Fluoride ingestion in children: a review of 87 cases.

All cases of fluoride ingestion in children younger than 12 years old reported to the Rocky Mountain Poison Center between January 1 and December 31, 1986, were retrospectively reviewed. Eighty-seven cases were identified. Eighty-four cases involved accidental ingestion of dental fluoride products in the home (tablets, drops, rinses) in children 8 months to 6 years old. Two older children (8 and 9 years old) became symptomatic after fluoride treatment by a dentist. A 13-month-old child died after ingesting an unknown amount of sodium fluoride insecticide, the only insecticide exposure in our series. Postmortem total serum calcium value was 4.8 mg/dL (normal 8.8 to 10.3). No other patients had serious symptoms or sequelae. Twenty-six (30%) of 87 became symptomatic, with gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain) in 25 patients and drowsiness in 1. Only 3 patients became symptomatic later than 1 hour after ingestion. Analysis of data from 70 cases with sufficient information revealed that as the amount of fluoride ingested increased, the percentage of patients with symptoms increased. Not including the fatal case, 6 patients had serum calcium levels measured, and all were normal. Children who ingested up to 8.4 mg/kg of elemental fluoride in dental products had mild and self-limited symptoms, mostly gastrointestinal.

Acute acetaminophen overdose during pregnancy.

During a nationwide acetaminophen overdose study conducted at the Rocky Mountain Poison and Drug Center from 1976-1985, 113 patients entered into the study were reported to be pregnant at the time of the overdose. Follow-up, including appropriate laboratory and pregnancy outcome data, was available in 60 cases. Of these, 19 women overdosed during the first trimester, 22 during the second trimester, and 19 during the third trimester of pregnancy. Of the 24 patients with acetaminophen levels above the acetaminophen overdose nomogram line, ten were treated with N-acetylcysteine within 10 hours post-ingestion; eight delivered normal infants and two had elective abortions. Of ten patients treated with N-acetylcysteine 10-16 hours post-ingestion, five delivered viable infants, two had elective abortions, and three had spontaneous abortions. Of four women treated with N-acetylcysteine 16-24 hours post-ingestion, one mother died, and there was one spontaneous abortion, one stillbirth, one elective abortion, and one delivery. Multiple logistic regression demonstrated a statistically significant correlation between the time to loading dose of N-acetylcysteine and pregnancy outcome, with an increase in the incidence of spontaneous abortion or fetal death when treatment was begun late. We recommend that pregnant women who take an acetaminophen overdose and have a potentially toxic serum level be treated with N-acetylcysteine as early as possible.

Hydrofluoric acid dermal exposure.

A retrospective review of 237 consecutive cases of dermal exposure to dilute (6-11%) hydrofluoric acid (HF)- containing rust stain remover consumer products reported to the Rocky Mountain Poison and Drug Center during 1986 was done to evaluate the toxicity of these agents and the efficacy of topical treatment with calcium gluconate gel. In 148 cases (62%), failure to follow manufacturers' recommended safety procedures was the likely cause of exposure. 219 patients developed the following symptoms: dermal swelling, redness, or both (131, 55%); blistering (12, 5%); black discoloration under fingernails (12, 5%); or pain without reported dermal changes (64, 27%). Local complications were noted in 7 cases (3%) (infection, 4 cases; fingertip dermal necrosis, 3 cases). No systemic toxicity was noted. 116 patients (49%) received treatment with topical calcium gluconate gel; 53 were followed until complete resolution of symptoms. There appeared to be a relationship between earlier initial gel application and more rapid resolution of signs and symptoms. Some degree of dermal injury may be quite common following exposure to dilute (6-11%) HF-containing rust stain remover consumer products. Failure to follow manufacturers' recommended safety procedures may be responsible for many exposures. Treatment with topical calcium gluconate gel may be effective, and more rapid resolution of signs and symptoms may occur with earlier initiation of this therapy.

Allergic reaction to sulfiting agents.

Sodium metabisulfite (MBS) is a commonly used food and drug preservative. We report the case of a 32-year-old man with a documented history of allergy to MBS who developed an anaphylactic reaction after ingestion of MBS-treated foods. The patient had a prolonged clinical course requiring two emergency department visits and three weeks of outpatient steroid therapy. It is believed that this patient's relapse and delayed recovery may have been related to his continued exposure to sulfites during treatment. The emergency physician should be aware that some medications commonly used to treat allergic reactions and asthma contain MBS.