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DOUCHES

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Douches are used primarily for general cleansing, deodorizing, relief of pruritus, erythema, and edema, removal of secretions and discharges, and for some psychological reasons. They may also be used to alter vaginal flora by altering pH of the vagina.

Specific Substances

    A) CONSTITUENTS OF THE GROUP
    1) ANTIMICROBIALSBenzethoniumBenzalkonium chloridesParabensHexachloropheneChlorothymolBoric acidPhenolMentholThymolEucalyptolCetypyridium chlorideOxyquinoloneSodium borborateEthanolPovidone-Iodine
    2) LOCAL ANESTHETICSPhenolMentholEucalyptolBenzocaine
    3) COUNTER IRRITANTSMentholThymolMethyl Salicylate
    4) ASTRINGENTSAlumsZinc oxideZinc sulfateAluminum powders
    5) PROTEOLYTICSPapain
    6) SURFACTANTSSodium lauryl sulfateNonoxynol 4Dioctyl sodium sulfosuccinate
    7) PH ALTERING AGENTSLactic acidCitric acidSodium bicarbonateSodium perborateUreasSodium acetate
    GENERAL TERMS
    1) Vaginal douche
    2) Vaginal douches

Available Forms Sources

    A) FORMS
    1) Douche preparations are available in a number of different products with varying ingredients and mechanisms of action.
    2) Douches are available as liquids, liquid concentrates, powders for use with water, and powder for use with other powders (Hoag, 1977). The majority of marketed products are attractively packaged and pleasantly smelling and may be attractive to young children.
    3) Types of Ingredients with potential concentrations (Hoag, 1977):
    a) ANTIMICROBIALS
    Benzethonium1:750
    Benzalkonium chlorides1:5,000 to 1:2,000
    Parabens0.05 to 0.3%
    Hexachlorophene0.02%
    Chlorothymol
    Boric acid1 to 4%
    Phenol0.5 to 1%
    Menthol0.1 to 2%
    Thymol
    Eucalyptol
    Cetypyridium chloride1:10,000 to 1:2,000
    Oxyquinolone1:1,000
    Sodium borborate
    Ethanol1 to 8%
    Povidone-Iodine10%

    b) LOCAL ANESTHETICS
    Phenol0.5 to 1%
    Menthol0.1 to 2%
    Eucalyptol
    Benzocaine1 to 20%

    c) COUNTER IRRITANTS
    Menthol0.1 to 2%
    Thymol
    Methyl Salicylate10 to 25%

    d) ASTRINGENTS
    Alums0.5 to 12%
    Zinc oxide15 to 25%
    Zinc sulfate0.25 to 4%
    Aluminum powders5 to 16%

    e) PROTEOLYTICS
    1) Papain
    f) SURFACTANTS
    1) Sodium lauryl sulfate
    2) Nonoxynol 4
    3) Dioctyl sodium sulfosuccinate
    g) PH ALTERING AGENTS
    1) Lactic acid 1%
    2) Citric acid
    3) Sodium bicarbonate
    4) Sodium perborate
    5) Ureas
    6) Sodium acetate
    B) USES
    1) Douches are used primarily for general cleansing, deodorizing, relief of pruritus, erythema, and edema, removal of secretions and discharges, and for some psychological reasons. They may also be used to alter vaginal flora by altering pH of the vagina (Hoag, 1977).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) The signs and symptoms of acute exposure to various douche preparations depends on the contents and concentrations of the various ingredients used.
    B) Typical preparations contain borates, acetic acid, germicides, anionic, cationic, and nonionic detergents, wetting agents, ethanol, and aromatics.
    C) Because these agents are in low concentrations, toxicity is unlikely unless large amounts have been taken.
    0.2.4) HEENT
    A) Although not caustic, douches may cause redness and irritation of the eyes due to surfactants or astringents.
    0.2.5) CARDIOVASCULAR
    A) Hypotension may be a rare symptom in large ingestions.
    0.2.7) NEUROLOGIC
    A) CNS depression may be noted if the preparation contains ethyl alcohol. Seizures might be observed with large ingestions.
    0.2.8) GASTROINTESTINAL
    A) Nausea, vomiting, and diarrhea may occur if ingested.
    0.2.20) REPRODUCTIVE
    A) Vaginal douching has been identified as a potential risk factor for tubal ectopic pregnancy.

