eMedicine Specialties > Pediatrics: General Medicine > Pulmonology
Hydrocarbon Inhalation Injury: Treatment & Medication
Updated: Jun 25, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The care of patients with inhalation abuse is mainly supportive. Because many potential complications involving the pulmonary, cardiovascular, and neurologic systems may be present, careful assessment and stabilization of the ABCs should be paramount in the initial management. In addition to acute medical treatment, patients suspected of chronic solvent-inhalant use should be carefully evaluated by a team trained in the treatment of childhood substance abuse.
- Acute inhalant abuse
- Medical care of patients following acute decompensation from hydrocarbon inhalation is primarily supportive. Those with significant neurologic impairment who are unable to protect their airway should undergo endotracheal intubation and mechanical ventilation to prevent aspiration and respiratory deterioration. Hypoxic injury to other organ systems, particularly the heart, should be sought and treated.
- Because of the sensitization of the myocardium to catecholamines, inotropic agents and bronchodilators should be avoided. Some authors suggest the use of amiodarone to treat ventricular arrhythmias if used early in treatment. Epinephrine administration during resuscitation may be harmful and can lead to recurrence of ventricular fibrillation.
- Electrolyte abnormalities should be corrected.
- Chronic inhalant abuse
- Management of chronic solvent-inhalant abuse should be directed at preventing further abuse.
- Therapy for commonly involved organs, including the central and peripheral nervous systems, kidneys, liver, lungs, heart, and bone marrow, is primarily supportive.
- In patients with significant electrolyte abnormalities, typically due to distal renal tubular acidosis, parenteral fluid and electrolyte repletion may be necessary. Correction of potassium and phosphorus deficiency may result in rapid improvement in muscle strength. Hypocalcemia is frequently encountered during fluid and electrolyte repletion.
Consultations
Patients who are suspected of solvent-inhalant abuse should be carefully evaluated by experts who are trained in the treatment of childhood substance abuse. Consultation with specialists, including cardiologists and neurologists, may also be warranted, depending on the individual needs of the patient. Any patient who has unstable hemodynamics or cardiac arrhythmias or who has significantly altered mental status should be admitted to and observed in the pediatric intensive care unit.
Diet
Patients should remain on a diet of nothing by mouth (NPO) until muscle weakness clearly will not necessitate institution of mechanical ventilation. Also, because of the risk of hypocalcemic seizures, patients should remain NPO during initial fluid and electrolyte repletion.
Medication
Electrolyte replacement agents
These agents are used to correct hypokalemia and hypophosphatemia in inhalation cases. Electrolytes are used to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance and to reestablish osmotic equilibrium of specific ions.
Potassium phosphate (Neutra-Phos-K, K-Phos)
Preferable to potassium chloride because it allows for correction of both hypokalemia and hypophosphatemia. Contains 4.4 mEq of potassium per 3 mmol of phosphate. Elemental phosphorus equals 31.25 mg/mmol. Should be ordered in millimols of phosphorus, not milliequivalents of potassium, to avoid confusion as to the phosphorus content.
Adult
3-4.5 g (95-142.4 mmol) per d PO divided tid/qid
Alternatively, 1.5-2 g (47.5-63.3 mmol) IV over 24 h
Pediatric
0.08-0.24 mmol/kg IV infused over 4-6 h; reassess phosphorus level before additional doses
Concurrent use with ACE inhibitors may result in elevated serum potassium concentrations; potassium-sparing diuretics and potassium-containing salt substitutes can produce severe hyperkalemia; in patients taking digoxin, hypokalemia may result in digoxin toxicity; caution if discontinuing potassium administration in patients maintained on digoxin
Hyperkalemia; renal failure; conditions in which potassium retention is present; oliguria or azotemia; crush syndrome; severe hemolytic reactions; anuria; adrenocortical insufficiency
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Do not rapidly infuse because rapid or central IV infusion may cause cardiac arrhythmias; high plasma concentrations of potassium may cause death because of cardiac depression, arrhythmias, or arrest; plasma levels do not necessarily reflect tissue levels; patients receiving infusions >0.5 mEq (potassium) per kg/h (>20 mEq/h) should be on an ECG monitor; when a concentration >40 mEq (potassium) per L is infused, local pain and phlebitis may also follow; do not co-infuse with calcium-containing products
Calcium gluconate
Patients with hypocalcemia may need replacement, particularly in the presence of carpopedal spasm or hypocalcemic seizures. One gram of calcium gluconate equals 90 mg of elemental calcium.
