Toxicity Related To COVID19

Preventive Measures.
By
Mona Eldesoky
Assistant Lecturer of Forensic Medicine and Clinical Toxicology
Faculty of Medicine, Cairo University

Under supervision of
Dr Nevine Elkady
Lecturer of Forensic Medicine and Clinical Toxicology
Faculty of Medicine, Cairo University

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Outlines:
Disinfectants :
1.Types and toxicities.
2.Recomendetions.
Personnel protective equipment PPE:
1.Hazards.
2.Recomendations.
Prophylactic Medications:
1.Types.
2.Recomneded doses.
3. Side effects and toxicity.
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Disinfectants

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Disinfectants against coronavirus :
• Sodium hypochlorite
• 70% ethyl alcohol
• Povidone-iodine (1% iodine)
• Isopropyl alcohol.
• Hydrogen peroxide

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Examples of exposure
1. mixing chemicals together.
2. using bleach or hydrogen peroxide to wash hands or skin
leading to rashes.
3. using cleaners on face masks and inhaling the toxic
fumes.
4. children getting into unattended supplies.

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Toxicities due to preventive
measures (household cleaners):

household cleaner exposures from January through March,

an increase of 20% from the same period in 2019.
(according to CDC)

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 Hydrogen Peroxide
According to the CDC:

• household (3 %)hydrogen peroxide is effective

Spray it on the surface to be cleaned and let it sit on
the surface for at least 1 minute. 

• Hydrogen peroxide is not corrosive, so it’s okay to

use it on metal surfaces.

• You can pour it on the area, and you don’t have to

wipe it off because it essentially decomposes into
oxygen and water.”
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mechanisms of toxicity:
1. local tissue injury :
• Dilute hydrogen peroxide is an irritant
• concentrated hydrogen peroxide is a caustic.
2. Gas formation results
liberating molecular oxygen and water. One milliliter of 3%
hydrogen peroxide liberates 10 mL of oxygen at standard
temperature and pressure; 1 mL of the more concentrated
35% hydrogen peroxide liberates more than 100 mL of
oxygen Forensic Medicine & Clinical Toxicology Department
Clinical picture
sudden oxygen embolization : rapid deterioration in
mental status, cyanosis, respiratory failure, seizures,
and myocardial ischemia.
the ingestion of dilute hydrogen peroxide are usually
much more benign, with nausea and vomiting the most
commonly reported symptoms

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Management
Nasogastric aspiration if the patient presents
immediately after ingestion especially in abdominal
distension
Clinical or radiographic evidence of gas in the heart
should be placed in the Trendelenburg position to
prevent gas from blocking the right ventricular outflow
tract and referred for hyperbaric therapy.

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: Sodium hypochlorite
The CDC recommends :
• a diluted bleach solution:
⅓ cup bleach per 1 gallon(3.7L) of water or 4 teaspoons
bleach per 1 quart of water—for virus disinfection.
• Once the solution is mixed, don’t keep it for longer
than a day because the bleach will lose potency and
can degrade certain plastic containers.
• you can use bleach tablets instead. (1 tablet is equal
to ½ cup liquid bleach.
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Mixing
• admixture of ammonia and Sodium hypochlorite: chloramine (highly
soluble pulmonary irritant )
domestic exposure to chlorine gas is common.
• The admixture of an acid to bleach liberates chlorine gas
Chlorine is a potent pulmonary irritant that can cause severe
bronchospasm and acute lung injury.

Ingestion
of large amounts of household liquid bleach (5% sodium hypochlorite
on rare occasions can result in esophageal burns with subsequen
stricture formation.

