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Hydrogen peroxide

1. NAME
   1.1 Substance
   1.2 Group
   1.3 Synonyms
   1.4 Identification numbers
      1.4.1 CAS number
      1.4.2 Other numbers
   1.5 Main brand names, main trade names
   1.6 Main manufacturers, main importers
2. SUMMARY
   2.1 Main risks and target organs
   2.2 Summary of clinical effects
   2.3 Diagnosis
   2.4 First aid measures and management principles
3. PHYSICO-CHEMICAL PROPERTIES
   3.1 Origin of the substance
   3.2 Chemical structure
   3.3 Physical properties
      3.3.1 Colour
      3.3.2 State/Form
      3.3.3 Description
   3.4 Hazardous characteristics
4. USES
   4.1 Uses
      4.1.1 Uses
      4.1.2 Description
   4.2 High risk circumstance of poisoning
   4.3 Occupationally exposed populations
5. ROUTES OF EXPOSURE
   5.1 Oral
   5.2 Inhalation
   5.3 Dermal
   5.4 Eye
   5.5 Parenteral
   5.6 Other
6. KINETICS
   6.1 Absorption by route of exposure
   6.2 Distribution by route of exposure
   6.3 Biological half-life by route of exposure
   6.4 Metabolism
   6.5 Elimination and excretion
7. TOXICOLOGY
   7.1 Mode of action
   7.2 Toxicity
      7.2.1 Human data
         7.2.1.1 Adults
         7.2.1.2 Children
      7.2.2 Relevant animal data
      7.2.3 Relevant in vitro data
      7.2.4 Workplace standards
      7.2.5 Acceptable daily intake (ADI)
   7.3 Carcinogenicity
   7.4 Teratogenicity
   7.5 Mutagenicity
   7.6 Interactions
8. TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS
   8.1 Material sampling plan
      8.1.1 Sampling and specimen collection
         8.1.1.1 Toxicological analyses
         8.1.1.2 Biomedical analyses
         8.1.1.3 Arterial blood gas analysis
         8.1.1.4 Haematological analyses
         8.1.1.5 Other (unspecified) analyses
      8.1.2 Storage of laboratory samples and specimens
         8.1.2.1 Toxicological analyses
         8.1.2.2 Biomedical analyses
         8.1.2.3 Arterial blood gas analysis
         8.1.2.4 Haematological analyses
         8.1.2.5 Other (unspecified) analyses
      8.1.3 Transport of laboratory samples and specimens
         8.1.3.1 Toxicological analyses
         8.1.3.2 Biomedical analyses
         8.1.3.3 Arterial blood gas analysis
         8.1.3.4 Haematological analyses
         8.1.3.5 Other (unspecified) analyses
   8.2 Toxicological Analyses and Their Interpretation
      8.2.1 Tests on toxic ingredient(s) of material
         8.2.1.1 Simple Qualitative Test(s)
         8.2.1.2 Advanced Qualitative Confirmation Test(s)
         8.2.1.3 Simple Quantitative Method(s)
         8.2.1.4 Advanced Quantitative Method(s)
      8.2.2 Tests for biological specimens
         8.2.2.1 Simple Qualitative Test(s)
         8.2.2.2 Advanced Qualitative Confirmation Test(s)
         8.2.2.3 Simple Quantitative Method(s)
         8.2.2.4 Advanced Quantitative Method(s)
         8.2.2.5 Other Dedicated Method(s)
      8.2.3 Interpretation of toxicological analyses
   8.3 Biomedical investigations and their interpretation
      8.3.1 Biochemical analysis
         8.3.1.1 Blood, plasma or serum
         8.3.1.2 Urine
         8.3.1.3 Other fluids
      8.3.2 Arterial blood gas analyses
      8.3.3 Haematological analyses
      8.3.4 Interpretation of biomedical investigations
   8.4 Other biomedical (diagnostic) investigations and their interpretation
   8.5 Overall interpretation of all toxicological analyses and toxicological investigations
   8.6 References
9. CLINICAL EFFECTS
   9.1 Acute poisoning
      9.1.1 Ingestion
      9.1.2 Inhalation
      9.1.3 Skin exposure
      9.1.4 Eye contact
      9.1.5 Parenteral exposure
      9.1.6 Other
   9.2 Chronic poisoning
      9.2.1 Ingestion
      9.2.2 Inhalation
      9.2.3 Skin exposure
      9.2.4 Eye contact
      9.2.5 Parenteral exposure
      9.2.6 Other
   9.3 Course, prognosis, cause of death
   9.4 Systematic description of clinical effects
      9.4.1 Cardiovascular
      9.4.2 Respiratory
      9.4.3 Neurological
         9.4.3.1 Central nervous system (CNS)
         9.4.3.2 Peripheral nervous system
         9.4.3.3 Autonomic nervous system
         9.4.3.4 Skeletal and smooth muscle
      9.4.4 Gastrointestinal
      9.4.5 Hepatic
      9.4.6 Urinary
         9.4.6.1 Renal
         9.4.6.2 Other
      9.4.7 Endocrine and reproductive systems
      9.4.8 Dermatological
      9.4.9 Eye, ear, nose, throat: local effects
      9.4.10 Haematological
      9.4.11 Immunological
      9.4.12 Metabolic
         9.4.12.1 Acid-base disturbances
         9.4.12.2 Fluid and electrolyte disturbances
         9.4.12.3 Others
      9.4.13 Allergic reactions
      9.4.14 Other clinical effects
      9.4.15 Special risks
   9.5 Other
   9.6 Summary
10. MANAGEMENT
   10.1 General principles
   10.2 Life supportive procedures and symptomatic/specific treatment
   10.3 Decontamination
   10.4 Enhanced elimination
   10.5 Antidote treatment
      10.5.1 Adults
      10.5.2 Children
   10.6 Management discussion
11. ILLUSTRATIVE CASES
   11.1 Case reports from literature
12. Additional information
   12.1 Specific preventive measures
   12.2 Other
13. REFERENCES
14. AUTHOR(S), REVIEWER(S), DATE(S) (INCLUDING UPDATES), COMPLETE ADDRESS(ES)




