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
• Aliphatic hydrocarbons
substances that contain carbon and hydrogen;
Aromatic hydrocarbons are cyclic compounds
they are liquid at room temperature  . All petroleum distillates (eg,
containing a benzene ring (eg, benzene, toluene,
and xylene). They are used primarily in solvents,
mineral seal oils, and naphtha) are hydrocarbons;
glues, nail polish, paints, and paint removers  .
however, not all hydrocarbons are petroleum
distillates. Hydrocarbons also often are mixed with agents that have systemic toxicity such as camphor,
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  .
children typically is an unintentional occurrence
that can be prevented through safe packaging
TOXICITY — Hydrocarbons
also can be classified according to their toxicity
and storage. In contrast, hydrocarbon aspiration
in teenagers usually occurs intentionally (eg,
during inhalant abuse, or when attempting to
aspiration) — Examples include asphalt, tars,
mineral oil, liquid petrolatum, motor oil, axle EPIDEMIOLOGY — Hydrocarbon accounted
grease, baby oil.
• Aspiration hazard — Clinical effects typically are
ingestions by children younger than six years of age in 2002  . Between 1997 and 1999, an
estimated 6400 children younger than five years
turpentine, gasoline, kerosene, mineral seal oil
departments for possible hydrocarbon aspiration
after ingestion of household cleaning products 
cigarette lighter fluid, and mineral spirits.
. Gasoline, lubricating oils, motor oils, mineral
• Systemic toxicity — Halogenated and aromatic
spirits, lighter fluid, naphtha, and kerosene were
hydrocarbons are absorbed readily through the
the most common exposures  . In 1998,
unintentional ingestion of hydrocarbon resulted in
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
intentional ingestion. Death from hydrocarbon
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
heavy metals, camphor) also have systemic toxicity. Determinants of toxicity — With the exception of aromatic and halogenated compounds, most
hydrocarbons cause clinical toxicity only when
the body and into the CNS [5,6] . Neurons, which
aspirated or inhaled because they are poorly
absorbed through the gastrointestinal tract. The
Manifestations in the CNS also occur secondary to
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
together determine a compound's ability to cause
compounds to spread or "creep" over a larger
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
Secondary changes include atelectasis, interstitial
viscosity facilitates deeper
inflammation, and hyaline membrane formation.
penetration into the tracheobronchial tree The
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
Vital signs — Between 30 and 60 percent of
patients with hydrocarbon aspiration have fever
at the time of presentation (38 to 40ºC)  .
pulmonary injury. Gasoline and naphtha also can cause direct CNS depression based upon their
Respiratory — Pulmonary manifestations result
although their onset may be delayed for 12 to 24 The
hours. Immediate signs of aspiration include
inversely related to viscosity and surface tension and
resonance on percussion, suppressed or tubular breath sounds, and crackles. Displacement of
distal airways while the low surface tension
facilitates spread over a greater area. As an are
aggravate hypoxemia caused by inflammation
example, simple petroleum distillates (kerosene, polish)
include tachypnea, dyspnea, cyanosis, diminished
low viscosity permits greater penetration into the
degree of pulmonary injury. Physical findings may
to be aspirated and cause pulmonary injury. The
Respiratory examination findings vary with the
surface tension, and high volatility are more likely
aspiration hazards. They have high potential to
cause aspiration pneumonitis but rarely cause
pulmonary aspiration chemical
pneumonia, and hemorrhagic pulmonary edema, PATHOPHYSIOLOGY — Hydrocarbon aspiration primarily
which quickly progresses to shock and respiratory
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
Hematologic — Leukocytosis occurs early in the
Pneumatoceles may develop in areas of extensive
consolidation during the recovery period. (See
unrelated to pneumonitis and may last as long as
"Spontaneous pneumothorax in children").
one week  . Hemolysis, hemoglobinuria, and
findings — The
consumptive coagulopathy also may occur with
significant ingestion  .
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
symptoms at presentation. Patients with normal
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
Decontamination — The child's clothing should
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
be removed to prevent
between two and eight hours after aspiration. The
Pneumatoceles may develop in this latent period.
gastrointestinal tract in children with hydrocarbon
Cardiovascular — Cardiac arrhythmia may occur
ingestion should avoid gastric emptying or lavage
and induction of emesis because of the risk for
aspiration during these procedures [12,13] .
leading to fatal arrhythmia ("sudden sniffing
death"). Gastrointestinal — Ingestion
hydrocarbons causes direct local irritation to the pharynx,
(eg, heavy metals or insecticides)
• Large volume of ingestion (eg, a suicide attempt)
These effects usually are mild and rarely require
The following measures, taken before gastric
emptying, can minimize the risk of aspiration: nervous
system — Hydrocarbon
• Endotracheal intubation with a balloon-cuffed
ingestion or inhalation may have direct CNS
effects, including somnolence, headache, ataxia, dizziness,
• Petroleum distillates that contain toxic additives
associated with nausea and hematemesis  .
halogenated and aromatic hydrocarbons)
intestine, with edema and mucosal ulceration.
• Lateral decubitus or Trendelenburg positioning
• 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  :
drowsiness, tremors, or convulsions  . (See
Pulmonary management — The treatment of
Endotracheal intubation is indicated in patients
• All children for whom close follow-up cannot be
[1,14] . Additional measures include oxygen,
physiotherapy, and continuous positive airway
pneumonitis that is refractory to conventional supportive
• Asymptomatic children with normal chest
receiving extracorporeal membrane oxygenation
• Asymptomatic children with mildly abnormal
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
PROGNOSIS — Although most children survive
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
coma) may dominate the course.
Pneumatoceles rarely rupture and do not require treatment
The prognosis is affected by the volume of
hydrocarbon aspiration should not be treated routinely
involved, and the adequacy of medical care. The
typical clinical course averages two to five days.
secondary infection, including the following, are
The mild CNS depression that is seen soon after
• Recurrence of fever after the first 48 hours 
provided that pulmonary involvement does not
• Increasing infiltrate in chest radiograph
• Leukocytosis Disposition — Indications
The small airways are at greatest risk for long-
term injury  . 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  . More than 80
• Symptomatic child with abnormal initial chest
percent had at least one pulmonary function
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
ingestion should be observed for at least six
• Patient with substantially abnormal chest
hours because the symptoms and radiographic
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  .
• 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
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,
heavy metal or organophosphate insecticide)
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
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
controlled human studies [17,18] .
• Pneumatoceles rarely rupture and do not
(eg, epinephrine and isoproteronol) should not
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).
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
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