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Abstract

Introduction: Hospital admissions due to ingestion of laundry detergent pods have increased since their introduction in 2001. Ingestion of these pods can result in lethargy and acute respiratory failure not typically seen with detergent ingestions. Patient A, a 15 month-old female, presented to an outside emergency department with coughing and emesis after she was discovered holding a laundry detergent pod. The patient exhibited a waxing and waning level of consciousness in the ED that progressed to lethargy. Her pulmonary exam was initially normal. Patient A was intubated for airway protection during transport in the setting of her depressed neurological status and emesis. On admission to the PICU, the patient initially had normal lung compliance. She underwent upper endoscopy that showed esophageal erythema without ulceration. On hospital day #2, the patient became difficult to both oxygenate and ventilate. Her P/F ratio, which was 333 on admission, decreased to 100 and her OI increased to 11 (from 2.9). The patient required mechanical ventilation until HD#5 when she was extubated. At PICU discharge, she was of normal neurological status, except for swallowing difficulties identified on evaluation for rehabilitation. Patient B, a 24 month-old female, was evaluated for similar findings of cough and lethargy. Her mother found her vomiting and foaming at the mouth after handling a concentrated detergent pod. She noted that this colored pod may have appeared similar to candy she previously gave her daughter. Patient B demonstrated decreased alertness in the emergency department. She was also wheezing on physical exam. She was intubated for airway protection during transport. Her chest x-ray initially showed perihilar accentuation, but subsequently developed right-sided infiltrates. She required PIPs as high as 40 and a PEEP of 10 to maintain adequate oxygenation and ventilation. Her P/F ratio decreased to 116 and her OI increased to 14.6. She had a normal esophagogastroduodenoscopy. The patient required 9 days of mechanical ventilation which were notable for frequent oxygen desaturations and persistent consolidations concerning for atelectasis. The patent also required inpatient rehabilitation for one week prior to discharge. Concentrated laundry detergent pods were released to the consumer market in 2001. Initially, the most common reported symptoms were nausea, emesis, cough, stridor, and increased drowsiness (Williams, 2012). Compared to traditional detergent exposure, drowsiness and emesis are more common (CDC, 2012). One death has been reported in the lay press (CNN, 2013). Here, we document the ICU course for two patients after concentrated laundry pod exposure. Both cases were notable for features of drowsiness and emesis leading to medical evaluation. Both cases showed subsequent development of lethargy shortly after presentation sufficiently severe to require intubation for airway protection during transport. Both cases progressed to hypoxemic respiratory failure within two days of presentation with significant depression of P/F ratio with elevation of OI requiring between 5 and 9 days of mechanical ventilation. Intensivists caring for these children should be aware that acute respiratory failure may present after resolution of mental status changes and should be cautious about early extubation of these patients. Formal rehabilitation consultation may identify swallowing issues not present on standard neurological exam.