AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Randy J Goldstein, MD, FACEP, FAAP, Medical Director, Emergency Department, Las Palmas Medical Center, El Paso, Texas
Randy J Goldstein is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Editors: William T Zempsky, MD, Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center; Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
hydrocarbon toxicity, hydrocarbon aspiration, hydrocarbon poisoning, gasoline, turpentine, furniture polish, household cleansers, propellants, kerosene, pine oil, sniffing, huffing, bagging
Background
Exposure to hydrocarbons is common in modern society. Hydrocarbons are easily accessible in products such as gasoline, turpentine, furniture polish, household cleansers, propellants, kerosene, and other fuels. Although hydrocarbons include all compounds composed predominantly of carbon and hydrogen, the compounds of interest are derived from petroleum and wood. Most of the dangerous hydrocarbons are derived from petroleum distillates and include aliphatic (straight-chain) hydrocarbons and aromatic (benzene-containing) hydrocarbons. Other hydrocarbons such as pine oil and turpentine are derived from wood.
Types of exposure include accidental ingestion, intentional recreational abuse, accidental inhalation, and dermal exposure or oral ingestion in a suicide attempt. The highest rates of morbidity and mortality result from accidental ingestion by children younger than 5 years. Aspiration pneumonitis is the most common complication of hydrocarbon ingestion, followed by central nervous system (CNS) and cardiovascular complications.
Pathophysiology
The toxic potential of hydrocarbons is directly related to their physical properties. Viscosity refers to the compound's resistance to flow; as the viscosity increases, the aspiration potential decreases. Volatility refers to the compound's ability to vaporize. Highly volatile compounds with low viscosity are more likely to be inhaled or aspirated into the respiratory system.
Pulmonary effects
Pulmonary toxicity is the result of hydrocarbon aspiration. The lower the viscosity and higher the volatility, the greater the risk of pulmonary aspiration. The hydrophobic nature of hydrocarbons allows them to penetrate deep into the tracheobronchial tree, producing inflammation and bronchospasm. The volatile chemical may displace alveolar oxygen, leading to hypoxia. Direct contact with alveolar membranes can lead to hemorrhage, hyperemia, edema, surfactant inactivation, leukocyte infiltration, and vascular thrombosis. The result is poor oxygen exchange, atelectasis, and pneumonitis.
Respiratory symptoms generally begin in the first few hours after exposure and usually resolve in 2-8 days. Complications include hypoxia, barotrauma due to mechanical ventilation, and adult respiratory distress syndrome (ARDS). Prolonged hypoxia may result in encephalopathy, seizures, and death.
Gastrointestinal effects
Local irritation is the usual GI manifestation of hydrocarbon ingestion. Abdominal pain and nausea are common complaints. Vomiting increases the likelihood of pulmonary aspiration.
CNS effects
Hydrocarbon toxicity produces various CNS effects. Initial effects are similar to the disinhibition observed in patients with alcohol intoxication. Narcoticlike depression may also be observed. Euphoria may develop, as in alcohol or narcotic toxicity. Eventually, lethargy, headache, obtundation, and coma may follow. Seizures are uncommon and are believed to be due to hypoxia.
Cardiac effects
Dysrhythmias are a major concern. Etiologies include hypoxia, myocardial sensitization to catecholamines, and direct myocardial damage. Sudden death has been reported as a result of coronary vasospasm due to hydrocarbon inhalation.
Other effects
Hydrocarbons are reported to cause bone marrow toxicity and hemolysis. Chlorinated hydrocarbon toxicity may cause hepatic and renal failure, and toluene toxicity may lead to renal tubular acidosis. Direct contact with the skin and mucous membranes may cause effects ranging from local irritation to extensive chemical burns.
Frequency
United States
An estimated 80,000 hydrocarbon exposures are reported to poison centers annually. Most exposures are unintentional and involve young children.
