Article, Emergency Medicine

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

a b s t r a c t

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 depart- ment, and were treated with Hyperbaric oxygen therapy. Two of the four patients were critically ill requiring in- tubation. 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 ther- apy 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 por- tal venous gas emboli should be treated with hyperbaric oxygen therapy.

(C) 2016

  1. Introduction

Hydrogen peroxide (H2O2) is an easily accessible, clear, odorless liq- uid. It is used for a variety of household and industrial purposes. In low concentrations of 3%-9%, it has been used as an antiseptic or hair bleaching agent. In high concentrations, often termed “food grade” of 35% or higher, it has been used as an industrial-strength cleaning agent [1]. Additionally, some groups have advocated the consumption of highly concentrated H2O2 with claims of anticipated Health benefits including the treatment of cancer, the reduction of bacterial burden, and others [2,3]. Contrary to these purported benefits, prior literature and case reports have demonstrated adverse effects from the ingestion of hydrogen peroxide related to its oxidizing and tissue-damaging ef- fects (lipid peroxidation) and the vascular gas emboli liberated after in- gestion [4,5]. Patients ingesting food grade hydrogen peroxide have been shown to develop varying degrees and severity of esophagitis, gas- tritis, gastric ulcers, perforated visci, pneumatosis, pneumobilia, venous portal gas and arterial gas emboli (AGE) [1,6]. The latter is associated with higher morbidity and mortality from multiple Potential causes

? Support: We received no funding or grants for this project. This work has not been previously presented.

* Corresponding author.

E-mail address: [email protected] (S.M. Hendriksen).

such as acute stroke, coronary artery occlusion, and ischemia in the vas- cular beds of other vital organs [7]. (See Figs. 1-6.)

Hydrogen peroxide (H2O2) is converted by the mucosal surface and RBC enzyme catalase to water and oxygen. It has been estimated that 1 mL of 35% H2O2 could liberate more than 100 mL of gaseous oxygen; thus even a tablespoon of food grade H2O2 would rapidly liberate 1500 mL of gaseous oxygen into the gastric mucosa if swallowed [7]. Rapid liberation of oxygen may result in gastric distention, emesis, and potentially perforation of viscera. Gastrointestinal absorption into the mesenteric and portal Venous system prior to its decomposition in the stomach or intestine may result in the liberation of oxygen and ve- nous gas emboli [6]. The presence of venous gas increases the risk for AGE via a right to left Intracardiac shunt such as a patent foramen ovale (PFO). The overall incidence of PFO at autopsy has been found to be 27.3% in the general population [8]. Additionally, excessive venous gas could overwhelm the pulmonary vascular filter, transposing gas em- boli to the arterial circulation with devastating consequences for pa- tients. Indeed, AGE from H2O2 has been reported in multiple cases to cause acute cerebral stroke [7,9,10]. With such rapid liberation of oxy- gen, even an accidental ingestion of a single mouthful of food grade H2O2 represents a significant danger.

We present a case series of four patients who accidentally ingested concentrated H2O2 resulting in venous gas emboli, who were success- fully treated with Hyperbaric oxygen therapy. (See Table 1.)

http://dx.doi.org/10.1016/j.ajem.2016.12.027

0735-6757/(C) 2016

809.e6 S.M. Hendriksen et al. / American Journal of Emergency Medicine 35 (2017) 809.e5809.e8

  1. Case series
    1. Case 1

Fig. 1. right upper quadrant bedside ultrasonography.

Fig. 3. Ultrasound image of the hepatic system after hyperbaric Oxygen treatment of the patient in Case 1.

A bedside ultrasound still image obtained of Case 1 at presentation (see Fig. 1), demonstrated extensive portal venous gas and pneumobilia. The bright line separating the heterogeneous hyperechoic gas filled liver on the top of the image from the relative hypoechoic non gas filled kid- ney inferiorly is Morrison’s pouch, a potential space where fluid and

A 33 year-old female restaurant employee accidentally drank an esti- mated 250 mL of 35% H2O2 mistaking it for water. Shortly after the inges- tion, she developed nausea, abdominal pain, and hematemesis. On arrival to the emergency department (ED), she was intubated for airway protec- tion. Her blood pressure was 126/91 mm Hg; her heart rate was 97 beats/ min. No obvious oropharynx or laryngeal caustic injury was noted during the intubation. An abdominal bedside ultrasound exam visualized dy- namic movement of gas bubbles in the portal venous system. A non-con- trast CT scan of the head was normal. A CT scan of the chest, abdomen and pelvis demonstrated portal venous gas, pneumatosis of the stomach and esophagus, and gas in the right ventricle and pulmonary artery. Her neu- rologic exam was without deficit prior to rapid sequence induction and intubation. HBO therapy was provided with 100% oxygen at 2.8 ATA for 40 min, followed by a staged decompression given the possibility of a PFO and inability to follow neurologic exams after intubation. The follow- ing day an EGD was performed that demonstrated Grade Ia esophagitis and IIa gastritis. Extubation occurred one day after HBO therapy, and the patient’s neurologic exam was normal at that time. A repeat abdom- inal ultrasound and a CT imaging performed after HBO therapy, demon- strated complete resolution of gas. The patient was discharged without significant sequela on hospital day 3.

