Hydrocarbon toxicity: Difference between revisions

(Text replacement - "2/2" to "secondary to")
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*Cardiac: arrhythmias, Afib, PVCs, Vtach, torsades
*Cardiac: arrhythmias, Afib, PVCs, Vtach, torsades
* "Sudden sniffing death syndrome"= suspected cardiac sensitization to catecholamines
*"Sudden sniffing death syndrome"= suspected cardiac sensitization to catecholamines
**Classic scenario: Sniffer is startled during use, collapses and dies
**Classic scenario: Sniffer is startled during use, collapses and dies
* CNS/PNS <ref> Tormoehlen L et al. Hydrocarbon toxicity: A review. Clinical toxicology 2014; 52: 479-489 </ref>
*CNS/PNS <ref> Tormoehlen L et al. Hydrocarbon toxicity: A review. Clinical toxicology 2014; 52: 479-489 </ref>
**Stage 1: HA, dizziness, nausea, tinnitus
**Stage 1: HA, dizziness, nausea, tinnitus
**Stage 2: Slurred speech, confusion, hallucinations, diplopia, ataxia
**Stage 2: Slurred speech, confusion, hallucinations, diplopia, ataxia
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==Management==
==Management==
#Pulmonary
#Pulmonary
#* Secure airway, if needed.  
#*Secure airway, if needed.  
#* Beta2 agonist if wheezing (not proven benefit), consider [[Bipap]]/[[Cpap]] (may further barotrauma)
#*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
#*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
#*Antibiotic prophylaxis show no benefit, but use if superinfection present
#* Steroids not recommended  for chemical pneumonitis and can lead to increased superinfection
#*Steroids not recommended  for chemical pneumonitis and can lead to increased superinfection
#Cardiovascular
#Cardiovascular
#* Treat hypotension with aggressive [[IVF]]
#*Treat hypotension with aggressive [[IVF]]
#* Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias)
#*Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias)
#* Treat ventricular dysrhythmias with [[propranolol]], [[esmolol]], or [[lidocaine]]
#*Treat ventricular dysrhythmias with [[propranolol]], [[esmolol]], or [[lidocaine]]
#Dermal
#Dermal
#* Pre-arrival decontamination, remove clothing
#*Pre-arrival decontamination, remove clothing
#* Soap and water, saline for eye exposure
#*Soap and water, saline for eye exposure
#GI
#GI
#* [[GI decontamination]] controversial
#*[[GI decontamination]] controversial
#* Majority do not benefit
#*Majority do not benefit


==Disposition==
==Disposition==

Revision as of 15:41, 4 July 2016

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 [1]
    • Stage 1: HA, dizziness, nausea, tinnitus
    • Stage 2: Slurred speech, confusion, hallucinations, diplopia, ataxia
    • Stage 3: Obtundation, seizure, death
  • Renal: Toluene in particular may cause weakness secondary to severe hypokalemia

Differential Diagnosis

Drugs of abuse

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

  1. 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
  2. Cardiovascular
    • Treat hypotension with aggressive IVF
    • Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias)
    • Treat ventricular dysrhythmias with propranolol, esmolol, or lidocaine
  3. Dermal
    • Pre-arrival decontamination, remove clothing
    • Soap and water, saline for eye exposure
  4. 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
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