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clinical
ACUTE POISONING:
EXPOSURE TO DIY PRODUCTS
Nicola Bates BSc (Brunel), BSc (Open),
MSc, and Zoe Tizzard BSc, are
information officers at the National
Poisons Information Service, London
This article has been subjected to
double blind peer review
26
H
ome improvement is an increasingly
popular pastime and there is a wide
range of decorating DIY products available
to the general public. Accidental exposure in
the home may occur following splashes or
spills, or when products are not used safely,
for example in inadequately ventilated areas
or without protective clothing. Adults may
also be poisoned after deliberate ingestion
or inhalation of products. Although intentional exposures are rare, they tend to result
in more severe toxicity.
In children, exposure usually occurs while
exploring their environment and may involve
ingestion or dermal exposure. Children may
have accidents when they are left
emergency nurse vol 10 no 8 december 2002/january 2003
GARRY PARSONS
NICOLA BATES and ZOE TIZZARD describe the clinical features and treatment of exposure to the
most commonly used DIY products in domestic environments
clinical
unattended with products that have been
stored incorrectly or within reach. Examples
include drinking from jam jars in which paint
brushes are soaking in white spirit, or
drinking paint stripper from a container on
which the child-resistant closure has not
been replaced properly.
Many substances used in home
improvement are relatively innocuous but
others can cause severe poisoning. This
article describes the clinical features and
treatment of exposure to the most
commonly used DIY products about which
we receive enquiries. It is important to note
that industrial products brought home from
work may be more hazardous, and may
contain substances that are in more
concentrated forms or that are not found in
domestic products.
WHITE SPIRIT
White spirit, or turpentine substitute, should
not to be confused with turpentine oil,
which is potentially much more dangerous.
White spirit is a solvent in products such as
paint, varnishes, thinners, furniture polish,
window cleaners, inks, degreasers, wood
preservatives, aerosols, asphalt products and
dry cleaning agents. It is also available as a
colourless non-viscous liquid, and is used to
‘thin’ paints and clean paint and varnish
from decorating tools.
Many cases of accidental ingestion of
white spirit are uneventful and patients may
remain completely well. However, white
spirit has a drying and defatting action on
mucous membranes, and therefore can
cause buccal and gastrointestinal irritation
leading to soreness in the mouth and throat,
nausea, vomiting and abdominal pain on
ingestion. Diarrhoea may occur and
occasionally there may be excoriation and
burning of the perianal area. White spirit is
poorly absorbed from the gastrointestinal
tract and therefore systemic effects are not
normally anticipated. However, there may
be drowsiness if very large quantities are
ingested.
The most significant risk from ingestion of
white spirit is from pulmonary aspiration.
White spirit is volatile, with a low surface
tension and can be aspirated easily; this may
occur during ingestion or if patients
subsequently vomit. Indicative signs of
aspiration include respiratory distress with
coughing and choking, and tachypnoea
vol 10 no 8 december 2002/january 2003 emergency nurse
followed by dyspnoea. These signs can be
delayed for up to 24 hours after aspiration
but are manifest usually within six hours
(Anas et al 1981). Local irritation of the lungs
leads to chemical pneumonitis, haemorrhagic bronchopneumonia and, in severe
cases, pulmonary oedema. Pyrexia may
occur and white blood cell count may be
raised. White spirit is absorbed across the
lungs (Åstrand et al 1975) and systemic
effects such as central nervous system (CNS)
depression and convulsions may occur.
Activated charcoal is of no benefit after
white spirit ingestion. It does not bind white
spirit and may cause vomiting, therefore
increasing the risk of aspiration. Oral fluids
may be encouraged. Asymptomatic patients
may be discharged home and advised to
return if there are signs of aspiration, such
as choking, coughing or wheezing. If
patients start vomiting or wheezing, or
aspiration is suspected, lung sounds should
be checked and if these are abnormal
baseline chest X-rays should be performed.
All cases of suspected aspiration should be
observed for at least six hours. Further care
is symptomatic and supportive. Noncardiogenic pulmonary oedema should be
treated with oxygen and positive expiratory
end pressure ventilation in intubated
patients, or constant positive airway pressure
in non-intubated patients.
