1 Hydrocarbons, Volatile Substances and Caustics David R. Fisher, D.O. Tintinalli Chapters 180 & 181...

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Hydrocarbons, Hydrocarbons, Volatile Substances Volatile Substances

and Causticsand Caustics

David R. Fisher, D.O.David R. Fisher, D.O.

Tintinalli Chapters 180 & 181Tintinalli Chapters 180 & 181

February 23, 2006February 23, 2006

22

Hydrocarbons and Volatile Hydrocarbons and Volatile SubstancesSubstances

Exposure may cause life Exposure may cause life threatening toxicity and threatening toxicity and in some cases sudden in some cases sudden deathdeath

33

HydrocarbonsHydrocarbons

Carbon and hydrogen atoms Carbon and hydrogen atoms – Aliphatic (open chain) and aromatic (benzene ring)Aliphatic (open chain) and aromatic (benzene ring)

Household and occupational settings Household and occupational settings – FuelsFuels– Lighter fluidsLighter fluids– Lamp oilLamp oil– PaintsPaints– Paint removersPaint removers– PesticidesPesticides– MedicationsMedications– Cleaning and polishing agentsCleaning and polishing agents– Spot removersSpot removers– DegreasersDegreasers– LubricantsLubricants– SolventsSolvents

44

Volatile SubstancesVolatile Substances Liquid chemicals or gasesLiquid chemicals or gases

– May be abused for euphoric effectsMay be abused for euphoric effects

HydrocarbonsHydrocarbons– Glue (toluene)Glue (toluene)– Propellants (butane, trichloroethylene, Freon)Propellants (butane, trichloroethylene, Freon)– GasolineGasoline

Non-hydrocarbonsNon-hydrocarbons– Nitrites (isobutyl nitrite)Nitrites (isobutyl nitrite)– Nitrous oxideNitrous oxide

55

ClassificationClassification Most hydrocarbons result from petroleum Most hydrocarbons result from petroleum

distillationdistillation

– Aliphatic mixtures of hydrocarbons of different chain Aliphatic mixtures of hydrocarbons of different chain lengths lengths

Chain length and branching determines the phase of the Chain length and branching determines the phase of the hydrocarbon at room temperaturehydrocarbon at room temperature

– Short-chain (methane, propane or butane): gasesShort-chain (methane, propane or butane): gases

– Intermediate-chain: liquidsIntermediate-chain: liquids Most hydrocarbon exposures seen in the EDMost hydrocarbon exposures seen in the ED

– Long-chain: waxes/solidsLong-chain: waxes/solids

66

ClassificationClassification Wood distillatesWood distillates

– Turpentine and pine oilTurpentine and pine oil– GI absorption greater than petroleum distillatesGI absorption greater than petroleum distillates– CNS depressionCNS depression

Aromatics and halogenated aliphatic Aromatics and halogenated aliphatic hydrocarbons hydrocarbons – Industrial solventsIndustrial solvents– Inhalation route of toxicity Inhalation route of toxicity – Substance abusers and some jobs most often affectedSubstance abusers and some jobs most often affected– CNS, cardiovascular, hepatic, renal and hematologic CNS, cardiovascular, hepatic, renal and hematologic

toxicitytoxicity

Additives such as lead in gasoline and pesticidesAdditives such as lead in gasoline and pesticides– Toxic additive usually dictates the clinical approachToxic additive usually dictates the clinical approach

77

EpidemiologyEpidemiology Most exposures ingestion or inhalationMost exposures ingestion or inhalation

– 3-10 % of all unintentional childhood poisonings in the 3-10 % of all unintentional childhood poisonings in the USUS

– Most frequent:Most frequent: Gasoline, kerosene, lighter fluid, mineral seal oil and Gasoline, kerosene, lighter fluid, mineral seal oil and

turpentineturpentine

10% of youths inhale volatiles to get high10% of youths inhale volatiles to get high– Butane, aerosols, cleaners and glueButane, aerosols, cleaners and glue

Most exposures have a benign clinical courseMost exposures have a benign clinical course– 80,000 hydrocarbon exposures80,000 hydrocarbon exposures– 5% moderate to severe toxicity5% moderate to severe toxicity– 12 died in 2001 in US 12 died in 2001 in US

88

Determinants of ToxicityDeterminants of Toxicity Toxic potential of hydrocarbons depends on: Toxic potential of hydrocarbons depends on:

– Physical characteristicsPhysical characteristics Volatility, viscosity, surface tensionVolatility, viscosity, surface tension

– Chemical characteristicsChemical characteristics Aliphatic, aromatic, halogenated Aliphatic, aromatic, halogenated

– Presence of toxic additivesPresence of toxic additives Pesticides, heavy metalsPesticides, heavy metals

– Route of exposureRoute of exposure

– ConcentrationConcentration

– Dose Dose

99

Aspiration Potential Depends Aspiration Potential Depends On:On:

Viscosity Viscosity – Lower viscosity, greater risk for aspiration Lower viscosity, greater risk for aspiration

LowLow– Gasoline, kerosene, mineral seal oil, turpentine and aromatic and Gasoline, kerosene, mineral seal oil, turpentine and aromatic and

halogenated hydrocarbonshalogenated hydrocarbons HighHigh

– Diesel oil, grease, mineral oil, paraffin wax and petroleum jellyDiesel oil, grease, mineral oil, paraffin wax and petroleum jelly

Surface tension Surface tension – Lower increases risk of aspirationLower increases risk of aspiration

VolatilityVolatility– Higher, increased risk of systemic absorption and Higher, increased risk of systemic absorption and

toxicity toxicity Aromatic hydrocarbons, halogenated hydrocarbons or gasolineAromatic hydrocarbons, halogenated hydrocarbons or gasoline

1010

Determinants of ToxicityDeterminants of Toxicity

Dermal exposure Dermal exposure – Local toxicity Local toxicity

Occasionally leads to systemic absorption Occasionally leads to systemic absorption

Pulmonary toxicity Pulmonary toxicity First pass exposure through the lungs First pass exposure through the lungs

1111

Determinants of ToxicityDeterminants of Toxicity

Toxicity characteristic of organ system Toxicity characteristic of organ system affectedaffected– PulmonaryPulmonary– NeurologicNeurologic– GIGI– CardiacCardiac– HepaticHepatic– RenalRenal– HematologicHematologic– DermalDermal

1212

Pulmonary ToxicityPulmonary Toxicity

11°° adverse affect of hydrocarbon exposure adverse affect of hydrocarbon exposure