    Hydrogen peroxide

    International Programme on Chemical Safety
    Poisons Information Monograph 946
    Chemical

    This Monograph contain the following sections
    completed: 1, 2, 3, 4.1, 7.2, 9 & 10.


    1.  NAME

        1.1  Substance

             Hydrogen peroxide

        1.2  Group

             Oxygen and compounds
             Peroxide

        1.3  Synonyms

             Albone; Albone 35;
             Albone 35CG; Albone 50;
             Albone 50CG; Albone 70;
             Albone 70CG; Dihydrogen dioxide;
             Hioxyl; Hydrogen dioxide;
             Hydroperoxide; Inhibine;
             Interox; Kastone; Oxydol;
             Perhydrol; Perone;
             Perone 30; Perone 35;
             Perone 50; Perossido di idrogeno;
             Peroxan; Peroxide;
             Peroxyde d'hydrogene; Superoxol;
             T-Stuff; Wasserstoffperoxid;
             Waterstofperoxyde

        1.4  Identification numbers

             1.4.1  CAS number

                    7722-84-1

             1.4.2  Other numbers

                    UN2014 (DOT)
                    UN2015 (DOT)
                    UN2984 (DOT)

                    NIOSH/rtecs:  MX0900000

        1.5  Main brand names, main trade names

        1.6  Main manufacturers, main importers

    2.  SUMMARY

        2.1  Main risks and target organs

             The dissociation of hydrogen peroxide is a violent and
             exothermic reaction.  Ingestion results in gastrointestinal
             irritation, the severity of which depends on the
             concentration of the solution.  There is also a risk of gas
             embolism.  A number of deaths have been reported in the
             literature.  In most cases the exposures were to concentrated
             solutions of 30 to 40%.
    
