Surface Tension

Want to know what dangerous wellness trend causes harm with bubbles? Why the treatment for too much oxygen can be more oxygen? And how concentration can make the difference between a mild exposure and a medical emergency?

A woman collapses at a yoga retreat after severe abdominal pain, frothy vomiting, a seizure, and sudden paralysis. Her CT scan reveals a strange clue: gas where it doesn’t belong. Can you identify the toxin—and choose the treatment—before permanent damage is done?

Your patient is waiting. Your diagnosis—and your decision—matter.

Pick Your Poison is an interactive medical mystery podcast about toxicology, poisoning, emergency medicine, and the clues that lead to a diagnosis.

Transcripts are available at pickpoison.com.

This podcast is fictional and is intended for entertainment and educational purposes only. It is not medical advice.

Transcript

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This is Pick Your Poison. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. Want to know what dangerous wellness trend causes harm with bubbles? Why the treatment for too much oxygen is more oxygen? And how concentration is the difference between life and death?
  Stay right here to find out.
 This is an interactive story. 
 Will our patient live or die? 
 It's up to you and the choices you make. 
 Take a few deep breaths

Today's episode starts at a yoga retreat. The day-long session at a fancy spa was a gift from a friend and colleague who said it helped her deal with some of the burnout and moral injury that comes with the job. You're not sure you have a whole day to spend at a spa or doing yoga, but she insisted, going so far as to buy you a gift certificate so you had no excuse.

The retreat is outside in perfect sunny weather. The sound of babbling water from the creek nearby is calming, in a cool breeze, ruffles your hair. As you move through the yoga poses tension eases from your neck and back and you're normally racing thoughts at least slow down as the day progresses, You decide to pass on the favor and get a gift certificate for another colleague before you leave. 

Lunch is a delicious meal of locally grown vegetables and grains. The only thing missing is coffee, but they do have tea which you drink multiple cups of. The woman sitting next to you, takes several sips from a bottle of clear liquid. Your first thought is that it's alcohol though maybe that's less likely here at this health and wellness resort. 

A few minutes later, the woman puts her hand to her stomach, becomes pale, and vomits on the ground next to you. You grab some napkins, then grab her hair until she stops. You try not to look too closely, in the interest of not vomiting up your own lunch, but you do notice a funny frothy element like soap bubbles as it comes out of her mouth. 

Finally, it stops she wipes her face with the napkins you give her and drink some water. As she does, she clutches her chest and abdomen saying it burns so bad. The yoga instructor tells everyone to go back to their mats for the afternoon session, asking the the woman if she would like to rest or requires further assistance. The woman shakes her head. She wants to continue and moves over to her mat, next to yours.

The woman still looks pale and somewhat sweaty, but determined. The instructor moves into a downward dog, the class follows. As soon as her head goes down the woman next to you vomits again it's still frothy, but this time you notice a few small streaks of red blood. You lean over and recommend she sit down and rest for a few minutes. This time, she listens, resting her head on her arms.

At the end of the session, you're rolling up your yoga mat to move on to the next activity when the woman collapses to the ground with violent shaking movements in all of her limbs. It's a generalized tonic-clonic seizure. Someone rushes over with a spoon and tries to jam it in her mouth.

Question number one: If you see someone having a seizure, what do you do?

A. Put a spoon in their mouth to keep them from biting their tongue.
 B. Roll them onto their side.
 C. Sit them up.

The answer is B. Just roll them onto their side. It will be difficult to sit them up or keep them that way, and trying to fight against the seizure might actually do more harm than good by accidentally injuring them. Do not put anything in the mouth of a person having a seizure. Ever. It could break their teeth, cause more injury to the inside of their mouth, or obstruct their airway. Just roll the person onto their side so they don't choke on their own secretions and wait for the seizure to stop. Most seizures, as we've discussed before, will stop in less than five minutes, though every second, I can tell you from long experience, may seem like hours.

You grab the spoon and say no don't do that. You are the woman on her side while someone calls 911.

Someone says they've called 911 and medics are on the way. After about 2 minutes, The violent shaking of her limbs stops. Her eyelids flutter open. She's clearly awake, though not yet talking. However, she's only moving the right side of her body.