Typically unintentional childhood ingestionTypically unintentional childhood ingestion– Small amounts of aliphatic hydrocarbons stored at Small amounts of aliphatic hydrocarbons stored at

homehome– Limited GI absorptionLimited GI absorption

Ingestion of aromatics or halogenated less likely Ingestion of aromatics or halogenated less likely to result in aspiration as GI absorption is greaterto result in aspiration as GI absorption is greater

1313


Risk and degree of aspiration not volume Risk and degree of aspiration not volume dependentdependent

Occurs from aspiration into pulmonary Occurs from aspiration into pulmonary treetree– Occurs at time of ingestionOccurs at time of ingestion– Hydrocarbons do not reflux into airwayHydrocarbons do not reflux into airway– Vomiting increases risk of aspiration Vomiting increases risk of aspiration

1414


Aspiration chemical pneumonitis Aspiration chemical pneumonitis – Altered surfactant functionAltered surfactant function– Destruction of alveoli & capillaries Destruction of alveoli & capillaries – Bronchospasm and V/Q mismatchBronchospasm and V/Q mismatch

CNS manifestations CNS manifestations – Hypoxia 2Hypoxia 2° ° to pneumonitis to pneumonitis – Toxicity after pulmonary absorption of Toxicity after pulmonary absorption of

volatile hydrocarbon volatile hydrocarbon

1515


OtherOther– PneumatocelesPneumatoceles– Pneumothoraces Pneumothoraces – PneumomediastinumPneumomediastinum– Bacterial superinfectionBacterial superinfection– ARDSARDS– Long-term pulmonary dysfunction Long-term pulmonary dysfunction – DeathDeath

1616


Irritation of oral mucosa and Irritation of oral mucosa and tracheobronchial treetracheobronchial tree

Symptoms:Symptoms:– CoughingCoughing– ChokingChoking– GaspingGasping– DyspneaDyspnea– Burning of the mouthBurning of the mouth

1717


If symptomatic, aspiration until proven If symptomatic, aspiration until proven otherwiseotherwise

Physical exam:Physical exam:– Grunting respirationsGrunting respirations– RetractionsRetractions– TachypneaTachypnea– TachycardiaTachycardia– Cyanosis Cyanosis – Odor of hydrocarbons may be presentOdor of hydrocarbons may be present

1818

Pulmonary ToxicityPulmonary Toxicity Temp 39Temp 39°° C or > common C or > common

Auscultation: normal, wheezing, decreased or Auscultation: normal, wheezing, decreased or absentabsent

ABG: widened A-a gradient or hypoxemiaABG: widened A-a gradient or hypoxemia

Necrotizing pneumonitis and hemorrhagic Necrotizing pneumonitis and hemorrhagic pulmonary edema may occur within hours in pulmonary edema may occur within hours in severe aspiration severe aspiration

Fatalities occur within 24-48 hoursFatalities occur within 24-48 hours

1919


Most with significant aspiration have abnormal CXRsMost with significant aspiration have abnormal CXRs

– Time course of changes variesTime course of changes varies Correlation with physical examination may be poor Correlation with physical examination may be poor

– Changes as early as 30 minutes after aspiration Changes as early as 30 minutes after aspiration Initial radiograph in symptomatic patient may be deceptively clearInitial radiograph in symptomatic patient may be deceptively clear

– Changes usually by 2-6 hoursChanges usually by 2-6 hours Almost always present by 18-24 hours if they are to occurAlmost always present by 18-24 hours if they are to occur

2020

Pulmonary ToxicityPulmonary Toxicity Infiltrates vary Infiltrates vary

Usually dependent lobesUsually dependent lobes

Multilobar > single-lobe Multilobar > single-lobe

R > L R > L

Radiographic changes limited to bilateral perihilar Radiographic changes limited to bilateral perihilar regions with clear lung bases are also common regions with clear lung bases are also common

Mild radiographic changes does not guarantee Mild radiographic changes does not guarantee sympomssympoms

2121

CNS ToxicityCNS Toxicity

Direct response to systemic absorption of hydrocarbonDirect response to systemic absorption of hydrocarbon GI, aspiration, dermalGI, aspiration, dermal

Indirect result of severe hypoxia 2Indirect result of severe hypoxia 2° ° to aspirationto aspiration

Asphyxiation via:Asphyxiation via:– Loss of ventilatory driveLoss of ventilatory drive– Use of plastic bag or other device during baggingUse of plastic bag or other device during bagging

2222

CNS ToxicityCNS Toxicity Exposure to volatile hydrocarbons Exposure to volatile hydrocarbons

– Inadvertent vs. deliberate solvent abuseInadvertent vs. deliberate solvent abuse

Volatile solvent abuse Volatile solvent abuse – Teenagers and younger adultsTeenagers and younger adults– Low SES and Native AmericansLow SES and Native Americans

Huffers and baggers Huffers and baggers – Huffers inhale through rag soaked with the hydrocarbon held to Huffers inhale through rag soaked with the hydrocarbon held to

mouthmouth– Baggers rebreathe into a bag containing the hydrocarbonBaggers rebreathe into a bag containing the hydrocarbon

May result in significant hypercarbia and hypoxiaMay result in significant hypercarbia and hypoxia

2323

CNS ToxicityCNS Toxicity Hydrocarbon affinity for lipid-rich neural tissue, dose-Hydrocarbon affinity for lipid-rich neural tissue, dose-

dependant effect:dependant effect:– DizzinessDizziness– Slurred speechSlurred speech– AtaxiaAtaxia– LethargyLethargy– ObtundationObtundation– ComaComa– ApneaApnea– ExhilarationExhilaration– GiddinessGiddiness– TremorTremor– AgitationAgitation– ConvulsionsConvulsions– ConfusionConfusion– HallucinationsHallucinations– Psychosis Psychosis – Confused with alcohol intoxicationConfused with alcohol intoxication

2424

Chronic CNS sequelae Chronic CNS sequelae

May result from recurrent inhalational May result from recurrent inhalational exposure exposure

– Common with house paintersCommon with house painters

– Intentional sniffingIntentional sniffing Solvent abuseSolvent abuse

– Toluene Toluene

Leaded gasoline Leaded gasoline – Encephalopathy, ataxia, tremor, chorea and myoclonusEncephalopathy, ataxia, tremor, chorea and myoclonus– Effects of tetraethyl lead and its toxic metabolitesEffects of tetraethyl lead and its toxic metabolites

2525

Chronic CNS sequelae Chronic CNS sequelae

OtherOther

– Recurrent headachesRecurrent headaches

– Cerebellar ataxiaCerebellar ataxia

– Chronic encephalopathy Chronic encephalopathy TremorsTremors Emotional labilityEmotional lability Mental status changesMental status changes Cognitive impairmentCognitive impairment Psychomotor impairmentPsychomotor impairment