Accidental inhalation of white spirit may
cause headache, dizziness, nausea and
mild upper respiratory tract irritation.
Systemic effects are unlikely after small,
accidental exposure. After accidental
inhalation exposure, patients should be
taken away from exposure and all
contaminated
clothing
removed.
Respiratory function should be assessed
and oxygen given as necessary. Further
treatment is symptomatic and supportive.
Coma and convulsions may occur
following inhalation at very high
concentrations. There may also be an
increased risk of cardiac arrhythmia,
possibly due to myocardial sensitisation to
catecholamines. However, severe effects
are usually seen only in patients who have
been intentionally inhaling solvents or as
a result of industrial exposure. Reversible
hepatic, bone marrow and nervous system
toxicity has been attributed to acute
exposure to paint containing white spirit
(Atkinson et al 1989).
27
clinical
Patients showing systemic toxicity should
be observed for at least 24 hours. Treatment
is primarily symptomatic, with support of
cardiovascular and respiratory systems.
Patients should be kept calm, and using
epinephrine or related sympathomimetic
stimulants should be avoided due to the risk
of ventricular fibrillation.
The level of consciousness, electrocardiograms (ECGs) and respiratory function
should be monitored, as well as liver and
kidney function in severe cases. A full blood
count should be checked. Chest X-rays are
indicated in patients with respiratory symptoms and in cases of suspected aspiration.
White spirit on the skin (Anderson et al
1986) or splashed in the eyes (Grant and
Schuman 1993) may cause mild irritation, but
prolonged or repeated contact can cause
more severe irritation. If white spirit is spilt on
the skin it should be thoroughly irrigated with
soap and water, or saline. Further treatment
is symptomatic and supportive. Emollients will
relieve mild irritation. The eye(s) should be
stained with fluorescein and if there is
evidence of corneal damage, patients should
be referred to an ophthalmologist.
METHYLATED SPIRITS
Methylated spirits is also known as meths or
industrial methylated spirits, and is a mixture
of ethanol (90 to 95 per cent) and methanol.
The methylated spirits sold for general use is
dyed purple to prevent it being mistaken for
water or any other clear fluid. It is used to
remove stains and sometimes to clean paint
brushes. On the skin or in the eyes, it may
cause irritation but severe effects are not
expected. Ingestion of methylated spirits
causes inebriation and management is the
same as for ethanol intoxication. Although
methanol is a more toxic alcohol than
ethanol, it does not present acute problems
in methylated spirits due to its low concentration, and because ethanol acts as an antidote to methanol poisoning by preventing
methanol being metabolised into toxic
metabolites.
PAINT
There are many types of domestic paint available. Lead pigments were removed from
household paints and primers in the UK by
the mid 1970s and the use of mercury as a
preservative was phased out by the end of
that decade. However, lead toxicity can be a
28
risk when old paint is stripped. Lead is mainly absorbed after inhalation of fumes or
ingestion of particles. Some young children,
such as those with pica, are at particular risk
of ingesting paint particles. Chemical stripping is the recommended method for removing lead-containing paint, as heating and
sanding liberate lead fumes and respirable
particles, respectively. Lead toxicity has been
discussed in a previous article (Dines and
Cullen 2001).
The toxicity of household paint depends
upon whether it is water- or solvent-based.
A useful guide is to check the instructions for
cleaning brushes given on paint tins. If
brushes can be cleaned in water, the paint is
water-based; if they are to be cleaned in
white spirit, the paint is solvent-based.
Water-based paint such as emulsion is of
low oral toxicity. However, products from
countries where manufacturers are less well
regulated may contain potentially toxic
chemicals. Emulsion paints may irritate the
gastrointestinal tract when consumed in large
quantities and lead to nausea, vomiting and
diarrhoea. Water-based paints can be
removed from the skin with soap and water.
Solvent-based paints such as gloss paint
contain hydrocarbon solvents such as white
spirit that defat mucous membranes, and so
cause buccal and gastrointestinal irritation. If
very large quantities are ingested, patients
may be drowsy but no other systemic effects
are anticipated. Aspiration of petroleum
distillates may occur during ingestion or if
patients vomit. Clinical features and
treatment of aspiration are outlined above.