Mortality/Morbidity
- Pulmonary toxicity is the major cause of morbidity and mortality. Approximately 20 deaths per year result from hydrocarbon poisoning; most of these deaths occur in children younger than 5 years.
- Long-term exposure may result in significant morbidity. Cardiomyopathy, cerebellar atrophy, dementia, cognitive deficits, and peripheral neuropathy have all been reported with long-term hydrocarbon inhalant abuse.
- Sudden death has been reported as a result of coronary vasospasm due to hydrocarbon inhalation.
Age
- Accidental ingestion usually occurs in children younger than 5 years. Improper storage and mislabeled containers of hydrocarbons are common contributing factors.
- Abuse by inhalation is most common in adolescents and young adults.
History
- Unintentional ingestion
- The most common scenario involves a young child whose ingestion is often not witnessed. The parent may smell the chemical on the child's skin, clothing, or breath, or they may report that their child is coughing, choking, cyanotic, or vomiting.
- If the ingestion is unwitnessed, the amount ingested is usually impossible to quantify.
- Sources of ingested hydrocarbons range from cleaning products in the kitchen to solvents in the garage. Often, these chemicals are not properly labeled, or they are inadvertently stored in a beverage container.
- A history of coughing, choking, vomiting, or cyanosis is highly correlated with the likelihood of pulmonary aspiration.
- Intentional inhalation
- Volatile hydrocarbons can be inhaled by means of a variety of techniques.
- Sniffing involves inhaling the fumes of a liquid from an open container.
- Huffing involves applying the chemical to a cloth or rag and then inhaling the hydrocarbon by covering the nose and mouth with the cloth or rag.
- Bagging involves placing the hydrocarbon in a bag and then placing the bag over the face to inhale the fumes.
Physical
In cases of hydrocarbon aspiration, the patient's temperature may be elevated due to the body's reaction to the foreign substance.
Other findings at physical examination may include the following:
- Respiratory findings
- Coughing
- Choking
- Fever
- Tachypnea
- Grunting
- Cyanosis
- Rales
- Wheezing
- CNS findings
- Headache
- Dizziness
- Lethargy
- Ataxia
- Seizures
- Coma
- Gastrointestinal findings
- Nausea
- Vomiting
- Abdominal pain
- Cardiac finding: Arrhythmia
- Cutaneous findings
- Mucosal irritation
- Chemical burns
Causes
- Aliphatic hydrocarbons
- Fuels
- Solvents
- Furniture polish and paints
- Aromatic hydrocarbons
- Halogenated hydrocarbons
- Refrigerants
- Propellants
- Cleaning products
- Paint strippers
- Solvents
- Wood distillates
Atelectasis, Pulmonary
Inhalation Injury
Near Drowning
Pneumonia
Respiratory Distress Syndrome
Lab Studies
- ABG assessment
- ABG analysis is useful in documenting hypoxemia in severely affected patients.
- Hypercarbia may be observed in patients with respiratory depression and decreased gas exchange.
- Serum chemical tests
- In the acute phase, serum chemical results are expected to be within the normal ranges.
- An increased anion gap may indicate co-ingestion of another toxin.
Imaging Studies
- Chest radiography
- A chest radiograph must be obtained in all symptomatic patients.
- Initially, the chest radiographic results may be normal, but positive findings may develop over the first few hours after ingestion.
- Common findings include fine perihilar opacities, bibasilar infiltrates, and atelectasis.
- Obtain repeat radiographs if any acute change in the patient's respiratory status occurs because a pneumothorax or pneumomediastinum may develop.
- If discharge is being considered for an asymptomatic patient, a chest radiograph should be obtained 6 hours after the ingestion to document the negative findings.
Other Tests
- Bedside pulse oximetry is useful in the emergency department because hypoxia is a direct result of hydrocarbon aspiration.
- Obtain an ECG if cardiac arrhythmia is a concern.
