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

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

• Toxicology (Main)
• Inhalants

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.