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 :Case
 woman who had listened to news reports advising that all
groceries be thoroughly cleaned before they are eaten.
She filled her sink with hot water, a 10% bleach solution,
and vinegar, and left her produce to soak in it.
While unloading the rest of her groceries she noticed a
chlorine-like smell, developed difficulty breathing, began
coughing and wheezing.
taken to an emergency room, she recovered with oxygen
and bronchodilators.
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Isopropyl Alcohol
:CDC recommended
1. Alcohol solutions with at least 70 % alcohol are
effective against the coronavirus on hard surfaces.
2. First, clean the surface with water and detergent.
3. apply the alcohol solution.
4. do not dilute it.
5. and let it sit on the surface for at least 30 seconds to
disinfect.
6. Alcohol is generally safe for all surfaces but can
discolor some plastics.
Present in hand sanitizers (so for hand and surfaces)
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WHO recommended alcohol based hand sanitizers
are mainly made of ethanol, isopropyl alcohols,
hydrogen peroxides in different combinations (These
chemicals have known toxic and hazardous impact on
environment when released by evaporation
 Ingestion of isopropyl alcohol accidentally or
deliberately leads to severe respiratory or central nervous
system depression

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 Ethanol toxicity is also associated with respiratory
depression which results into respiratory arrest,
hypothermia, cardiac dysrhythmias with possible cardiac
arrest, hypoglycemia, ketoacidosis and hypotension ).
 methanol published by public health England showed
oral and dermal toxicity of methanol with observation
not to use in hand hygiene products.

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 :Case of hand sanitizer
The C.D.C. report a cases. unresponsive preschool-age child
who had ingested an unknown amount of a 64-ounce bottle
of ethanol-based hand sanitizer. The bottle was found open
on the kitchen table.
The child was rushed to a hospital in an ambulance and
admitted to the pediatric intensive care unit overnight. She
was discharged and sent home after 48 hours.

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 povidone-iodine (1% iodine)betadine
in-vitro virucidal activity, killing 99.99% of the SARS-CoV-2
virus in 30 seconds.

The products :Solution (10% PVP-I), Skin Cleanser (7.5%

PVP-I), Gargle and Mouthwash (1.0% PVP-I) and Throat
Spray (0.45% PVP-I). )

 already know of tooth staining and rare allergic reactions

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Topical iodine:
Significant systemic absorption .
Ingestion of iodine:
abdominal pain, vomiting, diarrhea, GI bleeding,
delirium, hypovolemia, anuria, and circulatory collapse.
Severe caustic injury of the GI tract may occur.
Contact dermatitis can result from repetitive
applications of iodophors.

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Management
• Nasogastric aspiration and lavage may be
performed to limit the caustic effect of the iodine.
• Irrigation with a starch solution will convert iodine to
the much less toxic iodide, and, in the process, turn
the gastric effluent dark blue-purple.
• Milk may be a useful alternative.
• Activated charcoal adsorbs iodine and may be
useful.

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Case of povidone iodine

excessive use of iodine mouthwash and nasal spray resulted

in increased iodine levels and mild bleeding. The problem
resolved by stopping aspirin and reducing the iodine use.

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Disinfectant in health facilities:
Flammable Agents
1.Ethanol (70–95%) or isopropanol (50–100%)
2.Hydrogen peroxide, 0.5.
3.0.5% of phenolic cresol also toxic by inhalation.
Gas Produce or Toxic Agents
4.Glutaraldehyde.
5.Formaldehyde.
Corrosion or Breakdown
6.sodium hypochlorite (effective concentration, 0.21%)
7. potassium peroxymonosulfate.
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What NOT to Use Against Coronavirus
Homemade Hand Sanitizer
“Not only can you hurt yourself, but it could give you a false sense of
security.” 

Vodka
product does not contain enough ethyl alcohol (40% with the 70 %required)
to kill the coronavirus. 

Distilled White Vinegar

no evidence that they are effective against the coronavirus.