Seizures can cause paralysis in the postictal phase. The postictal phase, as we've talked about before, is the period after the seizure, generally, lasting for minutes to hours, though, in rare cases as much as a day. Typically patients are sleepy and sedated, they can be agitated and altered. Sometimes they have a Todd's paralysis, which weakness on one side of the body after a seizure. If her weakness is due to Todd's paralysis, it'll get better over the next few minutes to few hours. The medics arrive and whisk her away to the emergency department. 

This is fiction, so of course you're the doctor.

The patient's vital signs are as follows: temperature 98.6°F, or 37°C; heart rate 97 beats per minute; respiratory rate 18 breaths per minute; blood pressure 120/80; and oxygen saturation 100% on room air.

She’s awake though drowsy. She's able to tell you that she has no past medical history, including no prior history of seizures. She doesn't take any medicines. No allergies to medicines, and she denies tobacco, alcohol and drugs. 

She doesn't remember what happened, in medical term, she's amnestic for the event. This is pretty common after a seizure, patients don’t remember what happened.

You ask her what she does remember. She remembers what was served for lunch and remembers developing severe abdominal pain along with nausea and vomiting. She wanted to do yoga anyway, but doesn't remember anything after that.

Is this food poisoning? Everyone ate the same thing for lunch and no one else including yourself has any symptoms. So foodborne illness is pretty unlikely. While you're taking the history, the nurse does a fingerstick and says her blood glucose is 100 mg/dL which is normal. The tech tears off and hands you an EKG, also completely normal. No abnormalities to suggest an increased risk for a cardiac arrhythmia.

You move on to the physical exam. She's awake, alert, and oriented. As noted she's a little sleepy, but her mental status is otherwise normal. Her cranial nerves are intact. There are a few tiny abrasions along both sides of her tongue. Heart and lungs are clear. An abdominal exam she has moderate tenderness in the epigastric region, which is the top middle just under the sternum, but no rebound or guarding meaning no signs of peritonitis. Her left arm and leg are moving normally with good muscle strength, but she can't move her right arm or leg at all. They're completely paralyzed.

What do you make of this paralysis? It's been an hour since the seizure at this point in terms of her mental status. Her postal phase is clearly improving. She's still sleepy but definitely more awake and getting back to normal the muscle strength however doesn't seem to be improving at all. 

Is this a Todds paralysis? 

Leading directly to Question #2. Should we do a stroke evaluation?

Yes

No

This is always a very difficult question in the emergency department standing there at the bedside. We don't know if this if this is a postal symptom caused by the seizure that will improve without intervention as the postal phase wears off or if in fact, the patient had a stroke, which in turn caused the seizure. It's a chicken and the egg question as to which came first in most cases when this happens.

The answer is A. Yes for two reasons, first there's no test to tell us if this is a Todds paralysis meaning it has to be a diagnosis of exclusion. If a patient comes in with a history of seizures in a history of Todd's paralysis, then I might not worry, but otherwise we have to assume the worst until proven otherwise. Second clot busting medicines work best the sooner they are given. Meaning waiting an hour or two to see if this wears off is too long if it is in’t a Todd’s but a stroke. 

Most hospitals have very specific stroke alert protocols involving rapid imaging, specialty consultations with neurologists, and protocols for administering clot-busting medicines ie thrombolytics like TPA and TNK as soon as possible. 

I don't wanna get sucked into boring protocol, details, or small nuances in most hospitals CT scans are quick and easy to get from the emergency department. This is usually done first to rule out into cranial hemorrhage. Then, if the patient meets the criteria, the clotbusting medicines are administered now CT scan isn't the best test for showing a stroke an MRI is much more useful, but these take longer to get and are not available in all emergency departments. You send the patient down for a CT scan of her brain. Ruling out intracranial hemorrhage is also important because the side effect of thrombolytics in all cases is bleeding and so you wanna make sure that patient doesn't have an intracranial hemorrhage for obvious reasons before you give something with the potential to cause bleeding. 

Rather than believe with the details in our patient, let me summarize it by saying you sent her down for a head CT, which is negative no bleeding no masses no obvious stroke and you follow your local protocols regarding thrombolytics and let's move on because as you know, this is not a neurology podcast, but it toxicology podcast. 

You also order basic labs, a chest X-ray, and a brain MRI, knowing it's going to be several hours at best before you get the scan done. In the meantime, the nurses continue to monitor the patient. 

