A 3 years old child brought by his family with h/o ingesting unknown amount of charcoal lighter 30 minutes ago . He have vomited once , otherwise no other symptoms. On arrival to ED , his vitals within normal for his age , he was active and playful , and systemic examination is unremarkable . Your junior went to see the child and came to discuss with you his plan of management. He want to give him activated charcoal and keep him for 2 hours observation and then discharged home.
Q1. Do you agree with your junior's management plan ?
Q2 What are the expected toxicity with such ingestion ?
Lighter Kid Cont'
Thank you all for your excellent comments .Proud of you all
Key points
1.Hydrocarbon ingestion commonly cause CNS, respiratory and cardiac effects
2.Activated charcoal and any other GI decontamination is contraindicated in hydrocarbon poisoning
There are many types of hydrocarbons ,but many share the chemical pnemonitis risk.Halogonated hydrocarbon have more risk of cardiac toxicity ( check stormy night post)
This includes ventricular dysrhythmias due to myocardial sensitization to catecholamines.This can cause risk of sudden sniffing death in hydrocarbon sniffing.
Management For asymptomatic patient, they need observation for 6 hours after which they can be discharged with follow up.Early CXR for asymptomatic patient have low yield in predicting delayed pnemonitis Symtpmatic patient need admission and treatment usually supportive
References
1.National Management Guidelines of Poisoning ,3rd edition
2.https://wikem.org/wiki/Hydrocarbon_toxicity
After ingestion of even a very small amount of liquid hydrocarbon, patients initially cough, choke and may vomit. Young children may have cyanosis, hold their breath, and cough persistently. Older children and adults may report burning in the stomach.
Treatment includes
Supportive care
Avoidance of gastric emptying (sometimes suspected based on the odour of breath or clothing).
Any contaminated clothing is removed, and the skin is washed. (CAUTION: Gastric emptying, which increases the risk of aspiration, is contraindicated.) Charcoal is not recommended. Patients who do not have aspiration pneumonitis or other symptoms after 4 to 6 hours are discharged. Patients who have symptoms are admitted and treated supportively; antibiotics and corticosteroids are not indicated.
Good evening Dr.Suad,
Thank you for sharing this interesting case with us
1- I don’t agree with the management
- I will start ABCD
- ingestion of hydrocarbon , need supporative care, any contaminated clothes should be removed and skin washed , activated charchoal is not recommended ,
- If patient is asymptomatic , he need 4-6 hr observation
- If he is symptomatic , should be admitted
2- It has minimal side effect , mainly aspiration pneumonitis , and othetrs like, CNS toxicity, arrhythmia
No i do not agree with my junior decision , AC does no bind to hydrocarbons effectively and also increase risk of aspiration , this child should be kept under observation for 6 hours and then prior to discharge will need CXR (patient vomited which make him high risk for aspiration, since asymptomatic doing CXR early has low yield), also will need an ECG and VBG to check for acidosis: criteria to discharge in 6 hours if 1- asymptomatic 2- normal vitals 3- normal chest exam 4- normal CXR.
Expected toxicity : 1- Pulmonary ( Aspiration pnemonia/pneumonitis /ARDS) 2- Cardiac ( Arrythmias, A fib, PVCs, Vtach,"Sudden sniffing death syndrome") 3- CNS (headache, N&V, Confusion, hallucination, ataxia, seizures , Coma)
No i dont agree
it can cause chemical pneumonitis
1- Management of hydrocarbons ingestion with activated charcoal is actually contraindicated, as they don’t bind them and may cause further risk of aspiration. In this case, the child is asymptotic so he will need an ongoing care and vital to be monitored for at least 6 hrs and discharged if GCS, ECG, Vitals are within the normal ranges and no respiratory symptoms.
2- Expected toxicities:
CNS
Cardiac symptoms
If Aspiration occurs: chemical pneumonitis.
This child need to be kept for observation for 6 h
If he he asymptomatic can be discharge
And there is no role for activate charcol in hydrocarbon ingestion .