Toxin

Hydrocarbon Ingestion

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Hydrocarbon Ingestion, Hydrocarbon Aspiration, Motor Oil Ingestion, Gasoline Ingestion, Lighter Fluid Ingestion, Petroleum Product Poisoning, Halogenated Hydrocarbon, Aromatic Hydrocarbon, Aliphatic hydrocarbon, Toxic Effect of Hydrocarbon Gas, Toxic Effect of Petroleum

  • Definitions
  1. Hydrocarbon Ingestion
    1. Broad class of compounds
    2. Examples: Motor oil, gasoline or Lighter Fluid Ingestion
  • Epidemiology
  1. Acute toxic exposures in U.S.: 28,000 per year (50% are pediatric)
    1. Intentional (e.g. Huffing, Suicide) in 15% of cases
    2. Occupational Asthma
  • Pathophysiology
  1. Types of hydrocarbons
    1. Straight or branched chain hydrocarbons (aliphatic)
    2. Ring shaped hydrocarbons (aromatic)
    3. Halogenated Hydrocarbons
  2. Toxicity
    1. Rapidly absorbed into the cellular lipid bilayer
    2. Interacts with cellular functionality
  3. Routes of Injury
    1. Chemical Burns to skin
    2. Ingestion (and aspiration risk, esp. in first 30 minutes)
    3. Inhalation Injury
  • Precautions
  1. Aspiration into lungs (with Vomiting) is greatest risk
    1. Common complication of ingestion with Vomiting (esp. in first 30 minutes of ingestion)
    2. Suspect aspiration if presents with coughing, gagging, Choking, respiratory distress, Hypoxia
    3. Aspiration is more likely with less viscous, low surface tension, high volatility hydrocarbons
      1. Gasoline
      2. Kerosene
      3. Naphtha
    4. High viscosity aspirations (e.g. motor oil) are less likely except in decreased airway protection (low GCS)
  2. Hydrocarbons are directly toxic to pneumocytes (which produce surfactant)
    1. Results in pneumocyte destruction, non-compliant lungs and ARDS
  • Findings
  • All Hydrocarbons
  1. Cardiovascular dysfunction
    1. Hypertension
    2. Tachyarrythmias (including Ventricular Tachycardia)
    3. Catecholamine surge
      1. Fever
      2. Hypertension
      3. Tachycardia
    4. Myocardial sensitization to Catecholamines and prolonged cardiac depolarization
      1. Risk of QTc Prolongation (risk of Ventricular Tachycardia, Torsades de Pointes)
      2. Common with Halogenated Hydrocarbons (e.g. chloroform)
      3. May occur with other hydrocarbons
  2. Pulmonary
    1. Pneumonitis
    2. Pulmonary Edema
    3. Asphyxia
  3. Neurologic
    1. Lethargy to Coma
    2. Seizures
    3. Euphoria
    4. Hallucinations
  • Findings
  • Specific Hydrocarbons
  1. Amyl nitrite
    1. Methemoglobinemia
  2. Chlorinated hydrocarbons
    1. Hepatic Dysfunction
  3. Chlorofluorocarbons
    1. Cold Injury
    2. Pulmonary Edema
  4. Methylene Chloride (Dichloromethane)
    1. Carbon Monoxide Poisoning
  5. N-Hexane
    1. Neuropathy
  6. Toluene (e.g. Huffing)
    1. Hypokalemia
    2. Acute Kidney Injury
    3. Hepatotoxicity
    4. High Anion Gap Metabolic Acidosis
    5. Altered Mental Status
    6. Ataxia
  • Imaging
  1. Chest XRay
    1. Demonstrates aspiration findings within 6 hours in 90% of volatile Hydrocarbon Aspirations
  • Diagnostics
  1. Electrocardiogram
  2. Telemetry monitoring
  • Management
  1. Decontamination
    1. Use soap and water (except in phenol exposure)
    2. Use topical Polyethylene glycol for phenol exposure
    3. Avoid charcoal
      1. Not effective and risk of further aspiration
    4. Avoid Nasogastric Tube in most Hydrocarbon Ingestions (NG ineffective)
      1. Exceptions: Organophosphates, carbon tetrachloride, Benzene, methylene chloride
  2. ABC Management with Primary Survey and Secondary Survey
    1. Evaluate for aspiration with secondary respiratory and airway compromise
    2. Evaluate for hemodynamic instability
    3. Evaluate for decreased mental status
    4. Consider Endotracheal Intubation (see Advanced Airway for indications)
  3. Normalize electolyte abnormalities
    1. Correct Serum Potassium
    2. Correct Serum Magnesium
  4. Consider nebulized Bronchodilators (e.g. Albuterol)
    1. Avoid systemic Terbutaline (may worsen tachydysrhythmia)
    2. Avoid Corticosteroids (not effective)
  5. Stabilize Hypotension
    1. Fluid Resuscitation
    2. Avoid strong Beta adrenergic Vasopressors (e.g. Epinephrine, Dopamine)
    3. Decrease Positive End-Expiratory Pressure (PEEP)
    4. Consider Intravenous Phenylephrine if Vasopressor needed
  6. Manage Ventricular Arrhythmias
    1. Follow ACLS Protocol for Ventricular Fibrillation or Ventricular Tachycardia (with the following exceptions)
    2. Avoid Epinephrine
    3. Employ Antiarrhythmics (e.g. Amiodarone, Lidocaine) early
    4. Consider Beta Blocker in refractory ventricular Arrhythmia (decreases myocardial Hypersensitivity)
      1. Consider Esmolol 500 mcg/kg IV bolus, followed by 50 mcg/kg/min
  7. Disposition
    1. Observe asymptomatic patients for 6 hours
      1. Obtain repeat Chest XRay at 6 hours
      2. If no signs or symptoms of aspiration at 6 hours, typically safe to discharge
    2. Arrange transfer to higher level of care if signs of aspiration
      1. ECMO may be considered
      2. Exogenous surfactant has been used
  • Complications
  1. Chronic neurologic hematologic or oncologic sequelae
  • References
  1. Swadron and Nordt in Herbert (2017) EM:Rap 17(7): 14
  2. Kinker and Glauser (2021) Crit Dec Emerg Med 35(9): 19-27