ophthalmologist for a patient with evidence of corneal injury.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with persistent GI, skin or eye irritation or self-harm ingestions should be referred to a healthcare facility for evaluation and treatment.
    B) As spontaneous vomiting may be delayed, it is recommended that patients who have ingested these products be maintained in an upright or prone position and monitored for a minimum of 2 hours (Temple & Veltri, 1979).

Monitoring

    A) No specific lab work is needed in most patients. If patients have more than mild symptoms, testing should be directed at evaluation of other causes for the symptoms.
    B) Monitor serum electrolytes in patients with protracted vomiting or diarrhea.
    C) Obtain a chest radiograph and monitor pulse oximetry in patients with respiratory distress.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Spontaneous vomiting usually occurs within 1 hour of ingestion of a toxic dose; however, delayed vomiting may occur. Use of activated charcoal is generally not indicated.
    2) Dermal exposures should be washed with water and contaminated clothing removed. Patients with an inhalation exposure should be taken to fresh air.
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.2) PREVENTION OF ABSORPTION
    A) Ingestion of nonionic or anionic detergents is generally self-limiting, requiring no treatment. Suggested treatment modalities, though, may include dilution, and observation for the possible development of esophageal or gastrointestinal tract irritation or burns or respiratory distress.
    B) Spontaneous vomiting will normally occur within 1 hour of ingestion if a toxic dose has been ingested; however, delayed vomiting may occur (Temple & Veltri, 1979).
    C) If spontaneous vomiting has not occurred within 1 hour of ingestion, it is very unlikely that a toxic dose has been ingested and no further treatment is required.
    D) ACTIVATED CHARCOAL
    1) Administration of activated charcoal is unnecessary.
    E) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.3) TREATMENT
    A) SUPPORT
    1) If spontaneous vomiting has not occurred within 1 hour of ingestion, it is very unlikely that a toxic dose has been ingested and no further treatment is required.
    2) Primarily supportive care. If the patient has oral irritation they should rinse their mouth. Patients with persistent vomiting may require IV fluids.
    B) MONITORING OF PATIENT
    1) No specific lab work is needed in most patients. If patients have more than mild symptoms, testing should be directed at evaluation of other causes for the symptoms. Monitor serum electrolytes in patients with protracted vomiting or diarrhea. Obtain a chest radiograph and monitor pulse oximetry in patients with respiratory distress.
    C) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    D) IRRITATION SYMPTOM
    1) Observe patients with ingestion carefully for the possible development of esophageal or gastrointestinal tract irritation or burns. If signs or symptoms of esophageal irritation or burns are present, consider endoscopy to determine the extent of injury.
    E) AIRWAY MANAGEMENT
    1) Monitor for evidence of respiratory distress (eg, stridor, retractions, coughing, tachypnea). Treat respiratory irritation or bronchospasm with inhaled beta agonists. Consider endotracheal intubation early in patients with evidence of upper airway injury or edema.
    F) ENDOSCOPIC PROCEDURE
    1) Gastrointestinal burns are rare after ingestion of anionic detergents, but have been reported (Herrington et al, 1998). Consider endoscopy in patients with persistent vomiting, stridor, or drooling.

Inhalation Exposure

    6.7.1) DECONTAMINATION
    A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
    B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) 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).

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) Remove contaminated clothing and jewelry and irrigate exposed areas with copious amounts of water. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    6.9.2) TREATMENT
    A) IRRITATION SYMPTOM
    1) Treat dermal irritation or burns with standard topical therapy. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Abstracts

