Under the Sink: A Pediatric Poisoning Emergency

A toddler is found screaming beneath the kitchen sink, surrounded by spilled household cleaners. Which exposure is responsible—and why can inducing vomiting or using common poisoning treatments make the situation worse? Test your toxicology instincts in this interactive pediatric emergency.

Transcript

This is Pick Your Poison. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. Want to know when inducing vomiting can make a poisoning worse? What poisoning not only causes life long damage, but increase the risk of cancer by 1000&?
Stay right here to find out.
This is an interactive story.
Will our patient live or die?
It's up to you and the choices you make.
Button up you white coat and lets get started.
Today's episode starts with unanswered phone calls. Five to be exact.
You're checking in, trying to check in, on a distant relative, an elderly 80-year-old aunt. She hasn't answered your texts, not particularly surprising, but she's not answering any phone calls to either, making you concerned. You rush over to her house to make sure she's OK.
Fortunately, the front door is unlocked, so you can get inside. Your aunt is nowhere to be seen. You do find a child in the house—a two-year-old, a distant cousin.
The child is sitting inside the cabinet underneath the kitchen sink. He's screaming. Bottles of cleaning supplies are strewn across the floor. You pull him out and pick him up. He's covered in sticky liquid. Your feet squelch. Bottles and spray bottles are missing their caps and tipped over spilling multicolored liquid across the floor.
You bounce the child gently up and down and say some soothing words to calm him, difficult to do because you're also running around the house searching for your great-aunt. She's not anywhere to be found downstairs. You take the stairs two at a time, going upstairs and shouting her name.
There's no response.
The child is still screaming. You bounce him up on your hip a few more times. Finally, you find your aunt wedged into the floor next to her bed. You lean down and shake her, trying to wake her up. She groans and opens her eyes, mumbling a few words.
None of which make any sense.
In the meantime, the baby is still screaming. A wet spot on your shirt which keeps getting bigger. The child is not only crying, but drooling like crazy.
Okay, so this is a bit of a chaotic situation.
Did your aunt fall and hit her head? Does she have an intracranial hemorrhage? A stroke, Did she get sick and fall? And why won't this child stop screaming? Is he just upset that his parents aren't here, or is he channeling your anxiety?
Question number one: Who needs to go to the hospital?
A. Your aunt
B. The child
C. Neither
D. Both
The answer is D. Both need medical attention. Your aunt is clearly not OK. The toddler may or may not be OK but we don't know what he got into under the sink and at the very least he should undergo an evaluation.
Let's get right to it and fast forward to the emergency department where of course you are the ER doctor. Your colleague is caring for your elderly aunt and your patient is the two year-old. You've called his mom and she's at the bedside.
She says her son was fine when she dropped him off several hours ago, desperate for childcare, as her babysitter canceled and she had important meetings. She thought your aunt seemed a little off but was late for work and without other options. He hadn't had any cough or flu symptoms, no fevers or chills, and no vomiting or diarrhea. She says he's otherwise healthy, and doesn't take any medicines.
You lean in several times to hear what she's saying because he's sitting on her lap and still crying inconsolably. It's been close to an hour at this point he hasn't stopped crying and not even mom's arrival can soothe him. Also he's still drooling his entire shirt as wet and mom shirt has a big wet spot just like yours. When you and mom ask him if anything hurts, he says, "Ow," but can't further communicate what's causing this distress.
On exam, his temperature is 98.6°F, or 37°C. Heart rate is 140 bpm his respiratory rate is 35 breaths per minute his blood pressure is 80/50 with an oxygen saturation of 100% on room air. Normal vital signs for two year-old.
He's awake and alert with a normal mental status, other than the inconsolable crying. His pupils are equal, round, and reactive to light. It's hard to do a real cranial nerve exam on a child, especially one who's crying, but there's nothing obviously wrong. You check his ears. No redness or fullness to suggest an ear infection. It's difficult to look in his mouth because he keeps screaming, but with a tongue depressor, you're able to get a quick look, and you don't see anything abnormal. His heart and lungs are normal. He doesn't seem to have any abdominal tenderness to palpation. He's moving all of his extremities with good strength, and there's no rash or any external lesions.