Medical Care
- Airway, breathing, and circulation: Stabilization of the airway is always the first priority of treatment. Give supplemental oxygen to all patients, and perform beside pulse oximetry. Early intubation, mechanical ventilation, and use of positive end-expiratory pressure may be warranted in a patient in whom oxygenation is inadequate or in a patient who has severe respiratory distress or a decreased level of consciousness. Take all precautions to minimize the patient's risk of vomiting and further aspiration. A trial of bronchodilators may prove useful in patients with suspected bronchospasm.
- Cutaneous decontamination in cases of cutaneous exposure: Decontaminate the skin as soon as possible by removing the involved clothing and thoroughly washing the skin with soap and water. Vapor inhalation and cutaneous absorption may occur long after the exposure. Health care providers must take precautionary action to minimize their own exposure to the toxic substance.
- Gastric decontamination in cases of oral ingestion: Gastric decontamination is controversial. If gastric decontamination is considered, the airway must be stabilized to minimize the risk of aspiration secondary to the patient's vomiting. Because a major complication of hydrocarbon ingestion is aspiration, reserve the use of gastric decontamination for only cases of large intentional ingestions or those involving an increased risk of systemic toxicity.
- Gastric decontamination includes the induction of emesis by administering ipecac syrup and then gastric lavage.
- The use of ipecac syrup is rarely indicated to induce emesis; exceptions involve situations in which the patient's mental status is within normal limits and in which a large volume of a known toxic substance has been ingested. Never induce emesis after the ingestion of a low-viscosity hydrocarbon (eg, gasoline, kerosene, furniture polish, mineral spirits) because the aspiration risk is high. The induction of emesis is rarely indicated in children because they usually do not ingest a large volume.
- Regarding gastric lavage, the risk and complications of aspiration outweigh the benefits. If lavage is attempted, nasogastric lavage is advised because the ingested substance is a liquid, and the use of a large-caliber orogastric tube greatly increases the risk of vomiting and aspiration. Lavage is useful in cases in which the hydrocarbon has an inherent systemic toxicity or contains additives with known toxicity.
- A useful mnemonic for remembering such hydrocarbons is CHAMP, which stands for the following: camphor, halogenated hydrocarbons, aromatic hydrocarbons, (heavy) metal-containing hydrocarbons, and pesticide-containing hydrocarbons.
- Activated charcoal has a limited role in the management of hydrocarbon ingestion. Charcoal poorly adsorbs most hydrocarbons. Furthermore, charcoal tends to distend the stomach and cause vomiting, increasing the aspiration potential. The use of activated charcoal is indicated in cases of a suicide attempt or in cases in which another adsorbable toxic substance have been co-ingested.
Consultations
- Contact the local poison control center in all hydrocarbon ingestions.
- Consult a psychiatrist, psychologist, or other mental health professional if the exposure was a result of a suicide attempt.
- A substance abuse professional may provide assistance in cases of recreational or long-term hydrocarbon abuse.
No specific antidotes are available. Treatment with corticosteroids and prophylactic antibiotics is not beneficial. In some cases, steroids may be harmful.
Further Inpatient Care
- Patients may be safely discharged home if all of the following conditions are met:
- They have been observed in the emergency department for at least 6 hours.
- They are asymptomatic.
- Their chest radiographic findings are normal.
- They are instructed to return if respiratory symptoms develop.
- Patients who have respiratory symptoms consistent with hydrocarbon aspiration should be observed or admitted to the hospital for at least 12 hours. Patients whose respiratory symptoms improve during this time may be safely discharged home.
- Patients who have respiratory distress and require mechanical ventilation should be admitted to an intensive care unit.
Deterrence/Prevention
- For primary prevention, see Patient Education.
- Inhalant abuse occurs in adolescents and adults and should be deterred. Hydrocarbons may be inhaled for recreation, similar to drugs and alcohol. Hydrocarbons might also be inhaled as part of suicidal gestures and attempts.
- Treatment of the underlying causes of these behaviors might help in preventing hydrocarbon use.
- Maintain a high index of suspicion with any adolescent who has signs of alcohol intoxication or recreational drug use.