Case Reports

    A) LAUNDRY DETERGENT PACKETS
    1) CASE SERIES: Between August 2010 and October 2011, the Milan Poison Control Center received 578 calls related to inadvertent exposure to laundry detergent packets (each packet contained 30 to 35 mL of concentrated liquid laundry detergent), with most cases (n=474; 81%) occurring in children under 4 years of age. Symptoms included vomiting (n=308; 69.8%), coughing (n=72; 16.3%), laryngospasm (n=3), ocular hyperaemia (n=70; 15.9%), corneal lesion (n=8; 1.85%) and skin irritation (n=32; 7.2%). In a comparison of patients that developed toxicity, 76% of cases exposed to concentrated laundry detergent packets became symptomatic compared to 27% of cases exposed to traditional laundry detergent (Celentano et al, 2012).
    2) CASE REPORTS: Poison Centers have received reports of pediatric exposures to highly concentrated laundry detergent packaged in small, single-use packets. Severe events such as profuse vomiting, CNS depression, aspiration and respiratory distress have been associated with young children swallowing or biting into these packets (American Association of Poison Control Centers, 2012).
    3) CASE SERIES: Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures occurring in children 5 years of age or less. Most exposures (n=518; 80.1%) occurred as a result of ingestion alone. The most common symptoms of ingestion included vomiting (n=124), coughing (n=21) and nausea (n=18). Ocular exposure produced conjunctivitis with or without eye pain (n=64), eye pain alone (n=13) and keratitis (n=4). Other symptoms included rash (n=4), irritation (n=2), chemical burn (n=2) and paraesthesia (n=1) following dermal contact (Williams et al, 2011).
    B) ADULT
    1) ROUTE OF EXPOSURE
    a) INTRAVENOUS
    1) A 31-year-old man with a 3 year history of depression intentionally injected 40 mL of bath detergent containing 8% solution of surfactants. The family found him 17 hours later complaining of anuria and right arm pain. At the hospital, he was tachycardic, hypotensive with no palpable pulses, and tachypneic with bilateral crackles. Initial lab work revealed metabolic acidosis (base excess -5.9 mEq/L), increased BUN (9 mmol/L), serum creatinine (240 mcmol/L), and CPK (2649 international units/L). Bleeding times were prolonged, and the patient's urine was dark red. His condition continued to deteriorate, necessitating intubation. Recurrent ventricular tachycardia was refractory to pharmacological management and required electrical defibrillation 33 times. Hemodialysis was initiated to remove the surfactants and was continued, along with continuous hemodiafiltration (CHDF), for renal failure. The patient was extubated on day 12 and discharged on day 28. A renal biopsy on day 49 showed partial recovery from acute tubular necrosis (Okumura et al, 2000).
    C) PEDIATRIC
    1) ROUTE OF EXPOSURE
    a) INHALATION
    1) A 15-month-old girl died of tracheal obstruction 6 days after inhaling nonphosphate laundry detergent powder (Foote, 1973).

Range Of Toxicity

Summary

    A) TOXICITY: Inadvertent exposures usually result in mild, transient irritation. Massive ingestion of these products may cause systemic toxicity. Low phosphate detergents are more alkaline and may cause more caustic injury. Intravenous injection of 40 mL of bath detergent caused life-threatening toxicity. LAUNDRY DETERGENT PACKETS: Children who have ingested small amounts of the concentrated laundry detergents from single-use packets (each containing 30 to 35 mL of detergents) have experienced severe symptoms, such as profuse vomiting, CNS depression, aspiration and respiratory distress.

