Hydrogen peroxide poisoning is a pathological condition that occurs when taking a toxicant inside, its intravenous administration or external use of a drug with a high concentration. The clinical picture includes a burning sensation and distension in the stomach, pain behind the sternum, nausea. There may be signs of chemical burn, gas embolism. Pathology is diagnosed on the basis of anamnesis, FGDS data, coagulogram results, contrast radiography of the abdominal organs. Treatment involves the removal of poison, decongestant and infusion therapy, anesthesia, antibiotics, sedatives.
ICD 10
T49.8 By other means of topical application
General information
Poisoning with hydrogen peroxide occurs with improper use of 3% or 6% solution, as well as perhydrol (27% or 31%). It accounts for about 5% of all lesions with cauterizing poisons. 3% of the liquid causes severe pathological conditions only with intravenous infusion. Products with a higher concentration cause chemical burns when ingested or applied to the skin. Pathology is often found in children 4-7 years old, the elderly, people practicing non-traditional methods of treatment. Gastrointestinal tract injuries associated with oral peroxide intake are more common in countries with a low level of medical literacy of the population.
Causes
A common cause of pathology is accidental ingestion of the drug through the mouth. This becomes possible if the rules of storage of the substance are violated, if it is found in containers from under food and beverages. The lesion is usually severe, since the medication does not have a pronounced taste. A person manages to take 2-3 sips before he realizes that the liquid is not food. Other situations in which hydrogen peroxide poisoning occurs:
- Suicide. Oral administration of a drug with a high concentration is carried out when trying to pass away on their own. The degree of traumatization of the gastrointestinal tract is high, since the victim purposefully chooses the most aggressive form of H2O2 and takes the maximum possible number of sips.
- Non-traditional treatment. There is an unconfirmed theory that intravenous infusion of peroxide promotes tissue oxygenation. People who implement the procedure in practice may develop a gas embolism of the vessels feeding the heart, brain, lungs, other organs and systems.
- Inhalation of vapors. Vapors of the drug entering the respiratory tract can cause irritation and swelling, which leads to respiratory failure of a mechanical type. This is possible at enterprises using a toxicant as a foaming agent or oxidizer, if employees are not provided with personal respiratory protection devices.
- Washing of deep wounds. Treatment of massive injuries and internal cavities with a large amount of antiseptic in 0.2% of cases causes penetration of atomic oxygen bubbles into the bloodstream and blockage of blood vessels. The consequences do not differ from the administration of the drug directly into the circulatory system.
- Errors in the choice of funds. They consist in the fact that when self-treating small wounds, the patient uses 6% peroxide intended for disinfection of medical instruments. The damage is limited to superficial chemical burns. There is no threat to life. Specialized assistance is not required.
Pathogenesis
The pathogenesis of peroxide exotoxicoses has several mechanisms. Highly concentrated fluids lead to the formation of colliquation necrosis. There is a kind of melting of tissues exposed to the toxicant. They become flabby, softened. An inflammatory roller forms around it. The focus is infiltrated by neutrophils, macrophages and histiocytes. There is a risk of secondary infection. With proper treatment, the wound heals by secondary tension after 3-4 weeks.
The oxygen synthesized by ingestion of peroxide is able to penetrate into the blood by diffusion. Gas bubbles form in the vascular bed, which clog it and restrict the blood supply to certain areas of the body. The most dangerous is ischemia of the tissues of the central nervous system, myocardium, lungs. It is possible to damage less significant structures: kidneys, liver, intestines, skeletal muscles. H2O2 reduces the activity of catalase and peroxidase. This leads to the development of hemolysis. There is a methemoglobin-forming effect, which is due to the oxidation of iron to a trivalent state.
Symptoms
Poisoning with hydrogen peroxide is accompanied by the development of a clinical picture, which directly depends on the concentration and amount of the drug, the route of its introduction into the body. After getting into the stomach of a 3% solution, patients complain of a feeling of bloating, moderate soreness, nausea, copious belching. After consuming 6% of the substance or perhydrol, signs of chemical damage are detected: sharp soreness, visible white skin burns near the mouth, on the mucous membrane of the lips, cheeks, palate and tongue. There is a decrease in blood pressure, psychomotor agitation, shock.