             Ingestion of the more concentrated solutions (>10%, but
             particularly 30 to 40% and above) should be regarded as
             serious because of the risk of more severe irritation.  The
             risk of gas embolism is probably also increased with the
             concentrated solutions, although a large quantity of a dilute
             solution may also produce embolism.  Death may occur within
             minutes of ingestion.

        2.2  Summary of clinical effects

             Ingestion:  These effects may occur with solutions of
             3% but usually only where a large quantity has been ingested,
             effects are generally more severe if a concentrated solution
             has been ingested.
    
             Vomiting (the vomitus may be frothy due to the liberation of
             oxygen - risk of aspiration), haematemesis, 'burningœ throat
             and gastric distension (due to the release of oxygen). 
             Lethargy, coma, convulsions, shock, and respiratory arrest
             have been reported.  Gastrointestinal bleeding and burns to
             the stomach and duodenum may occur.  These are usually not
             severe and resolve with symptomatic treatment.
    
             Gas embolism has been reported in adults and children. In
             severe cases ischaemic ECG changes and EMD (electromechanical
             dissociation) may be observed because of embolisation of the
             heart restricting blood flow.
    
             Inhalation: Transient dyspnoea and cough, with concentrated
             solutions there may be more severe irritation and
             inflammation of the respiratory tract
    
             Dermal:  Irritant to the skin with paraesthesia, blistering
             and whitening; solutions >10% may cause burns.  Bleaching of
             the skin usually resolved within a few hours.
    

             Ocular: Irritation with a burning sensation, conjunctival
             hyperaemia, lacrimation and severe pain which resolves within
             a few hours. With more concentrated solutions effects may
             take up to 24 hours to resolve. There are rare cases of
             temporary cornal injury resulting from application of 3%
             solution to the eye (on contact lenses) including punctuate
             staining of the cornea, decreased vision, cornal opacity and
             oedema. 
    
             Intravenous: vomiting, pain at injection site, ventricular
             fibrillation, embolism of heart and lung tissue, haemolytic
             anaemia, renal failure and death.
    
             Rectal: rectal bleeding, nausea, distension and difficulty
             urinating.

        2.3  Diagnosis

             Gastrointestinal (GI) irritation possibly accompanied by
             vomiting of frothy material and gas embolism can help the
             diagnosis if the exposure is not known. Whitening of the skin
             and mucous membranes and pain may be signs of exposure.

        2.4  First aid measures and management principles

             Ingestion: Gastric decontamination is not worthwhile
             for ingestion of hydrogen peroxide due to its rapid
             dissociation.  Asymptomatic patients who have ingested only a
             small quantity of low concentrated solutions (3 to 6%)
             probably do not require treatment.  Any patient with
             haematemesis, abdominal discomfort, persistent vomiting,
             central nervous system (CNS) or respiratory effects must be
             admitted.
    
             Treatment is supportive. If gastric distension is severe a
             fine bore gastric tube may be passed to aid the release of
             gas.  Endoscopy should be considered in patients with
             haematemesis or persistent vomiting or if the solution was
             >10%.
    
             Patients with severe clinical effects require abdominal and
             chest X-rays.  The Trendelenburg positioning (head down,
             elevated foot of bed) should be avoided since this may trap
             air in the apex of the right ventricle and cause obstruction
             of the blood flow.  Monitor the ECG in severe cases. 
             Ventilation may be required in patient with severe
             respiratory effects.
    

             Hyperbaric oxygen therapy has been suggested for patients
             with evidence of cerebral embolism due to hydrogen
             peroxide.
    
             Inhalation: remove from exposure; supportive care should be
             given.
    
             Dermal: irrigate thoroughly with saline or water and treat
             symptomatically.
    
             Ocular:  irrigate thoroughly with running water or saline
             for 15 minutes.  Refer to an ophthalmologist.
    
             Intravenous: monitor ECG and check renal function.  Perform
             X-rays.
    
             Rectal: give supportive care; parenteral (then oral)
             steroids may be of benefit.  Sigmoidoscopy is recommended to
             determine the extent of the injury.