Essentially, we have an otherwise normal child who appears to be in pain and is crying inconsolably after being found unattended at the house of an elderly relative.
What are some things that can cause this? Well, literally almost anything. It's possible he developed some sudden medical illness over the course of a few hours, but of course you know this a toxicology podcast. Also, I'm sure you haven't forgotten that we found him in the cabinet under the sink.
Fortunately, you the presence of mind despite the chaos to snap a picture of the cleaning supplies while trying to get your aunt and your patient to the emergency department. You pull it up on your phone.
Bottles are tipped over and spilled, leaking in every direction. You zoom in to read the labels. You see bug spray for killing ants and cockroaches, liquid to unclog your drains like Drano or Liquid-Plumr, bleach, and kitchen cleaning spray like 409 or lysol, for counters. There's also dishwasher detergent.
Question #2. Which of the following is the most likely cause of our patient's symptoms?
1. insecticide.
2. Drain cleaner
3. Bleach
4. Kitchen spray
5. Dishwasher detergent
The answer is B. drain cleaner. Specific ingredients in all of these things, of course vary from brand to brand and certainly from country to country. We don't always know the name or the specific preparation to be able to look up the ingredients. But we can, and often do as toxicologists, make an educated guess.
Bug sprays often contain pyrethrins or pyrethroids, insecticide derived from chrysanthemums, which have natural bug-deterring abilities. Hypersensitivity reactions are possible like you could imagine from a flower, but they typically don't cause significant toxicity otherwise. Kitchen spray cleaners often contain ammonia products, irritate yes, but not likely the source of significant toxicity either.
What about bleach? Sodium hypochlorite. It can be caustic, as I'm sure you know, but if you sips of typical household, concentration rarely cause significant toxicity. In higher concentrations like for industrial use or enlarge quantities than it can be toxic, but that's not like likely to have happened here.
As far as dishwasher detergent goes, it's important to know if it's liquid or pods. The liquid, again, can be irritating, but it's basically soap. The pods, however, contain products that unfortunately cause more significant toxicity, causing airway, swelling, and compromise and pediatric patients may require intubation and ventilation. We don't even know exactly what's in all of these dishwasher and laundry pods because the information is supposedly proprietary. If you have small children in your house, I would be very very cautious about having dishwasher and detergent pods because they're far more toxic than either in liquid preparation. Your aunt uses liquid detergent.
Leaving us with drain cleaner as the unfortunately likely cause.
Question 3. Is liquid drain cleaner:
A. An acid
B. A base
And bonus question which we'll discuss later: Are burns from acid exposure or base exposure typically worse?
The answer is B. drain cleaner is a base, usually lye. Meaning sodium are potassium hydroxide. Ingredients vary as I said earlier, some even contained bleach, but it's lye which causes the injury in these cases. Lye causes caustic injury, meaning burns to the mouth and the gastrointestinal tract if swallowed.
You were able to get a look in the little guy's mouth and good news. You didn't see any burns. He also doesn't have any burns around the outside of his mouth either.
Question 4. This means we can rule out significant caustic injury.
A. True
B. False
The answer here is B. False.
There's a significant amount of pediatric data showing that the absence of intraoral burns doesn't rule out potential injury to the esophagus or the stomach. Basically, the child might've gulped it down quickly, too quickly to have caused significant contact and burns inside the mouth, but that doesn't mean it it's not causing burns or injury as it moves down through the digestive tract.
Not only does the lack of intraoral burns not rule out deeper injuries, but there are two things that are still concerning. He won't stop crying, and he's having excessive drooling. Both of these are symptoms of G.I. tract injury in pediatric patients.
Question 5 What do we do next?
