Rosen & Barkin's 5-Minute Emergency Medicine Consult (356 page)

• Accidental exposures typical in young children
  
• Inhalation abuse of volatile hydrocarbons
  
• Suicide attempts in adolescents and adults
  

DIAGNOSIS

• Often asymptomatic at presentation
  
• Odor of hydrocarbons on breath
  
• Early: Euphoria:
  
  • Disinhibition
    
• Late: Dysphoria:
  
  • Ataxia
    
  • Confusion
    
  • Hallucination
    
• Sudden sniffing death:
  
  • Cardiac arrest in volatile-substance abusers secondary to hypersensitization of myocardium leading to malignant dysrhythmias on adrenergic stimulation
    
• Pulmonary:
  
  • Mild to severe respiratory distress
    
  • Cyanosis
    
  • Aspiration (primary complication)
    
• CNS:
  
  • Intoxication
    
  • Euphoria
    
  • Slurred speech
    
  • Lethargy
    
  • Coma
    
• GI tract:
  
  • Local mucosal irritation
    
  • Gastritis
    
  • Diarrhea
    
• Cardiac:
  
  • Tachycardia
    
  • Dysrhythmias (volatile-substance abuse)
    
• Dermal:
  
  • Local erythema
    
  • Maculopapular or vesicular eruptions
    
  • Defatting dermatitis from chronic skin exposure
    
  • Huffer face rash in chronic abusers
    

• Route, type, quantity, and time of exposure:
  
  • Determine intentionality and coingestions
    
• Symptoms:
  
  • Vomiting, respiratory distress, mental status change or pain
    
• Bystander actions or pre-hospital interventions
  

• Evaluate for airway compromise in patients with decreased level of consciousness and vomiting
  
• Respiratory symptoms generally occur within 30 min but are frequently delayed several hours
  
• Monitor for hypoxia, hypotension, and cardiac dysrhythmias
  
• Cyanosis and hypoxia suggest respiratory failure but may result from methemoglobinemia
  
• Temperature may be elevated at presentation following aspiration and indicates pneumonitis:
  
  • Fever after 48 hr suggests bacterial superinfection
    

Obtain information on the following:

• Product: Exact name on label, manufacturer, and ingredients
  
• Nature of ingestion or exposure: Accidental or intentional
  
• Estimated amount ingested
  
• In industrial settings, Material Safety Data Sheets (MSDSs)
  

ECG for intoxicated volatile-substance abusers

• Pulse oximetry:
  
  • If abnormal, follow with arterial blood gases.
    
• Electrolytes; BUN, creatinine, and glucose levels; and liver function tests:
  
  • For halogenated and aromatic hydrocarbon exposure
    
  • Metabolic acidosis
    
  • Hypokalemia
    
• Carboxyhemoglobin levels for methylene chloride exposure:
  
  • Methylene chloride metabolized to carbon monoxide in vivo
    

CXR:

• Abnormalities visible 20 min–24 hr after exposure (usually by 6 hr)
  
• Increased bronchovascular marking and bibasilar and perihilar infiltrates (typical)
  
• Lobar consolidation (uncommon)
  
• Pneumothorax, pneumomediastinum, and pleural effusion (rare)
  
• Pneumatoceles resolve over weeks
  
• Repeat chest radiograph if worsening respiratory symptoms
  

• Caustic, pesticide, or toxic alcohol ingestions
  
• Accidental vs. intentional:
  
  • Psychiatric evaluation for all intentional ingestions
    
• Child neglect:
  
  • Poor supervision or unsafe home environment
    

TREATMENT

• Decontaminate clothes, skin, and hair of any hydrocarbon exposure
  
• Do not induce emesis.
  
• Ipecac contraindicated owing to increased risk of aspiration
  
• Keep volatile-substance abusers calm and avoid interventions that cause anxiety or distress.
  
• Management of
  accidental
  hydrocarbon exposures at home controversial:
  
  • <1% require physician intervention.
    
  • For asymptomatic or quickly asymptomatic after ingestion with reliable observer available
    
  • Applies only when exact product and its components are known and there is no indication for gastric decontamination or possibility for delayed organ toxicity
    

• ABCs
  
• IV access and fluid resuscitation if hypotensive or ongoing fluid losses
  
• Oxygen
  
• Cardiac monitor
  
• Naloxone, thiamine, D
  ₅₀
  W (or Accu-Chek) if altered mental status
  

• Supportive care
  
• Treat respiratory symptoms:
  
  • Oxygen
    
  • Nebulized
    
  • β
    ₂
    -agonist for bronchospasm (albuterol)
    
  • Endotracheal intubation and mechanical ventilation for respiratory failure
    
  • Steroids not indicated for bronchospasm
    
  • Avoid using epinephrine in volatile-substance abusers as it may precipitate dysrhythmias
    

• Albuterol 2.5–5 mg NEB (peds: 0.15–0.3 mg/kg) for bronchospasm
  
• Dextrose: D
  ₅₀
  W 1 ampule of 50 mL or 25 g (peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• Symptomatic patients
  
• Patients with potential delayed organ toxicity (carbon tetrachloride or other toxic additives)
  

• Observe for 6 hr then discharge:
  
  • Asymptomatic patients with normal chest radiograph and pulse oximetry findings
    
  • Asymptomatic patients with abnormal CXR and normal oxygenation and respiratory rate may be discharged if reliable follow-up is ensured.
    
  • Symptomatic patients on presentation who quickly become asymptomatic
    
• Observe volatile-substance abusers until mental status clears.
  

Psychiatry consultation as needed

• Follow up in 24 hr for patients who remain asymptomatic after a minimum of 6 hr observation
  
• Asymptomatic patients with an abnormal CXR should have a repeat study in 24 hr
  

• Main complication from hydrocarbon exposure is aspiration:
  
  • Aspiration risk is inversely related to viscosity and surface tension and directly related to volatility
    
• Provide external decontamination
  
• Gastric decontamination is rarely indicated
  
• Avoid induced emesis and cathartics
  
• Observe patients a minimum of 6 hr post ingestion for evidence of toxicity
  
• Admit symptomatic patients to hospital
  
• Admit when there is potential for delayed organ toxicity
  
  • CHAMP
    

• Anas N, Namasonthi V, Ginsburg CM. Criteria for hospitalizing children who have ingested products containing hydrocarbons.
  JAMA
  . 1981;246:840–843.
  
• Dice WH, Ward G, Kelly J, et al. Pulmonary toxicity following gastrointestinal ingestion of kerosene.
  Ann Emerg Med
  . 1982;11:138–142.
  
• Esmail A, Meyer L, Pottier A, et al. Deaths from volatile substance abuse in those under 18 years: Results from a national epidemiological study.
  Arch Dis Child
  . 1993;69:356–360.
  
• Hydrocarbons. In
  Poisindex® System [internet database]
  . Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
  
• Klein BL, Simon JE. Hydrocarbon poisonings.
  Pediatr Clin North Am
  . 1986;33:411–419.
  
• Machado B, Cross K, Snodgrass WR. Accidental hydrocarbon ingestion cases telephoned to a regional poison center.
  Ann Emerg Med
  . 1988;17:804–807.
  

CODES