Hydrocarbon toxicity: Difference between revisions

Revision as of 16:11, 7 August 2015

Background

usual exposures:

kids with unintentional exposure
occupational exposure - dermal, inhalational
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

risk factors: high volume, vomiting, gagging, choking, coughing
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

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

Authors:

@@ Line 5: / Line 5: @@
 # 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===
@@ Line 20: / Line 25: @@
 # CXR on presentation nonpredictive, but usually appear by 6hrs
-*cardiac: arrhythmogenic, Afib, PVCs, Vtach, torsade, "sudden sniffing syndrome"
+*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
@@ Line 26: / Line 33: @@
 * CXR: immediately if symptomatic, otherwise early CXR not predictive of pneumonitis. Observe for 4-6hrs then obtain CXR
 * EKG: dysrhythmias
-* labs: if toxic, to ascertain electrolytes, acid/base status
+* Lab: As needed To evaluate for acidosis, anemia, renal/hepatic toxicity, coagulation, methemoglobinemia, carboxyhemoglobinemia depending on specific exposure
 ==Management==
-* antiobiotic prophylaxis show no benefit, but patients are at risk for superinfection
+Pulmonary<br />
-* steroids not recommended and can lead to increased superinfection
+* Secure airway, if needed.
-* patients with severe toxicity will need intubation, high PEEP, possibly high frequency jet ventilation, and ECMO for refractory hypoxemia
+* 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<br />
+* Treat hypotension w aggressive IVF
+* Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias)
+* Treat ventricular dysrhythmias with propranolol, esmolol or lidocaine
+Dermal<br />
+* pre-ED decontamination, remove clothing
+* soap and water, saline for eye exposure
+GI<br />
+* GI decontamination controversial
+* Majority do not benefit
 ==Disposition==
-* Home
+* Home if:
 **6hrs of obs
 **no abnormal lung findings
 **adequated O2
 **not tachypneic
-**nl CXR at 6hrs
+**normal CXR at 6hrs
 *Expedited Follow Up
-**Asymptomatic BUT radiographic e/o pneumonitis, home with follow up next day
+**If asymptomatic BUT radiographic evidence of pneumonitis, home with follow up next day
-*Admit
+*Admit if:
-**clinical e/o toxicity or intentional ingestion
+**clinical evidence of toxicity or intentional ingestion
 ==See Also==
@@ Line 54: / Line 74: @@
 *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.
-<references/>
+<references/><br />
+Tintinalli's Emergency Medicine
 [[Category:Tox]]