2626

Peripheral Nervous System Peripheral Nervous System ToxicityToxicity

Peripheral polyneuropathy Peripheral polyneuropathy – Demyelinization and retrograde axonal degeneration Demyelinization and retrograde axonal degeneration

Onset of symptoms may be delayed months to Onset of symptoms may be delayed months to years years

Long distal nerves most vulnerableLong distal nerves most vulnerable– Foot and wrist dropFoot and wrist drop– Numbness and paresthesias Numbness and paresthesias – Similar clinical picture in those who sniff unleaded Similar clinical picture in those who sniff unleaded

gasoline gasoline

2727

Gastrointestinal ToxicityGastrointestinal Toxicity

Most act as intestinal irritants Most act as intestinal irritants – Burning in the mouth and throatBurning in the mouth and throat– Abdominal painAbdominal pain– BelchingBelching– NauseaNausea– VomitingVomiting– DiarrheaDiarrhea

Corrosive GI injury and pancreatitis Corrosive GI injury and pancreatitis reportedreported

2828

Cardiac ToxicityCardiac Toxicity

V-tach and V-fib V-tach and V-fib

Halogenated and aromatic hydrocarbonsHalogenated and aromatic hydrocarbons

AliphaticsAliphatics– Dysrhythmia and sudden deathDysrhythmia and sudden death– Heart sensitized to catecholamines Heart sensitized to catecholamines

2929

Cardiac ToxicityCardiac Toxicity Sudden sniffing death Sudden sniffing death

– Solvent abusers die suddenly after exertion, panic or frightSolvent abusers die suddenly after exertion, panic or fright Release of catecholamines induces fatal dysrhythmiasRelease of catecholamines induces fatal dysrhythmias

Others deathsOthers deaths– Asphyxia, respiratory depression, vagal inhibitionAsphyxia, respiratory depression, vagal inhibition

Volatile abuseVolatile abuse– Decreased myocardial contractilityDecreased myocardial contractility– Decreased peripheral vascular resistance Decreased peripheral vascular resistance – Bradycardia Bradycardia – Atrioventricular conduction blocksAtrioventricular conduction blocks

3030

Renal and Metabolic Renal and Metabolic ToxicityToxicity

Halogenated hydrocarbons Halogenated hydrocarbons Carbon tetrachlorideCarbon tetrachloride Trichloroethylene Trichloroethylene Chlorinated paraffinsChlorinated paraffins Acute renal failureAcute renal failure Centrilobular hepatic necrosisCentrilobular hepatic necrosis

– Large ingestions Large ingestions Renal excretion of aliphatic hydrocarbons may occur Renal excretion of aliphatic hydrocarbons may occur

– Visible hydrocarbon droplets in urineVisible hydrocarbon droplets in urine

– Hemorrhagic cystitis reportedHemorrhagic cystitis reported

3131

Renal and Metabolic Renal and Metabolic ToxicityToxicity

Toluene AbuseToluene Abuse– ProteinuriaProteinuria– Renal insufficiencyRenal insufficiency– Renal tubular acidosisRenal tubular acidosis– Non-anion gap metabolic acidosisNon-anion gap metabolic acidosis– HypokalemiaHypokalemia– HypophosphatemiaHypophosphatemia– RhabdomyolysisRhabdomyolysis– High anion gap metabolic acidosis High anion gap metabolic acidosis

Accumulation of hippuric and benzoic acid metabolites Accumulation of hippuric and benzoic acid metabolites

3232

Hepatic ToxicityHepatic Toxicity

Halogenated hydrocarbonsHalogenated hydrocarbons

– Carbon tetrachloride Carbon tetrachloride 3 cc may be fatal3 cc may be fatal Chronic exposure may result in cirrhosis Chronic exposure may result in cirrhosis

– Chloroform and methylene chlorideChloroform and methylene chloride Cell destruction via lipid peroxidation from free radicals Cell destruction via lipid peroxidation from free radicals Acute fatty degeneration centrilobular necrosisAcute fatty degeneration centrilobular necrosis LFTs elevated 24 hours after ingestionLFTs elevated 24 hours after ingestion Development of liver tenderness and jaundice in 48-96 hoursDevelopment of liver tenderness and jaundice in 48-96 hours

3333

Hematologic ToxicityHematologic Toxicity

BenzeneBenzene– Chronic exposureChronic exposure

Aplastic anemiaAplastic anemia– Glue sniffersGlue sniffers

Acute myelogenous leukemiaAcute myelogenous leukemia Multiple myelomaMultiple myeloma

– Etiology of blood dyscrasias are the toxic Etiology of blood dyscrasias are the toxic metabolitesmetabolites

3434

Hematologic ToxicityHematologic Toxicity Hemolysis Hemolysis

– Gasoline, kerosene, tetrachloroethylene and mineral Gasoline, kerosene, tetrachloroethylene and mineral spiritsspirits

Consumptive coagulopathy reportedConsumptive coagulopathy reported

Delayed methemoglobinemiaDelayed methemoglobinemia– Hydrocarbons with amines (aniline)Hydrocarbons with amines (aniline)

Hemolytic anemiaHemolytic anemia– NaphthaleneNaphthalene

3535

Hematologic ToxicityHematologic Toxicity

Methylene chloride exposureMethylene chloride exposure– Endogenous production of carbon monoxideEndogenous production of carbon monoxide

– Carbon monoxide formation may continue Carbon monoxide formation may continue after cessation of exposureafter cessation of exposure

– Consider CO production if present with CNS Consider CO production if present with CNS and cardiac symptoms and cardiac symptoms

3636

Dermal ToxicityDermal Toxicity Hydrocarbons are irritants and sensitizers:Hydrocarbons are irritants and sensitizers:

– PruritisPruritis– Local erythemaLocal erythema– PapulesPapules– VessiclesVessicles– Generalized scarlatiniform eruptionGeneralized scarlatiniform eruption– Exfoliative dermatitisExfoliative dermatitis

Huffer’s rash on face in chronic volatile HC Huffer’s rash on face in chronic volatile HC abuseabuse

Defatting dermatitis similar to chronic Defatting dermatitis similar to chronic eczematoid dermatitiseczematoid dermatitis

3737

Dermal ToxicityDermal Toxicity Frostbite with inhalational abuse of fluorinated agentsFrostbite with inhalational abuse of fluorinated agents

Cellulitis and sterile abscesses with injection Cellulitis and sterile abscesses with injection

Partial and full-thickness burns with immersion Partial and full-thickness burns with immersion

