Ingestion of food grade hydrogen peroxide with resultant gastrointestinal and neurologic symptoms treated with hyperbaric oxygen therapy: case report and review with emphasis on the therapeutic value of HBO2 in vascular gas embolism.

A 52-year-old male accidentally ingested approximately 100 mL of 35% hydrogen peroxide (H2O2), resulting in the sudden onset of gastrointestinal and neurologic symptoms. Non-contrast abdominal CT revealed extensive portal venous gas and gastric pneumatosis. The patient was treated with hyperbaric oxygen therapy which resulted in complete resolution of symptoms. The case highlights the therapeutic value of hyperbaric oxygen therapy in the treatment of vascular gas embolism and mitigation of concentrated H2O2 ingestion toxicity.

Application of a new hyperbaric oxygen therapy protocol in patients with arterial and venous gas embolism due to hydrogen peroxide poisoning.

Hydrogen peroxide (H2O2) ingestion can cause vascular gas embolism (GE). Hyperbaric oxygen therapy (HBO2) is known to improve neurological abnormalities in patients with arterial gas embolism (AGE). Previously, HBO2 based on the U.S. Navy Table 6 diving protocol has been adopted for treating AGE and preventing the progression of portal venous GE, caused by H2O2 ingestion, to AGE. However, the indication and protocol for HBO2 have not been established for GE related to H2O2 ingestion. Herein, we describe a case in which GE caused by H2O2 ingestion was treated using HBO2 with a short protocol. A 69-year-old female patient presented with abdominal pain, vomiting, and transient loss of consciousness after ingesting 35% H2O2. Computed tomography revealed gastric wall and portal venous gas. She was administered an HBO2 protocol with 2.8-atmosphere absolute (ATA) compression for 45 minutes. This was followed by a 2.0-ATA treatment for 60 minutes with a five-minute air break, after which all gas bubbles disappeared. After HBO2 treatment, brain magnetic resonance imaging revealed focal cytotoxic edema lesions; however, the patient was discharged without additional symptoms.

Portal Venous Gas Following Ingestion of Hydrogen Peroxide Successfully Treated with Hyperbaric Oxygen Therapy.

The primary toxicity of hydrogen peroxide results from its interaction with catalase, which liberates water and oxygen. We report the case of a 14-year-old Japanese girl with portal venous gas that was caused by oxygen liberated from intentionally ingested hydrogen peroxide. Although she had a past history of atrial septal defect, recovery without cardiac or neurological sequelae was achieved using hyperbaric oxygen therapy. Emergency physicians must be aware of the danger of liberated oxygen due to hydrogen peroxide ingestion.

Accidental Concentrated Hydrogen Peroxide Ingestion Associated with Portal Venous Gas.

A case of a 52-year old male patient who presented to the emergency department with severe nausea and vomiting following accidental ingestion of H2O2. A computed tomography (CT) abdomen performed at our institution demonstrated extensive portal venous gas throughout the liver with few gas droplets seen in the extrahepatic portal vein portion. Pneumatosis was also noted in the wall of the gastric antrum. Upper GI Endoscopy was done revealing diffuse hemorrhagic gastritis and mild duodenal bulb erosion. The patient was treated with hyperbaric oxygen. On the second day of admission, the patient was able to eat without difficulty or pain. Accidental ingestion of high concentration H2O2 solution has been shown to cause extensive injury to surrounding tissues. The injury occurs via three main mechanisms: corrosive damage, oxygen gas formation, and lipid peroxidation. We report a case of accidental ingestion of a highly concentrated (35%) solution of H2O2 causing portal venous gas.

Outcomes After High-Concentration Peroxide Ingestions.

STUDY OBJECTIVE: In cases of high-concentration peroxide ingestion reported to US poison centers, we describe medical outcomes, examine the role of hyperbaric oxygen, and review the use of endoscopy. METHODS: The study was a retrospective analysis of a structured database, the National Poison Data System. The chart for each poison center case of a high-concentration (>10%) peroxide ingestion was obtained and abstracted in a standardized fashion; 1,054 cases were initially considered and 294 cases met inclusion criteria. The primary outcome of possible embolic event was defined as seizure, altered mental status, respiratory distress, hypoxia, hemodynamic instability, ECG changes, radiographic evidence of cerebrovascular accident, focal neurologic deficit on examination, pulmonary embolism, cardiac emboli, elevated troponin level, physician bedside diagnosis, or rapid improvement after hyperbaric oxygen therapy. Both descriptive statistics and logistic regression models were used to analyze the data. RESULTS: In the 10-year study period, 41 of 294 patients (13.9%; 95% confidence interval 10.2% to 18.4%) with symptoms after high-concentration peroxide ingestion demonstrated evidence of embolic events, and 20 of 294 (6.8%; 95% confidence interval 4.2% to 10.3%) either died or exhibited continued disability when the poison center chart was closed. Improved outcomes were demonstrated after early hyperbaric oxygen therapy. Endoscopy revealed grade 3 or 4 lesions in only 5 cases. CONCLUSION: Symptomatic high-concentration peroxide exposures had a high incidence of associated embolic events in this cohort. Patients with evidence of embolic events had a high rate of death. Early hyperbaric oxygen therapy may be useful, but routine endoscopy is unlikely to be of benefit.