Unfortunately, there's no improvement in the paralysis, and with every minute that passes, postictal paralysis is less and less likely. Can a Todd’s paralysis last for hours? Yes. But it's an unusual presentation to begin with, and the longer it lasts, the the more concerned I am that there's a different reason for this problem.

The nurse asked you for more nausea medicine this is the third dose you've given and she continues to have nausea and vomiting. Also, she tells the nurse her abdominal pain is getting worse. Despite the pain medicine you ordered earlier. Her vomit continues to have some streaks of red blood the nurse tells you it looks weird. It's frothy and foamy looking.

Rather than getting better, the patient seems to be getting worse so you go back to re-examine her. There hasn't been any improvement in the paralysis. you re-examine her abdomen, noting she's extremely tender. You send her back to radiology for a CT of her abdomen and pelvis. 

Shortly thereafter, the radiologist calls. 

"There's air everywhere," he says.

"Air?"

"There's portal venous gas. Bowel pneumatosis, especially in the stomach. Basically, there are air bubbles everywhere.”

Air looks black on a CT scan of course we expect to see it in the lungs. It's also normal for air to be inside the stomach and the gastrointestinal tract but it's not supposed to be inside your abdominal cavity or in the walls of your organs are in your blood vessels. This is a fairly unusual finding.

What can cause it? Question #3.

A recent abdominal procedure

A colonoscopy

Lung disease like asthma

All of the above

The answer is D. All of the above can cause it.

"Has this patient had a recent procedure?" he asks.

"A procedure?" you say. "No, I don't think so. She denied any significant past medical history. Why?"

If a patient had a recent procedure, say surgery or procedure via a large Venus or arterial catheter, for example, then you might see air, which was introduced during the procedure and will eventually go away as the patient heals. But your patient hasn't had a recent procedure so this explanation doesn't fit. She’s not having an asthma attack either. 

What xenobiotics could cause this? Well, there are a fair number of things which can cause bowel perforation steroids is a classic one chemotherapeutic agents can cause your normal tissues to breakdown and necrosis. 

“is there a perforation in the bowels you ask?”

"no he says just the gas everywhere.”

Bowel perforations aren't rare they can happen after procedure like a colonoscopy or in a serious infection like diverticulitis. But she doesn't have a perf, just the air. Laxatives are one thing that can cause it, by increasing the amount of gas overall inside your gastrointestinal tract leading to some of it being absorbed. The patients don't usually have significant abdominal pain because it's just some extra air not serious abdominal pathology.

You pull up the CT scan to take a look for yourself. This isn't a mild case of an extra gas bubble or two. 

No. 

There's air everywhere in the portal system of the liver in the stomach in the parts of the small intestine close to the stomach. It's very obvious and easy to see even with your minimal CT reading skills meaning this is a very serious finding.

Portal Venus, gas and intestinal new mitosis is definitely associated with one particular toxin. This toxin can also cause corrosive injury to the gastrointestinal tract as well as seizures and paralysis in severe cases.

This is a tough one, but it's time to Pick Your Poison. Is this:

A. Cyanide toxicity
 B. Oxygen toxicity from 100% oxygen exposure
 C. Hydrogen peroxide toxicity
 D. Bleach toxicity, i.e., sodium hypochlorite

The answer is C. This is hydrogen peroxide toxicity. Portal venous gas and pneumatosis on CT scan are pretty diagnostic. If you're interested, look up CT images after hydrogen peroxide ingestion. The images are pretty striking. Basically, you see black throughout the liver and inside the bowel wall where it's not supposed to be.

 Another clue is the patient's frothy vomit. If you've ever used hydrogen peroxide to clean something, you know when you pour it, it's bubbly. This is exactly what the vomit looks like its ingested.

You go back in the room to ask the patient what was in the clear liquid in the small bottle she was drinking from at lunch. She says she can't remember the name, but points to her bag, saying it’s inside. You pull it out. It has a handwritten label on it reading hydrogen peroxide.

Uh-oh. Your suspicions were right. 

You ask her why she drank it, she says to hyperoxygenate and cleanse her system. Why? You ask again. She says it was recommended by someone she follows on social media, a health and wellness expert. 

