Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 677
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 120-123

Difficult airway management in a case of hair dye poisoning

Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication7-Jul-2017

Correspondence Address:
D Anandhi
Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_1_17

Rights and Permissions

Airway management is a unique and a defining element to the specialty of emergency medicine. There is no doubt regarding the significance of establishing a patent airway in the critically ill patient in the emergency department. Failure to secure the airway can drastically increase the morbidity and mortality of the patient within few minutes. Cannot intubate and cannot ventilate situation is a nightmare to all emergency physicians. Hence, knowledge of alternative measures to secure the airway and ventilate the patient is necessary. Prompt decision to proceed for emergency surgical airway (cricothyroidotomy or tracheostomy) is one of the utmost important rescue measures under such circumstances. Hesitating to perform this procedure may lead to repeated unsuccessful attempts at oral-tracheal intubation and inadvertently to hypoxia and subsequent brain damage and death. To an emergency physician, the main responsibility is to provide critical care and a definitive airway to all patients, regardless of the cause of their presentation. Here, we report a fatal case of hair dye poisoning that presented with severe angioedema and airway compromise. The most important take-home message from this case report is that every emergency physician should have the ability to predict “difficult airway” and recognize “failed airway” very early and be skilled in performing rescue techniques when routine oral-tracheal intubation fails. Any delay at any step in the “failed airway” management algorithm may not save the critically ill dying patient. In our patient, though we predicted the “difficult airway,” her brain had sustained irreversible hypoxic damage before we could provide oxygenation and ventilation.
The following core competencies are addressed in this article: Medical knowledge, Patient care.

Keywords: Cannot intubate-cannot ventilate, emergency surgical airway, emergency tracheostomy, Super Vasmol poisoning

How to cite this article:
Anandhi D, Raju KP, Saya RP, Pandit VR. Difficult airway management in a case of hair dye poisoning. Int J Acad Med 2017;3:120-3

How to cite this URL:
Anandhi D, Raju KP, Saya RP, Pandit VR. Difficult airway management in a case of hair dye poisoning. Int J Acad Med [serial online] 2017 [cited 2023 Jun 10];3:120-3. Available from: https://www.ijam-web.org/text.asp?2017/3/1/120/209834

  Introduction Top

Super Vasmol is an easily accessible hair dye and an emerging cause of deliberate self-harm in South India. The major toxic ingredients of the dye are paraphenylenediamine (PPD), resorcinol, propylene glycol, and ethylenediaminetetraacetic acid (EDTA).

The main ingredients of hair dye are:[1]

  • PPD (<4%)
  • Resorcinol
  • Propylene glycol
  • Liquid paraffin
  • Cetostearyl alcohol
  • Sodium lauryl sulfate
  • EDTA sodium
  • Herbal extracts and preservatives and perfumes.[1]

Ingestion of Super Vasmol hair dye causes cervicofacial edema, respiratory distress due to upper airway obstruction, rhabdomyolysis, and acute kidney injury.[2] Treatment is mainly supportive with emphasis on early airway management and prevention of acute renal failure. This case report explains the need for preparedness in the emergency department to manage “cannot intubate-cannot ventilate” situation.

Suliman et al. reviewed 150 cases presenting to Khartoum Teaching Hospital with PPD poisoning over a period of 10 years. The clinical features commonly involved the gastrointestinal tract, skin, and eyes. Nearly all the patients had angioneurotic edema, and some cases developed flaccid paraplegia or paraparesis.[3]