- Immediately address any suspicions of inhalation abuse with the patient's parent or regular physician.
Complications
- Aspiration pneumonitis is the most common complication of hydrocarbon ingestion, followed by CNS and cardiovascular complications. The major respiratory complications are aspiration and lung injury secondary to pneumonitis. Pneumothoraces and barotrauma are potential complications of mechanical ventilation. Most patients improve after 24 hours, and symptoms resolve within 1 week.
- CNS complications include seizures, encephalopathy, and memory loss. These sequelae are usually believed to be secondary to a hypoxic insult.
- Myocarditis and cardiomyopathy are reported cardiovascular complications of hydrocarbon toxicity.
Prognosis
- With appropriate supportive care, most patients recover without residual complications.
Patient Education
- Patient education is crucial in the prevention of unnecessary or accidental exposure.
- Most exposures in young children are accidental and can be prevented.
- Parents should teach young children about the dangers of poisons, beginning at an early age.
- Advise the parents about the proper storage and labeling of harmful chemicals.
- Inform parents about common household products that may be dangerous, and recommend steps that they can take to minimize the possibility of an accidental exposure.
- Educate parents that they need to supervise their children when they are in high-risk areas (eg, kitchen, garage, laundry room) where toxic substances may be present.
- Provide the parents with the telephone number of their local poison control center.
- For excellent patient education resources, visit eMedicine's Poisoning - First Aid and Emergency Center and Substance Abuse Center. Also, see eMedicine's patient education articles Poisoning, Poison Proofing Your Home, and Substance Abuse.
Medical/Legal Pitfalls
- Failure to perform repeat evaluation, including chest radiography
- Early chest radiographic evaluation may reveal normal findings.
- Any change in the patient's clinical respiratory symptoms warrants repeat chest radiography, which may demonstrate new and important changes.
- Anas N, Namasonthi V, Ginsburg CM. Criteria for hospitalizing children who have ingested products containing hydrocarbons. JAMA. Aug 21 1981;246(8):840-3. [Medline].
- Arena JM. Hydrocarbon poisoning--current management. Pediatr Ann. Nov 1987;16(11):879-83. [Medline].
- Colucciello SA, Tomaszewski C. Substance abuse. In: Emergency Medicine, Concepts and Clinical Practice. 1998;4th Edition:2879-2901.
- Dice WH, Ward G, Kelley J, Kilpatrick WR. Pulmonary toxicity following gastrointestinal ingestion of kerosene. Ann Emerg Med. Mar 1982;11(3):138-42. [Medline].
- Eade NR, Taussig LM, Marks MI. Hydrocarbon pneumonitis. Pediatrics. Sep 1974;54(3):351-7. [Medline].
- Klein BL, Simon JE. Hydrocarbon poisonings. Pediatr Clin North Am. Apr 1986;33(2):411-9. [Medline].
- Lee DC. Hydrocarbons. In: Emergency Medicine, Concepts and Clinical Practice. 1998;4th Edition:1362-1366.
- Ramon MF, Ballesteros S, Martinez-Arrieta R, et al. Volatile substance and other drug abuse inhalation in Spain. J Toxicol Clin Toxicol. 2003;41(7):931-6. [Medline].
- Scalzo AJ. Inhalation Injuries. In: Pediatric Emergency Medicine, Concepts and Clinical Practice. 1997;2nd Edition:590-593.
- Shis RD. Hydrocarbons. Goldfrank's Toxicologic Emergencies. 1998;6th Edition:1383-1395.
- Ureta Raroque SS, Wiebe RA. Household products and environmental toxins. In: Essentials of Pediatric Intensive Care. 1997;2nd Edition:908-935.
- Wax PM, Beuhler MB. Hydrocarbons and Volatile Substances. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 2004;Sixth Edition:1124-1129.
Toxicity, Hydrocarbons excerpt Article Last Updated: Jun 21, 2006
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