    3.  PHYSICO-CHEMICAL PROPERTIES

        3.1  Origin of the substance

        3.2  Chemical structure

             Chemical formula: H2O2
             Molecular mass: 34

        3.3  Physical properties

             3.3.1  Colour

                    Colourless

             3.3.2  State/Form

                    Liquid

             3.3.3  Description

                    Hydrogen peroxide is an odourless liquid with a
                    bitter taste; it is an oxidising agent which in the
                    presence of organic matter or if permitted to become
                    alkaline vigorously decomposes to oxygen and water. 
                    The strength of a solution may be described as a
                    percentage or volume, where 1% hydrogen peroxide
                    releases 3.3 volumes of oxygen during decomposition. 
                    Thus, a 3% solution is equivalent to 10 volume and a
                    6% solution to 20 volume, etc.
    

                    Boiling point:  115 to 157°C
                    Melting point:  <50°C
                    Relative density (water = 1):  1.3
                    Solubility in water:  Miscible
                    Vapour pressure, kPa at 30°C:  0.7
                    Relative vapour density (air = 1):  1.2
                    Relative density of the vapour/air-mixture at 20°C
                    (air = 1):  1.06

        3.4  Hazardous characteristics

             Hydrogen peroxide decomposes on warming producing oxygen
             which increases fire hazard.  The substance is a strong
             oxidant and reacts violently with combustible and reducing
             materials causing fire and explosion hazard particularly in
             the presence of metals.  Hydrogen peroxide attacks many
             organic substances, e.g. textile and paper.

    4.  USES

        4.1  Uses

             4.1.1  Uses

             4.1.2  Description

                    Hydrogen peroxide is used as a 6% solution for
                    bleaching hair and some disinfectant solutions for
                    contact lenses contain 3% hydrogen peroxide.  Chlorine
                    free bleaches contain 6% hydrogen peroxide. Some newer
                    fabric stain removers/bleaches contain 5 to 15%
                    hydrogen peroxide. Industrial strengths of hydrogen
                    peroxide are manufactured up to 90%.  They are used
                    mainly as bleaching and oxidising agents.  Solutions
                    of 90% are used as rocket fuel.
    
                    Hydrogen peroxide (35%) is also sold as a health aid
                    for so-called 'hyperoxygenation therapy' for
                    everything from arthritis to AIDS and cancer.  It is
                    kept refrigerated, diluted for use, and taken
                    regularly (Leikin et al., 1993).

        4.2  High risk circumstance of poisoning

        4.3  Occupationally exposed populations

    5.  ROUTES OF EXPOSURE

        5.1  Oral

             Common route of exposure.

        5.2  Inhalation

             Hydrogen peroxide can be inhaled.

        5.3  Dermal

             Hydrogen peroxide is irritant to the skin.

        5.4  Eye

             Ocular exposure results in irritation with a burning
             sensation.

        5.5  Parenteral

             Intravenous injection of hydrogen peroxide has been reported.

        5.6  Other

             Rectal exposure is possible.

    6.  KINETICS

        6.1  Absorption by route of exposure

        6.2  Distribution by route of exposure

        6.3  Biological half-life by route of exposure

        6.4  Metabolism

        6.5  Elimination and excretion

    7.  TOXICOLOGY

        7.1  Mode of action

        7.2  Toxicity

             7.2.1  Human data

                    7.2.1.1  Adults

                             The dissociation of hydrogen
                             peroxide is a violent and exothermic
                             reaction. Ingestion results in
                             gastrointestinal irritation, the severity of
                             which depends on the concentration of the
                             solution.  There is also a risk of gas
                             embolism.  A number of deaths have been
                             reported in the literature.  In most cases
                             the exposures were to concentrated solutions
                             of 30 to 40%.
    

                             Ingestion of the more concentrated solutions
                             (>10%, but particularly 30 to 40% and above)
                             should be regarded as serious because of the
                             risk of more severe irritation.  The risk of
                             gas embolism is probably also increased with
                             the concentrated solutions, although a large
                             quantity of a dilute solution may also
                             produce embolism (Cina et al., 1994).  Death
                             may occur within minutes of ingestion
                             (Dickson and Caravati, 1994).
    
