Surrogate Alcohol or Nonbeverage Alcohol Consumption: The Surrogate Alcohol Questionnaire (SAQ).

BACKGROUND: Diagnosis and treatment of alcohol use disorders and their sequelae are common clinical questions for the consultation-liaison psychiatrist. At an urban, academic medical center, the authors consulted on several patients whose consumption of alcohol included nonbeverage forms of alcohol, (described in the literature as surrogate alcohols, nonbeverage alcohols, e.g., mouthwash). METHODS: The authors describe 4 patients who presented with surrogate alcohol consumption. The authors review the clinical issues and literature related to surrogate alcohol use. The authors describe the array of substances, which either contain ethanol, but are not intended for drinking, or which contain other intoxicating alcohols (e.g., methanol), that are consumed in lieu of traditional beverage alcohol. Furthermore, the authors discuss standard medical treatment interventions for ethanol and non-ethanol based alcohols. The authors propose a screening tool, the surrogate alcohol questionnaire, a tool to facilitate better recognition of surrogate alcohol use.

[Accidental central venous administation of 0.1 % chlorhexidine mouthwash]. / Akzidentelle zentralvenöse Verabreichung von 0,1 %iger Chlorhexidinmundspüllösung.

Medication errors are frequent and a serious safety concern. Chlorhexidine (CHX) is used daily in healthcare as a disinfectant. Its accidental intravascular injection is scarcely described. Serious complications, such as acute respiratory distress syndrome (ARDS) could be a consequence. We describe a case of central venous administration of 0.1% CHX mouthwash, its potential complications and possibilities of treatment. In contrast to another case report our patient had no detectable adverse side effects. The immediate hemofiltration and cleansing of the i. v. line may have contributed to this favorable outcome.

Gastric stricture following zinc chloride ingestion.

AIM: We present the case of an adult who ingested soldering fluid containing zinc chloride (ZC) in a suicide attempt. He developed a gastric stricture that was managed successfully by laparoscopic Roux-en-Y gastrojejunostomy. An extensive literature review shows that there are few reports of ZC ingestion. Furthermore, management of corrosive gastrointestinal tract injury is debatable. The evidence is summarized in this case report. RESULTS: ZC is a strong corrosive agent, which, following ingestion, is capable of producing widespread damage locally and systematically with long-lasting morbidity and significant mortality. The mainstay of treatment is supportive. Esophago-gastro-duodenoscopy is the diagnostic procedure of choice in the absence of perforation. Strictures that cannot be dilated endoscopically may require surgery. Emergency surgery is required for patients with evidence of perforation. Early and aggressive surgical resection in patients with high-grade burns may improve mortality and morbidity. CONCLUSION: Because of the lack of data, it remains debatable as to the optimal management strategies following ZC ingestion. Our patient was managed conservatively throughout the acute phase. However following recognition of the gastric stricture, surgical intervention ensued and he underwent successful laparoscopic Roux-en-Y gastrojejunostomy and was subsequently discharged having made an excellent recovery.

Child-resistant closures for mouthwash: do they make a difference?

OBJECTIVES: The Poison Prevention and Packaging Act of 1970 mandated that certain potentially hazardous drugs and other products be sold in child-resistant containers (CRCs). The Consumer Product Safety Commission estimates that CRCs for aspirin and oral prescription medicine saved the lives of about 700 children since the requirements went into effect in the 1970s. Under this Act, the Consumer Product Safety Commission issued a rule requiring child-resistant packaging for mouthwashes containing 3 g or more of ethanol per package. The effective date was July 24, 1995, and applied to all applicable products packaged on or after that date. METHODS: To determine the effectiveness of this 1995 ruling, all American Association of Poison Control Center Toxic Exposure Surveillance System data involving children younger than 6 years who ingested ethanol-containing mouthwash 10 years before the implementation of this ruling, the transition year, and 10 years after were reviewed. Only single-substance exposures were included. Data reviewed included the total number of exposures per pre and post years and the outcome. RESULTS: A total of 61,185 cases met the criteria. There were 18,275 exposures from 1985 through 1994 prerequirement (0.12% of all exposures); 39,376 from 1996 to 2005 postrequirement years (AR) (0.17% of all exposures); and 3,534 cases reported in 1995 (0.17% of all exposures). Definitive outcomes were coded in 62.6% of the prerequirement group and 42.2% of the AR group. CONCLUSIONS: Numerous factors affect these results. However, in those cases where definitive outcomes were coded, the AR group has better outcomes.