1. Activated charcoal
B. Give an acid to neutralize the lye
2. C. Pump his stomach
C. Observation
D. Call the pediatric gastroenterologist
The answer is D. Call the pediatric gastroenterologist.
If you gave A or B, C, hate to tell you, you might've made the child worse as these are contraindicated.
First, Charcoal to doesn't bind caustics so it won't help. Second, it's a thick, black liquid. If the patient does need endoscopy, i.e., a camera down the throat to check for injury, all the gastroenterologist will see is black. They won’t be able to see the burns even if they're there.
If you wanted to try to neutralize the lie with acid, you might cause more burns. Acids of course are also caustics. While the idea of trying to neutralize, the Poison sounds great in reality, There's no way to know what the pH is inside the patient's gastrointestinal tract, how much of what specific pH they might've ingested and how much acid it might take to neutralize it. Usually, we don't recommend pumping the stomach anymore after a toxic exposure because it's unclear that there's a benefit in this case however there's a definite risk. The lavage tube is big and you're putting it down through the esophagus and into the stomach blindly meaning we can't see where it's going after acoustic injection. There's a risk of perforation and if you jam big tube down there, you definitely increase that risk.
The other thing you definitely don't want to do is induce vomiting. This lie has already burned once on the way down. You don't want it to burn things twice on the way back up. Oh, and what about milk? I have to say I have no idea why we hear about milk all the time with poisoning because milk is not the antidote for anything.
Observation might be appropriate in a child with an exploratory ingestion who is completely asymptomatic. Our patient is definitely symptomatic. He appears to be in pain and he's definitely drooling so that's contraindicated here.
The gastroenterologist says he's got a full schedule, so he'll do the child's endoscopy in a few days.
Question 6 Do you agree with this?
A. Yes
B. No
The answer is B. No. This endoscopy needs to be done emergently. The safest and therefore ideal time is within 24 hours. After 24 hours, the risk of perforation increases, and endoscopy is generally contraindicated between 48 hours and two weeks post-ingestion because this is the time when the tissues are the weakest and most damaged and the risk of perforation is the highest.
You disagree with doing it in a few days and after discussion, he agrees to squeeze your cousins in later today in keeping with standard recommendations.
While we wait, let's talk about what happens after caustic exposure. First, What exactly is a caustic? It's something that causes damage to tissues on contact. So it can be either acidic or alkaline.
Alkali exposures, like lye cause liquefactive necrosis, meaning essentially the cells and the fat inside cells dissolve this results in a gelatinous coagulum, allowing deeper penetration into the subcutaneous tissues, and even the muscle.
Acid exposures cause coagulative necrosis. Essentially, it dries out the cells and causes an eschar, theoretically limiting deeper penetration.
The classic teaching is that acid burns are worse, though in truth, this depends on the outcome measure. In some studies acid ingestion is associated with higher mortality, but alkalize do cause more significant morbidity, specifically related to burns in the esophagus and stomach and subsequent long-term sequela.
You can die after caustic ingestion certainly but most patients don't leaving them at risk for a long-term sequela. And these are very, very serious and can cause lifelong problems. Patients who get esophageal burns in particular art at risk for scarring, which causes esophageal structure, meaning a very narrow part of the esophagus which can cause long-term problems with swallowing. This is more common in patients who drink large volume of caustics, for example, suicidal patients, but any patient with caustic exposure is at risk also after caustic injury. Patients have an increased risk of esophageal cancer 1000 times higher than the general population.
Your cousin goes for the endoscopy and shortly there after the gastroenterologist calls to tell you the results. He has grade 2B lesions throughout his esophagus, but no lesions in his stomach.
What does this mean? Gastroenterologist use the score called the Zargar grading score to report the severity of the burns. Grade one means that they saw some redness maybe some swelling but not an actual ulcer grade 2 a means they did see a superficial ulcer to be means that there are deeper or circumferential ulcers three a is multiple deep ulcers, possibly with necrosis and 3B means extensive necrosis.