Gloss paint on the skin may cause mild
irritation. Solvents should not be used to
remove solvent-based paints as they may
exacerbate any skin irritation. Fatty
substances such as peanut (arachis) and other
vegetable oils, animal fat, baby oil or
petroleum jelly may aid removal. However, it
is not essential to remove all the paint as it
will come off within a few days.
PAINT STRIPPER
Paint stripper can contain several chemicals,
but usually methylene chloride or sodium
hydroxide, and it is important to determine
the product name and contents.
Methylene chloride, also known as
dichloromethane, is a CNS depressant. The
main route of exposure is inhalation but
occasionally it may be ingested. Most
emergency nurse vol 10 no 8 december 2002/january 2003
clinical
domestic cases of methylene chloride
poisoning are minor, usually with only mild
CNS effects, or splashes on the skin or in the
eyes. But exposure to high concentrations in
poorly ventilated areas may cause more
serious effects.
Methylene chloride is partially metabolised
to carbon monoxide. It is also lipophilic, so
carboxyhaemoglobin (COHb) concentrations
can continue to rise after exposure has
ceased due to the release of methylene
chloride from adipose and other tissues and
its subsequent metabolism. COHb
concentrations of up to 50 per cent have
been reported following the use of
methylene chloride paint strippers (Fagin et al
1980). However, cases have also occurred
where there have been significant CNS effects
such as coma and convulsions but without
high COHb concentrations (Hall and Rumack
1990). Many methylene chloride paint
strippers also contain methanol but in such
low concentrations that methanol poisoning
is rarely a problem following exposure.
Inhalation of methylene chloride can cause
nausea, dizziness, headache, drowsiness,
feelings of intoxication, and irritation to the
eyes and upper respiratory tract. Coma and
occasionally death due to respiratory
depression have been reported with
exposures to high concentrations, but these
are more likely in occupational environments.
In severe cases, convulsions, cardiac
arrhythmia and pulmonary oedema may
occur. Hepatic and renal toxicity are rare but
may occur following prolonged exposure.
Acute toxic effects may
vol 10 no 8 december/January 2002/2003 emergency nurse
persist for hours after victims have been
removed from the source of exposure
because methylene chloride may continue to
be metabolised. COHb concentrations may
also continue to rise, peaking five or six hours
after exposure (Agency for Toxic Substances
and Disease Registry 1993). Cardiac effects
including dysrhythmia and myocardial
ischaemia have also been reported.
Ingestion of methylene chloride can cause
similar effects to inhalation but may also
inflame and burn the oral or oesophageal
mucosa. In severe cases, stricture formation
may occur (Roberts and Marshall 1976).
Methylene chloride irritates the skin and
chemical burns may occur from prolonged
exposure (Wells and Waldron 1984). Dermal
absorption is only likely following prolonged
or heavy skin contamination. In the eyes,
methylene chloride may cause immediate
burning sensations that should resolve after
thorough irrigation. However, there are rare
reports of corneal epithelium loss after
exposure (Grant and Schuman 1993).
Treatment of methylene chloride
exposure is supportive. Contaminated
clothing should be removed and exposed
skin or eyes should be decontaminated
thoroughly and injuries managed as thermal
burns. Emesis, gastric lavage and activated
charcoal are contraindicated due to the
corrosive effects of methylene chloride.
Nasogastric aspiration may be considered in
potentially serious cases in which large
volumes have been ingested.
Oral fluids may be given unless
perforation is suspected.
