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  • 1. KEROSENE POISONING Ranjit Pandey Cist college,KTM,Nepal ranjitpandey17@gmail.com
  • 2. CASE 21mths old boy ingested an estimated 20 ml of kerosene at 7:00 p.m on 063/2/15 and was brought to the Patan hospital 11 /2 hrs post exposure. His mother noticed child was having fast and noisy breathing however did not recall him coughing , vomiting or altered sensorium.o/e he was sick looking restless , kerosene odour was present on his breath. His vital signs were B.P=90/60 mm hg pulse=120/min , R/R=62/min,grunting, subcostal retraction positive. Temp 97.6o f no cyanosis spo2=100% with 02 The abdominal, cardiac and pulmonary examination were remarkable.Chest X-ray taken immediately was negative for e/o pneumonia. He was kept in observation for 12 hrs and was discharged on the next day.
  • 3. HEADINGS • CLASSIFICATION OF HYDROCARBONS • DETERMINANTS OF TOXICITY • ETIOLOGICAL FACTORS • INCIDENCE OF KEROSENE POISONING • PATHOPHYSIOLOGY • HISTOPATHOLOGY OF LUNG AT AUTOPSY. • CLINICAL FEATURES • COMPLICATION • INVESTIGATION • TREATMENT • PROGNOSIS • CONCLUSION • REVIEW QUESTION
  • 4. Classification of Hydrocarbons A) aliphatic e.g. kerosene,lubricating oil, tar b) aromatic e.g. benzene compounds(xylene and toluene) c) halogenated e.g. carbon tetrachloride and trichloroethane d) cyclic turpenes e.g. turpentine, pine oil
  • 5. DETERMINANTS OF TOXICITY • LIPOPHILICITY • VISCOSITY • VOLATILITY • SURFACE TENSION
  • 6. • Substance with <60ssu (saybolt second universal) i.e low viscosity have high aspiration potential and those with >100ssu i.e high viscosity have minimal risk. • Substance with low viscosity are kerosene mineral spirits, naphtha gasoline and lamp oil. • Hydrocarbons having high volatility low viscosity and low surface tension are more likely to be aspirated and therefore have the greatest toxicity
  • 7. ETIOLOGICAL FACTORS • Inappropriate storage • attractive colour • pleasant odour • low socioeconomic status • inquisitive nature • lack of parental awareness • hot seasons
  • 8. INCIDENCE • Common in children(13.4%) • intentional poisoning (58.2%) and accidental poisoning(41.8%)
  • 9. PATHOPHYSIOLOGY Aspiration of hydrocaron inhibit surfactant alveolar instability, early distal air way closure ventilation perfusion mismatch hypoxia
  • 10. HISTOPATHOLOGY -bronchospasm - interstitial inflammation -atelactasis -emphysema -hyperemia -infiltration of polymorphonuclear cells -vascular thrombosis -bronchial and bronchiolar necrosis -intraalveolar hemorrhage and edema
  • 11. CLINICAL FEATURES • Respiratory • central nervous system • gastrointestinal tract system • skin • other organ involvement
  • 12. Respiratory symptoms -Early tachypnoea ,rales hemoptysis ,gagging choking ,transient cyanosis,pumonary edema,continued non productive cough -late pnemonia( chemical and bacterial)
  • 13. CNS FEATURES(28%) • Lethargy, semicomatose, comatose,convulsion
  • 14. GIT FEATURES • Irritation is common • spontaneous vomiting • nausea, diarrhoea and abdominal pain
  • 15. -Skin-burnSkin-burn -other organ involvement is very-other organ involvement is very rare(DIC, hemolytic anemia andrare(DIC, hemolytic anemia and even pancytopenia haveeven pancytopenia have occasionally been reportedoccasionally been reported following inhalation,aspiration,following inhalation,aspiration, or ingestion ofor ingestion of hydrocarbon.Renal effects occurhydrocarbon.Renal effects occur infrequentlyinfrequently
  • 16. COMPLICATION • Pulmonary edema • Respiratory failure • empyema
  • 17. INVESTIGATION • Leucocytosis-misleading • chest X-ray- -may be normal for as long as 8-12 hr. after aspiration, may remain abnormal long after a patient is clinically normal and should not be used to guide acute treatment. Note:clinical presentation is better predictor of clinical course than the chest X-ray • other- increased transaminases
  • 18. TREATMENT • HOME TREATMENT • TREATMENT IN HOSPITAL
  • 19. HOME TREATMENT • Seek emergency medical care immediately,call the poison control center for guidance. • Donot induce vomiting(emesis) • determine the following information before calling emergency: -the patient’s age ,weight and condition -name of the products(ingredients and strength, if known) -the time it was swallowed -the amount swallowed
  • 20. •Patient can be managed at home provided that - a)patient is asymptomatic b)there is access to follow up mechanism c)no indication of child abuse or attempted suicide
  • 21. TREATMENT IN HOSPITAL • SUPPORTIVE CARE • GASTRIC EMPTYING • ACTIVATED CHARCOAL • CATHARTICS • STEROIDS • PROPHYLACTIC ANTIBIOTIC • T/T FOR SKIN EXPOSURE • T/T FOR PULMONARY EDEM,A
  • 22. Admission criteria for hydrocarbon ingestion • Symptomatic patients(e.g. fever, hypoxia, dysrrhythmias or respiratory symptoms • asymptomatic patients with abnormal chest X-rays s/o aspiration if sufficient home follow-up cannot be provided. • Patients who have the potential for delayed systemic toxicity. • Cases of attempted suicide or cases involving ingestion of large amounts of hydrocarbon.