                             Most cases of ingestion of hydrogen peroxide
                             result in only mild effects.  Of 270 cases of
                             hydrogen peroxide ingestion in one study only
                             24% required medical referral (Dickson and
                             Caravati, 1994).
    
                             Cerebral infarction, believed to have
                             resulted from gas embolisation of the
                             cerebral vasculature, has been reported in an
                             84 year old man who took 30 ml of 35%
                             hydrogen peroxide diluted in 100 to 300 mL of
                             water (Sherman et al., 1994).  Multiple brain
                             embolism occurred in a 63 year old who
                             ingested 120mL of 35% solution.  He recovered
                             (Ijichi et al., 1997).
    
                             Fatal doses:
                             Ingestion:
                             Ingestion of 240 mL of 35% hydrogen peroxide
                             in a 49 year old female caused death in 78
                             hours later (Litovitz et al., 1995).
    
                             Intravenous:
                             0.8mL of a 35% solution diluted in 200mL
                             normal saline (0.14% of hydrogen peroxide)
                             once daily for 5 days in a 50 year old male
                             (Leikin et al., 1993).
    
                             2mL (strength unknown) in a dialysis catheter
                             caused abdominal pain, hypertension, collapse
                             and coma within 1 hour. She made some
                             improvement with hyperbaric oxygen by the 8th
                             day, then had a cardiac arrest and
                             convulsions.  She recovered in the following
                             week and then had another cardiac arrest and
                             died 19 days post-injection (Litovitz et al.,
                             1997).

                    7.2.1.2  Children

                             Fatal doses:
                             Ingestion:
                             225 mL of 3% in a 16 month old, he was found
                             dead 10 hours later (Cina et al., 1994).
                             About 100 to 170 mL of 35% in a 2 year old,
                             taken off life-support 4 days later with
                             hypoxic encephalopathy (Christensen et al.,
                             1992).
    
                             Intravenous:
                             100mL of 3% hydrogen peroxide in a 7 month
                             old child (Lubec et al., 1996).

             7.2.2  Relevant animal data

             7.2.3  Relevant in vitro data

             7.2.4  Workplace standards

             7.2.5  Acceptable daily intake (ADI)

        7.3  Carcinogenicity

        7.4  Teratogenicity

        7.5  Mutagenicity

        7.6  Interactions

    8.  TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS

        8.1  Material sampling plan

             8.1.1  Sampling and specimen collection

                    8.1.1.1  Toxicological analyses

                    8.1.1.2  Biomedical analyses

                    8.1.1.3  Arterial blood gas analysis

                    8.1.1.4  Haematological analyses

                    8.1.1.5  Other (unspecified) analyses

             8.1.2  Storage of laboratory samples and specimens

                    8.1.2.1  Toxicological analyses

                    8.1.2.2  Biomedical analyses

                    8.1.2.3  Arterial blood gas analysis

                    8.1.2.4  Haematological analyses

                    8.1.2.5  Other (unspecified) analyses

             8.1.3  Transport of laboratory samples and specimens

                    8.1.3.1  Toxicological analyses

                    8.1.3.2  Biomedical analyses

                    8.1.3.3  Arterial blood gas analysis

                    8.1.3.4  Haematological analyses

                    8.1.3.5  Other (unspecified) analyses

        8.2  Toxicological Analyses and Their Interpretation

             8.2.1  Tests on toxic ingredient(s) of material

                    8.2.1.1  Simple Qualitative Test(s)

                    8.2.1.2  Advanced Qualitative Confirmation Test(s)

                    8.2.1.3  Simple Quantitative Method(s)

                    8.2.1.4  Advanced Quantitative Method(s)

             8.2.2  Tests for biological specimens

                    8.2.2.1  Simple Qualitative Test(s)

                    8.2.2.2  Advanced Qualitative Confirmation Test(s)

                    8.2.2.3  Simple Quantitative Method(s)

                    8.2.2.4  Advanced Quantitative Method(s)

                    8.2.2.5  Other Dedicated Method(s)

             8.2.3  Interpretation of toxicological analyses

        8.3  Biomedical investigations and their interpretation

             8.3.1  Biochemical analysis

                    8.3.1.1  Blood, plasma or serum
                             "Basic analyses"
                             "Dedicated analyses"
                             "Optional analyses"