Maximum Tolerated Exposure

    A) ROUTE OF EXPOSURE
    1) INGESTION
    a) A toxic dose ranges widely in the literature. As mortality is extremely rare and toxicity becomes readily apparent with vomiting and diarrhea, estimating a toxic dose is not beneficial. Typical effects of specific substances include:
    1) Low-phosphate detergents: usually caustic
    2) Hand dishwashing liquids: emesis, diarrhea
    3) Abrasive cleaners: nontoxic, unless they contain bleach
    4) Hand soap bars: emesis or mild diarrhea
    b) Nonionic Surfactants: Nonionic surfactants were once used to treat ulcers and as emulsifying agents. Patients have ingested as much as 15,000 mg/day without incurring overt toxic effects (Jones et al, 1948; Freeman et al, 1945; Fogelson & Shock, 1944; Kirsner & Wolff, 1944).
    c) An examination of calls for the unintentional ingestion of detergent products received by a consumer information service found that:
    1) In general, lower volumes of granular detergents were ingested than of liquid detergents.
    2) Most people who ingested either granular detergents or hand dishwashing liquids experienced no adverse effects, regardless of the amount ingested (Petersen, 1989).
    d) Washed, but poorly rinsed, dishes may lead to the chronic detergent ingestion of 1 mg/kg/day by adults; children may potentially ingest as much as 10 mg/kg/day (Mercurius-Taylor et al, 1984).
    e) LAUNDRY DETERGENT PACKETS
    1) SUMMARY: Poison Centers have received reports of serious toxicity in young children after inadvertent exposures to highly concentrated laundry detergent packaged in small, single-use packets. Symptoms have included profuse vomiting, drowsiness, CNS depression, wheezing, gasping and coughing in young children after swallowing or biting into these packets. One toddler aspirated and was placed on a ventilator after biting into a packet and another was placed on a ventilator for airway protection and support after swallowing a mouthful of detergent (American Association of Poison Control Centers, 2012).
    2) CASE SERIES: Between August 2010 and October 2011, the Milan Poison Control Center received 578 calls related to inadvertent exposure to laundry detergent packets (each packet contained 30 to 35 mL of concentrated liquid laundry detergent), with most cases (n=474; 81%) occurring in children under 4 years of age. Symptoms included vomiting (n=308; 69.8%), coughing (n=72; 16.3%), laryngospasm (n=3), ocular hyperaemia (n=70; 15.9%), corneal lesion (n=8; 1.85%), and skin irritation (n=32; 7.2%). In a comparison of patients that developed toxicity, 76% of cases exposed to concentrated laundry detergent packets became symptomatic compared to 27% of cases exposed to traditional laundry detergent (Celentano et al, 2012).
    3) CASE SERIES: Between March 2008 and April 2009, the United Kingdom National Poisons Information Service (NPIS) prospectively reviewed 647 calls related to liquid detergent capsules with most exposures occurring in children 5 years of age or less. Most exposures (n=518; 80.1%) occurred as a result of ingestion alone. The most common symptoms of ingestion included vomiting (n=124), coughing (n=21) and nausea (n=18). Ocular exposure produced conjunctivitis with or without eye pain (n=64), eye pain alone (n=13) and keratitis (n=4). Other symptoms included rash (n=4), irritation (n=2), chemical burn (n=2) and paraesthesia (n=1) following dermal contact (Williams et al, 2011).
    4) CASE REPORTS: In a review of calls to the United Kingdom National Poisons Information Service (NPIS) during October 2007 to October 2008, 472 calls were received regarding liquid laundry detergent packets (liquitabs). Of these exposures, 10 (2.1%) children 2 years of age or less developed CNS symptoms that included drowsiness, hyporesponsiveness, lethargy and a decreasing Glasgow Coma Scale rating (Wood & Thompson, 2009).
    2) INHALATION
    a) Inhalation of sodium lauryl sulfate at a 1% concentration resulted in considerable dyspnea in animals; 0.5% solutions produced mild to moderate effects, and 0.1% solutions were well tolerated (Hall, 1950).
    3) OCULAR
    a) Contact injury to the eye from surfactants (eg, splash contact) may occur with varying degrees of injury. Anionic surfactants cause less severe eye injury than do cationic surfactants. Nonionic surfactants have the least potential to cause severe contact eye injury (Grant, 1986).
    b) NONIONIC COMPOUNDS: No serious injury to the HUMAN eye at a concentration of 1% has been reported (Grant, 1986):
    1) Aptet 100
    2) Brij-35
    3) G 1045
    4) Myrj-52, -53
    5) Polysorbate 80 (Tween 80)
    6) Polyoxyethylene (20) oleyl ether
    7) Spans 20, 40, 85
    8) Tweens 20, 40, 81
    4) INTRAVENOUS
    a) CASE REPORT: A 31-year-old man with a long history of depression intentionally injected 40 mL of bath detergent containing 8% solution of surfactants. He developed hypotension, tachycardia, ventricular dysrhythmias, respiratory failure, hemolysis, rhabdomyolysis, renal failure, and coagulopathy. He eventually recovered with intensive supportive care (Okumura et al, 2000).

