Clinical, Toxicology, Toxins

Tide Pod Challenge: A Closer Look at the Toxicology

It seems like every few months a new challenge becomes a viral sensation on social media. Recently, teenagers and young adults have been ingesting laundry detergent pods in the aptly named Tide Pod challenge. Subsequently, the upsurge of intentional exposures has drawn national attention to the toxicological properties of laundry pods — and to their potentially lethal effects.

What are Laundry Detergent Pods (LDPs)?
Although available in Europe since 2001, manufacturers began marketing LDPs in the United States in 2011.1-4 They are single-use, concentrated liquid detergent packs housed in a water soluble wrapping.2,3,5,6 Examples include Tide Pods, Purex Ultra Packs, and All Might Packs.6-7 The exact composition of the LDPs varies by manufacturer, but most contain ethoxylated alcohols and propylene glycol in an alkaline, highly viscous liquid.2,3,5,7,8,9,10

How common are exposures?
Despite the recent media attention and the ongoing social media challenge, the problem of ingesting LDPs is hardly new, and unfortunately, becoming more common. The majority of exposures occur in children younger than 6 years old.11-12 In October 2012, the Centers for Disease Control & Prevention’s Morbidity and Mortality Weekly Report tracked 485 LDP exposures from May 17 – June 17, 2012. Of these, 454 were in children younger than 5 years old.12 From 2012-2013, the American Association of Poison Control Centers’ (AAPCC) National Poison Data System (NPDS) recorded 17,230 exposures to LDPs in children younger than 6 years old.13 One year later, there were 22,064 exposures in the same age bracket.14 In the month of January 2018, the AAPCC recorded 606 exposures in children less than 5 years old.15 Of course, exposures in teenagers has been increasing as well. In January 2018, there were 143 teenage exposure reported by the AAPCC. For comparison, in 2017 there were 53 teenage exposures, and only 39 in 2016.16

What are the Routes of Exposures?
The most common route of exposure is ingestion.4,6,11-14,17 Other routes include ocular, dermal, and aspiration, while some exposures occur via multiple routes.13,14,17

What are the Clinical Effects?
Exposures to LDPs cause more severe effects than those from traditionally packaged laundry detergent.2,3,6,12,18 At least one death has been caused by LDP exposure.19 Since the majority of exposures occur via ingestion, the most common effects are nausea, vomiting, and diarrhea.3,4,6,7,11,13,14 Dysphagia secondary to oropharyngeal and esophageal mucosal burns and ulcers has also been reported.1,3,7,13,14,18 Many cases include sudden and unexpected changes in mental status, which required intubation for airway protection.1-3,5,11,13-14,18,20-21 Some patients may experience seizures,11,14 and the respiratory system may experience effects such as coughing, wheezing and bronchospasm, aspiration pneumonitis, and edema of the epiglottic and aryepiglottic folds.1-3,5,11,13-14,18,22 Additionally, hypoventilation and apnea can occur.3,13-14 Renal and electrolyte abnormalities in the forms of acute kidney injury, metabolic acidosis, hyperlactatemia, and hyperglycemia may arise. 1-3,5,13-14,18,20-22 Ocular exposures often cause chemical conjunctivitis and corneal abrasions,3-4,7,13-14,23-26 while dermal contact causes irritation, rash, and chemical burns.4,6,13,14,22

What is the Mechanism of Poisoning?
The mechanism of poisoning is currently unknown, but several theories exist. Some propose that the altered mental status, metabolic acidosis, and hyperlactatemia are caused by the propylene glycol and its metabolism into lactate, acetate, and pyruvate.2,3,5,18,22 Others, however, argue that the concentration of propylene glycol in the detergent packs is not high enough to cause these effects.2,7,18 Instead, they attribute these effects, particularly the severe mental status changes and seizures, to the ethoxylated alcohols in the LDPs.2,3,5,18,22 As for the ocular, dermal, gastric, and airway burns and irritation, many postulate that the viscous, alkalotic properties of the liquid are to blame, but some suspect the concentration of the chemicals, not the pH, is responsible.2,3,5,15,23

What is the Treatment?
There is no antidote, and the mainstay of care is symptomatic management.22,27 Fortunately, the majority of cases are mild and can be safely discharged after a period of observation.7 The manufacturers often recommend drinking a glass of water to dilute their product if ingested, but several poison control centers suggest using small sips of water due to fear of aspiration.2,22

The potential for rapid and unexpected change in mental status and its potential to cause airway compromise should prompt heightened vigilance and frequent reassessments.1,2,11,27 All patients should undergo continuous pulse oximetry, and end-tidal CO2 monitoring also may be beneficial.27 Physicians should be prepared to rapidly intubate. Airway edema may respond to steroids and nebulized epinephrine.1,7,27 Nebulized beta-2 agonists may improve bronchospasm.3,27 Patients should be positioned to minimize the risk of aspiration, and anti-emetics should be considered. All ocular exposures should be copiously irrigated and undergo slit lamp examination to assess for corneal ulcers and abrasions.3,17 Dermal exposures should likewise be irrigated and assessed for chemical burns once contaminated clothes are removed.15,22 Additionally, toxicology or poison control should be consulted.22

