Toxicology and Poisoning Toxicology and Poisoning Hydrogen Peroxide Hydrogen Peroxide (H(2)O(2)) CAS:7722-84-1; UN 2984(8-20%); 2014 (20-52%); 2015 (>52%) Synonyms of hydrogen peroxide include dihydrogen dioxide, hydrogen dioxide, hydroperoxide, and peroxide. Victims exposed to only hydrogen peroxide gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with concentrated hydrogen peroxide solution can secondarily contaminate personnel by direct contact or through off-gassing vapor. Hydrogen peroxide is a powerful oxidizing agent. When it contacts organic material, spontaneous combustion can occur. Hydrogen peroxide is used commonly in aqueous solutions, which poses an inhalation and contact danger. Description - Pure hydrogen peroxide is a crystalline solid below 12 degrees F and a colorless liquid with a bitter taste above 12 degrees F. It is almost always used as an aqueous solution, which is available in dilute form (3% to 10%) for household use and in concentrated form (>30%) for industrial use. Hydrogen peroxide is unstable, decomposing readily to oxygen and water with release of heat. Commercial products contain a stabilizer (usually acetanilide) to slow the rate of spontaneous decomposition. Hydrogen peroxide is nonflammable, but it is a powerful oxidizing agent that can cause spontaneous combustion of any organic material it contacts. Routes of Exposure -- Inhalation - Inhalation of vapors, mists, or aerosols from concentrated solutions of hydrogen peroxide can cause significant morbidity. Because it is nearly odorless and nonirritating except at high concentrations, persons may not be aware of its presence. Odor is not a reliable indicator of hydrogen peroxide's presence and may not provide adequate warning of dangerous concentrations. Hydrogen peroxide vapors are heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas. Skin/Eye Contact - Hydrogen peroxide is poorly absorbed through intact skin. When used for household disinfectant purposes (3% to 5%), it is mildly irritating to the skin and mucous membranes. At concentrations of 10%, which is found in some hair-bleaching solutions, is strongly irritating. Solutions >20% are potentially corrosive. Ingestion - If ingested, dilutions of hydrogen peroxide up to 9% are generally nontoxic; however, even a 3% solution is mildly irritating to mucosal tissue and may cause vomiting and diarrhea. Ingestion of industrial strength solutions has been associated with fatalities. Sources/Uses - In industry, hydrogen peroxide is used as a bleach for textiles and paper, as a component of rocket fuels, and as a reagent for producing foam rubber and organic chemicals. In the home, dilute hydrogen peroxide solutions are used as disinfectants, deodorants, and as hair bleaching agents. Properties of Hydrogen Peroxide -- Appearance: Colorless liquid at room temperature; used commonly in aqueous solution Warning properties: Odor is inadequate as index of exposure; irritating at high concentrations OSHA PEL (Permissible Exposure Limit) = 1 ppm (averaged over an 8-hour workshift) NIOSH IDLH (Immediately Dangerous to Life or Health) = 75 ppm Molecular weight = 34.0 Boiling point (760 mm Hg) = 286 degrees F (141 degrees C) Freezing point = 12 degrees F (-11.l degrees C) Vapor pressure (86 degrees F) = 5 mm Hg Vapor density = 1.2 (air = 1 ) Very water soluble Nonflammable, but a powerful oxidizer;, may ignite any organic matter it contacts Health Effects Inhaled hydrogen peroxide can cause upper respiratory tract and mucous membrane irritation. Pulmonary edema also can occur. Ingestion of concentrated hydrogen peroxide solutions may cause corrosive burns of the oropharyngeal, esophageal, and gastric linings. Rapid production of oxygen in the stomach can cause gastric distention. Gastric perforation may occur, although this is rare. Acute Exposure -- Respiratory - Depending on concentration, vapors, mists, or aerosols can ca use upper airway irritation, rhinitis, hoarseness, shortness of breath, and burning chest tightness. High-dose exposure can result in severe mucosal congestion of the trachea and bronchi and delayed onset pulmonary edema. Neurologic - Severe high-dose inhalation results in systemic poisoning with prominent CNS effects including headache, dizziness, tremors, numbness, hyperreflexia, loss of consciousness, and seizures. Dermal - Prolonged exposure to concentrated vapor or to dilute solutions can cause irritation and temporary bleaching of skin and hair. Contact with concentrated solutions can cause severe bums with blistering. Ocular - Exposure to concentrated vapor, mist, or aerosol can cause stinging pain and lacrimation. Splash contact with solutions that are 5% or greater can cause corneal injury, sometimes with delayed effects. Gastrointestinal - Ingestion of household solutions usually causes mild mucosal irritation and vomiting. Gastric