Skin penetration may result in systemic toxicitySkin penetration may result in systemic toxicity

Exposure to heated high-viscosity, long chain Exposure to heated high-viscosity, long chain aliphaticsaliphatics– Tar, asphalt or bitumenTar, asphalt or bitumen– Associated with hyperthermia and difficult decontamination Associated with hyperthermia and difficult decontamination

3838

Prehospital TreatmentPrehospital Treatment Not all ingestions require ED evaluationNot all ingestions require ED evaluation

– Fewer than 1% require physician interventionFewer than 1% require physician intervention

Asymptomatic after ingestion watched safely at Asymptomatic after ingestion watched safely at homehome

Decision supported when:Decision supported when:– Ingestion is accidentalIngestion is accidental– Known ingredients Known ingredients – Ingredients not significantly systemically toxic when Ingredients not significantly systemically toxic when

ingested ingested – Reliable follow-up can be ensuredReliable follow-up can be ensured

3939

Prehospital TreatmentPrehospital Treatment

Symptomatic and intentional exposures Symptomatic and intentional exposures should be referred to hospital for further should be referred to hospital for further evaluation evaluation

Accidental volatile exposure and abusers Accidental volatile exposure and abusers need cardiac monitoring and ALS need cardiac monitoring and ALS transport due to potential of life-transport due to potential of life-threatening dysrhythmiasthreatening dysrhythmias

4040

ED TreatmentED Treatment ABCsABCs

Continuous cardiac monitoringContinuous cardiac monitoring

ECGECG

Odor:Odor:– Sweet Sweet

Halogenated hydrocarbonsHalogenated hydrocarbons– Especially chloroform or trichloroethyleneEspecially chloroform or trichloroethylene

– Petroleum Petroleum Gasoline or other petroleum derivativeGasoline or other petroleum derivative

4141

ED TreatmentED Treatment Dysrhythmias Dysrhythmias

– If present occur shortly after exposureIf present occur shortly after exposure Especially with inhalational useEspecially with inhalational use

Hypotension: aggressive fluid resuscitation Hypotension: aggressive fluid resuscitation

Catecholamines Catecholamines – Dopamine, norepinephrine or epinephrineDopamine, norepinephrine or epinephrine– Avoided to prevent precipitating dysrhythmiasAvoided to prevent precipitating dysrhythmias

Glucose, thiamine and naloxone should be considered Glucose, thiamine and naloxone should be considered in cases of altered mental statusin cases of altered mental status

4242

ED TreatmentED Treatment Staff protectionStaff protection

– Gloves, goggles and apronsGloves, goggles and aprons– Prevent possible 2Prevent possible 2° ° exposureexposure

Fully undress patient Fully undress patient – Prevents ongoing contamination from hydrocarbon-soaked Prevents ongoing contamination from hydrocarbon-soaked

clothes clothes

DecontaminationDecontamination– Pre-hospital preferablePre-hospital preferable– SkinSkin

Soap and water Soap and water – EyesEyes

Saline irrigationSaline irrigation

4343

ED TreatmentED Treatment CXR and ABG CXR and ABG

– Pulmonary aspiration and hypoxemia Pulmonary aspiration and hypoxemia

Abdominal X-ray Abdominal X-ray – Evidence of chlorinated HC ingestions like CClEvidence of chlorinated HC ingestions like CCl44

Polyhalogenated substances radiopaquePolyhalogenated substances radiopaque

LFTs and renal function LFTs and renal function – Aromatic and halogenated hydrocarbon Aromatic and halogenated hydrocarbon

exposuresexposures– Check for respective organ injuryCheck for respective organ injury

4444

ED TreatmentED Treatment

Carboxyhemoglobin Carboxyhemoglobin – Extent of endogenous CO production post methylene chloride Extent of endogenous CO production post methylene chloride

exposureexposure

Pulse oximetry Pulse oximetry – Doesn’t differentiate oxyhemoglobin from carboxyhemoglobinDoesn’t differentiate oxyhemoglobin from carboxyhemoglobin

Routine drug screens Routine drug screens – Not useful for hydrocarbons Not useful for hydrocarbons

All intentional ingestions: assess for coingestantsAll intentional ingestions: assess for coingestants– Acetaminophen levelAcetaminophen level– EtOH levelEtOH level– Anion gap Anion gap – OsmolalityOsmolality

4545

GI DecontaminationGI Decontamination Need depends on type of hydrocarbon and route of Need depends on type of hydrocarbon and route of

exposureexposure

For most ingestions GI decontamination of little benefit For most ingestions GI decontamination of little benefit

Supportive care and treatment for coexisting ingestionsSupportive care and treatment for coexisting ingestions

Risk vs. benefits:Risk vs. benefits:– Systemic toxicity by intestinal absorptionSystemic toxicity by intestinal absorption– Risks of aspiration associated with gastric emptyingRisks of aspiration associated with gastric emptying

4646

GI DecontaminationGI Decontamination Little data as to effectiveness of GI decontaminationLittle data as to effectiveness of GI decontamination

Most aliphatic HC ingestions do not require GI Most aliphatic HC ingestions do not require GI decontaminationdecontamination

Poor GI absorption Poor GI absorption

Toxicity limited primarily to pulmonary aspiration Toxicity limited primarily to pulmonary aspiration

Childhood accidental ingestion volume usually a swallow Childhood accidental ingestion volume usually a swallow or about 5 cc or about 5 cc

Suicidal ingestions involve large amounts of HCs and Suicidal ingestions involve large amounts of HCs and associated with spontaneous emesisassociated with spontaneous emesis– Further decontamination not usually requiredFurther decontamination not usually required

4747

GI DecontaminationGI Decontamination

Warranted:Warranted:

– Ingested HC with good GI absorptionIngested HC with good GI absorption

– May cause significant systemic toxicityMay cause significant systemic toxicity Toluene, chloroform, wood distillatesToluene, chloroform, wood distillates

– Additive in the toxic agent Additive in the toxic agent Organophosphate pesticides often mixed with Organophosphate pesticides often mixed with

petroleum distillatespetroleum distillates

4848


CHAMPCHAMP

– GI decontamination consideredGI decontamination considered

Camphor, halogenated hydrocarbons, aromatic Camphor, halogenated hydrocarbons, aromatic hydrocarbons, metals, pesticideshydrocarbons, metals, pesticides

If presents shortly after ingestion of these If presents shortly after ingestion of these hydrocarbons, aspiration with a small NG tube hydrocarbons, aspiration with a small NG tube may be usefulmay be useful