Hyperbaric oxygen therapy for the prevention of arterial gas embolism in food grade hydrogen peroxide ingestion.

Food grade hydrogen peroxide ingestion is a relatively rare presentation to the emergency department. There are no defined guidelines at this time regarding the treatment of such exposures, and providers may not be familiar with the potential complications associated with high concentration hydrogen peroxide ingestions. In this case series, we describe four patients who consumed 35% hydrogen peroxide, presented to the emergency department, and were treated with hyperbaric oxygen therapy. Two of the four patients were critically ill requiring intubation. All four patients had evidence on CT or ultrasound of venous gas emboli and intubated patients were treated as if they had an arterial gas embolism since an exam could not be followed. After hyperbaric oxygen therapy each patient was discharged from the hospital neurologically intact with no other associated organ injuries related to vascular gas emboli. Hyperbaric oxygen therapy is an effective treatment for patients with vascular gas emboli after high concentration hydrogen peroxide ingestion. It is the treatment of choice for any impending, suspected, or diagnosed arterial gas embolism. Further research is needed to determine which patients with portal venous gas emboli should be treated with hyperbaric oxygen therapy.

Hyperbaric oxygen therapy for systemic gas embolism after hydrogen peroxide ingestion.

BACKGROUND: Hydrogen peroxide is a commonly available product and its ingestion has been demonstrated to produce in vivo gas bubbles, which can embolize to devastating effect. OBJECTIVE: We report two cases of hydrogen peroxide ingestion with resultant gas embolization, one to the portal system and one cerebral embolus, which were successfully treated with hyperbaric oxygen therapy (HBO), and review the literature. CASE REPORT: Two individuals presented to our center after unintentional ingestion of concentrated hydrogen peroxide solutions. Symptoms were consistent with portal gas emboli (Patient A) and cerebral gas emboli (Patient B), which were demonstrated on imaging. They were successfully treated with HBO and recovered without event. CONCLUSIONS: As demonstrated by both our experience as well as the current literature, HBO has been used to successfully treat gas emboli associated with hydrogen peroxide ingestion. We recommend consideration of HBO in any cases of significant hydrogen peroxide ingestion with a clinical picture compatible with gas emboli.

Portal venous gas emboli after accidental ingestion of concentrated hydrogen peroxide.

BACKGROUND: Hydrogen peroxide is a common household product. It is clear and odorless making it easy to confuse with water, especially when improperly stored. Concentrated formulations are also available for consumer purchase. OBJECTIVE: We report a case of hydrogen peroxide ingestion in a child and discuss the potential consequences and treatment of such an exposure. CASE REPORT: A 12-year-old boy accidentally ingested a sip of concentrated hydrogen peroxide. He rapidly developed hematemesis and presented to the Emergency Department. His initial work-up was unremarkable, and his symptoms resolved quickly. However, diffuse gas emboli were found within the portal system on abdominal computed tomography. The child was treated with hyperbaric oxygen therapy and later found to have gastric irritation as well as an ulcer on endoscopy. He recovered fully from the incident. CONCLUSIONS: We present this case to increase awareness of the dangers of hydrogen peroxide ingestion in children. Fortunately, the child in this case recovered fully, but emergency physicians should be aware of the potential consequences and therapeutic options.

Treatment of portal venous gas embolism with hyperbaric oxygen after accidental ingestion of hydrogen peroxide: a case report and review of the literature.

BACKGROUND: It is well known that hydrogen peroxide ingestion can cause gas embolism. OBJECTIVE: To report a case illustrating that the definitive, most effective treatment for gas embolism is hyperbaric oxygen therapy. CASE REPORT: We present a case of a woman who presented to the Emergency Department with acute abdominal pain after an accidental ingestion of concentrated hydrogen peroxide. Complete recovery from her symptoms occurred quickly with hyperbaric oxygen therapy. CONCLUSION: This is a case report of the successful use of hyperbaric oxygen therapy to treat portal venous gas embolism caused by hydrogen peroxide ingestion. Hyperbaric oxygen therapy can be considered for the treatment of symptomatic hydrogen peroxide ingestion.

Hydrogen peroxide ingestion associated with portal venous gas and treatment with hyperbaric oxygen: a case series and review of the literature.