Acute ethanol toxicity from ingesting mouthwash in children younger than age 6, 1989-2003.

PURPOSE: The purpose of this study was to analyze American Association of Poison Control Centers (AAPCC) reports of suspected overingestion of mouthwash by children under age 6 and examine the effect of a 1995 Consumer Product Safety Commission (CPSC) rule requiring child-resistant packaging for mouthwashes containing at least 3 g (0.11 oz) of ethanol per package. METHODS: The volume of ethanol ingested per kg of body weight was computed for children at the 5th, 50th, and 95th percentiles. The potentially toxic and potentially lethal volumes of 100% ethanol at each weight were also determined. The authors used segmented regression to test the difference in slopes between 1989 to 1996 (preintervention) and 1996 to 2003 (postintervention). RESULTS: Incidence of overingestion rose from a low of 12.7 per 100,000 (1991) to 20.7 (1996). The increase ended with the adoption of the CPSC rule, declining to 16.8 per 100,000 in 2001 and rising to 17.9 in 2003. CONCLUSIONS: This study's analysis suggests that the CPSC rule requiring child-resistant packaging on containers of mouthwash containing 3 g or more of ethanol has been successful in reducing AAPCC's reports of mouthwash overingestion. Health care providers should take a more active role by informing parents of the dangers associated with accidental ingestion of ethanol-containing mouthwash. Manufacturers should print warnings about the potential hazard of high ethanol concentrations on labels more prominent and they should stop producing mouthwashes with such high concentrations of ethanol. Moreover, they should also consider discontinuing packaging mouthwash in large containers.

Lignocaine and chlorhexidine toxicity in children resulting from mouth paint ingestion: a bottling problem.

BACKGROUND: A pharmaceutical product was marketed in Australia for 'teething' in an almost identical container to a popular paediatric paracetamol preparation. The product contained lignocaine and chlorhexidine. The similarity of the packaging resulted in large number of therapeutic errors in which the 'teething' preparation was given in error for paracetamol. As the exact dose of the erroneously administered mouth paint was known this provided an opportunity for outcome assessment of lignocaine ingestion. METHODS: Calls to two state poison information centres regarding this product were prospectively followed up. Information collected included: demographics, type of exposure, details of the exposure and adverse effects. A systematic review of the literature was used to identify all previous reported cases of lignocaine and chlorhexidine ingestion. RESULTS: There were 28 cases with complete follow up where the product was given in therapeutic errors (10 girls and 18 boys; median age 11 months; range 2 months-4 years). The mean ingested dose of lignocaine was 2.7 mg/kg (standard deviation 1.3 mg) and chlorhexidine was 0.06 mg/kg (standard deviation 0.03 mg). The largest ingested lignocaine dose was 5.9 mg/kg. Two children developed minor symptoms: one vomited twice and the other was reported to have increased salivation and difficulty with solid food for 20 min. No other adverse effects were reported. The literature review suggested that severe effects occurred with doses more than 15 mg/kg. CONCLUSION: No major adverse effects occurred with lignocaine ingestions of less than 6 mg/kg and it would be appropriate to observe these patients at home. Chlorhexidine did not appear to cause clinical effects in this low concentration.

Systemic toxicity following ingestion of the chlorhexidine gluconate solution: a case report.

The purpose of this article is to discuss possible adverse effects and emergency treatments following the ingestion of chlorhexidine (CHX). In this case a dental student (age 25, male) accidentally swallowed one shot of 20% CHX solution, which is equal to 100 shots of the standard 0.2% CHX mouthwash. Clinical emergency treatment included: washing the oral cavity with 30 g of toothpaste, drinking 100 ml of 5% (w/v) alginate syrup and ingestion of 5 g of cork. The following adverse effects were experienced: headache, euphoria, giddiness, blurred vision (duration = 12 h), stomachache, gastric lavage with demulcents (duration = 24 h) and complete loss of taste sensation (duration = 8 h), which recurred during the next 48 h. No change in plasma aminotransferase level was seen. We used basic chemical information about the incompatibilities of CHX for clinical management of unintentional ingestion. It is known that CHX is a cation, and, therefore, first aid in case of intoxication with CHX involves using anionic materials.

Fatal large-volume mouthwash ingestion in an adult: a review and the possible role of phenolic compound toxicity.