                    8.3.1.2  Urine
                             "Basic analyses"
                             "Dedicated analyses"
                             "Optional analyses"

                    8.3.1.3  Other fluids

             8.3.2  Arterial blood gas analyses

             8.3.3  Haematological analyses
                    "Basic analyses"
                    "Dedicated analyses"
                    "Optional analyses"

             8.3.4  Interpretation of biomedical investigations

        8.4  Other biomedical (diagnostic) investigations and their 
             interpretation

        8.5  Overall interpretation of all toxicological analyses and 
             toxicological investigations

        8.6  References

    9.  CLINICAL EFFECTS

        9.1  Acute poisoning

             9.1.1  Ingestion

                    These effects may occur with solutions of 3%
                    but usually only where a large quantity has been
                    ingested, effects are generally more severe if a
                    concentrated solution has been ingested.
    
                    Vomiting (the vomitus may be frothy due to the
                    liberation of oxygen - risk of aspiration),
                    haematemesis, 'burningœ throat and gastric distension
                    (due to the release of oxygen).  Lethargy, coma,
                    convulsions, shock, and respiratory arrest have been
                    reported (Giberson et al., 1989).  Gastrointestinal
                    bleeding and burns to the stomach and duodenum may
                    occur.  These are usually not severe and resolve with
                    symptomatic treatment.
    
                    Gas embolism has been reported in adults (Luu et al.,
                    1992) and children (Cina et al., 1994; Christensen et
                    al., 1992; Litovitz et al., 1991; Rackoff and Merton,
                    1990).   In severe cases ischaemic ECG changes and EMD
                    (electromechanical dissociation) may be observed
                    because of embolisation of the heart restricting blood
                    flow (Christensen et al., 1992).
    

                    Cerebral infarction, believed to have resulted from
                    gas embolisation of the cerebral vasculature, has been
                    reported in an 84 year old man who took 30 mL of 35%
                    hydrogen peroxide diluted in 100 to 300 mL of water
                    (Sherman et al., 1994).  Multiple brain embolism
                    occurred in a 63 year old who ingested 120mL of 35%
                    solution.  He recovered (Ijichi et al., 1997).

             9.1.2  Inhalation

                    Transient dyspnoea and cough, with concentrated
                    solutions there may be more severe irritation and
                    inflammation of the respiratory tract.

             9.1.3  Skin exposure

                    Irritant to the skin with paraesthesia,
                    blistering and whitening; solutions >10% may cause
                    burns.  Bleaching of the skin usually resolved within
                    a few hours.

             9.1.4  Eye contact

                    Irritation with a burning sensation,
                    conjunctival hyperaemia, lacrimation and severe pain
                    which resolves within a few hours, with more
                    concentrated solutions effects may take up to 24 hours
                    to resolve. There are rare cases of temporary cornal
                    injury resulting from application of 3% solution to
                    the eye (on contact lenses) including punctuate
                    staining of the cornea, decreased vision, cornal
                    opacity and oedema.  Historically 1 to 3% solutions
                    were applied to the eye as an antibacterial agent.

             9.1.5  Parenteral exposure

                    Intravenous: vomiting, pain at injection site,
                    ventricular fibrillation, embolism of heart and lung
                    tissue, haemolytic anaemia, renal failure and death.

             9.1.6  Other

                    Rectal: rectal bleeding, nausea, distension and
                    difficulty urinating (Dickson and Caravati, 1994).

