Hydrocarbon aspiration in children and adolescents Patricia A Primm, MD Last literature review version 16.1: Janeiro 2008 | This topic last updated: Setembro 13, 2005 Modified by Jefferson P Piva (june2008)
INTRODUCTION — Hydrocarbons
are
organic
• Aliphatic hydrocarbons
substances that contain carbon and hydrogen;
Aromatic hydrocarbons are cyclic compounds
they are liquid at room temperature [1] . All petroleum distillates (eg,
kerosene,
containing a benzene ring (eg, benzene, toluene,
gasoline,
and xylene). They are used primarily in solvents,
mineral seal oils, and naphtha) are hydrocarbons;
glues, nail polish, paints, and paint removers [1] .
however, not all hydrocarbons are petroleum
Halogenated
distillates. Hydrocarbons also often are mixed with agents that have systemic toxicity such as camphor,
aniline
dyes,
heavy
metals,
hydrocarbons
chlorinated, chloride
and
or
brominated
chloroform,
trichloroethylene,
pesticides.
are
fluorinated,
(eg,
carbon
methylene
tetrachloride,
tetrachloroethylene).
The
terpenes include turpentine and pine oil. The
Ingestion of large quantities of hydrocarbons by
aliphatic hydrocarbons are petroleum distillates.
children is unusual because hydrocarbons are
They are found in furniture polish, lamp oil, and
foul-tasting. Aspiration of hydrocarbons by young
lighter fluid [1] .
children typically is an unintentional occurrence
HYDROCARBON
that can be prevented through safe packaging
TOXICITY — Hydrocarbons
also can be classified according to their toxicity
and storage. In contrast, hydrocarbon aspiration
[1] :
in teenagers usually occurs intentionally (eg,
• Nontoxic
during inhalant abuse, or when attempting to
(unless
complicated
by
gross
aspiration) — Examples include asphalt, tars,
siphon gasoline).
mineral oil, liquid petrolatum, motor oil, axle EPIDEMIOLOGY — Hydrocarbon accounted
for
approximately
ingestion 2
percent
grease, baby oil.
of
• Aspiration hazard — Clinical effects typically are
ingestions by children younger than six years of age in 2002 [2] . Between 1997 and 1999, an
limited
estimated 6400 children younger than five years
subsequent
of
turpentine, gasoline, kerosene, mineral seal oil
age
were
seen
in
hospital
emergency
to
direct
pulmonary
inflammation.
Examples
charcoal
and
include
departments for possible hydrocarbon aspiration
(furniture
after ingestion of household cleaning products [3]
cigarette lighter fluid, and mineral spirits.
. Gasoline, lubricating oils, motor oils, mineral
polish),
damage
lighter
fluid,
• Systemic toxicity — Halogenated and aromatic
spirits, lighter fluid, naphtha, and kerosene were
hydrocarbons are absorbed readily through the
the most common exposures [4] . In 1998,
gastrointestinal
unintentional ingestion of hydrocarbon resulted in
and/or
respiratory
systems.
Systemic effects include cardiac arrhythmia and
the deaths of four children younger than 13 years
central nervous system (CNS) depression. In
of age; an additional 14 deaths were caused by
addition
intentional ingestion. Death from hydrocarbon
to
halogenated
and
aromatic
hydrocarbons, hydrocarbons that are combined
aspiration usually is caused by respiratory failure.
with toxic additives (eg, organophosphates, CLASSES OF HYDROCARBONS — The structural classes of hydrocarbons are: • Aromatic hydrocarbons • Halogenated hydrocarbons • Terpene hydrocarbons
four
heavy metals, camphor) also have systemic toxicity. Determinants of toxicity — With the exception of aromatic and halogenated compounds, most
1
hydrocarbons cause clinical toxicity only when
the body and into the CNS [5,6] . Neurons, which
aspirated or inhaled because they are poorly
have
absorbed through the gastrointestinal tract. The
susceptible
aspiration
Manifestations in the CNS also occur secondary to
hazard
of
the
hydrocarbons
is
a
high
lipid
content,
the
solvent
to
are
particularly
properties
[7]
.
determined by three properties:
severe pulmonary injury and hypoxia.
• Volatility — The ability to vaporize or to exist in
The respiratory system also is affected by direct injury. Low viscosity, low surface tension, and
a gaseous form
• Surface
tension
cohesiveness) surface;
of
lower
—
The
adherence
molecules
along
surface
a
solvent
(or
of
aspirated
hydrocarbons
together determine a compound's ability to cause
liquid
tension
properties
chemical
allows
pneumonitis
pathologic
compounds to spread or "creep" over a larger
finding
pneumonia.
area
[1] is
Other
.
