Tanishq Suryavanshi is a medical student at McMaster University
Blair Bigham is an emergency medicine resident at McMaster University and a freelance journalist
Bandar Baw is an assistant professor, emergency physician and toxicologist at McMaster University
The early part of 2018 has seen the rise of the “Tide Pod Challenge”, in which people have posted viral videos of themselves attempting to eat laundry detergent pods from a variety of brands. The number of poison control calls for laundry detergent pod poisoning in the first 15 days of 2018 already equalled all calls in 2017, thanks to internet viral videos. These ingestions pose a significant concern for the healthcare system, as care spans a variety of disciplines and is a presentation that many may not be familiar with. We visited the literature that was available, spoke to experts in pediatrics, toxicology and general surgery to present some key points clinicians should be aware of.
Determining the reason for ingestion is a crucial step. A retrospective study in 2004 suggested that intentional ingestions, such as suicide attempts, are associated with higher grades of GI tract injury, with or without clinically obvious signs. Bear in mind that those participating in the Tide Pod Challenge are intentionally ingesting pods. Unintentional exposures occur commonly in pediatric populations or adults with dementia, and these are usually less severe. Incidental ingestions, such as occupational exposures, are rare and severity depends on dose of exposure (according to Tintinalli’s Emergency Medicine).
Manufcturers’ information sheets indicate that the pH of specific pods and their components vary from neutral to alkaline (Tide, All, Purex), meaning that some pods may lead to direct caustic damage and others may not. Additionally, individual reports have noted metabolic acidosis in many patients ingesting laundry detergent pods (LDPs), which may be associated with the propylene glycol content of the pods. Patients’ airways may be compromised due to direct caustic damage or to altered mental status as a result of acidosis. Oral Intubation with direct visualization is suggested for airway management in LDP ingestion. Blind nasotracheal intubation can exacerbate airway injuries, and is not suggested, as are supraglottic devices and bougies, which can increase tissue damage or cause perforation (according to Tintinalli’s Emergency Medicine).
Close monitoring is suggested in severe cases, due to systemic toxicity concerns, fluid depletion (due to diarrhea/vomiting), and altered mental status. Standard critical care principles should be applied to optimize hemodynamics, and antidotes provided for toxic alcohol exposure when warranted by laboratory findings (Tintinalli’s Emergency Medicine, Case Studies in Medical Toxicology).
After initial emergency management, it is important to determine the severity of esophageal damage (either caustic or corrosive). Medical text and case series suggest that endoscopy be used to evaluate the location and severity of caustic or corrosive GI injury after ingestion to offer insight into appropriate disposition; a rule of thumb is that intentional ingestions should undergo endoscopy, while unintentional ingestions should receive endoscopy only when signs or symptoms of significant injury are present (Tintinalli’s Emergency Medicine). If endoscopy is indicated, proceeding early after ingestion (<12 hours, not >24 hours) to avoid iatrogenic perforation is suggested (Tintinalli’s Emergency Medicine). Patients with signs of esophageal perforation should not undergo endoscopy; instead surgical consultation is suggested.
LDPs have been labelled a hazardous substance since 2012. Some action has been taken to make these products safer, such as Tide’s past efforts to make containers less accessible to children. However, continued harm from these laundry detergent pods from all brands indicate that further action is required. In addition to effective public awareness, manufacturers and regulators must take further action to address the appearance and accessibility of LDPs, and must act with urgency.
Editors’ note: *This blog was revised following comments made by readers after its initial publication*
I came across this post again while forwarding some information to one of my ER colleagues who was seeing an infant with a Tide Pod ingestion. Thank you for the clarifying edits to the post, which make it much clearer and more accurate. I agree that the manufacturer’s MSDS (Material Safety Data Sheet) is always the best source of truth so long as the brand/type of pod ingested is known. Your local poison control centre is often the quickest source for this information and related advice as they have become quite experienced with these calls. On that note, I see that the link provided for the Tide MSDS in the current post is actually for liquid Tide detergent. The link I provided above (https://www.pg.com/productsafety/msds/2014/Tide%20Pods%20MSDS%20July%202014.pdf) is the one for Tide Pods, and should be included in the post as the pH is quite different in these two formulations (the liquid detergent is mildly alkaline, but Tide Pods are neutral pH). Thanks again for spreading the important message about this issue!
* This comment was made on the original version of this blog posted 20 Feb 2018*
Please correct the misleading information in this post. While the viral Tide Pod videos are of course a risk to individuals and a reason for increased ED visits and calls to poison control, this article is WRONG in conflating the ingestion of laundry detergent pods with caustic ingestions. See https://www.pg.com/productsafety/msds/2014/Tide%20Pods%20MSDS%20July%202014.pdf – these products are NEUTRAL in pH and therefore are NOT caustic. They are not a cause of liquefaction necrosis and other forms of severe GI injury. The mechanism of injury is felt to be secondary to the powerful surfactants which cause mucosal irritation, rather than severe injury. The majority of severe consequences are respiratory.