        9.2  Chronic poisoning

             9.2.1  Ingestion

             9.2.2  Inhalation

             9.2.3  Skin exposure

             9.2.4  Eye contact

             9.2.5  Parenteral exposure

             9.2.6  Other

        9.3  Course, prognosis, cause of death

        9.4  Systematic description of clinical effects

             9.4.1  Cardiovascular

             9.4.2  Respiratory

             9.4.3  Neurological

                    9.4.3.1  Central nervous system (CNS)

                    9.4.3.2  Peripheral nervous system

                    9.4.3.3  Autonomic nervous system

                    9.4.3.4  Skeletal and smooth muscle

             9.4.4  Gastrointestinal

             9.4.5  Hepatic

             9.4.6  Urinary

                    9.4.6.1  Renal

                    9.4.6.2  Other

             9.4.7  Endocrine and reproductive systems

             9.4.8  Dermatological

             9.4.9  Eye, ear, nose, throat: local effects

             9.4.10 Haematological

             9.4.11 Immunological

             9.4.12 Metabolic

                    9.4.12.1 Acid-base disturbances

                    9.4.12.2 Fluid and electrolyte disturbances

                    9.4.12.3 Others

             9.4.13 Allergic reactions

             9.4.14 Other clinical effects

             9.4.15 Special risks

        9.5  Other

        9.6  Summary

    10. MANAGEMENT

        10.1 General principles

             Ingestion: Gastric decontamination is not worthwhile
             for ingestion of hydrogen peroxide due to its rapid
             dissociation. Asymptomatic patients who have ingested only a
             small quantity of low concentrated solutions (3-6%) probably
             do not require treatment.  Any patient with haematemesis,
             abdominal discomfort, persistent vomiting, central nervous
             system (CNS) or respiratory effects must be admitted.
    
             Treatment is supportive, if gastric distension is severe a
             fine bore gastric tube may be passed to aid the release of
             gas.  Endoscopy should be considered in patients with
             haematemesis or persistent vomiting or if the solution was
             >10%.
    
             Patients with severe clinical effects require abdominal and
             chest X-rays.  The Trendelenburg positioning (head down,
             elevated foot of bed) should be avoided since this may trap
             air in the apex of the right ventricle and cause obstruction
             of the blood flow (Henry et al., 1996).  Monitor the ECG in
             severe cases.  Ventilation may be required in patient with
             severe respiratory effects.
    
             Hyperbaric oxygen therapy has been suggested for patients
             with evidence of cerebral embolism due to hydrogen peroxide
             (Sherman et al., 1994).
    
             Inhalation: remove from exposure, supportive care
    
             Dermal: Irrigate thoroughly with saline or water and treat
             symptomatically.
    
             Ocular: Irrigate thoroughly with running water or saline
             for 15 minutes. Refer to an ophthalmologist.
    
             Intravenous:  monitor ECG and check renal function. 
             Perform X-rays.
    

             Rectal: supportive care, parenteral (then oral) steroids
             may be of benefit.  Sigmoidoscopy is recommended to determine
             the extent of the injury (Dickson and Caravati, 1994).

        10.2 Life supportive procedures and symptomatic/specific treatment

             See section 10.1

        10.3 Decontamination

             Gastric decontamination is not worthwhile for ingestion
             of hydrogen peroxide due to its rapid dissociation.

        10.4 Enhanced elimination

             See section 10.1

        10.5 Antidote treatment

             10.5.1 Adults

                    No antidote available.

             10.5.2 Children

                    No antidote available.

        10.6 Management discussion

             See section 10.1

    11. ILLUSTRATIVE CASES

        11.1 Case reports from literature

    12. Additional information

        12.1 Specific preventive measures

        12.2 Other

    13. REFERENCES

        Christensen DW, Faught WE, Black RE, Woodward GA and Timmons
        OD. (1992) Fatal oxygen embolization after hydrogen peroxide
        ingestion. Crit Care Med 20 (4):543-544
    
        Cina SJ, Downs JCU and Conradi SE. (1994) Hydrogen peroxide: a
        source of lethal oxygen embolism.  Case report and review of the
        literature.  Am J Forensic Med Pathol 15 (1):44-50
    

        Dickson KF and Caravati EM. (1994) Hydrogen peroxide - 325
        exposures reported to a regional poisons control center.  Clin
        Toxicol 32 (6):705-714
    
        Giberson TP, Kern JD, Pettigrew DW 3d, Eaves CC Jr & Haynes JF Jr
        (1989) Near-fatal hydrogen peroxide ingestion. 18(7): 778-779.
    