If after caustic exposure, the endoscopy shows no injury or mild injury in the top child is able to drink and doesn't appear uncomfortable then they can be discharged. Patient with the 2B injury have a 75% risk of esophageal stenosis in the future and those with three a have almost 100% risk of esophageal structure patients with 3B injury have mortality rates that can be as high as 65%. If the patient has a 2B or greater level of injury, it's recommended that a feeding tube be passed down by the gastroenterologist during the endoscopy. This allows, the patient to be fed via the tube until the burns heal. It also prevents the risk of perforation by blindly inserting the tube at the bedside.
The gastroenterologist also suggests a three day course of steroids for your patient. This is a little bit controversial in the guidelines change from time to time steroids can reduce inflammation, and therefore might keep the ulcer from getting larger, but the flipside of that coin is that they also impaired wound healing and so could potentially increase the risk of perforation. This is the reason why it's recommended for patients only with two be lesions at the present time to try to balance these competing effects. He also recommends a proton pump, inhibitor, i.e. and acid blocker. There's limited evidence that these are helpful, but there's almost no risk of harm with a short course.
Most pediatric exploratory ingestions are fine because the child usually doesn't drink very much if anything at all severe injuries are estimated to occur in about 1 to 14% with a structure risk in about 6 to 10%. I keep mentioning strictures? Why do we worry about esophageal structures so much. Because they can cause significant difficulty with swallowing in the future and they're extremely difficult to treat gastroenterologist can dilate them during an endoscopy, but it often doesn't work very well and every time they try to dilate the structures there's a risk of perforation. This can lead to lifelong problems and the need for serial endoscopies in addition as I noted to the risk of esophageal cancer.
Endoscopy is a pretty invasive procedure. It carries a risk of perforation after caustic congestion as I've said, so some people have said what about CT scan of the esophagus in the abdomen instead. There is some evidence that this might be useful and some protocols. Suggest a CT scan is preferred over endoscopy in adult patients in pediatric patients. However, endoscopy is still the preferred test is not every lesion will be seen on CT, and of course we try to avoid radiation in pediatric patients, but if you work in a place without a pediatric gastroenterologist, this would certainly be a reasonable test while you were waiting to get the patient transferred or as a help to determine next steps. CT is certainly the test of choice if there's any concern for perforation. Perforation would be treated typically with surgical intervention and is a contraindication to endoscopy as I've mentioned.
Your colleague who is taking care of your elderly aunt reports her workup for traumatic injuries, including intracranial hemorrhage, was fortunately negative. He did find that she has sepsis and septic shock from a urinary tract infection, so she's being admitted to the hospital and is improving after treatment with IV fluids and antibiotics.
Your patient is admitted to the hospital with a feeding tube. After several days, the feeding tube is removed. He's able to eat. Fortunately, he's discharged with no long-lasting sequelae due to the misadventure.
Let me take a quick minute to ask you to please make sure your kitchen cabinets, bathroom cabinets, garage cabinets and anywhere else you store toxins are locked up and childproof. Also beware of visiting friends and family members without kids who haven’t taken precautions. This easy step goes a long way to keeping kids safe.
Lye often pops up in pop culture for poisoning people and getting rid of bodies. Experts say it would take years and years to dissolve a body with lye, not quick enough to make it useful for concealing evidence.
Real life, A dermatologist in California was indicted on charges of trying to poison her husband with drain cleaner after a hidden camera showed her pouring it into a teacup. Also, like can cause significant injury on the skin and has been thrown on unfortunate victims, causing extensive disfiguring and potentially life-threatening burns.
The last question in today's podcast in the pop culture consult. What cost substance was used in breaking bad to try to dissolve a body instead dissolving the bathtub and causing it to crash several stories down into the basement.
1. Lye
2. Sulfuric acid
3. Hydrofluoric acid
Follow the X and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.