OBJECTIVE: To describe a case of fatal mouthwash ingestion and review possible sources of toxicity. DESIGN: Case report. SETTING: Veterans Administration Medical Center. PATIENT: Single patient with massive mouthwash ingestion. MAIN RESULTS: This patient was a 45-year-old man who developed cardiovascular collapse and multiorgan system failure following a massive ingestion of mouthwash (almost 3 liters). His presentation was remarkable for a profound anion-gap metabolic acidosis and a significant osmolar gap. No other co-ingestants were identified, and he expired despite full supportive care including dialysis and mechanical ventilation. An autopsy failed to identify any other cause of death. Nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure in the reported toxic range of these ingredients. CONCLUSIONS: When ingested in large quantities, the phenolic compounds in mouthwash may contribute to a severe anion-gap metabolic acidosis and osmolar gap, multiorgan system failure, and death. These compounds, in addition to alcohol, may account for the adverse effects associated with massive mouthwash ingestion.

Acute ethanol toxicity from ingesting mouthwash in children younger than 6-years of age.

The purpose of our study was to analyze reports of the American Association of Poison Control Centers (AAPCC) of suspected overingestion of ethanol from mouthrinses by children younger than 6 years of age between 1989 and 1994. Annual incidence rates of reported ethanol exposures attributed to mouthrinses were calculated. Lethal and toxic amounts of several mouthrinses were calculated using peak blood ethanol concentrations of 500 and 50 mg per 100 mL, respectively. In 1994, there were 2937 calls reported by poison control centers related to ethanol-containing mouthrinses, an estimated incidence of 168 reported exposures per 100,000 children younger than 6 years of age. A 15-kg child who ingests 212 mL (7.2 oz.) of Listerine (26.9% ethanol) ingests 57 mL (1.9 oz.) of ethanol, which is potentially lethal. Approximately one-tenth that amount of ethanol can produce a toxic reaction. Physicians, dentists, and other health care providers should inform parents of the dangers associated with accidental ingestion of mouthrinse and encourage them to keep mouthrinse out of the reach of children. The Food and Drug Administration (FDA) should require readily visible warning labels and child-resistant caps for containers with potentially toxic volumes of ethanol. The American Dental Association (ADA) should re-evaluate its acceptance criteria for advertising cosmetic mouthrinses in its publications and consider including child-resistant caps and warning labeling.

A report of acute ethanol poisoning in a child: mouthwash versus cologne, perfume and after-shave.

The ingestion of ethanol-containing products, such as cologne, perfume and after-shave, in children under six years of age is common, but serious poisoning is rarely reported. Thus, it has been recently suggested that children ingesting up to 3.5 ounces of these products may be safely observed at home as long as they remain asymptomatic. While it may be assumed that products with a significantly lower alcohol content represent a much smaller poisoning hazard, mouthwashes are a relatively frequent cause of serious poisoning in children. In the following case report, 75 milliliters of mouthwash caused hypoglycemia, coma and manifestations of tonic seizure activity. Because of the palatable nature of mouthwash, wine and liquor, it appears that children are more apt to drink large quantities, consuming dangerous amounts of ethanol. The apparent safety of cologne, perfume, and after-shave may be due to a lack of palatability as well as the irritant nature of high concentrations of ethanol. This case suggests that consumer items such as mouthwash should be packaged in child-resistant containers.

Fatal ethanol intoxication from household products not intended for ingestion.

Fatal acute ethanol intoxication is frequently encountered in medicolegal practice. Although the vast majority of acute ethanol toxicity deaths follow the ingestion of conventional alcoholic beverages, ethanol can be obtained from a variety of commercial products, which often contain high levels of ethyl alcohol but are not manufactured or designed for consumption. Such products may be easily purchased in locales where statutory limitations restrict liquor availability on Sundays or during the early morning hours. Several acute ethanol fatalities have been encountered in New Mexico that were directly related to consumption of non-beverage ethanol-containing products, all of them occurring during times when alcoholic beverage sales were restricted. Despite the fact that manufacturers deliberately include compounds in these products that discourage ingestion, this policy apparently does little to deter individuals who are searching for a source of ethanol when no conventional beverages are available. The products that were consumed in these fatalities also contained other compounds which would be toxic at much greater concentrations, but which were inconsequential in their effects in comparison with the direct toxic effect of ethanol. Investigation of the scene and awareness that alcohol-containing products can be fatally abused are essential to detecting these unconventional ethanol sources.