Black Swans in the ER — or, Purell is Lovely with a Little Chianti

From an Emergency Medicine journal piece about “black swans” during toxicology rounds in an ER. An excerpt. Be sure to hang in until the last paragraph.

Acute Ethanol Poisoning in a 4-Year-Old as a Result of Ethanol-Based Hand-Sanitizer Ingestion
Engel JS, Spiller HA
Pediatr Emerg Care

Several retrospective reviews of regional poison center data have suggested that pediatric ingestion of ethanol-based hand sanitizers rarely causes significant symptoms. Mrvos and Krenzelok looked at such exposures reported to the Pittsburgh Poison Center in children under age 6, identifying 647 cases. None had more than minor symptoms. (Clin Toxicol 2008;31[4]:633.) Miller et al analyzed 1358 similar cases from the Texas Poison Control Network; again there were no moderate or major effects. (Generally, a toxic effect is classified as moderate or major if it requires treatment.)

This case report from the Kentucky Regional Poison Center demonstrates that although rare, major sequelae can occur from these ingestions. A 4-year-old girl was brought to the emergency department with ataxia, combativeness, and altered mental status after falling and hitting her head. History revealed recent ingestion of Purell hand sanitizer (62% ethanol). Her bedside glucose level was 165 mg/dL, and a head CT was negative. The child was intubated for airway protection during transfer to a pediatric ICU. The serum ethanol level was 243 mg/dL, corresponding to an estimated ingestion of 1.5 oz to 2.0 oz of the hand sanitizer.

Several case reports have made of adults with significant intoxication after deliberate ingestion of these products. One hospital patient who ingested an estimated 450 mL of hand sanitizer became unresponsive with a serum alcohol of 376 mg/dL. When he sobered up, he noted that, “It had a horrible taste, but I was drunk pretty quick.” (Mayo Clin Proc 2007;82[10]:1288.)

I am particularly fond of this closing paragraph:

In the interests of science, I did a simple taste test to see why a child might swallow more than a lick of hand sanitizer. Actually, the product I sampled was slightly sweet and not really unpleasant, somewhat reminiscent of the Italian liqueur Limoncello.