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Detergents, familiar and indispensable products in the home, are synthetic surface-active agents that are chemically classified as anionic, nonionic, or cationic (Table II–22). Most of these products also contain bleaching (chlorine-releasing), bacteriostatic (having a low concentration of a quaternary ammonium compound), or enzymatic agents. Accidental ingestion of detergents by children is very common, but severe toxicity rarely occurs.

Table II-22 Cationic Detergents

  1. Mechanism of toxicity. Detergents may precipitate and denature protein, are irritating to tissues, and have keratolytic and corrosive actions.

    1. Anionic and nonionic detergents are only mildly irritating, but cationic detergents are more hazardous because quaternary ammonium compounds may be caustic (benzalkonium chloride solutions of 10% have been reported to cause corrosive burns).

    2. Low-phosphate detergents and electric dishwasher soaps often contain alkaline corrosive agents such as sodium metasilicate, sodium carbonate, and sodium tripolyphosphate.

    3. The enzyme-containing detergents may cause skin irritation and have sensitizing properties; they may release bradykinin and histamine, causing bronchospasm.

  2. Toxic dose. Mortality and serious morbidity are rare, but the nature of the toxic effect varies with the ingredients and concentration of the specific product. Cationic and dishwasher detergents are more dangerous than anionic and nonionic products. For benzalkonium chloride solutions, ingestion of 100–400 mg/kg has been fatal.

  3. Clinical presentation. Immediate spontaneous vomiting often occurs after oral ingestion. Large ingestions may produce intractable vomiting, diarrhea, and hematemesis. Corrosive injury to the lips mouth, pharynx, and upper GI tract can occur. Exposure to the eye may cause mild to serious corrosive injury, depending on the specific product. Dermal contact generally causes a mild erythema or rash.

    1. Phosphate-containing products may produce hypocalcemia, hypomagnesemia, tetany, and respiratory failure.

    2. Methemoglobinemia was reported in a 45-year-old woman after copious irrigation of a hydatid cyst with a 0.1% solution of cetrimide, a cationic detergent.

  4. Diagnosis is based on a history of exposure and prompt onset of vomiting. A sudsy or foaming mouth may also suggest exposure.

    1. Specific levels. There are no specific blood or urine levels.

    2. Other useful laboratory studies include electrolytes, glucose, calcium, magnesium and phosphate (after ingestion of phosphate-containing products), and methemoglobin (cationic detergents).

  5. Treatment

    1. Emergency and supportive measures

      1. In patients with protracted vomiting or diarrhea, administer IV fluids to correct dehydration and electrolyte imbalance (See Hypotension).

      2. If corrosive injury is suspected, consult a gastroenterologist for possible endoscopy. Ingestion of products containing greater than 5–10% cationic detergents is more likely to cause corrosive injury.

    2. Specific drugs and antidotes. If symptomatic hypocalcemia occurs after ingestion of a phosphate-containing product, administer IV calcium (See Calcium). If methemoglobinemia occurs, administer methylene blue (See Methylene Blue).

    3. Decontamination (See Decontamination)

      1. Ingestion. Dilute orally with small amounts of water or milk. A significant ingestion is unlikely if spontaneous vomiting has not already occurred.

        1. Do not...

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