Fig. 2. CT coronal image of pneumobilia in patient number I.

blood can collect in trauma. Note the pneumobilia in the hepatic system causing deflection and refraction of ultrasound waves and creating the heterogenic liver seen in this image.

A CT of the chest abdomen and pelvis with contrast was performed at presentation (see Fig. 2) which also demonstrated pneumobilia seen on the ultrasound of the patient. A post HBO therapy formal (non ED bedside) ultrasound image of the hepatic system (see Fig. 3) demonstrated resolution of the pneumobilia. Note the relative homoge- nous nature of the liver compared to Fig. 1 with pneumobilia.

    1. Case 2

A 75 year-old old woman accidentally consumed approximately 3 mouthfuls of 35% H2O2, mistaking it for a colonoscopy preparation. Her husband obtained the product for use in homeopathy. Immediately after the ingestion, she vomited and then collapsed with loss of con- sciousness. She was intubated at the scene and was stabilized at a tertia- ry facility. A CT demonstrated portal venous and mediastinal gas (see Fig. 4). Head imaging was unremarkable, and the patient was trans- ferred for HBO therapy. Upon arrival, the patient’s blood pressure was 109/55 mm Hg, and her heart rate was 88 bpm. Sedation was continued, and the patient underwent emergent HBO therapy at 2.8 ATA for 60 min

Fig. 4. CT coronal image of pneumobilia in patient in Case 2.

S.M. Hendriksen et al. / American Journal of Emergency Medicine 35 (2017) 809.e5809.e8 809.e7

Fig. 5. CT coronal image of pneumobilia in patient in Case 3.

(US Navy Treatment Table 6). While weaning the patient from sedation on hospital day 2, there was concern for the presence of left-sided weak- ness. Neurology was consulted and recommended continuing hyper- baric oxygen treatment and obtaining an MRI. With clearance from sedation, the patient’s neurologic exam continued to improve. However, given the concern that her Transient weakness was still the result of an AGE, during which gas is frequently not visible on imaging, the patient underwent additional HBO therapy (US Navy Treatment Table 9). Fur- ther neurologic exams were unremarkable. An MRI was obtained that did not reveal a stroke. No additional imaging was completed to demon- strate resolution of the portal venous or mediastinal gas. The patient was discharged on hospital day 8 with a normal neurologic exam.

    1. Case 3

A 36 year-old male drank 35% hydrogen peroxide having mistaken it for water in his home. He had it for cleaning purposes at his business. He reported ingesting one-half of a mouthful and then after realizing it was hydrogen peroxide immediately tried to induce vomiting. On arrival at the tertiary hospital his BP was 131/91 and heart rate was 55 bpm. A CT scan at a tertiary facility demonstrated portal venous gas and pneumatosis (see Fig. 5). The patient was transferred for HBO therapy. On arrival, his neurologic exam was normal, and his vitals were stable. Mild epigastric tenderness was present; tympanic drum-like sounds

Fig. 6. CT coronal image of pneumobilia in patient in Case 4.

were ellicited on percussion. HBO treatment was provided with 100% O2 at 2.8 ATA for 60 min (US Navy Treatment Table 6). Physical and neurologic exams were normal on hospital day 2, and the patient was discharged with no additional imaging and in good condition.

    1. Case 4

A 98 year-old man accidentally consumed several mouthfuls of 35% H2O2, mistaking it for water. He immediately experienced abdominal pain, nausea and emesis. A CT scan demonstrated portal venous gas (see Fig. 6). After consulting with poison control, a transfer was initiated for HBO treatment. His blood pressure at that time was 146/83 mm Hg, pulse was 63 beats/min. Initial neurologic exam was unremarkable. He was treated following a US Navy Table 6 dive protocol. He had no further neurologic sequela, so no further HBO treatments were administered. The patient’s abdominal pain resolved, and he was able to then tolerate oral intake. No additional imaging was obtained to demonstrate resolu- tion of the portal venous gas. The patient was discharged neurologically intact on hospital day 3 without any lasting injury or sequelae.

  1. Discussion

Concentrated H2O2 ingestion is a relatively uncommon event. Though some in the lay public and specific naturopathic organizations endorse consumption of hydrogen peroxide for health benefits, there is now a growing body of literature, case reports, and expert opinion dating back to the 1990?s that would indicate that the consumption of H2O2 can be detrimental [1,4,5,7,9,10,11]. Many harmful exposures are accidental ingestions in which hydrogen peroxide is mistaken for water or some other beverage.