distention due to liberation of oxygen in the stomach may occur, but hollow viscus rupture is uncommon when dilute solutions are ingested. Ingestion of concentrated solutions, however, can be more devastating. Extreme irritation, inflammation, and burns of the alimentary tract can occur and hollow viscus distention and rupture is a significant danger. Hydrogen peroxide enemas have caused colonic rupture, intestinal gangrene with gas embolization, and fulminant acute ulcerating colitis. Potential Sequelae - Survivors of severe inhalation injury may sustain permanent lung damage. Severe eye exposures may result in corneal ulceration and blindness. Chronic Exposure -- Because hydrogen peroxide is rapidly decomposed by catalase in the body, it is unlikely to cause systemic or chronic toxicity. However, repeated exposures to hydrogen peroxide vapor may cause chronic irritation of the respiratory tract and atelectasis. Repeated contact with vapor or solution may result in bleaching of skin and hair. Hydrogen peroxide is unlikely to cross the placenta to cause a direct risk to the unborn. However, if maternal respiration were severely compromised as a result of-hydrogen peroxide exposure, there could possibly be an indirect effect on the ferns. Prehospital Management Hydrogen peroxide vapor causes upper respiratory and mucous membrane irritation. Swallowing a concentrated solution can cause vomiting and corrosive burns, gastric distention, and even rupture. There is no specific antidote for hydrogen peroxide poisoning. Treatment requires supportive measures. Potential for Secondary Contamination -- Victims exposed to only hydrogen peroxide vapor do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with concentrated hydrogen peroxide solution can secondarily contaminate personnel by direct contact or through off-gassing vapor. Hot Zone -- Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. Rescuer Protection - Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with hydrogen peroxide solution or concentrated vapor is possible. ABCs - Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Victim Removal - If victims can walk, lead them out of the Hot Zone to the Decontamination Zone Ira victim is unable to walk, remove him or her on a backboard or gurney. If there is no means of transport, carefully drag the victim out. Decontamination Zone -- Victims with exposure to only vapors of hydrogen peroxide or to dilute solutions (3% to 5% [household strength]) and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination. Rescuer Protection - Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with concentrated liquid soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice. ABCs - Quickly establish a patent airway. Stabilize the cervical spine with a collar if traumas suspected. Supplemental oxygen can be administered if available. Evaluate the need for an intravenous line, cardiac monitor, and life support. Basic Decontamination - Rapid skin decontamination is critical. Remove and double-bag contaminated clothing. Patients who axe able and cooperative may remove their own clothing and assist with basic decontamination. Flush liquid-exposed skin and hair with plain water for at least 5 minutes. Flush exposed or irritated eyes with plain water or saline for at least 5 minutes. Remove contact lenses if present. In case of hydrogen peroxide ingestion, do not induce emesis. Administer a glass of plain water or milk to dilute stomach contents if the patient is conscious and able to swallow. The effectiveness of activated charcoal to absorb hydrogen peroxide is unknown. Patient Transfer - As soon as basic decontamination is completed, move the patient to the Support Zone. Support Zone -- Be certain that patients have undergone basic decontamination (see Decontamination Zone above). Patients who have undergone proper decontamination or who have been exposed to only vapor pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases. ABCs - Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support. Advanced Treatment - Intubate the trachea if indicated (severe respiratory compromise or apnea). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so. Treat wheezing and bronchospasm with aerosolized bronchodilators. Additional Decontamination - If skin or eyes remain irritated, flush with plain water or saline for 3 to 5 minutes. Remove contact lenses if present. In case of hydrogen peroxide ingestion, do not induce emesis. Administer a glass of water or milk to dilute stomach contents flit was not given in the Decontamination Zone and ff the patient is conscious and able to swallow. The effectiveness of activated charcoal to absorb hydrogen peroxide is unknown. Transport to Medical Facility - Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility. If a patient has ingested hydrogen