4949

GI DecontaminationGI Decontamination Altered mental statusAltered mental status

– Airway should be protected with a cuffed ET tubeAirway should be protected with a cuffed ET tube– Especially during lavageEspecially during lavage

Ipecac induced emesis contraindicated Ipecac induced emesis contraindicated

Charcoal not recommended for most hydrocarbon Charcoal not recommended for most hydrocarbon ingestionsingestions– Distends the stomach increasing the risk for vomiting and Distends the stomach increasing the risk for vomiting and

aspiration aspiration – Only use if a CHAMP hydrocarbon has been ingested Only use if a CHAMP hydrocarbon has been ingested – Extreme caution due to aspiration risk Extreme caution due to aspiration risk

5050


Cathartics no proven efficacy in Cathartics no proven efficacy in hydrocarbonshydrocarbons

Many already have diarrhea Many already have diarrhea

Oil based cathartics contraindicated Oil based cathartics contraindicated – Increase GI absorption Increase GI absorption – Risk of lipoid pneumonia when aspirated Risk of lipoid pneumonia when aspirated

5151

Pulmonary TreatmentPulmonary Treatment Nebulized oxygen helpfulNebulized oxygen helpful

Inhaled Inhaled ββ2 2 agonists for bronchospasmagonists for bronchospasm

PEEP and CPAPPEEP and CPAP– Consider barotraumaConsider barotrauma

ECMO and high-frequency jet ventilation:ECMO and high-frequency jet ventilation:– Severe aspiration resulting in refractory hypoxemiaSevere aspiration resulting in refractory hypoxemia

Steroids contraindicated Steroids contraindicated – Impairs cellular immune responseImpairs cellular immune response– Increased chance of bacterial superinfectionIncreased chance of bacterial superinfection

AntibioticsAntibiotics– No proven role except in superimposed bacterial pneumonitisNo proven role except in superimposed bacterial pneumonitis

5252

OtherOther Few antidotes to counteract actions of HCsFew antidotes to counteract actions of HCs

NAC and hyperbaric ONAC and hyperbaric O22 may help prevent hepatic toxicity after CCl may help prevent hepatic toxicity after CCl44 exposureexposure

Hyperbaric oxygen may be indicated in those with CO toxicity after Hyperbaric oxygen may be indicated in those with CO toxicity after exposure to methylene chloride exposure to methylene chloride

ββ blockers useful for HC induced malignant arrhythmias blockers useful for HC induced malignant arrhythmias

Little evidence for hemodialysis efficacyLittle evidence for hemodialysis efficacy

Specific antidotes for complications of toxic additives such as Specific antidotes for complications of toxic additives such as organophosphates, pyrethrins or heavy metal organophosphates, pyrethrins or heavy metal

5353

Tar and Asphalt injuryTar and Asphalt injury Difficult to remove without causing further tissue injuryDifficult to remove without causing further tissue injury

Pre-hospital cooling with cold water to limit injuryPre-hospital cooling with cold water to limit injury

Debridement of blistered skin may aid removal of Debridement of blistered skin may aid removal of adherent substancesadherent substances

De-Solv-It De-Solv-It – Surface active petroleum based solventSurface active petroleum based solvent– Non-irritating and effective in removing these agentsNon-irritating and effective in removing these agents– Should only apply briefly Should only apply briefly

Others: Others: – Polyoxyethylene sorbitan-containing ointments Polyoxyethylene sorbitan-containing ointments – Petroleum preparations such as neosporin and polysporin may Petroleum preparations such as neosporin and polysporin may

workwork

5454

Tar and Asphalt injuryTar and Asphalt injury

May apply all but De-Solv-It under an occlusive May apply all but De-Solv-It under an occlusive dressing for 24 hours to solubilize the substance dressing for 24 hours to solubilize the substance so it may be washed offso it may be washed off

Not necessary to remove all the tar with first visitNot necessary to remove all the tar with first visit

Close follow-up required Close follow-up required

Excision and skin grafting for severe hot tar burnsExcision and skin grafting for severe hot tar burns

5555

DispositionDisposition

Toxicologist or poison control center consulted Toxicologist or poison control center consulted – Symptomatic HC exposures Symptomatic HC exposures – Asymptomatic exposures with halogenated, Asymptomatic exposures with halogenated,

aromatic and hydrocarbon exposures with toxic aromatic and hydrocarbon exposures with toxic additivesadditives

Discharge after 6 hour observation period if:Discharge after 6 hour observation period if:– Asymptomatic with a normal chest X-ray or with Asymptomatic with a normal chest X-ray or with

abnormal chest X-ray if reliable follow-up can be abnormal chest X-ray if reliable follow-up can be ensuredensured

5656

Hospitalization RequiredHospitalization Required

Aliphatic hydrocarbons and symptomatic at the time of evaluationAliphatic hydrocarbons and symptomatic at the time of evaluation

Significant amounts of methemoglobinemia-producing Significant amounts of methemoglobinemia-producing hydrocarbonshydrocarbons

Hydrocarbons capable of producing delayed complications Hydrocarbons capable of producing delayed complications – Halogenated hydrocarbons causing hepatic toxicityHalogenated hydrocarbons causing hepatic toxicity

Hydrocarbons with toxic additivesHydrocarbons with toxic additives– Organophosphates and organic metal compoundsOrganophosphates and organic metal compounds

Suicidal Suicidal

Complications of solvent abuseComplications of solvent abuse

5757

CausticsCaustics

5858

EpidemiologyEpidemiology 100 K caustic exposures yearly100 K caustic exposures yearly

– Dermal, occular and oral ingestionDermal, occular and oral ingestion

Usually < 6 years oldUsually < 6 years old

Most unintentionalMost unintentional– Suicidal intent results in more severe injurySuicidal intent results in more severe injury

In 2000:In 2000:– 387 exposures resulted in severe morbidity387 exposures resulted in severe morbidity– 20 deaths20 deaths

5959

Sources: Chemicals in Sources: Chemicals in industryindustry

AcidsAcids– CleanersCleaners

HClHCl HH22SOSO44

– Etching and metal cleaningEtching and metal cleaning HFHF

– Metal PlatingMetal Plating Chromic acidChromic acid

– Leather and Textile Leather and Textile tanningtanning Formic acidFormic acid

AlkaliAlkali– Cleaning fluidsCleaning fluids

NaOHNaOH KOHKOH

– ConcreteConcrete CaOHCaOH

– PhotographyPhotography LiOHLiOH

– FertilizerFertilizer Ammonium hydroxideAmmonium hydroxide

6060

Sources: HouseholdSources: Household CommonCommon

Most less concentrated than Most less concentrated than industryindustry

AcidsAcids– Sulfuric acidSulfuric acid

Drain cleanersDrain cleaners Automobile batteriesAutomobile batteries

– HCl HCl CleanersCleaners

– Formic acidFormic acid Airplane glueAirplane glue

– HFHF Rust removersRust removers

AlkaliAlkali– NaOHNaOH

Drain cleaners, oven Drain cleaners, oven cleaners, Clinitest tabletscleaners, Clinitest tablets