Tea Tree Oil

While there is preliminary research that suggests tea tree oil may have an
effect against the herpes simplex virus, there is no evidence that it can kill
coronaviruses. Forensic Medicine & Clinical Toxicology Department
the CDC recommends five steps to
minimize the poisoning risk:
1. Follow the directions on product labels.
2. don’t mix chemicals.
3. wear protective gear like gloves.
4. use all products in a well-ventilated area.
5. store chemicals out of the reach of kids.
 The coronavirus is dangerous enough without letting
attempts at prevention be part of the problem.
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Clean and Disinfect Your Home
two very different things.
• Cleaning is about removing contaminants from a surface.
• Disinfecting is about killing pathogens.
• Do both daily if anything or anyone has entered or exited
your home.
Transmission from person-to-person is a much greater risk
than transmission via surfaces, but the CDC still
recommends you clean and disinfect 
frequently touched surfaces in our homes at least once.
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Examples of Surfaces for Necessary Cleaning and
Disinfection
1.Tables Hard backed chairs
2.Door knobs Light switches
3.Phones Tablets
4.Touch screens  Remote controls 
5.Keyboards Door or fixture handles
6.Desks Toilets
7.Sinks
 Take care in handling of masks and face shield.
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 Everyone Should
 Wash your hands often with soap and water for
at least 20 secono.in kids learn them to sing a
song for 20 seconds.
 If soap and water are not readily available, use a
hand sanitizer that contains at least 70%
alcohol. Cover all surfaces of your hands and rub
them together until they feel dry.
 Avoid touching your eyes, nose, and
mouth with unwashed hands.
 Avoid close contact

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 soap may be one of the most important
technological breakthroughs of all time.
 Studies have shown that there is no added health
benefit for consumers (this does not include
professionals in the healthcare setting) using soaps
containing antibacterial ingredients compared with
using plain soap. (CDC)

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protective personnel equipment
PPE
• Gowns.
• Gloves.
• Masks.
• Face Shields.

www.bbc.com/news/uk-
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Masks

news.llu.edu

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 Inside your home: Avoid close contact with people
who are sick.
o If possible, maintain 6 feet between the person
who is sick and other household members.
 Outside your home: Put 6 feet of distance between
yourself and people who don’t live in your
household.
o Remember that some people without symptoms
may be able to spread virus.

• Cover your mouth and nose with a mask when

around others
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Types of masks
Medical masks  WHO recommends the following groups use
medical masks.

 Health workers

 Anyone with symptoms suggestive of COVID-19, including

people with mild symptoms 

• People caring for suspect or confirmed cases of COVID-19 outside

of health facilities

• People aged 60 or over

 People of any age with underlying health conditions

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 Respirators such as FFP2, FFP3, N95, N99 ,3M): specifically
designed for healthcare workers who provide care to COVID-
19 patients in settings and areas where aerosol generating
procedures are undertaken.
 Non-medical masks (fabric masks, home-made masks) can
act as a barrier to prevent the spread of the virus from the
wearer to others.(double layers).
 Please reserve medical masks to health workers.
 Masks with exhalation valves or vents should NOT be worn
to help prevent the person wearing the mask from spreading
COVID-19 to others (source control).
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The potential side effects
(1)false sense of security.
(2)Inappropriate use of face mask: not touch their masks, use
masks frequently, dispose correctly.
(4) an uncomfortable feeling and an impulse to touch your eyes.
(5) Face masks make breathing more difficult. For people with
COPD, intolerable to wear as they worsen their breathlessness.
(6) fraction of carbon dioxide previously exhaled is inhaled at
each respiratory cycle. increase breathing frequency and
deepness increase the amount of inhaled and exhaled air.
(7) This may also worsen the clinical condition of infected people
if the enhanced breathing pushes the viral load down into their
lungs.

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Side effects from Prolonged use of PPE:

1. N95 and surgical masks:

 headaches, difficulty breathing, due to:

mechanical factors

Tight straps and pressure on superficial facial and cervical nerves ,

Cervical neck strain, sleep deprivation, irregular mealtimes, and
emotional stress .

hypercapnia, and hypoxemia

Hypercapnia: (tight fitting) increased lung ventilation and respiratory

activity. cause confusion, impaired cognition, and disorientation,
hypoxemia: caused chest discomfort and tachypnea.
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 Skin manifestations: 
acne, rashes and Urticaria and contact dermatitis.

shearing and breakdown of the skin :the bridge of the nose

and cheek bones especially with tight fitting masks.

sensitivity to components of masks and PPE.