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) LD50- (ORAL)MOUSE:
    1) 1400-4600 mg/kg
    B) LD50- (ORAL)RAT:
    1) 520-2500 mg/kg
    C) LD50- (ORAL)RAT:
    1) 1000-4125 mg/kg
    D) LD50- (ORAL)RAT:
    1) 1820 mg/kg (Swisher, 1968)
    E) LD50- (ORAL)RAT:
    1) 3700-5400 mg/kg (Swisher, 1968)
    F) LD50- (ORAL)RAT:
    1) > 10 g/kg PEG-5-25 Soy Sterol

Pharmacology Toxicology

Pharmacologic Mechanism

    A) These substances are irritants. Toxicity is generally limited to cutaneous, ocular, oral, or gastrointestinal irritation.

Toxicologic Mechanism

    A) The low toxicity associated with these substances is markedly increased with the inclusion of various caustic substances such as sodium tripolyphosphate and various carbonates and other corrosive substances in the low-phosphate group.
    B) The pH is usually adjusted to decrease skin irritation, but mucous membranes and eyes may be irritated. Sodium metasilicate, sodium carbonate, and other caustics may be included and, depending upon the amount, may produce corrosive burns of the mouth, pharynx, esophagus, or, if aspirated, the lungs.
    C) Some detergent preparations contain water softeners (eg, trisodium phosphate) that may bind calcium and produce hypocalcemia with tetany. This complication is very rare.
    D) Repeated dermal exposure has been shown to induce cytokine cascade (deJongh et al, 2008).

Animal Toxicology

Clinical Effects

    11.1.6) FELINE/CAT
    A) Nine of 11 cats given 10 mL of 30% (vol/vol) solution of nonphosphate detergent incurred corrosive gastric or esophageal injuries. These injuries killed 4 of the cats (Lee et al, 1972).
    11.1.13) OTHER
    A) OTHER
    1) The predominant effects are emesis and ptyalism. Intravascular hemolysis may occur following enema administration, especially in animals with liver disease (Coppock et al, 1988).

Treatment

    11.2.1) SUMMARY
    A) GENERAL TREATMENT
    1) SUMMARY
    a) Begin treatment immediately.
    b) Keep animal warm and do not handle unnecessarily.
    c) Remove the patient and other animals from the source of contamination or remove dietary sources.
    2) Treatment should always be done on the advice and with the consultation of a veterinarian.
    3) Additional information regarding treatment of poisoned animals may be obtained from a Veterinary Toxicologist or the National Animal Poison Control Center.
    4) ASPCA ANIMAL POISON CONTROL CENTER
    a) ASPCA Animal Poison Control Center, 1717 S Philo Road, Suite 36 Urbana, IL 61802
    b) It is an emergency telephone service which provides toxicology information to veterinarians, animal owners, universities, extension personnel and poison center staff for a fee. A veterinary toxicologist is available for consultation.
    c) Contact information: (888) 426-4435 (hotline) or www.aspca.org (A fee may apply. Please inquire with the poison center). The agency will make follow-up calls as needed in critical cases at no extra charge.
    5) Additional information may be obtained from the American Society for the Prevention of Cruelty to Animals at www.aspca.org/apcc
    6) SMALL ANIMALS: Due to lack of reports of large animal intoxication with this substance, the following sections address small animals (dogs and cats) only.
    7) In the case of a poisoning involving large animals, consult a veterinary poison control center.
    11.2.2) LIFE SUPPORT
    A) GENERAL
    1) MAINTAIN VITAL FUNCTIONS: Secure airway, supply oxygen, and begin supportive fluid therapy if necessary.
    11.2.4) DECONTAMINATION
    A) GASTRIC DECONTAMINATION
    1) GENERAL TREATMENT
    a) INGESTIONS GREATER THAN 20 G/KG
    1) CAUTION
    a) Carefully examine patients with chemical exposure before inducing emesis. If signs of oral, pharyngeal, or esophageal irritation, a depressed gag reflex, or CNS excitation or depression are present, EMESIS should NOT be induced.
    b) HORSES OR CATTLE: DO NOT attempt to induce emesis in ruminants (eg, cattle) or equids (eg, horses).
    c) Induce emesis only if the patient has ingested greater than 20 g/kg and has not spontaneously vomited (Coppock et al, 1988).
    2) DOGS AND CATS
    a) IPECAC: If within 2 hours of exposure, induce emesis with syrup of ipecac 1 to 2 mL/kg per mouth.
    b) APOMORPHINE: Dogs may vomit more readily with 1 tablet (6 mg) of apomorphine diluted in 3 to 5 mL water and instilled into the conjunctival sac or per mouth.
    1) Dogs may also be given apomorphine intravenously at 40 mcg/kg, though this route may not be as effective.
    3) LAVAGE
    a) In the absence of gag reflex or if vomiting cannot be induced, place a cuffed endotracheal tube and begin gastric lavage.
    b) Pass a large bore stomach tube and instill 5 to 10 mL/kg water or lavage solution, then aspirate. Repeat 10 times.
    11.2.5) TREATMENT
    A) GENERAL TREATMENT
    1) PERSISTENT VOMITING
    a) Persistent vomiting may necessitate administration of antiemetics (Coppock et al, 1988).
    2) SUPPORTIVE CARE
    a) Begin electrolyte and fluid therapy with isotonic solutions as needed at maintenance doses (66 milliliters solution/kilogram body weight/day intravenously) or, in hypotensive patients, at high doses (up to shock dose 60 milliliters/kilogram/hour). Monitor for urine production and pulmonary edema.
    3) MONITORING
    a) Observe asymptomatic patients for 8 hours in the primary care clinic.
    b) Unless life threatening signs develop, these patients may be kept in the primary care clinic (24 hour monitoring is not necessary).