– Sodium HypochloriteSodium Hypochlorite Household bleachHousehold bleach Most common alkali Most common alkali

exposure reported exposure reported Most exposures benignMost exposures benign 3 deaths in 20003 deaths in 2000

– AmmoniumAmmonium Glass, tub and tile Glass, tub and tile

cleanerscleaners

6161

Alkali PathophysiologyAlkali Pathophysiology

May be deep due to liquefaction necrosisMay be deep due to liquefaction necrosis

Proteins rapidly denaturedProteins rapidly denatured

Lipids undergo saponificationLipids undergo saponification

Cellular destruction on contactCellular destruction on contact

Thrombosis of microvasculature Thrombosis of microvasculature – Leads to further necrosisLeads to further necrosis

6262

Alkali PathophysiologyAlkali Pathophysiology Solid alkali exposureSolid alkali exposure

– Oropharynx and proximal esophagusOropharynx and proximal esophagus Less distal esophageal injuryLess distal esophageal injury

Liquid ingestionLiquid ingestion– Esophageal injuriesEsophageal injuries

– Severe intentional ingestion Severe intentional ingestion May result in multisystem organ injuryMay result in multisystem organ injury

– Gastric perforationGastric perforation– Necrosis of abdominal viscera Necrosis of abdominal viscera – Pancreas, gallbladder and small intestine injuryPancreas, gallbladder and small intestine injury

6363

Alkali PathophysiologyAlkali Pathophysiology Household bleachHousehold bleach

– 3-6% sodium hypochlorite solution3-6% sodium hypochlorite solution– pH of 11pH of 11– Not corrosive to esophagusNot corrosive to esophagus– Ingestion may cause emesisIngestion may cause emesis

22° ° to gastric or pulmonary irritation to gastric or pulmonary irritation

Industrial bleachIndustrial bleach– Higher concentrations of sodium hypochloriteHigher concentrations of sodium hypochlorite– Esophageal necrosis with ingestionEsophageal necrosis with ingestion– Aspiration pneumonitisAspiration pneumonitis– Sight-limiting occular injuriesSight-limiting occular injuries

6464

Acid PathophysiologyAcid Pathophysiology Strong acids produce coagulation necrosisStrong acids produce coagulation necrosis

– Tissue destruction and cell death results in eschar formationTissue destruction and cell death results in eschar formation Protects against deeper injuryProtects against deeper injury

Not esophageal sparingNot esophageal sparing

May settle in stomachMay settle in stomach– Gastric necrosis, perforation and hemorrhage Gastric necrosis, perforation and hemorrhage

Less tissue destruction than alkaliLess tissue destruction than alkali

Higher mortality than alkali ingestionHigher mortality than alkali ingestion– May be due to complications of systemic absorption May be due to complications of systemic absorption

Metabolic acidosisMetabolic acidosis HemolysisHemolysis Liver failureLiver failure

6565

Clinical FeaturesClinical Features

Severe painSevere pain OdynophagiaOdynophagia DysphoniaDysphonia Oral and facial Oral and facial

burnsburns Respiratory distressRespiratory distress Abdominal painAbdominal pain DroolingDrooling Coughing Coughing VomitingVomiting

Laryngotracheal Laryngotracheal injuryinjury– DysphoniaDysphonia– StridorStridor– Respiratory distressRespiratory distress

Esophageal and GI Esophageal and GI injuryinjury– DysphagiaDysphagia– OdynophagiaOdynophagia– Epigastric painEpigastric pain– VomitingVomiting

6666

Clinical FeaturesClinical Features

Conflicting data as to reliability of Conflicting data as to reliability of presence or absence of signs and presence or absence of signs and symptoms for predicting upper GI injurysymptoms for predicting upper GI injury

No single symptom or group of symptoms No single symptom or group of symptoms has 100% positive or negative predictive has 100% positive or negative predictive value for esophageal injury value for esophageal injury

6767

Management: Initial Management: Initial AssessmentAssessment

ED staff should take precautions to prevent ED staff should take precautions to prevent personal injury 2personal injury 2° ° to exposure from patientto exposure from patient

Initial step is airway evaluationInitial step is airway evaluation– May have oral, pharyngeal or larygnotracheal injury May have oral, pharyngeal or larygnotracheal injury

– Ideally should have fiberoptic evaluation prior to Ideally should have fiberoptic evaluation prior to intubation to determine extent of damage intubation to determine extent of damage

– Blind nasotracheal intubation is contraindicated due Blind nasotracheal intubation is contraindicated due to risk of further injuryto risk of further injury

6868

AirwayAirway

Establish airway early Establish airway early – Avoids 2Avoids 2° ° effects of injury such as edemaeffects of injury such as edema

Oral intubation with direct visualization is Oral intubation with direct visualization is the first choice for definitive managementthe first choice for definitive management

Surgical cricothyrotomy may be requiredSurgical cricothyrotomy may be required

6969

Initial ManagementInitial Management

Directed history and physical examDirected history and physical exam– Type and amount of caustic ingestedType and amount of caustic ingested

– Intentional or unintentionalIntentional or unintentional

– Hemodynamic instabilityHemodynamic instability Shock from:Shock from:

– GI bleeding, perforation and volume depletionGI bleeding, perforation and volume depletion

– Peritoneal signsPeritoneal signs Hollow viscus perforationHollow viscus perforation

– Chest discomfortChest discomfort MediastinitisMediastinitis

– Eyes and skin for dermal and ocular exposureEyes and skin for dermal and ocular exposure

7070

Laboratory and Ancillary Laboratory and Ancillary TestsTests

ABGABG– Strong acids may cause acid-base disordersStrong acids may cause acid-base disorders– Arterial line if serial ABGs requiredArterial line if serial ABGs required

ElectrolytesElectrolytes– Calcium and magnesium after HF acid exposureCalcium and magnesium after HF acid exposure

Hepatic profileHepatic profile

CBCCBC

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Laboratory and Ancillary Laboratory and Ancillary TestsTests

Coagulation profileCoagulation profile

Upright chest X-rayUpright chest X-ray– Detects peritoneal and mediastinal airDetects peritoneal and mediastinal air