29
clinical
Table 1. Summary of common DIY products and their risks
PRODUCT
MAIN INGREDIENTS
RISKS
White spirit
Petroleum distillates
> Aspiration hazard, irritation
to eyes and skin
Methylated spirits
Ethanol
> Inebriation
Paint
Water-based
Solvent-based
> Low toxicity
> Aspiration hazard,
irritation to eyes and skin
Paint stripper
Methylene chloride
> CNS depression, irritant to
skin, eyes and gastrointestinal
tract (risk of burns)
> Corrosive, risk of burns to
skin, eyes and gastrointestinal tract
Sodium hydroxide
Creosote
Petroleum distillates
> Aspiration hazard, irritation
to eyes and skin, burns
particularly if splashed on skin
in hot weather and not
washed off properly
Wallpaper stripper
Sugar soap
Detergents
> Mild irritation, small risk
of foam aspiration
Wallpaper paste
Potato starch
> Low toxicity
Expanding foam
Polyurethane
> Mild local skin irritation,
difficult to remove
In cases of suspected corrosive injury,
gastro-oesophagoscopy should be undertaken within 12-24 hours of the event to
assess the extent and severity of injury.
Prolonged follow up and treatment such as
surgical intervention may be required for
patients with perforation or stricture.
COHb concentrations should be
determined in all cases where systemic
effects are present, even in mild cases
where headache or nausea is the only
symptom. Oxygen should be given. The
half-life of COHb produced by methylene
chloride exposure is about 2.5 times
longer than that of COHb produced by
exposure to carbon monoxide, so oxygen
therapy is likely to be more prolonged in
methylene chloride exposure cases.
Observation for asymptomatic patients is
unlikely to be required but observation of
symptomatic patients will depend on
COHb concentrations and clinical
condition. Oxygen should be administered
until COHb concentrations are less than 5
per cent. ECGs, arterial blood gases, liver
and renal functions should be monitored
in all cases where systemic effects are
present.
30
Despite hyperbaric oxygen therapy
seeming to have no significant effect on
COHb half-life after methylene chloride
exposure, it may sometimes improve
outcome (Rioux and Myers 1989).
Consequently, it should be considered for
patients with prolonged CNS effects or
persistently elevated concentrations.
Sodium hydroxide is used in some paintstripping products. It is a strong alkali and if
ingested can cause immediate burning pain
in the mouth, retrosternal and epigastric pain
in the oesophagus and stomach respectively,
and swelling of the lips. This may be
followed by vomiting, hematemesis, mucosal
burns, dysphagia and shock. Acute
complications include gastrointestinal
haemorrhage and perforation. Dyspnoea
and stridor may occur and in severe cases
there may be upper airway obstruction.
Sodium hydroxide may cause severe burns
on the skin or in the eyes. Exposure should
be managed supportively. It is essential to
irrigate affected areas copiously with water
or saline. Testing skin pH immediately after
irrigation may be misleading. It should be
done 15 minutes after an initial 30-minute
irrigation to allow residual alkali to diffuse up
emergency nurse vol 10 no 8 december 2002/january 2003
clinical
REFERENCES
Agency for Toxic Substances and Disease
Registry (1993) Methylene chloride toxicity.
Environmental Medicine. 47, 5,1159-1166.
Anas N et al (1981) Criteria for hospitalising
children who have ingested products
containing hydrocarbons. Journal of the
American Medical Association. 246, 840-843.
Anderson C et al (1986) Animal model for
assessment of skin irritancy. Contact
Dermatitis. 15, 143-151.
Åstrand I et al (1975) Exposure to white spirit.
Part I. Concentration in alveolar air and blood
during rest and exercise. Scandinavian Journal
of Work and Environmental Health. 1, 15-30.
Atkinson L et al (1989) Toxic reaction to
inhaled paint fumes. Postgraduate Medical
Journal. 65, 559-562.
Dines A, Cullen G (2001) Lead poisoning.
Emergency Nurse. 9, 4, 17-21.
Fagin J et al (1980) Carbon monoxide
poisoning secondary to inhaling methylene
chloride. British Medical Journal. 281, 6253,
1461.
Grant W, Schuman J (1993) Toxicology of the
Eye. Fourth edition. Springfield IL, Charles C
Thomas.
Hall A, Rumack B (1990) Methylene chloride
exposure in furniture-stripping shops:
Ventilation and respirator use practices.
Journal of Occupational Medicine. 32, 1, 3337.
O’Donoghue J et al (1996) Caustic soda burns
to the extremities: difficulties in management.
British Journal of Clinical Practice. 50, 2, 108109.
Rioux J, Myers R (1989) Hyperbaric oxygen for
methylene chloride poisoning: Report on two
cases. Annals of Emergency Medicine. 18,
691-695.