  Case Report Top

A 26-year-old married woman had consumed 100 ml of Super Vasmol hair dye with an intent of deliberate self-harm. She was initially taken to a primary health center where she had developed swelling of face, lips, neck, and hoarseness of voice. She was treated with gastric lavage, intravenous hydrocortisone, and antihistamines and then was referred to our tertiary care center. When she presented to our emergency department 5 h after consumption, she was agitated, restless, and unable to vocalize. She had extensive swelling over face, lips, and neck, and her tongue was swollen and protruding outside the oral cavity [Figure 1]. Her pulse rate was 100/min, blood pressure was 100/60 mmHg, room air oxygen saturation was 85%, and respiratory rate was 30/min. She was treated with oxygen through nonrebreathing face mask and intravenous hydrocortisone. In view of severe angioneurotic edema with upper airway obstruction, we decided to secure the airway immediately with endotracheal intubation.
Figure 1: Clinical picture showing swollen tongue, facial puffiness, and angioedema

Click here to view

Since we anticipated difficult airway, anesthesiologist was called in for backup. One hundred percent oxygen and pretreatment with 50 mg of intravenous ketamine were provided to the patient. Paralytic agent was not given in view of anticipated difficult airway. The first attempt by emergency physician at oral-tracheal intubation using gum-elastic bougie was unsuccessful due to swollen tongue which could not be displaced laterally with direct laryngoscope. Immediately, bag-valve-mask ventilation was resumed but unable to ventilate the patient effectively. While anesthesiologist was attempting at nasotracheal intubation, the patient sustained hypoxia and went into bradycardia and cardiorespiratory arrest. Cardiopulmonary resuscitation was started with chest compressions and 1 mg of intravenous adrenaline. In view of “CANNOT INTUBATE, CANNOT VENTILATE” situation, we prepared for emergency cricothyroidotomy. Because of the tense, extensively swollen unidentifiable neck, we were unable to locate the anatomical landmarks for cricothyroidotomy. Hence, cricothyroidotomy was deferred, and we decided to perform emergency tracheostomy. Using a number twenty surgical blade, midline vertical incision (3 cm in length) was given two fingers breadth gap above suprasternal notch. Skin and strap muscles were cut layer by layer, and trachea was identified. Horizontal incision was made through the membrane between tracheal rings and 6 mm size cuffed endotracheal tube was inserted and inflated [Figure 2]. Endotracheal tube placement was confirmed with bilaterally equal breath sounds and five-point auscultation method. Cardiopulmonary resuscitation was continued throughout the procedure as per ACLS guidelines. In spite of our resuscitation efforts, the patient expired within 30 min of arrival to the emergency department. Her postmortem examination revealed edematous supraglottic larynx.
Figure 2: Emergency tracheostomy, after failed intubation

Click here to view

  Discussion Top

Super Vasmol is a popular and an easily available hair dye in India. It is emerging as a popular means of deliberate self-harm in developing countries probably due to its low cost. The major ingredients of the hair dye are PPD, resorcinol, propylene glycol, EDTA, sodium lauryl sulfate, preservatives, and perfumes. The main compound responsible for clinical toxicity is PPD.[4] PPD is a coal-tar derivative, which on oxidation produces Bondrowski's base, an allergenic and highly toxic compound.[4] It is widely used in industrial products for color enhancement such as dyes, tattoos, gasoline, photographic development, and dark-colored cosmetics.[4] Propylene glycol is associated with hyperosmolality, raised anion gap metabolic acidosis, central nervous system depression, arrhythmias, and renal dysfunction. Resorcinol is a phenol derivative, which may also contribute to renal toxicity. The mechanism of rhabdomyolysis is due to leakage of calcium ions from the smooth endoplasmic reticulum, followed by continuous contraction and irreversible change in the muscle's structure. Rhabdomyolysis is the main cause of acute renal failure, and the morbidity is high once renal failure develops.[2] The characteristic clinical triad of hair dye poisoning is early angioneurotic edema with stridor (80%), rhabdomyolysis with chocolate-colored urine (60%), and acute kidney injury.[5] The combined effects of the individual toxicants result in significant morbidity and mortality [Table 1].
Table 1: Short and long-term toxicities of Hair dye poisoning