Intentional ingestionIntentional ingestion– ECG, aspirin, acetaminophen for co-ECG, aspirin, acetaminophen for co-

ingestions ingestions

7272

Gastric DecontaminationGastric Decontamination CharcoalCharcoal

– Does not bind caustics wellDoes not bind caustics well– Impedes visualization Impedes visualization

IpecacIpecac– Do not giveDo not give– Vomiting Vomiting

Precipitates perforationPrecipitates perforation Results in repeated exposure of airway and GI tract to caustic Results in repeated exposure of airway and GI tract to caustic

agentagent

NG tubeNG tube– Risks outweigh benefitsRisks outweigh benefits

High risk of perforation with alkali ingestionHigh risk of perforation with alkali ingestion Endoscopist may insert with acid ingestion to aspirate residual Endoscopist may insert with acid ingestion to aspirate residual

7373

Neutralization and DilutionNeutralization and Dilution

Not recommendedNot recommended– Should not be done in pre-hospital or ED Should not be done in pre-hospital or ED

settingsetting

Risks outweigh benefitsRisks outweigh benefits– RisksRisks

Vomiting, airway injury, perforation Vomiting, airway injury, perforation

– Benefits Benefits Not clearly demonstrated in clinical settingNot clearly demonstrated in clinical setting

7474

EndoscopyEndoscopy Location and severity of injury post ingestionLocation and severity of injury post ingestion

Endoscopist consult for all cases of caustic Endoscopist consult for all cases of caustic ingestion for decisioningestion for decision

Endoscopy within first several hours after Endoscopy within first several hours after ingestioningestion

CT or US may be used and may screen for CT or US may be used and may screen for intraabdominal necrosis outside the GI tract or in intraabdominal necrosis outside the GI tract or in areas not reachable with endoscopyareas not reachable with endoscopy

7575

SteroidsSteroids ControversialControversial

Might decrease stricture formation post caustic ingestion due to Might decrease stricture formation post caustic ingestion due to inhibition of the inflammatory responseinhibition of the inflammatory response

Benefit not established in studiesBenefit not established in studies

May increase risk of infection, perforation and hemorrhageMay increase risk of infection, perforation and hemorrhage

Never recommended in acid ingestionsNever recommended in acid ingestions

If steroids used, may add penicillin that covers oral floraIf steroids used, may add penicillin that covers oral flora– Otherwise, no support for prophylactic antibioticsOtherwise, no support for prophylactic antibiotics

7676

Systemic ToxicitySystemic Toxicity

Alkali injuryAlkali injury– Direct tissue necrosisDirect tissue necrosis

Acid injuryAcid injury– Absorption of acid in addition to local tissue Absorption of acid in addition to local tissue

destructiondestruction– Acid-base disorders, hemolysis and renal failure may Acid-base disorders, hemolysis and renal failure may

resultresult– Manipulation of pH with sodium bicarbonate may be Manipulation of pH with sodium bicarbonate may be

required if the pH is below 7.10 due to metabolic required if the pH is below 7.10 due to metabolic acidosis acidosis

7777

Ocular ExposuresOcular Exposures

Devastating to visionDevastating to vision

30% of corneal transplants for eye injuries due 30% of corneal transplants for eye injuries due to chemicalsto chemicals

Alkali worse than acidAlkali worse than acid– Penetrates deep into ocular tissue Penetrates deep into ocular tissue

Destructive after superficial removalDestructive after superficial removal

– Acid causes superficial damage of coagulation Acid causes superficial damage of coagulation necrosis which limits penetrationnecrosis which limits penetration

7878

Ocular ExposuresOcular Exposures Treat immediately with copious irrigationTreat immediately with copious irrigation

– At least 2 L of NS per affected eyeAt least 2 L of NS per affected eye

– Nitrazine paper to ensure acid or base has been Nitrazine paper to ensure acid or base has been eliminatedeliminated

– pH after successful irrigation should be between 7.5-8.0 pH after successful irrigation should be between 7.5-8.0 Wait 10 minutes post irrigation for most accurate assessmentWait 10 minutes post irrigation for most accurate assessment

– Complete eye examination including fluorescein Complete eye examination including fluorescein staining and all except the most superficial exposures staining and all except the most superficial exposures should have ED ophthalmology consultationshould have ED ophthalmology consultation

7979

Treatment of Dermal Treatment of Dermal ExposuresExposures

Most injuries occur on the extremitiesMost injuries occur on the extremities

Most respond well to copious normal saline Most respond well to copious normal saline irrigationirrigation

Alkali exposures may appear superficial, but burn Alkali exposures may appear superficial, but burn deeply for extended periodsdeeply for extended periods– Need irrigation for long periods Need irrigation for long periods – Need to remove residual compoundNeed to remove residual compound

For powders such as lime, need to brush off the dry For powders such as lime, need to brush off the dry compound and remove clothes prior to irrigationcompound and remove clothes prior to irrigation

8080

Treatment of Dermal Treatment of Dermal ExposuresExposures

Portland/Ready-mix cementPortland/Ready-mix cement– Alkali lime mixtureAlkali lime mixture– CaOH, NaOH and KOH produced when water mixed CaOH, NaOH and KOH produced when water mixed

with dry compoundwith dry compound– May present with severe pain without obvious injuryMay present with severe pain without obvious injury– Eventually develop blisters and skin necrosis if not Eventually develop blisters and skin necrosis if not

irrigated early irrigated early

All cutaneous caustic injuries require close All cutaneous caustic injuries require close follow-up or early referral to a plastic surgeon follow-up or early referral to a plastic surgeon to ensure the injuries are not progressingto ensure the injuries are not progressing

8181

Surgery, Stents, DilatationSurgery, Stents, Dilatation Major ingestions may result in immediate perforation of Major ingestions may result in immediate perforation of

the GI tract and require surgerythe GI tract and require surgery

Emergency laparotomyEmergency laparotomy– Peritoneal signsPeritoneal signs– Free intraperitoneal airFree intraperitoneal air

Esophageal perforation diagnosed by mediastinal air on Esophageal perforation diagnosed by mediastinal air on plain films or endoscopyplain films or endoscopy

Some require dilation or stenting within first three Some require dilation or stenting within first three weeks post injury vs. early surgical resectionweeks post injury vs. early surgical resection

8282


All patients with symptoms post All patients with symptoms post ingestions should be admitted ingestions should be admitted

Mild to moderate dermal exposures may Mild to moderate dermal exposures may be irrigated, aseptic dressings applied be irrigated, aseptic dressings applied and discharge with close follow-upand discharge with close follow-up

8383


Admit:Admit:– Dermal injuries:Dermal injuries:

