Dishwashing Tablet Ingestion

Dishwashing tablet ingestions can cause clinical signs of varying severity. These can include vomiting, gastrointestinal irritation or ulceration, pulmonary aspiration and even gas embolism in extreme cases. Respiratory signs can also be a prominent feature in these cases, and pets will often develop some referred upper airway noise secondary to pharyngeal irritation.

 

Buddy is a 12-week-old Border Collie. He was left in the laundry whilst his owners were at work. Buddy has pulled down a new box of Finish Powerball All in One dishwashing tablets and ingested 4-5 large tablets. Shortly after the owners returned home, they found evidence of vomit on the floor and bubbles were seen coming out of his nose and mouth. The owners rushed Buddy to your clinic for assistance.
Whilst you expect this product to cause gastrointestinal irritation, you are not familiar with its content and decide to contact the Animal Poisons Centre. They advised you that the chemical composition is as follows:

 

  • Sodium carbonate: 30-60%
  • Sodium percarbonate: 10-30%
  • Polyethylene glycol: <10%
  • Cellulose: <3%
  • Non-hazardous ingredients to 100%
  • The pH of a 1% solution is 10-10.5, and each dishwashing tablet weighs 18 grams.

 

Buddy has continued vomiting and an audible wheezing. Upon auscultation, his lungs sound wet.

Question: What treatments are suitable for Buddy?

A: Apomorphine
Incorrect.

Buddy is already vomiting. Inducing vomiting will product no further benefit and is likely to increase the risk of dehydration, pulmonary aspiration and corrosive injury to the oesophagus.

B: Antiemetics
Correct.

An antiemetic would be very beneficial for Buddy. He has continued vomiting and is at risk of dehydration and aspiration as he is doing so.

C: Activated Charcoal
Inorrect.

There is no evidence that it would be helpful in this situation.

D: Gastrointestinal protectants
Correct.

Dishwashing tablets are irritating to the gastrointestinal tract and sucralfate +/- a H2 blocker or a PPI could be beneficial.

E: Chest X-ray
Correct.

Especially with the wheezing and wet lung sounds, they would be very beneficial if there is aspiration pneumonitis.

F: Bronchodilators
Correct.

This can cause bronchospasm, so bronchodilators may be of benefit.

G: Antibiotics
Correct.

While this may result in a pneumonitis and not a pneumonia situation, antibiotics may be very helpful to try to prevent secondary infections in lungs that will not have normal defences.

H: Diazepam
Incorrect

No, there is no indication and sedating the pet will probably not be of any benefit.

I: Oxygen
Correct

Often oxygen is needed in pets who are not oxygenating well.

You are familiar with sodium carbonate as you and have noticed that it can also be found in most laundry powders, however you are unsure of sodium percarbonate. Given the owner had estimated that Buddy could have ingested 5 tablets, you calculate that the total amount of sodium percarbonate could up to 30% of 5 x 18 g = 27 g.

Question: Which of the following statements is correct?

A: Sodium percarbonate is twice as alkaline as sodium carbonate as such 30% is equal to 60% sodium carbonate.
Incorrect.
B: Sodium percarbonate has a high sodium content and as such ingestions can result in sodium toxicity.
Incorrect.
C: Sodium percarbonate and sodium carbonate are the same chemical just in different states.
Incorrect.
D: Sodium percarbonate dissociates into sodium, carbonate and hydrogen peroxide.
Correct.

Sodium percarbonate dissolves readily in water and dissociates into sodium (29.3%), carbonate (38.2%) and hydrogen peroxide (32.5%).

Question:  Which of the following statements is false regarding sodium percarbonate and more specifically hydrogen peroxide.

A: Ingestion of concentrated hydrogen peroxide may exert a direct cytotoxic effect via lipid peroxidation
Incorrect.

This is a true statement.

B: Hydrogen peroxide is alkali and therefore an ingestion can cause a corrosive injury.
Correct.

Hydrogen peroxide is not alkaline, however concentrated hydrogen peroxide may cause a corrosive injury through other mechanisms.

C: Concentrated hydrogen peroxide is caustic and exposure may result in local tissue damage.
Incorrect.

Ingestion of hydrogen peroxide can cause irritation of the gastrointestinal tract with nausea, vomiting, haematemesis and foaming at the mouth; the foam may obstruct the respiratory tract or result in pulmonary aspiration.

D: Ingestion of concentrated hydrogen peroxide can also result in the generation of substantial volumes of oxygen.
Incorrect.

Significant gastric distension and belching may be caused by the liberation of large volumes of oxygen in the stomach. Following ingestion, hydrogen peroxide is readily absorbed through the stomach mucosa and into the portal venous system. It is then rapidly metabolised, predominantly by catalases within red cells, to yield oxygen and water. Where the amount of oxygen evolved exceeds its maximum solubility in blood, venous or arterial gas embolism may occur. It might come as a surprise that each 10 ml of concentrated hydrogen peroxide yields almost 1.2L of oxygen!