In our case series of 4 patients the presenting symptoms ranged from nausea and vomiting to syncope and collapse with sustained loss of consciousness. All 4 patients had evidence on CT scan of portal venous gas emboli with one patient demonstrating gas in the right ventricle. Two of the four patients were critically ill requiring intubation. Three of four patients required only one Hyperbaric oxygen treatment to re- solve their symptoms. The fourth patient was treated twice due to con- cern for AGE causing cerebral ischemia and stroke with continued focal deficits.

The goal of HBO therapy is to reduce the venous gas burden, prevent

complications of venous emboli, and to actively treat or prophylactically prevent an AGE. HBO therapy works by decreasing bubble size accord- ing to Boyle’s law and by increasing the solubility of O2 in plasma ac- cording to Henry’s law, forcing gas emboli back into solution, where the excess gas can be counter-diffused and ventilated off by the lungs.

Only 1 of the 4 patients had imaging after initial HBO therapy to doc- ument resolution of venous gas emboli. The resolution of portal venous gas after HBO therapy has been previously demonstrated in a larger case series of 11 patients with H2O2 ingestion. Nine of eleven patients had complete resolution of venous gas on CT after one HBO treatment, and the other two had near complete resolution of portal venous gas emboli [11]. It is not clear whether a CT scan after HBO treatment to document the resolution of venous gas is necessarily beneficial to the patient if the patient already demonstrates clinical improvement. Providers could consider Abdominal ultrasound here as a less expensive means to deter- mine quantity of portal gas or pneumobilia, both initially and on follow up, avoiding exposure of the patient to needless additional radiation. Ul- trasound is similar in sensitivity to CT for the detection of portal venous gas [12,13]. In contrast to the previous study in which no patients re- quired intubation, two of our patients were critically ill requiring intu- bation, and one of our patients had gas beyond the venous portal system making AGE a higher concern.

There are currently no guidelines determining which patients with H2O2 ingestion should be treated with HBO, or how many would need to be treated to prevent one AGE. Portal venous gas emboli are known to resolve spontaneously, but how long that process takes and what

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Table 1

Summary of cases.

Patient H2O2 ingestion initial symptoms Pre-HBO Imaging HBO treatments Post HBO imaging

33 F Accidental

250 mL of 35%

75 F Accidental

3 mouthfuls of 35%

36 M Accidental

1/2 mouthful of 35%

98 M Accidental

Several mouthfuls of 35%

Nausea Abdominal pain hematemesis

Emesis LOC

Emesis Abdominal pain

Nausea Emesis

Abdominal US:

  • Portal Venous Gas CT CAP:
  • Esophageal pneumatosis
  • Gastric pneumatosis
  • Right ventricular gas
  • Pulmonary artery gas
  • Portal venous gas Head CT:
  • No pathology CT CAP:
  • pneumobilia
  • portal venous gas
  • Pneumomediastinum CT ABD:
  • Portal venous gas
  • Pneumatosis CT ABD:
  • portal venous gas

1 Abd US:

  • No gas CT CAP:
  • No gas

2 MRI brain:

  • No stroke None obtained

1 None obtained

1 None obtained

Loc: Loss of consciousness, CT CAP: Computed Tomography of the Chest Abdomen and Pelvis, CT ABD: Computed Tomography of the abdomen and pelvis.

risk the patient incurs during this time is not known. Given the high morbidity and mortality that can occur with a secondary AGE and the relatively low incidence of serious complications with HBO therapy, it seems reasonable to consider HBO therapy once portal venous gas em- boli are detected [14]. In our practice, we consider treatment after H2O2 ingestion in patients with the following: critical illness, intubation pre- cluding accurate and detailed neurologic examination, gas passing from the portal venous system into the right side of the heart increasing the risk for potential AGE, clinical suspicion and signs of AGE, and signif- icant discomfort due to gastric or portal venous gas. More research is re- quired to determine which patients with ingestion of high concentration H2O2 can be safely observed versus empirically treated with HBO. If the decision is made to observe a patient, transfer to a facil- ity with a Hyperbaric chamber should still be considered in the event that the patient deteriorates or develops AGE necessitating HBO therapy.

  1. Conclusion

Ingestion of food grade hydrogen peroxide may result in portal ve- nous as well as arterial gas emboli. Hyperbaric oxygen therapy is an ef- fective treatment for vascular gas emboli related to hydrogen peroxide ingestion, including AGE. We observed bedside ultrasonography to be an effective tool in the detection and surveillance of resulting portal ve- nous gas. This series adds to the literature showing multiple cases with a diverse range of acuity all with excellent results from HBO therapy. Phy- sicians should consider HBO therapy for symptomatic ingestions of high concentrations of hydrogen peroxide.

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