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"
• Easily washes out pulmonary surfactant if aspirated

Examples

• Gasoline
• Lighter fluid
• Lamp oil
• Petroleum jelly (Vaseline)
• Paint
• Paint thinners
• Polish
• Toluene

Clinical Features

Pulmonary

• Aspiration
  • Low viscosity and surface tension of hydrocarbons make them high aspiration risk
  • Additional risk factors: high volume, vomiting, gagging, choking, coughing
  • CXR on presentation nonpredictive, but usually appear by 6hrs
• ARDS

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

• Stage 1: headache, 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

• 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

Toxic gas exposure

• Carbon monoxide toxicity
• Chemical weapons
• Cyanide toxicity
• Hydrocarbon toxicity
• Hydrogen sulfide toxicity
• Inhalant abuse
• Methane toxicity
• Smoke inhalation injury
• Ethylene dibromide toxicity

Evaluation

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 with aggressive IVF
• Avoid dopamine, epinephrine, norepinephrine (may cause dysrhythmias), procainamide (may cause arrhythmias), and amiodarone (QT prolongation)
• Treat ventricular dysrhythmias with propranolol, esmolol, or lidocaine
  • Due to overstimulation of beta receptors by hydrocarbon

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

See Also

• Toxicology (Main)
• Inhalants