The
severe
findings
primary
necrotizing
include
direct
destruction of the airway epithelium, alveolar
• Viscosity — The resistance to flow through an
septae, and pulmonary capillaries, as well as
orifice or the tendency of a compound to resist
solubilization
"stirring;" lower
Secondary changes include atelectasis, interstitial
viscosity facilitates deeper
The systemic
toxicity
of
the
lipid
surfactant
layer.
inflammation, and hyaline membrane formation.
penetration into the tracheobronchial tree The
of
hydrocarbons
is
inflammatory
response
from
chemical
irritation generally causes temperature elevation,
determined by their volatility. Gases such as
usually within hours of exposure.
methane, ethane, propane, butane, and benzene CLINICAL MANIFESTATIONS
are the most volatile. They cause asphyxia by replacing alveolar gas, are readily absorbed into the
circulatory
depression.
system,
However,
and they
cause
Vital signs — Between 30 and 60 percent of
CNS
rarely
patients with hydrocarbon aspiration have fever
cause
at the time of presentation (38 to 40ºC) [8] .
pulmonary injury. Gasoline and naphtha also can cause direct CNS depression based upon their
Respiratory — Pulmonary manifestations result
high volatility.
from
any
degree
of
hydrocarbon
aspiration,
although their onset may be delayed for 12 to 24 The
aspiration
hazard
of
hydrocarbons
is
hours. Immediate signs of aspiration include
inversely related to viscosity and surface tension and
directly
hydrocarbons
related with
to
volatility.
decreased
coughing,
Thus,
viscosity,
resonance on percussion, suppressed or tubular breath sounds, and crackles. Displacement of
distal airways while the low surface tension
alveolar
facilitates spread over a greater area. As an are
gas
by
vaporized
hydrocarbon
may
aggravate hypoxemia caused by inflammation
example, simple petroleum distillates (kerosene, polish)
vomiting.
include tachypnea, dyspnea, cyanosis, diminished
low viscosity permits greater penetration into the
furniture
and
degree of pulmonary injury. Physical findings may
to be aspirated and cause pulmonary injury. The
liquid
gagging,
Respiratory examination findings vary with the
low
surface tension, and high volatility are more likely
gasoline,
choking,
and edema.
chiefly
aspiration hazards. They have high potential to
The
cause aspiration pneumonitis but rarely cause
hydrocarbon
major
systemic symptoms.
necrotizing
pulmonary aspiration chemical
complications include
of
asphyxia,
pneumonitis,
lipoid
pneumonia, and hemorrhagic pulmonary edema, PATHOPHYSIOLOGY — Hydrocarbon aspiration primarily
affects
the
central
nervous
which quickly progresses to shock and respiratory
and
arrest. Pneumothorax, subcutaneous emphysema
respiratory systems. Volatile hydrocarbons are
of the chest wall, and pleural effusion, including
highly lipid soluble. They enter the circulation
empyema, also may occur. Secondary infection
through the lungs and rapidly diffuse throughout
2
with
bacteria
or
viruses
may
occur.
Hematologic — Leukocytosis occurs early in the
Pneumatoceles may develop in areas of extensive
clinical
consolidation during the recovery period. (See
unrelated to pneumonitis and may last as long as
"Spontaneous pneumothorax in children").
one week [10] . Hemolysis, hemoglobinuria, and
Radiographic
findings — The
course
of
hydrocarbon
aspiration
consumptive coagulopathy also may occur with
radiographic
significant ingestion [11] .
findings of hydrocarbon aspiration often occur before the development of physical findings. They
MANAGEMENT — All children with hydrocarbon
may be seen within 20 minutes or as late as 24
aspiration should be observed for at least six to
hours after aspiration.
eight hours in an emergency department setting. Chest radiographs should be obtained in all
The initial findings are multiple, small, patchy
patients who have cough or any respiratory
densities with ill-defined margins. The lesions become
larger
and
coalesce
as
the
symptoms at presentation. Patients with normal
injury
initial radiographs should have them repeated
progresses. In some cases, the radiographic
four to six hours after ingestion.
findings may be minimal at a few hours and then rapidly
progress
Emphysema
or
Radiographic
to
extensive
pneumothorax
Decontamination — The child's clothing should
develop.
continued inhalation
peak
exposure. All patients should have their skin cleaned. The eyes should be flushed if any
resolution of radiographic changes is gradual and
evidence of redness, tearing, or lid swelling is
lags behind clinical improvement, which usually
present.
three
to
five
typically
be removed to prevent
between two and eight hours after aspiration. The
occurs
abnormalities
infiltrates.
may
days
after
aspiration.