Laboratory Monitoring

    A) See appropriate managements for specific laboratory tests ie, borates, ethyl alcohol, etc.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) See specific management for each ingredient in the preparation ingested.
    B) In general, all that is needed is symptomatic and supportive care.
    C) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.
    1) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
    D) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    E) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).
    1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
    2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
    F) HYPOTENSION: Infuse 10 to 20 mL/kg isotonic fluid. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (ADULT: begin infusion at 0.5 to 1 mcg/min; CHILD: begin infusion at 0.1 mcg/kg/min); titrate to desired response.
    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.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) BORATES - The estimated lethal dose is difficult to establish. Children have taken over 10 grams with mild to moderate symptoms.
    B) AROMATICS - Usually only present in small quantities, hence toxicity unlikely.
    C) CATIONIC DETERGENTS - Estimated lethal dose is 100 to 400 mg/kg of benzalkonium chloride.
    D) ANIONIC DETERGENTS - Low toxicity, with an LD50 (animal) varying from 1 to 5 grams/kg.
    E) ETHANOL - Acute ingestion of 10 mL/kg of 10% (20 proof) ethanol should produce a blood ethanol level of 100 mg/dL.

Clinical Effects

Summary Of Exposure

    A) The signs and symptoms of acute exposure to various douche preparations depends on the contents and concentrations of the various ingredients used.
    B) Typical preparations contain borates, acetic acid, germicides, anionic, cationic, and nonionic detergents, wetting agents, ethanol, and aromatics.
    C) Because these agents are in low concentrations, toxicity is unlikely unless large amounts have been taken.

Heent

    3.4.1) SUMMARY
    A) Although not caustic, douches may cause redness and irritation of the eyes due to surfactants or astringents.
    3.4.3) EYES
    A) IRRITATION may be seen due to the surfactants and astringents. Since these products are expected to be placed on mucous membranes, they are not expected to be extremely irritating or caustic.

Cardiovascular

    3.5.1) SUMMARY
    A) Hypotension may be a rare symptom in large ingestions.
    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) Hypotension has been noted in overdose of cathartics, but is unlikely with a douche ingestion unless large amounts have been ingested (Tiess & Nagel, 1967).

Neurologic

    3.7.1) SUMMARY
    A) CNS depression may be noted if the preparation contains ethyl alcohol. Seizures might be observed with large ingestions.
    3.7.2) CLINICAL EFFECTS
    A) CENTRAL NERVOUS SYSTEM DEFICIT
    1) CNS depression from the ethyl alcohol containing preparations may occur upon ingestion. This may also be due to the various volatile oils such as menthol and eucalyptol.
    B) SEIZURE
    1) Seizures would be unlikely upon ingestion, but might occur if toxic doses of volatile oils were ingested (Patel & Wiggins, 1980).

Gastrointestinal

    3.8.1) SUMMARY
    A) Nausea, vomiting, and diarrhea may occur if ingested.
    3.8.2) CLINICAL EFFECTS
    A) VOMITING
    1) In general, nausea, vomiting, gastrointestinal irritation, and distention could result if these products were ingested.
    B) DIARRHEA
    1) Diarrhea might occur from the surfactants found in these products, if ingested.

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) SALPINGITIS
    1) Research and clinical evidence point to an increased incidence of pelvic inflammatory disease among women who douche at least once weekly (Neumann & DeCherney, 1976).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ACUTE ALLERGIC REACTION
    1) Many of the antimicrobials used in douches may be sensitizing and cause allergic reactions (Hoag, 1977).