  • 23. Supportive care • Remove contaminated clothing and shower if necessary. • Check for aspiration • administer oxygen
  • 24. Gastric emptying • Method- a)induced emesis-in awake ,alert patients b)gastric lavage Note:not done if a single petroleum distillate is involved because unintentional ingestion involves small quantities of hydrocarbons ,only very small amount is absorbed through GI tract.
  • 25. Condition where gastric emptying is beneficial- a)where hydrocarbon is used as solvent for an other dangerous toxin. b)when ingested along with an other toxin c) when large volume of hydrocarbon(>30 ml) is ingested in a suicidal attempt.
  • 26. Activated charcoal • Not indicated since little hydrocarbon is absorbed • may aggravate emesis • doesnot bind aliphatic hydrocarbon aggresively
  • 27. Cathartics • Also not indicated as little hydrocarbon is absorbed • diarrhoes usually occurs after aliphatic compounds ingestion.
  • 28. Role of steroids • Donot improve the outcome in patients with pulmonary involvement • may even be dangerous as they may increase the risk of super infection.
  • 29. Prophylactic antibiotic • Not routinely recommended. • Justified in following cases: -predisposing respiratory illness -patients who are extremely weak -patients with severe pneumonia -bacteria involvement is confirmed by cultures of sputum of blood.
  • 30. T/t for skin exposure • Irrigation perhaps of few hrs. for several days • skin debridement of burned skin. • Admission of transfer to a hospital that specialises in burn care.
  • 31. T/t of Pulmonary edema • Maintenance of adequate ventilation with close monitoring of Arterial blood gases • PEEP in intubated patients or CPAP in non- intubated if PO2 cannot be maintained >50mmhg with inspiration of 60%O2 by face mask or mechanical ventilation. • Pharmacological means.
  • 32. Prognosis or Expectations • Extensive damage to the mouth ,throat and stomach are possible and the ultimate outcome depends on the extent of this damage.Damage can continue to occur for several weeks after hydrocarbon was swallowed • death may occur as long as a months after hydrocarbon was swallowed.
  • 33. SEVERITY SCORE (Gupta et al. ) Parameter absent present others Fever 0 1 - Severe malnutrition 0 1 - Respiratory distress 0 2 4(presence of cyanosis) Neurological symptoms 0 2 4(presence of convulsion) Note:score- min-0 and max-10 -if score> 4 or equal-significant risk and patient to be transferred to centre with of ALS -if score < 7 or equal- pt. likely to survive -if score>8 or equal-risk of death several times -predictive value of this scoring system is 85%
  • 34. Conclusion • Symptomatic and supportive care are the main stay in the management of hydrocarbon exposure. • Treatments are controversial and individualised. • Consultation with specialists of the Nepal Poison information center and its consultants recommended for all such cases. • Urge treating physician to provide counselling to parents of exposed children about poison proofing their home to prevent recurrences. • Long term follow of severely symptomatic case for the development to chronic lung diseases.
  • 35. Review Question Which statement is false? A.Hydrocarbons with viscosities < 60 SSU are readily aspirated. B.Kerosene is an example of an aliphatic hydrocarbon. C.Renal injury occurs in greater than 70% of aliphatic hydrocarbon ingestions. D.Activated charcoal is not indicated when the only poison ingested is an aliphatic hydrocarbon. E.Steroid have not been show to benefit patients suffering from aliphatic hydrcarbon induced chemicalpneumonitis.
  • 36. THANKYOU