Click here to view

The main toxicities of this hair dye include severe edema of the face and neck which may be life-threatening and frequently requiring emergency tracheostomy which was clearly evident in our patient. Our case presented with severe angioedema of the upper airway requiring emergency tracheostomy. However, she sustained hypoxic brain injury before we could establish a patent airway. Antihistamines and steroids are commonly used in the management of airway edema because of the possibility of a hypersensitivity reaction to PPD. There is no specific antidote for PPD. Supportive management of hair dye poisoning includes managing the compromised airway through endotracheal intubation/emergency tracheostomy, antihistamines, steroids, and prevention/treatment of acute renal injury through forced alkaline diuresis and hemodialysis.[7]

It is preferable to consider tracheostomy over cricothyroidotomy in the presence of extensive neck swelling because of associated difficulty in identifying landmarks.[7]

In addition to the airway edema, fatality may occur due to rhabdomyolysis, acute renal failure, myocarditis, and hepatic failure.[8]

Mortality rate in hair dye poisoning varies from 30% to 60%.[10] Respiratory failure mainly determines the short-term mortality, whereas long-term morbidity is affected by muscular and renal damage. Early endotracheal intubation before the upper airway gets completely obstructed plays the key role in successful airway management. Delay in securing the airway leads to complete upper airway obstruction and hypoxic brain injury. In case, our patient's airway had been secured at the primary health-care center where she was taken initially, she might not have succumbed to this fatal poisoning. This case clearly signifies the importance of prehospital care and appropriate treatment during interhospital transfer.

  Conclusion Top

Hair dye poisoning is a life-threatening emergency which requires emergency resuscitation and aggressive management of the airway. Delay in establishing a patent airway may increase morbidity and mortality of the critically ill patient. All emergency physicians must be able to promptly recognize “cannot intubate and cannot ventilate” situation and be skilled in performing emergency surgical airway.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Shankar T, Babu GR, Ramakrishna S, Kathyayini B. Hair dye poisoning: A case report. J Med Dent Sci 2015;4:7869-73.  Back to cited text no. 1
Rammurthy P, Mundadan NG, Sunilkumar N, Suresh C. Super Vasmol hair dye: An emerging fatal poison. Indian J Clin Pract 2014;25:660-2.  Back to cited text no. 2
Suliman SM, Fadlalla M, Nasr Mel M, Beliela MH, Fesseha S, Babiker M, et al. Poisoning with hair-dye containing paraphenylene diamine: Ten years experience. Saudi J Kidney Dis Transpl 1995;6:286-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
Kumar PA, Talari K, Dutta TK. Super vasomol hair dye poisoning. Toxicol Int 2012;19:77-8.  Back to cited text no. 4
Chowdareddy N, Shashidhar G. Super Vasmol 33 poisoning: Case report. Sch J App Med Sci 2014;2:442-3.  Back to cited text no. 5
Kallel H, Chelly H, Dammak H, Bahloul M, Ksibi H, Hamida CB, et al. Clinical manifestations of systemic paraphenylene diamine intoxication. J Nephrol 2005;18:308-11.  Back to cited text no. 6
Garg SK, Tiwari R, Ahlawat A. Hair dye poisoning: An unusual encounter. Indian J Crit Care Med 2014;18:402-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
Senthilkumaran S, Thirumalaikolundusubramanian P. Acute hair dye poisoning: Lurking dangers. J Mahatma Gandhi Inst Med Sci 2015;20:33-7.  Back to cited text no. 8
  [Full text]  
Jain IS, Jain GC, Kaul RL, Dhir SP. Cataractogenous effect of hair dyes: A clinical and experimental study. Ann Ophthalmol 1979;11:1681-6.  Back to cited text no. 9
Sampathkumar K, Yesudas S. Hair dye poisoning and the developing world. J Emerg Trauma Shock 2009;2:129-31.  Back to cited text no. 10
[PUBMED]  [Full text]  


  [Figure 1], [Figure 2]

  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded86    
    Comments [Add]    

Recommend this journal