What is the management for a 3-year-old boy who accidentally ingested 5 ml of hydrogen peroxide and presented with hematemesis (vomiting blood-stained vomitus)?

Management of Hydrogen Peroxide Ingestion in a 3-Year-Old Child

The immediate management for this 3-year-old boy with hydrogen peroxide ingestion and hematemesis should include contacting poison control, monitoring for respiratory distress, and prompt medical evaluation for potential gastrointestinal injury. 1

Initial Assessment and Stabilization

• Vital sign monitoring: Check heart rate, blood pressure, respiratory rate, and oxygen saturation
• Airway assessment: Ensure airway is patent; watch for signs of stridor, respiratory distress, or oral burns
• Hemodynamic status: Assess for signs of shock (tachycardia, poor perfusion)
• Contact poison control immediately: Call the Poison Help hotline (800-222-1222 in the US) with information about:
  • Time of ingestion
  • Concentration of hydrogen peroxide (household 3% vs concentrated solutions)
  • Approximate amount ingested (5 ml reported)
  • Current symptoms (hematemesis, vomiting) 1

Diagnostic Evaluation

• Laboratory tests:

  • Complete blood count to assess for blood loss
  • Electrolytes and renal function
  • Coagulation profile if significant bleeding is present

• Imaging considerations:

  • Chest X-ray to rule out aspiration pneumonitis
  • Abdominal CT scan if there is concern for portal venous gas emboli (a known complication of hydrogen peroxide ingestion) 2

• Endoscopy: Consider urgent endoscopy if persistent vomiting, hematemesis, significant oral burns, or severe abdominal pain is present 3, 4

Treatment Approach

1. Do NOT induce vomiting or administer anything by mouth:

   • Avoid administering water or milk as dilution agents unless specifically advised by poison control 1
   • Do not administer activated charcoal or ipecac 1

2. Supportive care:

   • If gastric distension is painful, a gastric tube may be passed to release gas 3
   • Monitor for continued hematemesis or signs of significant blood loss
   • Observe for at least 4-6 hours for development of complications

3. Advanced interventions if needed:

   • For severe cases with evidence of gas embolism, hyperbaric oxygen therapy may be indicated 2
   • For significant GI bleeding or ulceration, appropriate acid suppression therapy may be required
   • If respiratory compromise develops, secure airway and provide respiratory support 3

Potential Complications to Monitor

• Gastrointestinal injury: Hydrogen peroxide can cause gastric ulcers and duodenal erosions, even with 3% solutions 4
• Gas embolism: Rapid decomposition of hydrogen peroxide produces oxygen bubbles that can enter the portal venous system 2, 5
• Respiratory issues: Aspiration of hydrogen peroxide or foam can cause respiratory distress

Disposition

• Mild cases: May be observed for 4-6 hours and discharged if asymptomatic
• Moderate to severe cases: Require admission for:
  • Continued hematemesis
  • Evidence of significant GI injury on endoscopy
  • Presence of portal venous gas emboli
  • Respiratory compromise

Key Pitfalls to Avoid

• Underestimating toxicity: Even household 3% hydrogen peroxide can cause significant gastric injury in children 4
• Delayed evaluation: Patients with persistent vomiting or bloody emesis require prompt medical evaluation and consideration of endoscopy 4
• Failure to recognize gas embolism: This is a potentially fatal complication that requires immediate intervention 5

Given the presence of hematemesis in this child, careful monitoring and evaluation for gastrointestinal injury is warranted, even though the amount ingested was relatively small.