Hydrocarbon toxicity

Background

• usual exposures:

1. kids with unintentional exposure
2. occupational exposure - dermal, inhalational
3. adolescent, young adults - intentional abuse

• high volatility, low viscosity make them a set-up for aspiration, despite "simple ingestion"

Definitions

• "huffing"= soaks inhalant in rag and places over mouth and nose
• "bagging"= hydrocarbon placed in a bag and inhales deeply
• "sniffing"= hydrocarbon inhaled directly

Examples

• Gasoline
• Charcoal starter
• Lamp oil
• Petroleum jelly
• Paint
• Paint thinners
• Polish

Clinical Features

• pulm: aspiration

1. risk factors: high volume, vomiting, gagging, choking, coughing
2. CXR on presentation nonpredictive, but usually appear by 6hrs

• cardiac: arrhythmogenic, Afib, PVCs, Vtach, torsades
• "sudden sniffing death syndrome"= suspected cardiac sensitization to catecholamines
  • Classic scenario: Sniffer is startled during use, collapses and dies
• CNS/PNS: excitation, followed by depression, ataxia, neuropathy

Workup

• CXR: immediately if symptomatic, otherwise early CXR not predictive of pneumonitis. Observe for 4-6hrs then obtain CXR
• EKG: dysrhythmias
• Lab: As needed To evaluate for acidosis, anemia, renal/hepatic toxicity, coagulation, methemoglobinemia, carboxyhemoglobinemia depending on specific exposure

Management

Pulmonary

• Secure airway, if needed.
• Beta2 agonist if wheezing (not proven benefit), consider Bipap/Cpap (may further barotrauma)
• Severe toxicity will need intubation, high PEEP, possibly high frequency jet ventilation, and ECMO for refractory hypoxemia
• antibiotic prophylaxis show no benefit, but use if superinfection present
• steroids not recommended for chemical pneumonitis and can lead to increased superinfection

Cardiovascular

• Treat hypotension w aggressive IVF
• Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias)
• Treat ventricular dysrhythmias with propranolol, esmolol or lidocaine

Dermal

• pre-ED decontamination, remove clothing
• soap and water, saline for eye exposure

GI

• GI decontamination controversial
• Majority do not benefit

Disposition

• Home if:
  • 6hrs of obs
  • no abnormal lung findings
  • adequated O2
  • not tachypneic
  • normal CXR at 6hrs
• Expedited Follow Up
  • If asymptomatic BUT radiographic evidence of pneumonitis, home with follow up next day
• Admit if:
  • clinical evidence of toxicity or intentional ingestion

See Also

Toxicology (Main) Inhalants

Sources

Goldfrank's Toxicologic Emergencies

• Bass M. Sudden sniffing death. JAMA. 1970;212:2075-2079
• Bysani BK et al. Treatment of hydrocarbon pneumonitis: high frequency jet ventilation as an alternative to extracorporeal membrane oxygenation. Chest. 1994;106:300-303.
• Brock WJ et al. Cardiac sensitization: methadology and interpretation in risk assessment. Toxicol Pharmacol. 2003;38:78-90.

Tintinalli's Emergency Medicine