Continuing Care

    11.4.1) SUMMARY
    11.4.1.2) DECONTAMINATION/TREATMENT
    A) GENERAL TREATMENT
    1) SUMMARY
    a) Begin treatment immediately.
    b) Keep animal warm and do not handle unnecessarily.
    c) Remove the patient and other animals from the source of contamination or remove dietary sources.
    2) Treatment should always be done on the advice and with the consultation of a veterinarian.
    3) Additional information regarding treatment of poisoned animals may be obtained from a Veterinary Toxicologist or the National Animal Poison Control Center.
    4) ASPCA ANIMAL POISON CONTROL CENTER
    a) ASPCA Animal Poison Control Center, 1717 S Philo Road, Suite 36 Urbana, IL 61802
    b) It is an emergency telephone service which provides toxicology information to veterinarians, animal owners, universities, extension personnel and poison center staff for a fee. A veterinary toxicologist is available for consultation.
    c) Contact information: (888) 426-4435 (hotline) or www.aspca.org (A fee may apply. Please inquire with the poison center). The agency will make follow-up calls as needed in critical cases at no extra charge.
    5) Additional information may be obtained from the American Society for the Prevention of Cruelty to Animals at www.aspca.org/apcc
    6) SMALL ANIMALS: Due to lack of reports of large animal intoxication with this substance, the following sections address small animals (dogs and cats) only.
    7) In the case of a poisoning involving large animals, consult a veterinary poison control center.
    11.4.2) DECONTAMINATION
    11.4.2.2) GASTRIC DECONTAMINATION
    A) GASTRIC DECONTAMINATION
    1) GENERAL TREATMENT
    a) INGESTIONS GREATER THAN 20 G/KG
    1) CAUTION
    a) Carefully examine patients with chemical exposure before inducing emesis. If signs of oral, pharyngeal, or esophageal irritation, a depressed gag reflex, or CNS excitation or depression are present, EMESIS should NOT be induced.
    b) HORSES OR CATTLE: DO NOT attempt to induce emesis in ruminants (eg, cattle) or equids (eg, horses).
    c) Induce emesis only if the patient has ingested greater than 20 g/kg and has not spontaneously vomited (Coppock et al, 1988).
    2) DOGS AND CATS
    a) IPECAC: If within 2 hours of exposure, induce emesis with syrup of ipecac 1 to 2 mL/kg per mouth.
    b) APOMORPHINE: Dogs may vomit more readily with 1 tablet (6 mg) of apomorphine diluted in 3 to 5 mL water and instilled into the conjunctival sac or per mouth.
    1) Dogs may also be given apomorphine intravenously at 40 mcg/kg, though this route may not be as effective.
    3) LAVAGE
    a) In the absence of gag reflex or if vomiting cannot be induced, place a cuffed endotracheal tube and begin gastric lavage.
    b) Pass a large bore stomach tube and instill 5 to 10 mL/kg water or lavage solution, then aspirate. Repeat 10 times.

References

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