        Henry MC, Wheeler J, Mofensen HC, Caraccio TR, Marsh M, Comer GM,
        Singer AJ. (1996) Hydrogen peroxide 3% exposure.  Clin Toxicol 34
        (3): 323-327
    
        Ijichi I, Itoh T, Sakai R, Nakaji K, Miyauchi T, Takahashi R,
        Kadosaka S, Hirata M, Yoneda S, Kajita Y, Fujita Y (1997) Multiple
        brain embolism after ingestion of concentrated hydrogen peroxide. 
        Neurology 48 (1): 277-79
    
        Leikin J, Sing K and Woods K  (1993) Fatality from intravenous use
        of hydrogen peroxide for home 'superoxygenation therapyœ
        (abstract).  Vet Hum Toxicol 35 (4):342
    
        Litovitz Tl, Bailey Km, Schmitz BF, Holm KC & Klein-Schwartz W
        (1991) 1990 Annual report of the AAPCC National Data Collection
        System. Am J Emerg Med 9(5):461-509
    
        Litovitz TL, Felberg L, Soloway RA, Ford M, Geller R.  (1995) 1994
        Annual Report of the AAPCC toxic exposure surveillence system.  Am
        J Emerg Med 13 (5):551-597
    
        Litovitz TL, Smilkstein M, Felberg L,  Klein-Schwartz W, Berlin R
        and Morgan JL. (1997) 1996 Annual Report of the AAPCC toxic
        exposure surveillence system.  Am J Emerg Med 15 (5):447-500
    
        Lubec B, Hayn M, Denk W and Bauer G (1996)  Brain lipid
        peroxidation and hydroxyradical attack following the intravenous
        infusion of hydrogen peroxide in an infant.  Free Rad Biol Med 21
        (2):219-223
    
        Luu TA, Kelley MT, Strauch JA & Avradopoulos K (1992) Portal vein
        embolism from hydrogen peroxide ingestion. Ann Emerg med 21(11):
        1391-1393
    
        Rackoff Wr & Merton DF (1990) Gas embolism after ingestion of
        hydrogen peroxide. Pediatrics  85(4): 593-594
    
        Sherman SJ, Boyer LV and Sibley WA (1994) Cerebral infarction
        immediately after ingestion of hydrogen peroxide. Stroke
        25:1065-1067

    14. AUTHOR(S), REVIEWER(S), DATE(S) (INCLUDING UPDATES), COMPLETE 
        ADDRESS(ES)

        Author:     Medical Toxicology Unit,
                    Guyœs and St Thomasœ Trust
                    Avonley Road, London SE14 5ER, UK
    
        Date:       December, 1997
    
        Review:     As for author. 1997
    
        Peer review:         INTOX meeting, March 1998, London, UK 
                             (Members of group: Drs G. Allridge, L.
                             Lubomovir, R. Turk, C. Alonso, S. de Ben, K.
                             Hartigan-Go, N. Bates)
    
        Editor:     Dr M.Ruse (September, 1998)
    



See Also:
        Hydrogen peroxide (IARC Summary & Evaluation, Volume 71, 1999)
        Hydrogen peroxide (ICSC)
        Hydrogen peroxide solutinos of 20% to less than 35% (CHEMINFO)
        Hydrogen peroxide solutions of 35% and greater (CHEMINFO)
        Hydrogen peroxide solutions of 8% to less than 20% (CHEMINFO)
        Hydrogen peroxide solutions of less than 8% (CHEMINFO)