Roberts C, Marshall F (1976) Recovery after
‘lethal’ quantity of paint remover. British
Medical Journal. 1, 20-21.
Wells G, Waldron H (1984) Methylene
chloride burns. British Journal of Industrial
Medicine. 41, 420.
from the deeper dermis (O’Donoghue et al
1996). In cases of ocular exposure, the pH
of the eye should also be monitored.
Following ingestion, treatment is
supportive with urgent airway assessment
in severe cases. Abdominal and chest X-rays
may be needed to check for perforation.
Gastro-oesophagoscopy
should
be
undertaken within 12-24 hours to assess the
extent and severity of injury and determine
the most appropriate management course,
which may include surgical intervention.
CREOSOTE
Creosote is a mixture of phenolic and
petroleum distillate compounds, and is
used to preserve wood. The petroleum distillates are an aspiration hazard like white
spirit.
The petroleum distillates in creosote can
irritate the skin and result in burns
particularly if contact is prolonged. They can
also stain the skin. Dermal burns are a
particular problem if creosote is splashed on
the skin on hot, sunny days as the heat can
make the burns more severe. In warm
weather people also tend to wear shortsleeved shirts and not protective clothing
such as gloves. Creosote splashed on the
skin or in the eyes should be irrigated
immediately, and any burns should be
managed supportively. Systemic toxicity from
dermal exposure manifesting as CNS
depression is possible if exposed areas are
large and contact prolonged. However, this
is unlikely in domestic environments.
WALLPAPER STRIPPER AND SUGAR SOAP
Both wallpaper stripper and sugar soap contain mixtures of detergents. Wallpaper stripper is not as hazardous as paint stripper and
it is important to distinguish between the
two. Sugar soap is used as a general cleaning and degreasing agent. It is available as a
powder or liquid, is diluted for use, and is
used to clean paintwork and walls before
decorating as it improves paint adhesion.
Detergents irritate the gastrointestinal tract
and can cause vomiting and diarrhoea. Oral
fluids may be given. There is a very small risk
that these products may produce foam that
can be aspirated leading to aspiration
pneumonia. In practice, this is very rare but
if aspiration is suspected, for example if
coughing or breathing difficulties are noted,
lung sounds should be checked. Chest X-
vol 10 no 8 december 2002/january 2003 emergency nurse
rays should be performed if abnormalities
are present, with supportive management
as required. Detergent-containing products
may cause irritation to the eyes but are
unlikely to cause severe injury.
WALLPAPER PASTE
Children often eat wallpaper paste. It comprises mainly potato starch and is available
as powder to mix with water or as readyto-use paste. Some preparations contain
the fungicides, captan or a triazine, but
both are in very low concentrations and
may be considered non-toxic. No treatment is required following ingestion of
wallpaper paste.
EXPANDING FOAM
This is also known as polyurethane foam
and is used as a filler. These products usually contain polyurethane and a diisocyanate, with the ingredient most
commonly listed on containers being 4,4'diphenylmethane diisocyanate. Most
polyurethanes are thermoset materials so,
unlike thermoplastic materials, they cannot be melted and reshaped. In most cases exposure is dermal, usually involving the
hands. The foam sets very quickly and is
difficult to remove. It can cause some local
irritation to the skin on contact but does
not cause systemic toxicity. Manufacturers
usually recommend warm soapy water to
remove foam from the skin but, if this fails,
it may be worthwhile washing with vegetable oil. Removing set foam forcibly may
damage the skin and, if soapy water and
vegetable oil fail, it is best to leave the
foam, as it will come off in a few days.
Skin irritation should be managed supportively.
CONCLUSIONS
Table 1 summarises the type of commonly
used DIY products. Most cases of exposure
involve accidental ingestion in children, or
splashes to the skin or eyes in adults. Effects
are usually mild and require only symptomatic treatment. Some products however,
particularly paint strippers, can have serious
effects and require more active intervention.
This may also be true of industrial products
brought home from work. In most accidental exposures in domestic environments,
clinical features are relatively minor and
severe poisoning is rare.
31
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