REFERENCES
1. Kamit-Can F, Alparslan C, et al. The need for mechanical ventilation in a child exposed to a laundry detergent pod. Turk J Pediatr. 2016;58(3):323-326.
2. Beuhler M, Gala P, Wolfe H, Meaney P, Henretig F. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013;29(6):743-747.
3. Heppner J, Vohra Rais. Pick Your Poison. Household “HazMat”: a pair of SUDSy siblings. Pediatr Emerg Care. 2013;29 6):773-777.
4. Williams H, Jones S, Wood K, Scott R, Eddleston M, Thomas S, Thompson J, Vale J. Reported toxicity in 1486 liquid detergent capsule exposures to the UK National Poisons Information Service 2009-2012, including their ophthalmic and CNS effects. Clin Toxicol (Phila). 2014;52(2):136-40.
5. Schneir A, Rentmeester L, Clark R, Cantrell F. Toxicity following laundry detergent pod ingestion. Pediatr Emerg Care. 2013;29(6):741-742.
6. Forrester M. Comparison of pediatric exposures to concentrated “pack” and traditional laundry detergents. Pediatr Emerg Care. 2013;29(4):482-486.
7. Yin S, Behrman A, Colvin J. Laundry pack exposures in children 0-5 years evaluated at a single pediatric institution. J Emerg Med. 2015; 48(5):566-572.
8. The Procter & Gamble Company. Material Safety Data Sheet 3-in-1 Detergent- Unit Dose Liquid Laundry Detergent. July 2014. Available at: https://www.pg.com/productsafety/msds/2014/Tide%20Pods%20MSDS%20July%202014.pdf. Accessed January 20, 2018.
9. Henkel Consumer Goods, Inc. Material Safety Data Sheet Purex UltraPacks Liquid Laundry Detergent- ColdWater. November 2017. Available at: http://mymsds.henkel.com/mymsds/0007.2162766.3000.en.MSDS_US.29958569.0.US.pdf. Accessed January 20, 2018.
10. Sun Products Corporation. Material Safety Data Sheet All Stainlifter Mighty Pacs. August 24, 2017. Accessed January 20, 2018.
11. Stromberg P, Burt M, Rose R, Cumpston K, Emswiler M, Wills B. Airway compromise is children exposed to single-use laundry detergent pods: a poison center observational case series. Am J Emerg Med. 2015;33(3):349-351.
12. Centers for Disease Control and Prevention. Health hazards associated with laundry detergent pods- United States, May-June 2012. MMWR Morb Mortal Wkly Rep. 2012;61(41):825-829.
13. Valdez A, Casavant M, Spiller H, Chounthirath T, Xiang H, Smith G. Pediatric exposure to laundry detergent pods. Pediatrics. 2014;134(6):1127-1135.
14. Davis M, Casavant M, Spiller H, Chounthirath T, Smith G. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014. Pediatrics. 2016; 137(5).
15. American Association of Poison Control Centers. Laundry Detergent Packets and Children. Feb 2018. Available at: http://www.aapcc.org/alerts/laundry-detergent-packets/. Accessed Feb 3, 2018.
16. American Association of Poison Control Centers. Intentional Exposures Among Teens to Single-Load Laundry Packets. Feb 2018. Available at: http://www.aapcc.org/alerts/intentional-exposures-among-teens-single-load-laun/. Accessed Feb 3, 2018.
17. Bonney A, Mazor S, Goldman R. Laundry detergent capsules and pediatric poisoning. Can Family Physician. 2013;59(12):1295-1296.
18. Smith E, Liebelt E, Nogueira J. Laundry Detergent Pod Ingestions: Is There a Need for Endoscopy? J. Med. Toxicol. 2014;10:286-291.
19. Wallis L. Laundry Detergent Pods Pose a Dangerous Poisoning Risk for Children. The Am J of Nurs. 2015;115(2):15.
20. Fontane E. Ingestion of Concentrated Laundry Detergent Pods. J Emerg Med. 2015;49(1):e37-8.
21. Lim R, Forward K. Laundry Detergent Pod Ingestion. Pediatr Emerg Care. 2013;29(9):1053-4.
22. Karel L, Handzel M, Rosini J. Laundry detergent pod ingestion in 2 pediatric patients. J Emerg Nurs. 2015;41(1):80-2.
23. Mathew R, Kennedy K, Corbett M. Eyes and alkalis. Wave of paediatric eye injuries from liquid detergent capsules. BMJ 2010;340:c1186.
24. Lasnier O, El-Hadad C, Superstein R. Two cases of corneal abrasions in children exposed to liquid detergent capsules. Can J Ophthalmol. 2013;48:e29-e30.
25. Fayers T, Munneke R, Strouthidis NG. Detergent capsules causing ocular injuries in children. J Pediatr Ophthalmol Strabismus. 2006;43:250-251.
26. Halpern L. Laundry Detergent Pods Linked to Increased Eye Injuries in Children. The Am J of Nurs. 2017;117(5):15.
27. Shah L. Ingestion of Laundry Detergent Packets in Children. Crit Care Nurse. 2016;36(4):70-5.

Related Articles

Board Review Questions: December 2015

EM Resident 12/01/2015
Board Review Questions: December 2015 Provided by PEER VIII. PEER (Physician's Evaluation and Educational Review in Emergency Medicine) is ACEP's gold standard in self-assessment and educational revi

Wolff-Parkinson Wait!

Wolff-Parkinson Wait! A healthy 28-year-old male with no past medical history presents to the emergency department with palpitations and dizziness. Vital signs are within normal limits except for a r