As
Pneumatoceles may develop in this latent period.
a
general
rule,
decontamination
of
the
gastrointestinal tract in children with hydrocarbon
Cardiovascular — Cardiac arrhythmia may occur
ingestion should avoid gastric emptying or lavage
after
and induction of emesis because of the risk for
inhalation.
sensitize
the
Solvent
myocardium
hydrocarbons to
can
catecholamines,
aspiration during these procedures [12,13] .
leading to fatal arrhythmia ("sudden sniffing
Gastric
death"). Gastrointestinal — Ingestion
of
aliphatic
• Those
hydrocarbons causes direct local irritation to the pharynx,
lavage
may
be
esophagus,
stomach,
and
Orogastric
and
intestinal
irritation
small
may
toxic
effects
(eg,
(eg, heavy metals or insecticides)
be
• Large volume of ingestion (eg, a suicide attempt)
These effects usually are mild and rarely require
The following measures, taken before gastric
treatment.
emptying, can minimize the risk of aspiration: nervous
system — Hydrocarbon
• Endotracheal intubation with a balloon-cuffed
ingestion or inhalation may have direct CNS
endotracheal tube
effects, including somnolence, headache, ataxia, dizziness,
systemic
• Petroleum distillates that contain toxic additives
associated with nausea and hematemesis [1] .
Central
with
halogenated and aromatic hydrocarbons)
intestine, with edema and mucosal ulceration.
blurred
vision,
weakness,
• Lateral decubitus or Trendelenburg positioning
fatigue,
• Pinching off the nasogastric or orogastric tube
lethargy, stupor, seizures, and coma. In addition,
and withdrawing it quickly after the procedure
hypoxia caused by hydrocarbon aspiration may cause
emptying — Gastric
indicated for certain hydrocarbon ingestions [1] :
secondary
CNS
depression,
is complete
including
drowsiness, tremors, or convulsions [9] . (See
Pulmonary management — The treatment of
"Acute
hydrocarbon
toxic-metabolic
encephalopathy
in
pneumonitis
is
supportive.
Endotracheal intubation is indicated in patients
children").
3
with
CNS depression
or
impaired ventilation
• All children for whom close follow-up cannot be
[1,14] . Additional measures include oxygen,
established
physiotherapy, and continuous positive airway
Indications
pressure.
observation include:
Children
who
have
hydrocarbon
pneumonitis that is refractory to conventional supportive
therapy
may
be
candidates
for
discharge
after
six
hours
of
• Asymptomatic children with normal chest
for
radiograph
receiving extracorporeal membrane oxygenation
• Asymptomatic children with mildly abnormal
[15,16] .
chest
radiographs
who
do
not
develop
Bronchospasm should be treated with selective
symptoms during the observation period and
beta 2 agonists. Epinephrine and isoproterenol
who can receive adequate outpatient follow-up
should be avoided because they can cause fatal ventricular
dysrhythmia
in
the
PROGNOSIS — Although most children survive
hydrocarbon-
without complications or sequelae, some progress
sensitized myocardium (see above).
rapidly to respiratory failure and death. Systemic symptoms (eg, somnolence, convulsions, and
Corticosteroids have no beneficial effect on the course
of
hydrocarbon
aspiration
[17,18]
coma) may dominate the course.
.
Pneumatoceles rarely rupture and do not require treatment
[19]
.
Pneumonitis
caused
The prognosis is affected by the volume of
by
ingestion
hydrocarbon aspiration should not be treated routinely
with
antibiotics
unless
signs
or
aspiration,
the
specific
agent
involved, and the adequacy of medical care. The
of
typical clinical course averages two to five days.
secondary infection, including the following, are
The mild CNS depression that is seen soon after
present:
ingestion
seldom
produces
serious
morbidity
• Recurrence of fever after the first 48 hours [20]
provided that pulmonary involvement does not
• Increasing infiltrate in chest radiograph
occur.
• Leukocytosis Disposition — Indications
for
The small airways are at greatest risk for long-
immediate
term injury [23] . One study examined pulmonary
admission of children who have ingested or
function in 17 children eight to 14 years after
aspirated hydrocarbons include [21,22] :
hydrocarbon aspiration [24] . More than 80
• Symptomatic child with abnormal initial chest
percent had at least one pulmonary function
radiograph
abnormality. The clinical significance of these
• Patient with suicidal intent or massive ingestion
findings is uncertain.
• Hypoxic or obtunded patient regardless of chest
SUMMARY — Patients
radiograph findings
with
hydrocarbon
ingestion should be observed for at least six
• Patient with substantially abnormal chest
hours because the symptoms and radiographic
radiograph
findings may be delayed.
Indications for admission that become apparent
• Thorough washing of contaminated skin and
during up to six hours of observation include:
hair is an important part of therapy [13] .