 Formaldehyde is a chemical used in PPE that some are

sensitive and/or allergy.

 thiuram which is found in the ear loops of surgical masks

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Wear your Mask Correctly(CDC)
•Wash your hands before putting
on your mask
•Put it over your nose and mouth
and secure it under your chin
•Try to fit it against the sides of
your face
•Make sure you can breathe easily
•CDC does not recommend use of
masks or cloth masks for source
https://www.cdc.gov/
control if they have an exhalation
valve or vent as( 3M mask).
       

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Take Off Your Mask Carefully:
Untie the strings behind your head or stretch the
ear loops
• Handle only by the ear loops or ties.
• Fold outside corners together
• Be careful not to touch your eyes, nose, and
mouth when removing and wash hands
immediately after removing.

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2.goggles : pressure on these specific areas.

3. gloves: WHO does not recommend the use of

gloves by people in the community. The wearing of
gloves may increase risk of infection, since it can lead
to self-contamination or transmission to others when
touching contaminated surfaces and then the.

4. face shield: prevent droplet but not prevent viral

transmission, injuries in children.

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Prophylactic medications of COVID 19
• hydroxychloroquine.
• and supplements such as:
 zinc
 vitamin C
 vitamin D.

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Chloroquine and its derivatives
(hydroxychloroquine):
theconversation.com
• have been used for malaria and autoimmune rheumatic
diseases for almost 80 years
• Now for, prophylaxis for COVID 19 virus infection, as long as
they are not contraindicated. 
Recommended dose:
400mg twice a day on day 1, followed by 400mg once weekly for
7 weeks.
post-exposure prophylaxis with hydroxychloroquine 400mg daily
for 14 days.
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Adverse effects:
The most frequent :
1.cardiovascular problems (QT interval prolongation,
2.arrhythmias, cardiomyopathy).
3.Hypoglycemia.
4. eye or vision problems (e.g. retinopathy macular
degeneration) and hearing problems.
5. gastrointestinal disorders,muscle weakness, hypokalemia,
6.increased risk for seizures, extrapyramidal disorders.
7.hemolytic anemia in patients with G6PD deficiency.
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serious condition :
1.prolongation of the QT interval, cardiac arrhythmias
especially after long-term treatment.
2. Cardiomyopathy :risk factors for cardiomyopathy
combination with fluoroquinolones is definitely cardiotoxic
and should be avoided.
3.Diffuse parenchymal lung disease ,respiratory failure and
subsequent death can occur at high doses. 
4.Severe hypoglycemia.
5. vision disorders .
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chloroquine toxicity:
Doses more than5 grams.
1.Cardiac manifestations:
-ventricular dysrhythmias and hypokalemia
-Cardiovascular collapse and profound hypotension.  
-sodium channel blockade results in QRS widening.
-Potassium channel blockade can result in prolonged QTc
interval and torsades de pointes.
2.CNS manifestation:
seizures and CNS depression
3.hemolysis: particularly in patients with G6PD deficiency.

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Hydroxychloroquine:
- a derivative of chloroquine( less toxic).
-fatal dose is not well defined.
-The minimum dose reported to elicit severe symptoms
(hypotension, hypokalemia, and ventricular dysrhythmias) is
4 g .

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Management of toxicity:
# GIT DECONTAMINATION:
Orogastric lavage, activated charcoal and Multiple-dose activated
charcoal.(acute toxicity)
# SUPPORTIVE TECHNIQUES
such as oxygen, cardiac monitoring, an IV access, volume
resuscitation.
# MANIFESTATIONS OF QUININE CARDIOTOXICITY:
serum alkalinization,potassium supplementation, and overdrive
pacing.
# RECURRENT HYPOGLYCEMIA.
adequate infusion of dextrose. Subcutaneous octreotide, for
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Vitamin C :
myprotein.com · 
• is cheap and safe.
 as prophylaxis that 1 to 2 g vitamin C per day is safe
 Higher doses :
• well tolerated as excess vitamin C
• oxalate nephrolithiasis not a significant clinical concern.
• Gastrointestinal tract effects of high doses of vitamin C ma
include localized esophagitis,
• osmotic diarrhea.