peroxide, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus. Multi-Casualty Triage -- If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims. Patients with obvious injury, such as severe wheezing or dyspnea or skin or eye bums, should be transported immediately to a medical facility. Patients who have ingested hydrogen peroxide solutions (except minor ingestions of household strength solutions of 3% to 5%) should also be transported for medical evaluation. Persons with no eye, skin, or throat irritation or with mild or transient symptoms are unlikely to develop severe complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with advise to rest and to seek medical care if symptoms of toxicity develop. Emergency Department Management Concentrated hydrogen peroxide vapors can cause upper respiratory and mucous membrane irritation. Swallowing concentrated solution can cause vomiting and corrosive burns, gastric distension and even rupture. There is no specific antidote for hydrogen peroxide poisoning. Treatment requires supportive measures. Potential for Secondary Contamination -- Victims exposed to only hydrogen peroxide vapor do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with concentrated hydrogen peroxide solution can secondarily contaminate personnel by direct contact or through off-gassing vapor. Decontamination Area -- Patients with exposure to only vapors of hydrogen peroxide and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below. ABCs - Evaluate and support airway, breathing, and circulation. Monitor cardiac rhythm. Treat CNS compromise and seizures in the conventional manner. Basic Decontamination - If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapors do not require decontamination unless they have skin or eye irritation. Since contacting clothing or skin wet with concentrated hydrogen peroxide may cause bums, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek*, Saranex*) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel. If the patient's clothing is wet with hydrogen peroxide, quickly remove and double-bag the contaminated clothing and all personal belongings. Flush the exposed skin with copious water (preferably under a shower). Remove contact lenses and irrigate exposed eyes with water for at least 15 to 30 minutes. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids. Critical Care Area -- Be certain that appropriate decontamination has been carried out. See Basic Decontamination. ABCs - Evaluate and support airway, breathing, and circulation. Continuously monitor cardiac rhythm. Treat hypotension and seizures in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, and drug intoxication). Inhalation Exposure - Administer supplemental oxygen by mask to patients with respiratory complaints. Skin Exposure - If concentrated hydrogen peroxide solution was in contact with the skin, chemical bums may result. Treat chemical bums as thermal bums. Eye Exposure - If hydrogen peroxide was splashed in the eyes, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. Small corneal defects may be treated with topical ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury. Ingestion - Do not induce emesis because of the risk of corrosive injury. The effectiveness of activated charcoal and cathartics is unknown. Offer the alert patient 1 to 2 glasses of water or milk to dilute stomach contents if it has not been given previously and if the patient is conscious and able to swallow. Antidotes and Other Treatments - Large ingestions may produce gastritis from hydrogen peroxide decomposition, which releases large volumes of oxygen and causes gastric distention. Gently place a small nasogastric tube to relieve distention or to lavage an obtunded patient. Most ingestions of dilute hydrogen peroxide are benign, and mild irritation is self limited. There is no proven antidote for hydrogen peroxide poisoning. Enhanced elimination methods are neither necessary nor effective. Laboratory Tests - Useful laboratory tests include CBC, electrolytes, and glucose. Chest radiography and ABGs may be helpful in patients suffering from inhalation exposure. Disposition and Follow-up -- Consider hospitalization for symptomatic patients who have a history of significant inhalation exposure and patients who having ingested a concentrated solution. Delayed Effects - Patients with complaints of chest pain, chest tightness, or cough should be observed for 24 to 72 hours and reexamined periodically to detect delayed onset pulmonary edema or respiratory failure. Patient Release - Asymptomatic patients should be observed for 4 to 6 hours and discharged if no symptoms occur during this period. Advise discharged patients to seek medical care promptly if symptoms develop. Follow-up - Patients who require ophthalmic care should have their eyes evaluated within 24 hours. Reporting -- If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department. Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH. See Appendix XX for a list of these and other agencies that may be of assistance. Hydrogen Peroxide Patient Information Sheet This handout provides information and follow-up instructions for persons who may have been exposed to hydrogen peroxide liquid or vapor. What is hydrogen peroxide? Hydrogen peroxide is a strong oxidizing agent used widely in industry to bleach cloth and paper and to manufacture other chemicals. It also is an ingredient of some rocket fuels. Hydrogen peroxide is most often used as a liquid dissolved in water. It is found in dilute form (3% to 10%) in the home and in concentrated form (30% or greater) in industry. In the home, 3% solutions of hydrogen peroxide are used as disinfectants for cuts and scrapes, and slightly more concentrated solutions (10%)' are used in hair bleaches. Dilute solutions have almost no odor but stronger solutions have a sharp odor similar to that of ozone. What immediate health effects may result from hydrogen peroxide exposure? Most serious exposures to hydrogen peroxide are from concentrated solutions (10% or greater) and may occur after breathing the vapors, contacting the skin, or by accidental swallowing. Depending on the concentration, hydrogen peroxide vapor can cause eye and throat irritation, coughing, and breathing difficulty. Direct contact with concentrated vapors or solutions can cause serious eye or skin bums and bleaching of the haft. Since an odor is present only at high concentrations, the presence or absence of odor is not a good measure of exposure. Drinking a concentrated hydrogen peroxide solution can cause vomiting and severe burns of the throat and stomach. What is the treatment for hydrogen peroxide poisoning? There is no proven antidote for hydrogen peroxide poisoning, but its effects can be treated and most persons do recover fully. Persons who have experienced serious symptoms may need close medical observation for up to 72 hours. Are any future health effects likely to occur? After a single, small exposure with quick recovery, delayed or long-term effects are unlikely to occur. After a severe exposure, symptoms may be delayed up to 72 hours. The instructions on the reverse side of this page list some signs and symptoms to watch for--if any of them occur, seek medical care. What tests can be done if a person has been exposed? There are no specific blood and urine tests that can indicate exposure to hydrogen peroxide. However, blood tests and a chest X ray may be used to evaluate lung injury. Generally, the severity of irritation symptoms are the best measure of the seriousness of the exposure. Where can more information about hydrogen peroxide be obtained? More information about hydrogen peroxide may be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor, or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers. Hydrogen Peroxide Follow-up Instructions ( ) Call your doctor or the Emergency Department if you develop any of the following symptoms within the next 24 hours: * cough * difficulty breathing or shortness of breath * chest pain * increased pain or discharge from your eyes * increased redness, pain, or pus-like discharge in the area of a skin burn * fever * unexplained drowsiness, fatigue, headache * belly pain, vomiting, diarrhea ( ) No follow-up appointment is necessary unless you develop any of the symptoms described above. ( ) Call for an appointment with Dr. _________ in the practice of_________. When you call for your appointment, please tell the receptionist/nurse that you were treated in the Emergency Department at__________________ Hospital by __________ and were advised to be seen again in __ days. ( ) Return to the Emergency Department/__________Clinic on (date)__________ at____ AM/PM for a follow-up examination. ( ) Do not perform vigorous physical activities for __ days. ( ) You may resume everyday activities including driving and operating machinery. ( ) Do not return to work for __ days. ( ) You may return to work on a limited basis. See instructions below. ( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen injury to your lungs. ( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since these substances may aggravate injury to your stomach lining or may have other effects. ( ) You may continue taking the following medication(s) that your doctor(s) prescribed for you:____________________________________________________ _______________________________________________________________________ ( ) Other instructions:____________________________________________________ _______________________________________________________________________ Signature of patient _______________________ Date _________________________ Signature of physician _____________________ Date _________________________ Above courtesy of C.D.C.