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
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-arrival 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