See also

Poisoning - acute guidelines for initial management 
Coma 
Afebrile seizures 
Resuscitation
Poisoning - Camphor
Poisoning - Essential Oil

Key Points

1. CNS, respiratory and cardiac effects are of main concern
2. Activated charcoal is contraindicated in hydrocarbon poisoning
3. Inhalation injury may manifest up to 6 hrs after exposure
4. Ingestion of less than 5 mL of pure essential oil can lead to significant CNS toxicity in children

For 24 hour advice, contact the Victorian Poisons Information Centre on 13 11 26

Background

• Hydrocarbons can cause rapid onset of CNS symptoms including CNS depression and seizures.
• Volatile hydrocarbons can be aspirated and cause chemical pneumonitis.
• Cardiac dysrhythmias are less common
• Poisoning can occur from accidental exposure (often younger children) or deliberate exposure (often from inhalation eg from “sniffing” or “chroming”)

Sources:

Patients requiring assessment

• All patients with deliberate self-poisoning or significant accidental exposure
• Any symptomatic patient
• Any patient whose developmental age is inconsistent with accidental poisoning as non-accidental poisoning should be considered.

Risk Assessment

History 

Was exposure intentional or accidental?  
Dose:
Type of compound
Quantity ingested
Duration of exposure in inhalation
Co-ingestants (eg paracetamol)

Examination 

Respiratory

• Coughing / gagging / choking indicates aspiration
• Wheeze, tachypnoea, hypoxia, haemoptysis and pulmonary oedema are signs of evolving chemical pneumonitis.

Cardiovascular

• Dysrhythmias occur early in exposure

CNS

• CNS depression, coma and seizures may occur with large acute exposures. Onset is usually within 2 hours

GIT

• Nausea, vomiting and diarrhoea
• Excessive burping, heartburn, epigastric pain

Investigations

Asymptomatic children with small ingestions do not usually require investigation.

For children with more significant ingestions, or who are symptomatic:

• 12 lead ECG & cardiac monitoring for 4 hours
• FBE, UEC, LFTs, VBG
• CXR if respiratory symptoms

For all children with deliberate poisoning, perform further screening for co-ingestants (See Acute poisoning - guidelines for initial management):

• BSL
• Paracetamol level

Acute Management

1. Resuscitation

Standard procedures and supportive care 

• Intubate early for progressive CNS depression

• Ventricular dysrhythmias:
• Commence advance life support ( Resuscitation CPG)
• Intubate, hyperventilate, correct hypoxia
• Correct electrolyte disturbances
• Withhold catecholamine inotropes if possible 
  

• Seizures – Benzodiazepines remain standard first line treatment. Phenytoin should be avoided. Use these links for further guidance:
• Poisonings - Acute Guidelines for initial management 
• Seizures (see Afebrile seizures) 

• Chemical pneumonitis is managed supportively (Oxygen & bronchodilators – may require non invasive ventilation or intubation if severe).  Corticosteroids and prophylactic antibiotics are not indicated. Fever is common following aspiration with pneumonitis – antibiotics should be withheld until there is objective evidence of bacterial infection

2. Decontamination

Activated charcoal is specifically contraindicated in hydrocarbon poisoning as they do not bind hydrocarbons and increase the risk of hydrocarbon aspiration

Ongoing care and monitoring
Asymptomatic children with normal vital signs should be observed for 6 hours post exposure before discharge
Patients with milder respiratory or CNS symptoms should be admitted for a longer period of observation +/- supportive care

When to admit/consult local paediatric team, or who/when to phone

Admission should be considered for all adolescent patients with an intentional overdose.

Consult Contact Victorian Poisons Information Centre 13 11 26 for advice

When to consider transfer to a tertiary centre

Patients with CNS depression / seizures or dysrhythmia should be managed in a paediatric intensive care unit

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Discharge Criteria

Normal GCS  
Normal ECG
No respiratory symptoms (cough, dyspnoea, wheeze)
Normal observations including pulse oximetry
Period of observation as above
For deliberate ingestion a risk assessment should indicate that the patient is at low risk of further self harm in the discharge setting

Discharge information and follow-up

Accidental ingestion: Parent information sheet from Victorian Poisons Information centre on the prevention of poisoning

Intentional self –harm: Referral to local mental health services eg Orygen Youth Health: 1800 888 320 

Recreational poisoning: Referral to YoDAA, Victoria's Youth Drug and Alcohol Advice service: 1800 458 685  

 Last updated June 2017