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
    • Low viscosity and surface tension of hydrocarbons make them high aspiration risk
    • Additional 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 [1]

Renal

  • Toluene in particular may cause weakness secondary to severe hypokalemia

Differential Diagnosis

Drugs of abuse

Evaluation

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

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

Dermal

  • Pre-arrival decontamination, remove clothing
  • Soap and water, saline for eye exposure

GI

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

References

  1. Tormoehlen L et al. Hydrocarbon toxicity: A review. Clinical toxicology 2014; 52: 479-489

Authors:

Ross Donaldson