Management of kerosene poisoning
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Management of Kerosene Poisoning
Kerosene is an aliphatic petroleum distillate (low viscosity, low surface tension, high volatility) - properties that make aspiration into the airway the primary hazard, not systemic absorption from the gut. It is a leading cause of accidental poisoning especially in children in developing countries.
Pathophysiology at a Glance
| Property | Significance |
|---|---|
| Low viscosity | Spreads rapidly into the airway |
| High volatility | Volatilizes in the lung, causing bronchospasm |
| Low surface tension | Penetrates deeply into alveoli |
| Lipophilicity | CNS penetration; cardiac sensitization |
Target organs: Lungs > CNS > Heart. GI absorption is poor for aliphatic hydrocarbons like kerosene; pulmonary aspiration (during ingestion or vomiting) is the main mechanism of lung injury.
Clinical Features
Pulmonary (most important)
- Cough, choking, gagging - often immediately after ingestion
- Tachypnea, respiratory distress, cyanosis
- Aspiration pneumonitis within 30 minutes to 6 hours
- Hypoxemia, ventilation-perfusion mismatch, may progress to respiratory failure
- Lipoid pneumonia with chronic/large exposures
CNS
- CNS depression: drowsiness, lethargy, ataxia, confusion
- Seizures (rare)
- Euphoria/intoxication (inhalation abuse)
Cardiac
- Myocardial sensitization to catecholamines - risk of ventricular dysrhythmias
- Hemodynamic instability in severe cases
GI
- Nausea, vomiting, abdominal pain, diarrhea (local irritant effects)
- Vomiting increases aspiration risk
Other
- Dermal: chemical burns, defatting dermatitis on contact
- IV injection (rare): SIRS, hemolysis, renal/hepatic toxicity
Emergency Management
1. Airway & Breathing (Priority #1)
- Assess airway immediately; apply supplemental oxygen
- Monitor SpO2 continuously
- Do NOT induce vomiting - this dramatically increases aspiration risk
- If intubation is needed (severe respiratory failure, CNS depression, airway protection), perform with caution to avoid aspiration during the procedure
- Indications for positive-pressure ventilation / mechanical ventilation:
- Hypercarbia
- Severe respiratory distress
- Hypoxia unresponsive to supplemental O2
- Significant CNS depression
2. GI Decontamination - CONTRAINDICATED
- Do NOT perform gastric lavage or induced emesis - both increase risk of aspiration of kerosene
- Activated charcoal is not effective for petroleum distillates and is NOT indicated
- Small accidental ingestions (< 1 mL/kg in children) rarely cause serious systemic toxicity - observation is preferred
Exception: If kerosene was used as a vehicle for a more toxic substance (e.g., organophosphate insecticide dissolved in kerosene), then gastric decontamination may be considered cautiously via nasogastric tube, with airway protected by prior intubation.
3. Cardiac Monitoring
- Continuous ECG monitoring for dysrhythmias
- Avoid catecholamines (epinephrine, dopamine) if possible - they may trigger ventricular fibrillation in the sensitized myocardium
- For dysrhythmias: beta-blockers may be useful; avoid epinephrine
4. Supportive Care
- IV fluids for hydration if vomiting is significant
- Antipyretics for fever
- Bronchodilators (salbutamol) for bronchospasm
- There are no specific antidotes for kerosene/hydrocarbon poisoning
5. Surfactant Therapy
- Consider intrapulmonary surfactant for severe hydrocarbon pneumonitis (indicated by elevated oxygenation index, poor PaO2/FiO2 ratio, or poor lung compliance)
- Consult pulmonology for administration
6. What NOT to Do
- Corticosteroids - not shown to improve outcomes, not indicated
- Prophylactic antibiotics - not indicated (pneumonitis is chemical, not bacterial)
- Emetics (syrup of ipecac) - absolutely contraindicated
- Gastric lavage without prior intubation - contraindicated
Investigations
| Investigation | Purpose |
|---|---|
| Chest X-ray | Pneumonitis (can be delayed up to 6 hours; bilateral lower lobe infiltrates) |
| SpO2 / ABG | Oxygenation, ventilation status |
| ECG | Dysrhythmia detection |
| Blood glucose, electrolytes | Baseline metabolic status |
| LFTs, RFTs | If halogenated/aromatic hydrocarbon exposure suspected |
| FBC | Hemolysis if IV injection |
Disposition (Observation Protocol)
Minimum 6-hour observation for all symptomatic and asymptomatic patients.
| Condition | Disposition |
|---|---|
| Asymptomatic, normal CXR at 6 hours | Discharge with instructions to return if symptoms develop |
| Mild CNS depression, tachypnea, low-grade hypoxia, CXR findings not resolved | Inpatient admission (at least 24 hours) |
| Moderate-severe CNS depression, significant respiratory distress, cyanosis, significant hypoxia/hypercarbia, dysrhythmias, hemodynamic instability | ICU admission |
Special Situations
Dermal exposure: Remove contaminated clothing; wash skin thoroughly with soap and water. Treat chemical burns accordingly.
Eye exposure: Copious irrigation with saline; ophthalmology referral.
Inhalation (occupational/abuse): Remove from exposure, fresh air, supportive care. Observe for dysrhythmias.
Intentional ingestion (suicide attempt): Psychiatric evaluation before discharge; manage as above.
Key Teaching Points
- Aspiration is the major toxic mechanism - never induce vomiting
- Symptoms of aspiration can be delayed up to 6 hours - observe all patients
- There are no antidotes; treatment is supportive
- Catecholamines can trigger fatal arrhythmias in the sensitized myocardium - avoid if possible
- Corticosteroids and prophylactic antibiotics are NOT beneficial
Sources: Rosen's Emergency Medicine: Concepts and Clinical Practice (9780323757898); Park's Textbook of Preventive and Social Medicine (9789382219163)
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