What is the management for hydrogen peroxide (H2O2) poisoning?

Management of Hydrogen Peroxide Poisoning

Immediate Stabilization and Airway Management

Early aggressive airway management is critical in hydrogen peroxide poisoning, as respiratory failure and arrest are the proximate cause of death. 1

• Secure the airway immediately in patients with altered mental status, stridor, or respiratory distress, as laryngospasm and sub-epiglottic narrowing can develop within minutes of ingestion 1
• Prepare for endotracheal intubation or emergency tracheostomy if life-threatening laryngeal edema develops 1
• Administer 100% oxygen via non-rebreather mask or endotracheal tube to all symptomatic patients 1
• Monitor continuously for apnea, cyanosis, and cardiorespiratory arrest, which may occur rapidly following concentrated hydrogen peroxide exposure 1

Gastrointestinal Decontamination - What NOT to Do

Do NOT perform gastric lavage, induce vomiting, or administer activated charcoal, as hydrogen peroxide rapidly decomposes to oxygen and water via catalase. 1

• If gastric distension is painful due to oxygen gas formation, pass a gastric tube to release accumulated gas 1
• This is the ONLY indication for gastric tube placement - purely for decompression, not decontamination 1

Endoscopic Evaluation

Consider urgent endoscopy if there is persistent vomiting, hematemesis, significant oral burns, severe abdominal pain, dysphagia, or stridor. 1

• Concentrated hydrogen peroxide (>10%) causes corrosive damage to mucous membranes, resulting in blistering, oropharyngeal burns, and hemorrhagic gastritis 1
• Even 3% hydrogen peroxide can cause severe gastric ulcers and duodenal erosions in children after small ingestions 2
• Endoscopy helps assess the extent of gastrointestinal injury and guide further management 1, 2

Imaging for Gas Embolism

Obtain immediate CT imaging of the abdomen and brain if the patient ingested concentrated hydrogen peroxide (>10%), particularly if neurological symptoms are present. 3

• Portal venous gas embolism occurs commonly after concentrated hydrogen peroxide ingestion and can be visualized on CT scan 3
• Cerebral gas embolism causes multiple brain infarctions, manifesting as confusion, coma, convulsions, or focal neurological deficits 1
• Arterial gas embolism results from oxygen generation exceeding its maximum solubility in blood 1

Hyperbaric Oxygen Therapy

Administer hyperbaric oxygen therapy for patients with portal venous gas embolism, arterial gas embolism, or neurological manifestations following concentrated hydrogen peroxide ingestion. 3

• Hyperbaric oxygen successfully resolves portal venous gas embolism in 80-100% of cases 3
• Treatment at 2.5-3.0 atmospheres absolute pressure is recommended 3
• Most patients can be discharged within 1 day following successful hyperbaric oxygen treatment 3
• Hyperbaric oxygen prevents progression of cerebral infarction from arterial gas embolism 3

Dermal and Ocular Decontamination

For skin exposure, immediately irrigate with copious amounts of water and treat resulting lesions as thermal burns. 1

• Concentrated hydrogen peroxide causes inflammation, blistering, and severe skin damage requiring potential surgical intervention for deep burns 1

For eye exposure, irrigate immediately and thoroughly with water or 0.9% saline for at least 10-15 minutes. 1

• Instill local anesthetic to reduce discomfort and facilitate more thorough decontamination 1
• Solutions >10% can cause corneal ulceration or perforation 1
• Obtain ophthalmology consultation for exposures to concentrated solutions 1

Corticosteroids - Unproven Benefit

High-dose corticosteroids have been recommended for laryngeal and pulmonary edema, but their value remains unproven. 1

• Consider corticosteroids only if severe laryngeal edema or pulmonary edema develops 1
• Do not delay definitive airway management while administering corticosteroids 1

Concentration-Specific Risk Stratification

Household-strength 3% hydrogen peroxide exposures are usually benign (85.6% asymptomatic), but severe gastric injury can occur even with small ingestions in children. 2

• Concentrated solutions (>10%, particularly 35%) cause severe toxicity through corrosive injury, massive oxygen gas formation, and lipid peroxidation 1, 4, 3
• The 35% concentration is increasingly available in the natural health industry for purported HIV and cancer treatment, representing an emerging source of accidental poisonings 4
• Even two sips of 35% hydrogen peroxide can be fatal in young children 5

Critical Pitfalls to Avoid

• Never irrigate wounds in closed body cavities or under pressure with hydrogen peroxide, as this causes oxygen gas embolism 1
• Do not assume benign outcome based on initial presentation - shock, coma, and pulmonary edema can develop 24-72 hours post-exposure 1
• Do not discharge patients with persistent vomiting or bloody emesis without endoscopic evaluation, even after 3% hydrogen peroxide exposure 2
• Recognize that intravascular foaming can completely impede right ventricular output, causing sudden cardiovascular collapse 1