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Vitamin D:
• the daily dose :
400-600 IU that is recommended for the middle-age adults and ~1000-
2000 IU for low vitamin D risk group.
• toxicity :
• a toxicity threshold for vitamin D of 10,000 to 40,000 International
Units per day.
1. non-specific symptoms such as anorexia, weight loss, polyuria and
heart arrhythmias.
2. The primary toxicity concern is elevated serum calcium
concentration which can lead to vascular and tissue calcification
with subsequent damage to kidneys, blood vessels and the heart.
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Management:
• discontinuation of vitamin D therapy
• Rehydration and loop diuretic can promote calcium excretio
• Corticosteroids and bisphosphonates.
• severe hypercalcemia use Calcitonin

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Zinc supplementation:
 Recommended dose  The optimal dose of zinc for the
treatment and prevention of COVID-19 is not established.
 The recommended dietary :elemental zinc is 11 mg daily
for men and 8 mg for nonpregnant women.
 The doses used in registered clinical trials for COVID-19 vary
between studies, with a maximum dose of zinc sulfate 220
mg (50 mg of elemental zinc) twice daily.

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Toxicity:
hallmark of acute zinc toxicity :gastrointestinal (GI) distress, including
nausea, vomiting, abdominal pain and gastrointestinal bleeding.
Long-term zinc supplementation can cause :
• copper deficiency with subsequent reversible hematologic defects
(i.e., anemia, leukopenia) reversible sideroblastic anemia and a
reversible myelodysplastic syndrome.
• irreversible neurologic manifestations (i.e., myelopathy,
paresthesia, ataxia, spasticity).
•  In addition, oral zinc can decrease the absorption of medications
that bind with polyvalent cations.
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Management:
 GIT decontamination
 supportive
 Chelating:
• Edetate calcium disodium
• the combination of CaNa2EDTA and dimercaprol (BAL).
• the urinary excretion increased DMPS (sodium 2,3-
dimercapto-1-propane-sulfonate).(not now)
• deferiprone, noted to cause decreased serum zinc
concentrations
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Lactoferrin:
• Naturrally in body fluids and secretions as breast milk.
• non-toxic glycoprotein
• orally available as a nutritional supplement
• established in vitro antiviral efficacy against a wide range
of viruses, including SARS-CoV, a closely related
coronavirus to SARS-CoV-2.
 supplement containing 32 mg four to six doses per day for
10 day lower dose appeared to prevent the disease in
healthy contacts.
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• Side effects:
Nausea
Vomiting
Constipation
Chills
Increases iron level

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 References
• Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the covid-
19 crisis. BMJ 2020;:m1435. doi:10.1136/bmj.m1435
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doi:10.1093/obo/9780199756797-0046
• Advice on the use of masks in the community, during home care and in healthcare
settings in the context of the novel coronavirus (COVID-19) outbreak. X. Yao, F. Ye, M.
Zhang, C. Cui, B. Huang, P. Niu, et al.
• In vitro antiviral activity and projection of optimized dosing design of
hydroxychloroquine for the treatment of Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2) [published online ahead of print, 2020 Mar 9].
• Clin Infect Dis, (2020),http://dx.doi.org/10.1093/cid/ciaa237
Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response
strategy in long-term care hospitals? [published online ahead of print, 2020 Apr 17].
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COVID-19?. Nutrition (Burbank, Los Angeles County, Calif.), 79-80, 110948. Advance online publication.
https://doi.org/10.1016/j.nut.2020.110948

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•  
Desai AN, Aronoff DM. Masks and Coronavirus Disease 2019 (COVID-19). JAMA
Published Online First: 17 April 2020. doi:10.1001/jama.2020.6437
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