INTRODUCTION: Ingestion of concentrated hydrogen peroxide (H(2)O(2)) has been associated with venous and arterial gas embolic events, hemorrhagic gastritis, gastrointestinal bleeding, shock, and death. Although H(2)O(2) is generally considered a benign ingestion in low concentrations, case reports have described serious toxicity following high concentration exposures. Hyperbaric oxygen (HBO) has been used with success in managing patients suffering from gas embolism with and without manifestations of ischemia. METHODS: Poison center records were searched from July 1999 to January 2010 for patients with H(2)O(2) exposure and HBO treatment. Cases were reviewed for the concentration of H(2)O(2), symptoms, CT scan findings of portal gas embolism, HBO treatment, and outcome. RESULTS; Eleven cases of portal gas embolism were found. Ages ranged from 4 to 89 years. All but one ingestion was accidental in nature. In 10 cases 35% H(2)O(2) was ingested and in 1 case 12% H(2)O(2) was ingested. All abdominal CT scans demonstrated portal venous gas embolism in all cases. Hyperbaric treatment was successful in completely resolving all portal venous gas bubbles in nine patients (80%) and nearly resolving them in two others. Ten patients were able to be discharged home within 1 day, and one patient had a 3.5-day length of stay. CONCLUSIONS: HBO was successful in resolving portal venous gas embolism from accidental concentrated H(2)O(2) ingestions.

Cerebral air gas embolism from concentrated hydrogen peroxide ingestion.

INTRODUCTION: Ingestion of a small amount of concentrated hydrogen peroxide can cause cerebral air gas embolism (CAGE). Hyperbaric oxygen therapy (HBOT) is the standard of care in the treatment of CAGE. We report a case of CAGE after accidental ingestion of 33%hydrogen peroxide treated with HBOT resulting in reversal of both the clinical and radiologic abnormalities. CASE REPORT: A 48 year-old male took two sips of 33% hydrogen peroxide. A short time later, he developed hematemesis, left sided hemiplegia, confusion, and left homonymous hemianopsia. Initial laboratory studies, chest x-ray, and brain CT were normal. MRI demonstrated areas of restricted diffusion and T2 hyper intensities in multiple vascular territories consistent with ischemia due to CAGE. Eighteen hours after arrival, the patient underwent HBOT at 3 atmospheres absolute (ATA) for 30 minutes and 2.5 ATA for 60 minutes with clinical improvement. Follow-up MRI at six months demonstrated resolution of the hyper intensities. DISCUSSION: A search of MEDLINE from 1950 to present revealed only two cases of CAGE from ingestion of concentrated hydrogen peroxide treated with HBOT. Both cases, similar to ours, had complete resolution of symptoms. Of the seven reported cases of CAGE from hydrogen peroxide that did not undergo HBOT, only in one patient was there a report of symptom resolution. CONCLUSION: Ingestion of even a small amount of concentrated hydrogen peroxide can result in cerebral air gas embolism. Hyperbaric oxygen therapy may be of benefit in reversing the symptoms and preventing permanent neurological impairment.

[Acute intoxication with hydrogen peroxide with air emboli in central nervous system--a case report]. / Ostre zatrucie nadtlenkiem wodoru powiklane zatorami powietrznymi osrodkowego ukladu nerwowego--opis przypadku.

UNLABELLED: 54-year-old woman with brain gas emboli after an accidental ingestion of concentrated hydrogen peroxide was described. Hydrogen peroxide (H2O2) is a water-soluble, caustic liquid. Exposure to concentrated (> 30-35%) hydrogen peroxide may cause cardiorespiratory insufficiency, shock, convulsions, coma, and chemical burns of skin and mucous membranes. Arterial gas embolization in central nervous system is a relatively rare complication. There are three possible mechanisms of gas embolization: persisting patent foramen ovale, pulmonary gas emboli caused by aspiration of hydrogen peroxide to the lower respiratory tract, formation of gas emboli after reaching the brain. Absence of gas emboli and cerebral infarction in CT does not exclude intoxication. Hyperbaric therapy is most effective for brain air embolism complicating hydrogen peroxide poisoning in acute phase. Some authors suggested that this therapy is also effective if administered during the subacute phase. CONCLUSIONS: Neurologic symptoms after ingestion of hydrogen peroxide may suggest gas embolism of the cerebral vasculature. The absence of atrial septal defect does not exclude the possibility of cerebral air embolism. The absence of gas and cerebral infarction in CT scans does not exclude brain gas embolism. The use of hyperbaric therapy should be considered in treating severe cases of hydrogen peroxide poisoning.

Resolution of delayed altered mental status associated with hydrogen peroxide ingestion following hyperbaric oxygen therapy.

CASE REPORT: An 82-year-old women presented with altered mental status, seizure, and apnea after an accidental ingestion of concentrated hydrogen peroxide. Ingestion of concentrated peroxide can result in gas embolism of the cerebral vasculature. After hyperbaric treatment, the patient had prompt and full neurologic recovery. To the best of the authors' knowledge, this is the first reported case of reversal of significant altered mental status associated with hydrogen peroxide ingestion in temporal relation with hyperbaric oxygen therapy. Emergency physicians need to be aware of the dangers of peroxide ingestion and may wish to consider hyperbaric oxygen as a potential additional treatment for severe cases.