The symptoms of a gas embolism are determined by the lesion of an organ. With ischemia of the brain area, a focal neurological picture is formed: paresis of the extremities, visual and hearing impairments, facial asymmetry, changes in speech and coordination of movements, headache. Involvement in the process of the muscular wall of the heart is accompanied by the appearance of compressive pain behind the sternum, fear of death, deterioration of hemodynamics. With occlusion of the pulmonary arteries, shortness of breath, cyanosis of the upper body, the noise of a millstone over the projection of the heart, signs of shock are determined.
Local burns look like white, as if powdered areas. There is no pronounced soreness. Bubbles filled with serous contents may form. They are surrounded by an inflammatory shaft, the nearby tissues are hyperemic, edematous. In practice, there are injuries of 1 and 2 degrees. Deeper injuries usually do not occur. As the blisters heal, the necrotic layers of the epidermis are exfoliated, the affected area is covered with healthy skin.
Complications
The most dangerous complication of hydrogen peroxide poisoning is the formation of areas of myocardial necrosis or brain. It develops in 35-37% of cases of gas occlusion. The death of a large number of cardiomyocytes causes cardiogenic shock, cardiac arrest. If the patient survives, a scar forms in the thickness of the heart wall, the contractile function of the organ decreases. Damage to the structures of the central nervous system ends with irreversible or partially reversible violations of motor capabilities, thinking abilities, certain internal systems.
Burns of the digestive tract are infected a second time in 20% of patients. This slows down regenerative processes, contributes to the strengthening of the general toxic syndrome. In the absence of adequate therapy, suppuration of wounds develops. There is a risk of infectious shock. Bacterial contamination of external injuries of injuries ends in significant complications. In 1-2% of cases, subcutaneous suppuration is detected, which is easily eliminated by surgical sanitation followed by the application of antiseptic ointments.
Diagnostics
A preliminary diagnosis is made by an ambulance doctor who arrived at the scene. For confirmation, a number of examinations are required, which are carried out by a toxicologist and resuscitator, according to indications – a gastroenterologist or a combustologist. Laboratory specialists are involved in the work. Pathology should be distinguished from lesions caused by other poisons of similar action, thermal burns. The following diagnostic methods are used:
- Physical. Blood pressure is above 140/90, with shock ≤ 70/40. Pulse >90 beats/minute. There is psychomotor agitation, in severe cases — depression of consciousness. On examination, pallor, sweating, hypersalivation are noted. Blockage of the pulmonary vessels is accompanied by a blue coloration of the collar zone. There may be a picture of focal cerebral lesion, acute myocardial infarction.
- Instrumental. During FGDS, edema and necrotic changes in the mucous membrane of the esophagus, stomach are visible. In AMI, there is an increase or depression of the “ST” segment on the ECG. When the pulmonary arteries are blocked, a deviation of the electrical axis of the heart to the left is detected, the “S” wave on the I and aVl leads is more than 1.5 mm. According to the results of brain CT against the background of neurological symptoms, the zone of ischemic stroke can be determined.
- Laboratory. Coagulopathy is detected, with an active inflammatory process — leukocytosis, an increase in ESR. It is possible to reduce the level of hemoglobin, the growth of hematocrit > 48%. The methemoglobin index is above 1%. Damage to the heart leads to an increase in the concentration of troponin I > 1 ng/ml. As the pathological process develops, the activity of liver enzymes increases, the electrolyte composition of the internal media changes.
Treatment
Treatment is carried out in stages. The choice of the method depends on the features of the clinical course of pathology and the method of penetration of the poison. In all cases, with the exception of superficial injuries of a small area, hospitalization of the victim is necessary. In case of internal chemical burns, the patient is transported to the intensive care unit. Poisoning without signs of embolism is an indication for placement in the general toxicology department.
