Know How to Treat Hydrocarbon Poisoning

 

 
 
 

Bruce Evans, MPA, NREMT-P | From the August 2010 Issue | Sunday, August 1, 2010


Engine 57 and Medic 507 are dispatched to a child who’s short of breath and “sleepy.” En route, the dispatch center advises there’s a slight language barrier. Upon arrival, a 4-year-old child is found having difficulty breathing. Oxygen is applied with a non-rebreather mask, and the child tolerates the placement of the mask on his face.

His extended family is present, and the grandmother reports that the child may have ingested some lamp oil. The engine captain retrieves a disassembled decorative holiday oil lamp with a half-filled reservoir.

The child’s father explains the family was preparing for Diwali, known as the “festival of lights,” or “the awareness of the inner light” in Hindu culture.

The child’s condition deteriorates further with an episode of vomiting and progressive dyspnea. A strong smell of petroleum distillates is emanating from the vomit. The patient’s oxygen saturation drops to 84%, and the child becomes obtunded and unable to hold his head up.

This prompts a field intubation and an IV line en route. The family becomes more agitated and reverts to their native language. The engine captain contacts the 9-1-1 center via cell phone and accesses the AT&T language line with a Hindi interpreter, who immediately calms the family and explains the EMS care.

The child is placed in a cervical collar and pediatric backboard to ensure head movement won’t dislodge the tube. Waveform CO2 is monitored, and the immediate transport to the pediatric trauma center is initiated. The transport is uneventful, and the CO2 and oxygenation remain stable after intubation. The child progresses well and is discharged with reactive airway disease.

Dangers of Lamp Oil
Holiday celebrations often involve the ceremonial use of candles or lamps. The addition of fragrance to lamp oils has gained popularity in such decorative household items. These items are often present in homes with no children, and they’re typically displayed during holiday get-togethers because the adults of such a home wouldn’t consider them dangerous.

Many of these oils look and smell like common liquids children are used to. When added to lamps with clear oil reservoirs, they can be easily mistaken for colored drinks, such as juice or Kool-Aid. The cranberry color of many brands of lamp oil has a similar shade and color as cranberry or cherry juice. Lamp oils generally come in fragrances familiar to children, such as applewood, mesquite and citrus.
Numerous types of lamp oils are available with a variety of compositions. As a poison, lamp oil is categorized as a hydrocarbon poison. It’s a petroleum-based product related to kerosene in composition. When homes were lit with oil lamps,
kerosene was used as fuel. It didn’t burn clean and left a black, sooty mess on almost every surface.

Today, kerosene is used mostly in lanterns, but it still can be found in some lamp oil variations. Manufacturers, under pressure from consumers, decided to distill kerosene, so the oil could be burned indoors without as many problems.

Now, you can find “ultrapure” or “ultraclean” lamp oil at most supermarkets,
outdoor suppliers and camping stores. Lamps are safer than candles and are more reliable than flashlights; therefore, storing lamp oil has gained popularity in emergency preparedness.

Lamp oil must be kept at or near room temperature, not in a garage or shed where it could freeze. Frozen oil may defrost too quickly, posing an explosive hazard. Citronella oil includes an additive that keeps flying pests away; this oil is often burned in an outdoor lamp or torch. Technically, liquid paraffin lamp oil isn’t oil but paraffin wax that’s liquid at room temperature.

Hydrocarbon Facts
In 2008, the American Association of Poison Control Center’s (AAPCC) Toxic Exposure Surveillance System listed hydrocarbons in the top 10 most common groups of agents ingested by children less than 6 years old in the U.S. More than 80,000 ingestions were reported, with the average age of
ingestion being between 18–24 months.

The AAPCC also reported approximately 1,416 lamp oil poisonings for patients under the age of six. Sixty-four incidents involved patients between six and 19 years of age, and more than 200 cases were reported for patients over the age of 19, combining to comprise more than 1% of total poisonings.

The toxicity of hydrocarbons is directly associated with their physical properties, specifically the viscosity, volatility, surface tension and chemical activity of the hydrocarbon side chains. Viscosity is a measure of resistance to flow or stickiness. Substances with a lower viscosity (i.e., turpentine, gasoline, naphtha) are associated with a higher chance of aspiration, often penetrating deep into the lung tissue or alveolar membrane.