Reproductive

    3.20.1) SUMMARY
    A) Vaginal douching has been identified as a potential risk factor for tubal ectopic pregnancy.
    3.20.3) EFFECTS IN PREGNANCY
    A) PREGNANCY DISORDER
    1) ECTOPIC PREGNANCY - Vaginal douching has been identified as a potential risk factor for tubal ectopic pregnancy (Chow et al, 1985).
    B) PLACENTAL BARRIER
    1) Mahillon et al (1989) reported that vaginal douching with povidone-iodine (PI) solution during early pregnancy increased the iodine content of urine, amniotic fluid, and fetal thyroid.
    a) The authors speculate that the iodine content of the fetal thyroid increases rapidly with exposure to PI douches and may result in inhibition of fetal thyroid hormone synthesis.
    C) BIRTH WEIGHT SUBNORMAL
    1) A study, conducted by Fiscella et al (1998) using cross-sectional interview data from the 1988 National Survey of Family Growth, showed that regular douching was associated with an increased risk for low birth weight (LBW) infants (adjusted odds ratio of 1.29; 95% CI 1.06, 1.57), however the authors were unable to determine if douching specifically occurred during pregnancy. The adjusted odds ratio for the association between daily douching and LBW was 2.49 (95% CI 1.23, 5.01) as compared with an adjusted odds ratio of 1.13 (95% CI 0.83, 1.55) for the association between monthly douching and LBW. There did not appear to be a racial difference between douching and the risk of LBW.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) See appropriate managements for specific laboratory tests ie, borates, ethyl alcohol, etc.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Usually exposures are not severe enough to warrant laboratory testing. However, ethanol levels for CNS depressed patients may be of some value.
    2) There are no commonly available laboratory tests for the cationic or anionic surfactants, the volatile oils, or astringents.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) See appropriate managements for specific laboratory tests ie, borates, ethyl alcohol, etc.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Activated charcoal would only be necessary in those cases where significant amounts of douche has been ingested. In those cases, the amount of each ingredient should be calculated and compared to the toxic doses in other POISINDEX(R) managements.
    B) ACTIVATED CHARCOAL
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Lavage and/or activated charcoal would only be necessary in those cases where significant amounts of douche has been ingested. In those cases, the amount of each ingredient should be calculated and compared to the toxic doses in other POISINDEX(R) managements.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    C) GASTRIC LAVAGE
    1) INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes).
    a) Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.
    2) PRECAUTIONS:
    a) SEIZURE CONTROL: Is mandatory prior to gastric lavage.
    b) AIRWAY PROTECTION: Place patients in the head down left lateral decubitus position, with suction available. Patients with depressed mental status should be intubated with a cuffed endotracheal tube prior to lavage.
    3) LAVAGE FLUID:
    a) Use small aliquots of liquid. Lavage with 200 to 300 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in older children or adults) and 10 milliliters/kilogram body weight of normal saline in young children(Vale et al, 2004) and repeat until lavage return is clear.
    b) The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
    c) CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.
    4) COMPLICATIONS:
    a) Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications (Caravati et al, 2001).
    b) Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).
    5) CONTRAINDICATIONS:
    a) Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.
    6.5.3) TREATMENT
    A) SUPPORT
    1) See specific managements for each ingredient in the douche preparations. In the majority of cases, excluding massive overdoses, symptomatic treatment will be sufficient.
    B) SEIZURE
    1) SUMMARY
    a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
    b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
    c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).
    2) DIAZEPAM
    a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
    b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
    c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .
    3) NO INTRAVENOUS ACCESS
    a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
    b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).
    4) LORAZEPAM
    a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
    b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
    c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).
    5) PHENOBARBITAL
    a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
    b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
    c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
    d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
    e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
    f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).
    6) OTHER AGENTS
    a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):
    1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
    2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
    3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
    4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).
    C) HYPOTENSIVE EPISODE
    1) SUMMARY
    a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.
    2) DOPAMINE
    a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    3) NOREPINEPHRINE
    a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
    b) DOSE
    1) ADULT: Dose range: 0.1 to 0.5 microgram/kilogram/minute (eg, 70 kg adult 7 to 35 mcg/min); titrate to maintain adequate blood pressure (Peberdy et al, 2010).
    2) CHILD: Dose range: 0.1 to 2 micrograms/kilogram/minute; titrate to maintain adequate blood pressure (Kleinman et al, 2010).
    3) CAUTION: Extravasation may cause local tissue ischemia, administration by central venous catheter is advised (Peberdy et al, 2010).

