Hydrocarbon toxicity: Difference between revisions
Kghaffarian (talk | contribs) (revamped page, deeper discussion of treatment, added definitions) |
No edit summary |
||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
* | *Typical exposures: | ||
**Unintentional exposure (generally young children) | |||
**Intentional abuse (generally adolescents, young adults) | |||
**Occupational exposure - dermal, inhalation | |||
* | *High volatility, low viscosity → high risk for aspiration despite "simple ingestion" | ||
*Definitions | |||
**"huffing"= soaks inhalant in rag and places over mouth and nose | |||
* "huffing"= soaks inhalant in rag and places over mouth and nose | **"bagging"= hydrocarbon placed in a bag and inhales deeply | ||
* "bagging"= hydrocarbon placed in a bag and inhales deeply | **"sniffing"= hydrocarbon inhaled directly | ||
* "sniffing"= hydrocarbon inhaled directly | |||
===Examples=== | ===Examples=== | ||
*Gasoline | *Gasoline | ||
* | *Lighter fluid | ||
*Lamp oil | *Lamp oil | ||
*Petroleum jelly | *Petroleum jelly (Vaseline) | ||
*Paint | *Paint | ||
*Paint thinners | *Paint thinners | ||
| Line 30: | Line 29: | ||
* CNS/PNS: excitation, followed by depression, ataxia, neuropathy | * CNS/PNS: excitation, followed by depression, ataxia, neuropathy | ||
==Workup== | ==Differential Diagnosis== | ||
* CXR: immediately if symptomatic, otherwise early CXR not predictive of pneumonitis. Observe for 4-6hrs then obtain CXR | |||
* | |||
==Diagnosis== | |||
*Clinical 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 | |||
*EKG | |||
==Management== | ==Management== | ||
| Line 54: | Line 59: | ||
==Disposition== | ==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: | ||
**If asymptomatic | **Clinical evidence of toxicity | ||
*Admit | |||
** | |||
==See Also== | ==See Also== | ||
| Line 69: | Line 72: | ||
[[Inhalants]] | [[Inhalants]] | ||
== | ==References== | ||
<references/> | |||
*Bass M. Sudden sniffing death. JAMA. 1970;212:2075-2079 | *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. | *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. | *Brock WJ et al. Cardiac sensitization: methadology and interpretation in risk assessment. Toxicol Pharmacol. 2003;38:78-90. | ||
[[Category:Tox]] | [[Category:Tox]] | ||
Revision as of 06:06, 9 August 2015
Background
- Typical exposures:
- Unintentional exposure (generally young children)
- Intentional abuse (generally adolescents, young adults)
- Occupational exposure - dermal, inhalation
- High volatility, low viscosity → high risk 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
- Lighter fluid
- Lamp oil
- Petroleum jelly (Vaseline)
- 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
Differential Diagnosis
Diagnosis
- Clinical 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
- EKG
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
- 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
- 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.