You nearly avoid blurting out, clearly a misuse of that title.

Unless you're having respiratory problems like an asthma attack are poisoned with something like carbon monoxide, or are at high altitude, we all have all the oxygen our bodies needs to operate. It's like wearing an oxygen tank to walk around as a person with normal lungs. It doesn't make any sense and won't help.

I want to talk about how it works but first we need to move onto treatment because this is an emergency. Our patient is paralyzed after drinking hydrogen peroxide. I think we can safely say at this point that it's very unlikely she has a Todd's paralysis. Is she gonna have another seizure another stroke? we need to move quickly.

First, we did say that hydrogen peroxide can cause caustic injury, which we just talked about in our last episode so listen to that if you want more details. We discussed the patients can have significant injury in the esophagus and stomach without any lesions in the mouth. Consult gastroenterology did I hear you say?

It's a good idea and we probably do need to consult them. However, if they do decide to do an endoscopy, it'll be diagnostic rather than therapeutic, so I don't think this is the next most important step. There's no perforation on CT scan though clearly there's a risk she could perforate so surgery is not helpful at this moment either.

The most concerning symptom is the paralysis. We talked about and saw the air bubbles on the CT scan in her abdomen, but the thing we really fear after hydrogen peroxide ingestion is an air bubble, i.e. and air Emblas going to the brain. What are the symptoms of an air embolus? One of them is a stroke. 

I know you've seen nurses removing the air from IV lines and syringes before starting a drip or giving an injection. In truth, the risk of getting an air embolus from this is almost 0. Typically you need 50 mL, like a shot glass full of air, to cause air embolus rather a few bubbles. There are occasional exceptions and so that's why the nurses are careful and take these precautions to protect patients.

If we think she had a stroke, what about an MRI? This is a great thought and I think if you could get an MRI quickly, it would be useful that said if you work in a place where you can't get MRIs in a timely fashion I don't think it's absolutely necessary. We know she ingested hydrogen peroxide. We know she has air bubbles everywhere and we know she has unilateral weakness consistent with a stroke. I think it would be nice to have the emirate to confirm, but I don't think it's necessary. what we need is the treatment.

Question ***. What is it? 

hyperbaric oxygen

B12, hydroxylamine

Methylene blue

Vitamin K

The answer is a hyperbaric oxygen. This is a chamber that the patient goes inside and oxygen is pumped in at a very high pressure, forcing oxygen into the tissues. B12 hydroxylamine is the treatment for cyanide toxicity methylene blue is a treatment for methemoglobinemia and vitamin K, reverses anticoagulant, like cumin or warfarin.

So yes, our patient wanted to hyper oxygenate herself instead had a stroke and now requires hyperbaric oxygen therapy for treatment. Ironically. it's another thing that's popular with wellness influencers. Michael Jackson famously had one. We use them to treat a number of different things in the hospital first of course scuba diving injuries like the bends. Classically used in toxicology to treat carbon monoxide exposure. It's also used in wound care, 

How well does it work for hydrogen peroxide exposure well as with most things toxicology it's difficult to say for certain if there's a benefit. We don't want have a whole bunch of people drink a potentially lethal toxin to see if hyperbaric oxygen will help. Fortunately, the risks of hyperbaric oxygen are pretty small. There is a risk of eardrum rupture, and a small risk of oxygen toxicity itself, including a seizure but in this case, she's having a stroke I think it's pretty clear that the risk benefit analysis favors trying hyperbarics.

You call one of your colleagues and ER physician who sub specialized in hyperbarics he agrees to come in open the chamber and dive the patient. In addition, you work on getting an MRI.

While we're waiting for these things, let's talk about what hydrogen peroxide is and what toxicity it causes. Chemical formula for hydrogen peroxide is H2O2 wo so two hydrogen +2 oxygen’s. 

The first thing we need to know with a hydrogen peroxide, ingestion is the concentration. If you have hydrogen peroxide in your house, you probably have a typical 3% solution. If ingested, patients certainly can get symptoms. In general, abdominal pain and nausea and vomiting, mild caustic injury but most people do well. There are only one or two case reports of pediatric ingestions where children had bad outcomes from a few sips of 3% hydrogen peroxide toxicity.