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) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

Summary

    A) BORATES - The estimated lethal dose is difficult to establish. Children have taken over 10 grams with mild to moderate symptoms.
    B) AROMATICS - Usually only present in small quantities, hence toxicity unlikely.
    C) CATIONIC DETERGENTS - Estimated lethal dose is 100 to 400 mg/kg of benzalkonium chloride.
    D) ANIONIC DETERGENTS - Low toxicity, with an LD50 (animal) varying from 1 to 5 grams/kg.
    E) ETHANOL - Acute ingestion of 10 mL/kg of 10% (20 proof) ethanol should produce a blood ethanol level of 100 mg/dL.

Minimum Lethal Exposure

    A) SPECIFIC SUBSTANCE
    1) CATIONIC DETERGENTS -
    a) They are readily inactivated by tissues and ordinary soaps.
    b) BENZALKONIUM CHLORIDE - 100 to 400 milligrams/kilogram (15 to 17.4% solution) produced death (Tiess & Nagel, 1967).

Maximum Tolerated Exposure

    A) SPECIFIC SUBSTANCE
    1) AROMATICS -
    a) The aromatics are usually present in small quantities and probably do not represent any true toxicity.
    b) However, several ounces of a douch containing menthol may produce gastritis or CNS depression. Five to 15 milliliters of eucalyptus (pure oil) may cause vomiting, coma, and respiratory depression (Allan, 1910; Sewell, 1925).
    2) DETERGENTS -
    a) The anionic surface-active agents (sodium alkyl aryl sulfates, sodium alkyl sulfates, alkyl sodium isothionates) are only moderately toxic with the LD50 values in animals varying from 1 to 5 grams/kilogram.
    b) The non-ionic surfactants (alkylphenyl polyethoxyethanol, polyalkaline glycol, etc) are less toxic and no more hazardous than the anionic agents.
    3) ETHANOL -
    a) The toxic potential of the ethyl-alcohol contained in some of these preparations should not be overlooked.
    4) BORIC ACID -
    a) Ingestion of 10 grams has produced nausea and vomiting in a child (Linden et al, 1986). In a study of 784 patients with boric acid exposure, no severe or life-threatening symptoms were seen (Litovitz et al, 1986).
    5) CATIONICS -
    a) CETYPYRIDINIUM CHLORIDE - Skin irritation was seen in a rabbit at 0.4% (Warren et al, 1942).
    b) BENZALKONIUM CHLORIDE - 40 milliliters of a 33.3 percent solution produced burns (Van Berkel & de Wolff, 1988).

Pharmacology Toxicology

Pharmacologic Mechanism

    A) The overall action or objective of vaginal douches is to provide a cleansing action upon the vagina. The following specific ingredients and their respective claimed actions are found in different combinations in the majority of available products (Hoag, 1977):
    1) SURFACTANTS: Actylphenoxypolyethoxyethanol, methylbenzethomium chloride, and benzalkonium chloride are surfactants which lower surface tension and spread the douche evenly over the vaginal membranes.
    2) VAGINAL pH: Boric, succinic, and lactic acids affect vaginal pH.
    3) WETTING AGENTS: Sodium lauryl sulfate and dioctyl sodium sulfosuccinate are wetting agents which have a mucolytic cleansing action.
    4) BUFFER: Sodium lactate acts as a buffer.
    5) DOBERLEIN'S BACILLI: Lactose helps re-establish Doberlein's bacilli, whose biologic action tends to prevent infection.
    6) DETERGENTS: Alkyldimethylbenzyl ammonium chloride and polyoxyethylene nonylphenol are detergents.
    7) ENZYME: Papain removes mucous plugs and liquefies mucous secretions and coagulum.
    8) AROMATICS: Menthol, thymol, methyl salicylate, and oil of eucalyptus are aromatics.
    9) EPITHELIALIZATION: Urea aids in debridement, dissolves the coagulum, and promotes epithelialization.
    10) ANTISEPTICS/GERMICIDES: 9-aminoacridine, oxyquinoline sulfate, sodium perborate, phenyl-mecuric acetate, methylbenzethonium chloride, aminacrine, and N-myristyl-3-hydroxybutylamine are topical antiseptics or germicides. Ethyl alcohol is present as a germicide.

References

General Bibliography

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