• Child with mildly abnormal chest radiograph
• Children who are symptomatic on presentation,
who develops symptoms during the observation
who develop symptoms during the six-hour
period
observation period, or who have ingested a
• Child who develops symptoms related to toxic
particularly toxic agent (eg, furniture polish,
additives during the observation period (eg,
organophosphate,
heavy metal or organophosphate insecticide)
heavy
metal)
should
be
admitted to the hospital.
• Child with mild symptoms and normal chest
• Children who remain asymptomatic during six
radiograph who fails to improve during the
hours of observation should continue to be
observation period
4
observed at home. Parents should be instructed
• Corticosteroids have no beneficial effect on the
to return if any respiratory symptoms occur.
course of the illness as shown in double-blind
• Pulmonary therapy is initiated based upon the development
of
symptoms.
controlled human studies [17,18] .
Catacholamines
• Pneumatoceles rarely rupture and do not
(eg, epinephrine and isoproteronol) should not
require treatment.
be used to treat bronchospasm.
• Parents should be reminded to keep cleaning
• Antibiotics should be used if the patient
fluids and kerosene out of the reach of children
develops signs of secondary bacterial infection.
(eg, in locked cabinets, or out of the home).
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Osterhoudt, KC, Burns Ewald, M, Shannon, M, Henretig, FM. Toxicologic emergencies. In: Textbook of pediatric emergency medicine, 5th ed, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott, Williams & Wilkins, Philadelphia, 2006, p. 951. Watson, WA, Litovitz, TL, Rodgers, GC Jr, et al. 2002 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2003; 21:353. Barone, S. Child-resistant packaging. Consumer Product Safety Review. 2002; 6:3. (www.cpsc.gov/cpscpub/pubs/cpsr_nws23.pdf). Litovitz, TL, Klein-Schwartz, W, Caravati, EM, et al. 1998 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999; 17:435. Dinwiddie, SH. Abuse of inhalants: A review. Addiction 1994; 89:925. McHugh, MJ. The abuse of volatile substances. Pediatr Clin North Am 1987; 34:333. Kurtzman, TL, Otsuka, KN, Wahl, RA. Inhalant abuse by adolescents. J Adolesc Health 2001; 28:170. Amoroso, K, Ginsburg, C. Hydrocarbon ingestions. In: Essentials of Pediatric Intensive Care, Levin, DL, Morriss, FC (Eds). Quality Medical Publishing Inc, St. Louis, 1990. p.639. Wolfsdorf, J, Paed, D. Kerosene intoxication: an experimental approach to the etiology of the CNS manifestations in primates. J Pediatr 1976; 88:1037. Food and Drug Administration. Poison control case report summary-calendar year 1982. Rockville, MD, 1984. Banner, W Jr, Walson, PD. Systemic toxicity following gasoline aspiration. Am J Emerg Med 1983; 1:292. Shannon, M. Ingestion of toxic substances by children. N Engl J Med 2000; 342:186. Arena, JM. Hydrocarbon poisoning--current management. Pediatr Ann 1987; 16:879. Zucker, AR, Berger, S, Wood, LD. Management of kerosene-induced pulmonary injury. Crit Care Med 1986; 14:303. Scalzo, AJ, Weber, TR, Jaeger, RW, et al. Extracorporeal membrane oxygenation for hydrocarbon aspiration. Am J Dis Child 1990; 144:867. Liebelt, EL, DeAngelis, CD. Evolving trends and treatment advances in pediatric poisoning. JAMA 1999; 282:1113. Marks, MI, Chicoine, L, Kegere, G, Hillman, E. Adrenocorticosteriod treatment of hydrocarbon pneumonia in children — A cooperative study. J Pediatr 1972; 81:366. Steele, RW, Conklin, RH, Mark, HM. Corticosteroids and antibiotics for the treatment of fulminant hydrocarbon aspiration. JAMA 1972; 219:1434. Bergeson, PS, Hales, SW, Lustgarten, MD, Lipow, HW. Pneumatoceles following hydrocarbon ingestion. Report of three cases and review of the literature. Am J Dis Child 1975; 129:49. Karlson, KH Jr. Hydrocarbon poisoning in children. South Med J 1982; 75:839. Shannon, M. Petroleum distillate poisoning. Harwood-Nuss, A (Ed), JP Lippincott, 1991. Anas, N, Namasonthi, V, Ginsburg, CM. Criteria for hospitalizing children who have ingested products containing hydrocarbons. JAMA 1981; 246:840. Klein, BL, Simon, JE. Hydrocarbon poisonings. Pediatr Clin North Am 1986; 33:411. Gurwitz, D, Kattan, M, Levison, H, Culham, JA. Pulmonary function abnormalities in asymptomatic children after hydrocarbon pneumonitis. Pediatrics 1978; 62:789
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