Cross flexor or extensor surfacesCross flexor or extensor surfaces Facial injuriesFacial injuries Perineal injuriesPerineal injuries Partial thickness injuries greater than 10-15 % BSAPartial thickness injuries greater than 10-15 % BSA All full thickness injuriesAll full thickness injuries Less severe injuries at extremes of ageLess severe injuries at extremes of age

8484

Hydrofluoric AcidHydrofluoric Acid

Relatively weakRelatively weak

Glass etching, metal cleaning and Glass etching, metal cleaning and petroleum processing, chrome wheel petroleum processing, chrome wheel cleaner, rust removercleaner, rust remover

Great potential for causing morbidity and Great potential for causing morbidity and deathdeath

8585


Free Fl ion complexes with calcium and Free Fl ion complexes with calcium and magnesium resulting in cellular death magnesium resulting in cellular death

– Hypocalcemia, hypomagnesemia, Hypocalcemia, hypomagnesemia, hyperkalemia, acidosis and ventricular hyperkalemia, acidosis and ventricular dysrhythmiasdysrhythmias

– Ventricular fibrillation and death reported Ventricular fibrillation and death reported with dermal exposure of only 2.5 % of body with dermal exposure of only 2.5 % of body surface area surface area

8686


Most injuries to upper extremitiesMost injuries to upper extremities

– Benign appearanceBenign appearance

– Severe painSevere pain

– Slight white discoloration, may become black Slight white discoloration, may become black and necrotic with cellular death progressionand necrotic with cellular death progression

8787

Hydrofluoric Acid: Hydrofluoric Acid: TreatmentTreatment

Thoroughly irrigate with water Thoroughly irrigate with water

Next, place in a paste of calcium gluconate or Next, place in a paste of calcium gluconate or benzalkonium chloride solution benzalkonium chloride solution – Soaked until pain relief for end point of therapy Soaked until pain relief for end point of therapy

OtherOther– Intradermal injection of 5% Ca gluconate or Mg Intradermal injection of 5% Ca gluconate or Mg

sulfate around area sulfate around area – For distal upper extremity injuries, IV calcium For distal upper extremity injuries, IV calcium

gluconate gluconate

8888

Hydrofluoric Acid: Hydrofluoric Acid: TreatmentTreatment

Oral ingestion has high mortality rate Oral ingestion has high mortality rate

– NG tube and NS gastric lavage recommendedNG tube and NS gastric lavage recommended

– Oral magnesium or calcium should be given Oral magnesium or calcium should be given

– Hemodynamic monitoring for dysrhythmiasHemodynamic monitoring for dysrhythmias

– Follow calcium and magnesium levels closely Follow calcium and magnesium levels closely May require large dose supplementation of Ca or Mg May require large dose supplementation of Ca or Mg

8989

Airbag-Related BurnsAirbag-Related Burns

Aerosolized NaOH and Na carbonate released Aerosolized NaOH and Na carbonate released with airbag deployment with airbag deployment

Burns skinBurns skin– Usually minor due to chemical or heat from melted Usually minor due to chemical or heat from melted

clothing clothing – Requires basic burn care Requires basic burn care

Enters eyes with resulting chemical keratitis Enters eyes with resulting chemical keratitis – Copious irrigation, pH testing, ophthalmology consultCopious irrigation, pH testing, ophthalmology consult

9090

Long Term MorbidityLong Term Morbidity Most long-term sequelae are from injuries to GI tractMost long-term sequelae are from injuries to GI tract

Acid scars the pylorus with resulting gastric outlet Acid scars the pylorus with resulting gastric outlet obstructionobstruction

Alkali may result in esophageal stricturesAlkali may result in esophageal strictures– Resulting dysphagia, odynophagia and malnutritionResulting dysphagia, odynophagia and malnutrition

Caustic esophageal injuries at risk for cancerCaustic esophageal injuries at risk for cancer– 1000 X risk with ingestion1000 X risk with ingestion– Seen decades after initial ingestionSeen decades after initial ingestion– May need prophylactic esophagectomy with grade 3 lesionsMay need prophylactic esophagectomy with grade 3 lesions

9191

QuestionsQuestions

1. Toxic potential of hydrocarbons 1. Toxic potential of hydrocarbons depends on: depends on:

A. Physical characteristicsA. Physical characteristics B. Chemical characteristicsB. Chemical characteristics C. Presence of toxic additivesC. Presence of toxic additives D. Route of exposureD. Route of exposure E. All of the aboveE. All of the above

9292

QuestionsQuestions

2. Treatment of caustic exposures with steroids 2. Treatment of caustic exposures with steroids is controversial because: is controversial because:

A. Benefit is not established in studiesA. Benefit is not established in studies B. May increase risk of infection, perforation B. May increase risk of infection, perforation

and hemorrhageand hemorrhage C. Never recommended in acid ingestions. C. Never recommended in acid ingestions. D. If steroids used add penicillin to cover oral D. If steroids used add penicillin to cover oral

flora flora E. All of the aboveE. All of the above

9393

QuestionsQuestions

3. The CHAMP pneumonic refers to when 3. The CHAMP pneumonic refers to when GI decontamination is considered with GI decontamination is considered with exposure to: exposure to:

A. CamphorA. Camphor B. Halogenated hydrocarbonsB. Halogenated hydrocarbons C. Aromatic hydrocarbonsC. Aromatic hydrocarbons D. MetalsD. Metals E. PesticidesE. Pesticides F. All of the aboveF. All of the above

9494

QuestionsQuestions

4. With caustic exposures, you should 4. With caustic exposures, you should admit all patients with dermal injuries admit all patients with dermal injuries that:that:

A. Cross flexor or extensor surfacesA. Cross flexor or extensor surfaces B. Involve the faceB. Involve the face C. Involve the perineal area C. Involve the perineal area D. Are full thickness injuriesD. Are full thickness injuries E. All of the aboveE. All of the above

9595

QuestionsQuestions

5. With hydrofluoric acid exposure, which of the 5. With hydrofluoric acid exposure, which of the following may occur?following may occur?

A. HypocalcemiaA. Hypocalcemia B. HypomagnesemiaB. Hypomagnesemia C. HyperkalemiaC. Hyperkalemia D. AcidosisD. Acidosis E. All of the aboveE. All of the above

1-5: all of the above1-5: all of the above

1 Hydrocarbons, Volatile Substances and Caustics David R. Fisher, D.O. Tintinalli Chapters 180 & 181...

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Transcript of 1 Hydrocarbons, Volatile Substances and Caustics David R. Fisher, D.O. Tintinalli Chapters 180 & 181...