Hydrocarbon toxicity

Background

• Typical exposures:
  • Unintentional exposure (generally young children)
  • Intentional abuse (generally adolescents, young adults)
  • Occupational exposure - dermal, inhalation
• Intentional abuse methods:
  • Huffing= hydrocarbon soaked into rag and placed over mouth and nose
  • Bagging= hydrocarbon placed in a bag and fumes inhaled
  • Sniffing= hydrocarbon inhaled directly
• High volatility, low viscosity → high risk for aspiration despite "simple ingestion"

Examples

• Gasoline
• Lighter fluid
• Lamp oil
• Petroleum jelly (Vaseline)
• Paint
• Paint thinners
• Polish

Clinical Features

• Pulmonary: aspiration
  • Risk factors: high volume, vomiting, gagging, choking, coughing
  • CXR on presentation nonpredictive, but usually appear by 6hrs

• Cardiac: arrhythmias, 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

Differential Diagnosis

Drugs of abuse

• 25C-NBOMe‎
• Alcohol
• Amphetamines
• Bath salts
• Cocaine
• Ecstasy
• Gamma hydroxybutyrate (GHB)
• Heroin
• Inhalant abuse
  • Hydrocarbon toxicity
  • Difluoroethane (electronics duster)
• Marijuana
• Kratom
• Phencyclidine (PCP)
• Psilocybin ("magic mushrooms")
• Synthetic cannabinoids
• Chloral hydrate
• Body packing

Diagnosis

Workup

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

Evaluation

• Clinical diagnosis, based on history and physical exam

Management

1. 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
2. Cardiovascular
   • Treat hypotension with aggressive IVF
   • Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias)
   • Treat ventricular dysrhythmias with propranolol, esmolol, or lidocaine
3. Dermal
   • Pre-arrival decontamination, remove clothing
   • Soap and water, saline for eye exposure
4. GI
   • GI decontamination controversial
   • Majority do not benefit

Disposition

• Discharge after 6 hour observation if:
  • Asymptomatic
  • Normal vital signs (including SpO2)
  • No abnormal pulmonary findings
  • Normal CXR at 6hrs post exposure
    • If asymptomatic but radiographic evidence of pneumonitis, consider discharge with 24-hour follow-up.
• Admit:
  • Clinical evidence of toxicity

See Also

• Toxicology (Main)
• Inhalants