First aid
It is implemented by ambulance at the scene and during transportation. The toxicant is removed using a thick gastric tube. Clean cool water is used as a washing liquid. The non-probe method is contraindicated, since the situation may worsen during vomiting. Symptomatic therapy is required: narcotic analgesics, cholinolytics, antispasmodics, antishock, cardiotonics. In case of asystole or fibrillation, cardiopulmonary resuscitation measures are carried out.
Conservative therapy
Conservative inpatient treatment requires the introduction of antibiotics, steroid hormones, cholinolytics, antispasmodics. In the later stages, hemostatic agents are recommended. Anesthesia is carried out with the use of drugs or neuroleptanalgesia (fentanyl and droperidol). Volumetric infusion therapy is necessary, designed to restore CBV, remove hemolysis products, and correct hematocrit. Colloidal and saline solutions are used (up to 10 liters/ day). Next, infusions of diuretics are performed. If the kidneys are damaged, hemodialysis is indicated.
In the presence of symptoms of gas embolism, hyperbaric oxygenation is performed. The duration of the session is 45 minutes, the course is 5-12 procedures. The pressure is 2-3 atmospheres. Controlled hypothermia is possible, in which the patient’s body is cooled to 34 ° C. The method helps to improve the solubility of blood gases. In addition to the above, standard therapy is prescribed, which depends on the type of lesion: cardiac drugs for occlusion of coronary vessels, nootropic drugs for ischemic stroke.
Surgical treatment
Esophageal and gastric bleeding are eliminated endoscopically. With the help of a manipulator equipped with a needle and a video camera, the damage site is punctured with a solution of adrenaline with antibiotics, the integrity of the mucous membrane is restored with a special synthetic glue or cauterized with a laser. Massive tissue destruction requires open operative reconstruction. After the burns have healed, the patient may be shown to have an esophageal augmentation, since the scars contribute to the formation of strictures. Removal of gas emboli is carried out by aspiration with a catheter.
Rehabilitation
Rehabilitation measures are carried out both in a hospital setting and during outpatient follow-up of the victim. The period of hospitalization for light burns is 10 days, for medium burns — 20 days. Severe injuries require a stay in a medical facility for up to 1-2 months. A full course of rehabilitation can reach 2-4 months. The main condition is to follow a diet.
Fasting or parenteral nutrition is recommended for 1-2 days from the moment of injury. Then the patient is given liquid dishes: broth, milk, jelly. The food should be chilled. Later, the consumption of soft-boiled eggs, cottage cheese, mashed meat is allowed. After 2-4 weeks, it is allowed to eat slimy soups, porridges from soft cereals. Canned food, bread, whole boiled and fried potatoes, chips, hard cheeses, lump meat are prohibited. A complete rejection of the use of alcoholic beverages is necessary. Tea and coffee are allowed only when cooled to room temperature.
Prognosis and prevention
The prognosis ща hydrogen peroxide poisoning is favorable in the absence of gas embolism, superficial burns of the mouth and esophagus. The survival rate is close to 100%. Deep chemical injuries of the gastrointestinal tract in 8-10% of cases provoke the development of complications incompatible with life. Lethality in case of blockage of blood vessels depends on the organ that has undergone ischemia and the volume of damaged tissues. Transmural infarcts lead to the death of the patient in 40-50% of cases, AMI of a small size ends in death in 3-5% of situations. Embolism of large pulmonary vessels also has a high mortality rate.
To prevent of hydrogen peroxide poisoning, the medicine should be stored in closed cabinets, inaccessible to children and the elderly. It is unacceptable to pour the product into containers from drinking water, lemonades, alcohol. People suffering from mental illness should not stay at home alone. Before treating wounds, it is necessary to check the concentration of the drug used. The introduction of peroxide into the vein is not allowed. It should be remembered that such methods of oxygenation do not belong to classical evidence-based medicine.