We don't know the concentration of what our patient took, but I don't think it was a 3% solution. Another preparation is 35% hydrogen peroxide, meant for commercial use. It's usually supposed to be diluted with water to a lower concentration. It's on a list of one or two sips can kill for pediatric exposures and even a few sips can be dangerous in adults. There are cases where the undiluted 35% concentration was unfortunately stored in a water or juice bottle. Someone swigged down a couple of swallows and developed significant toxicity afterwards. I think it's a lot more likely that this is what our patient ingested.

Hydrogen peroxide is generally considered a weak acid, and it definitely causes caustic injury to the gastrointestinal tract when ingested. That's the first problem. This was the reason for our patients, nausea, vomiting, and abdominal pain as well as the blood streaked vomit.

The second problem is that peroxide releases oxygen into the body. Meaning air bubbles, and when the air bubbles get into places they don't belong, this can cause an air embolism, including stroke and even cardiac ischemia. Enough air bubbles in the gastrointestinal tract can cause perforation.

It's estimated that 30 mL of 35% hydrogen peroxide, when ingested, produces 3.5 liters of oxygen gas. Meaning two tablespoons of hydrogen peroxide can release enough oxygen to fill two large soda bottles. Imagine having two large soda bottles—and I mean American-sized here—of gas in your body. Sounds horrible.

Why would anyone do this? There are a lot of cases of accidental, pediatric ingestion, suicidal injections, and accidental exposures as I mentioned if the hydrogen peroxide wasn't an unlabeled to water bottle, unfortunately people do ingest it without actually wanting to harm themselves. It becomes popular every so often in the "health and wellness community" and I used the terms loosely here —with the idea that small amounts diluted in water can "hyperoxygenate the body."

Wait, did I hear you say why do we want to give more oxygen to the person who is already suffering from too much oxygen in the body? Great question and the answer here is pressure. Essentially hyperbaric oxygen is a large amount of pressure like if you scuba dive to a deep depth, this compresses, the air bubbles and forces them to be reabsorbed back into the tissues rather than the blood vessels where they are causing obstruction and ischemia leading to stroke.

It's estimated that the risk of an embolic event after hydrogen peroxide ingestion at concentrations of at least 10% is about 6 to 14% with about 7% having a severe outcome meaning continued disability or death. We don't know how much hyperbarics helps us given the difficulty with research as I noted earlier, but the risk of HBO is low definitely much less than the risk of heart attack or stroke so it's definitely worth doing if you are in a place where you can transfer the patient for hyperbarics or get it done at your hospital.

After the hyperbaric treatment, the patient gets the MRI and afterwards is admitted to the intensive care unit. The MRI shows scattered punctuate foci of restricted diffusion. This is a classic finding of cerebral gas symbolism normally, if you have a stroke, it's blockage in a certain blood vessel, resulting in a specific pattern in the brain, but with air, the air can be in any of the blood vessels and is therefore seen as a scattered non-focal pattern.

Other complications of hydrogen peroxide ingestion include hemorrhagic gastritis, airway collapse from airway irritation and swelling, pneumomediastinum ie air in the mediastinum, the area under the sternum, and spinal cord infarcts.

Hydrogen peroxide as I'm sure you know has been used for wounds. It's typically safe, especially in lower concentrations. There are a few case reports of patients with significant wounds exposed to higher concentrations of hydrogen peroxide, developing toxicity, and you really can't make these things up. There are reports of patients taking hydrogen peroxide as enemas, even a 3% solution in this case was enough to cause colitis. There are reports of rectal perforation.

OK back to our patient. She begins to improve during her ICU stay she doesn't have any further seizures or strokes when she's discharged she is able to move her arm and leg, though she is still markedly weak and having difficulty walking.

A few months later, you see a news article with the headline woman poisoned by health guru suing for damages. The article reports your patient is suing the online influencer for giving bad advice, resulting in significant health consequences. The influencer has responded that the advice was to use only one or two drops of hydrogen peroxide in water. You're glad the patient recovered and sigh inwardly at the thought you will no doubt be called to testify at the trial.

Last question in today’s podcast. Hydrogen peroxide releases so much oxygen that 90% concentrations are used as a source of oxygen for which of the following:

Rockets

Cars

Tractors

	Follow the X and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else. 
 	Thanks for listening. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available at pickpoison.com. 
 	 While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.