The surface tension is a cohesive force between molecules and is a measure of a liquid’s ability to “creep,” that is, to slowly spread. Like the viscosity, the surface tension is also related to aspiration risk: The lower the viscosity, the higher the risk of aspiration. Viscosity is the single most important chemical property associated with the aspiration risk.

Although most of this hydrocarbon is ingested, the off-gassing or volatility is the most dangerous aspect of this type of poisoning. Volatility is the tendency for a liquid to change phases and become a gas. Hydrocarbons with a high volatility can vaporize and displace oxygen, which can lead to a transient state of hypoxia or trigger pulmonary irritation. Toxicity from hydrocarbon exposure can present with various signs and symptoms depending on which organ system is involved.

Hydrocarbons can damage the pulmonary, nervous, cardiac, gastrointestinal, hepatic and renal systems; however, the pulmonary system and the lungs are the ones most commonly injured. Chemical pneumonitis results from a direct toxic effect by the hydrocarbon on the lung tissue and the basement membrane between the alveolar space and the capillary beds. Type II pneumocytes are most affected, resulting in decreased surfactant production. 

This decrease in surfactant results in alveolar collapse and hypoxemia. Hemorrhagic alveolitis, which commonly peaks three days after ingestion, resulting in interstitial inflammation, alveolar hemorrhage and edema can then occur. This condition is commonly classified as adult respiratory distress syndrome (ARDS).

The Role of EMS
It’s imperative that an EMS unit contact the local poison control center when they encounter hydrocarbon poisoning. Everywhere in the U.S. the poison control number is the same: 800/222-1222. This number should be programmed in every provider’s phone or vehicle cell phone unit.

Typically, the poison control center will ask for your unit identification, questions to help assess measurement of the total poisoning and the destination hospital. Most hospitals don’t have toxicologists available, and the poison control center will commonly call the receiving facility to ensure proper treatment is in progress and to assess the outcomes. Because many of these poisonings involve children, the potential for error is reduced by having redundancy in the communication loop to ensure consistency of care to national standards.

Furthermore, tracking these cases for science helps advance medicine. The appropriation of resources for poison prevention is dependent on accurate reporting and clearly identifying trends. Prehospital treatment is mainly supportive of quality airway management, including prevention of aspiration.

As controversial as pediatric intubation may be, bag-valve mask ventilation presents the risk of gastric distention, resulting in potential vomiting. The further inhalation of vapors from an ingested hydrocarbon can’t be prevented as it can with the securing
of the airway with an endotracheal tube. Rapid transportation and facility notification are important.

Lastly, the role of EMS in poison prevention should be in every agency’s toolbox. Hydrocarbon poisoning often leads to permanent disability and long-term respiratory consequences for the survivors. JEMS

References

  1. Lifshitz M, Sofer S, Gorodischer R. Hydrocarbon poisoning in children: A 5-year retrospective study. 2006 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clin Toxicol. 2003;14:78–82.
  2. Ellenhorn MJ. The hydrocarbon products. In Ellenhorn’s Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd ed, Ellenhorn MJ, Schonwald S, Ordog G, Wasserberger (Eds). Williams and Wilkins: Baltimore, 1997.
  3. Gummin DD, Hryhorczuk DO. Hydrocarbons. In Goldfrank’s Toxicologic Emergencies, 8th ed, Flomenbaum NE, Goldfrank LR, Hoffman RS, et al (Eds). McGraw-Hill; New York, 2006.
  4. Bronstein AC, Spyker DA, Cantilena Jr. LR, et al. 2007 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clin Toxicol. 2008;46: 927–1057.
  5. Bronstein AC, Spyker DA, Cantilena Jr. LR, et al. 2008 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol. 2009;47:911–1084.

    This article originally appeared in August 2010 JEMS as “Case of the Month”
     



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Related Topics: Patient Care, Airway and Respiratory, Special Patients, ” “lamp oil poisoning, ” “hydrocarbon poisoning”, “Case of the Month, Jems Case of the Month

 

Bruce Evans, MPA, NREMT-PBruce Evans, MPA, NREMT-P, is the EMS chief of the North Las Vegas Fire Department and the fire-science program coordinator at the College of Southern Nevada. He’s also chair of the Health and Safety Committee of the NAEMT, a member of the FESHE steering committee at the NFA and a JEMS editorial board member. Contact him at hawkeyeems@aol.com.

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