A 62-year old Caucasian female, a Psychiatrist, was brought by her friend for multiple falls and heavy alcohol intake for two weeks. Vital signs were within normal range and physical examination was pertinent for mild drowsiness, hands tremor and tenderness along left lateral chest. Ethanol level was 321 mg/dl. CXR and CT head were normal but CT chest revealed minimally displaced fractures of the left lateral sixth to eighth ribs. Patient was placed on alcohol withdrawal protocol, and managed conservatively for rib fractures. Patient was functioning normal by day 5, and awaiting placement to an alcohol rehabilitation facility. On day 8, she was found to be drowsy and confused with diffuse expiratory wheezes, and SpO2 88%. EKG, CXR and neurological examination were normal. Symptoms resolved completely within few hours. Patient had another similar episode the morning of day 9. While on rounds, nurse mentioned that a couple of hand sanitizer bottles were missing from the holders outside the rooms. On patient room’s search, three empty bottles of hand sanitizer were found. We suspected hand sanitizer ingestion, and contacted poison control. A stat alcohol level was high at 185 mg/dl (6 mg/dl on day 3). Poison control recommended supportive care and resumption of alcohol withdrawal protocol. Patient admitted to ingesting hand sanitizer.
Discussion:
Hand sanitizer ingestion is not uncommon. The American Association of Poison Control Centers (AAPCC) handle approximately 17,000 hand sanitizer exposure cases per year, primarily in children under 12 years old. Majority of these are accidental, but intentional ingestion is reported. Most hand sanitizers contain 45-90% ethyl alcohol or isopropyl alcohol or combination. In comparison, vodka, wines and beers contain 40%, 10-15% and 5-10% alcohol respectively. Treatment is supportive and poison control consultation is recommended. As ethyl alcohol and isopropyl alcohol are rapidly and completely absorbed from the GI tract, activated charcoal or gastric lavage is not helpful. Hemodialysis removes alcohol, isopropanol and its metabolite acetone, and can be used. Fomepizole and alcohol which are used in methanol and ethylene glycol poisoning to reduce production of toxic metabolites, are not recommended in alcohol or isopropyl alcohol poisoning as their metabolites (acetone) are less toxic. Our patient was recurrently confused due to intermittent ingestion of hand sanitizer (70% ethyl alcohol) and hypoxia/wheezing can be explained by the inhalation of sanitizer fumes and inactive ingredients such as glycol, glycerin among others. Hand sanitizer bottles at our institution can be conveniently taken out of the holders, and lids are equally easy to open. Quality groups in certain institutions advocate locked holders.
Conclusions:
This case highlights yet another cause of inpatient hypoxia and confusion, and the requisite to devise safety measures precluding abuse of hand sanitizers.