Adult
5-15 g/d PO/IV divided q6h
Pediatric
Infants: 400-800 mg/kg/d PO divided q6h; alternatively, 200-500 mg/kg/24 h IV divided q6h
Children: 200-500 mg/kg/d PO/IV divided q6h
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; antagonizes effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity; IV push
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not exceed 100 mg/min IV if undiluted; for diluted IV infusion, do not exceed 120-240 mg/kg/h, with a maximum concentration of 50 mg/mL; do not administer IM or SC; avoid scalp veins; watch peripheral infusion because extravasation may cause tissue necrosis; IV infusion may be associated with hypotension and bradycardia; in digitalized patients, may be associated with arrhythmias
Anticonvulsants and sedatives
These agents are used for withdrawal symptoms or seizure activity in inhalation cases.
Phenobarbital (Luminal, Solfoton)
Most helpful if withdrawal symptoms are evident. Can be continued for sedation for 5-10 d. Therapeutic level is 15-40 mg/L.
Adult
Seizures:
Loading dose: 15-20 mg/kg IV, start with 10 mg/kg and follow with the subsequent 10 mg/kg if needed; not to exceed 20 mg/kg
Maintenance dose: 60-200 mg/d PO/IV divided bid/tid
Sedation: 30-120 mg/d PO/IV divided bid/tid
Pediatric
Seizures:
Loading dose for neonates, infants, or children: 5-20 mg/kg/dose IV in a single or divided dose; may administer an additional 5 mg/kg/dose q15-30 min; not to exceed a cumulative dose of 30 mg/kg for seizure activity
Maintenance dose (monitor levels):
Neonates: 3-5 mg/kg/d PO/IV qd or divided bid
Infants: 5-6 mg/kg/d PO/IV qd or divided bid
Children 1-5 years: 6-8 mg/kg/d PO/IV qd or divided bid
Children 6-12 years: 4-6 mg/kg/d PO/IV qd or divided bid
>12 years: 1-3 mg/kg/d PO/IV qd or divided bid
Sedation of children: 6 mg/kg/d PO divided tid
CYP450 inducer; may decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase phenobarbital toxicity; rifampin may decrease phenobarbital effects; induction of microsomal enzymes may result in decreased effects of PO contraceptives in women (must use additional contraceptive methods to prevent unwanted pregnancy; menstrual irregularities may also occur)
Documented hypersensitivity; severe respiratory disease; marked impairment of liver function; nephritis; porphyria
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
IV push not to exceed 1 mg/kg/min or 100 mg/min; IV administration may cause respiratory arrest and hypotension or paradoxical reactions in children (eg, hyperactivity, irritability, insomnia); caution in hepatic or renal disease; adverse effects include drowsiness, cognitive impairment, ataxia, hypotension, hepatitis, rash, respiratory depression, apnea, megaloblastic anemia, and anticonvulsant hypersensitivity syndrome
Diazepam (Valium)
Used for sedation if withdrawal symptoms present. Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Individualize dosage and increase cautiously to avoid adverse effects.
Adult
2-10 mg/dose PO q6-12h prn
2-10 mg/dose IV/IM prn; not to exceed 30 mg/8 h
Pediatric
0.12-0.8 mg/kg/d PO divided q6-8h
0.04-0.2 mg/kg/dose IV/IM q2-4h prn; not to exceed 0.6 mg/kg within an 8-h period
CNS toxicity increased with coadministration of other CNS depressants (eg, phenothiazines, barbiturates, alcohol, MAOIs)
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Hypotension and respiratory depression may occur; use with caution in glaucoma, shock, and depression; administer the conventional IV product undiluted no faster than 2 mg/min; do not mix with IV fluids
Phenytoin (Dilantin)
May act in motor cortex where may inhibit spread of seizure activity. Activity of brainstem centers responsible for tonic phase of grand mal seizures may also be inhibited. Dose should be individualized. Administer larger dose before retiring if dose cannot be divided equally. Therapeutic level is 10-20 mg/L.
Adult
100 mg/dose PO/IV q8h initially and carefully titrate to 300-600 mg/d (or 6-7 mg/kg/d) divided q8-24h
Pediatric
Loading dose: 15-20 mg/kg IV; not to exceed 1500 mg/d
Maintenance dose: 5 mg/kg/d PO/IV divided q8-12h initially
Divide daily doses bid/tid unless extended cap
Typical dosage ranges:
Neonates: 5-8 mg/kg/d
6 months to 3 years: 8-10 mg/kg/d
4-6 years: 7.5-9 mg/kg/d
7-9 years: 7-8 mg/kg/d
10-16 years: 6-7 mg/kg/d
Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase phenytoin toxicity; CYP450 inducer; phenytoin effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate; phenytoin may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, PO contraceptives, and valproic acid
Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; sinus bradycardia; Adams-Stokes syndrome
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Perform CBC counts and urinalyses when therapy is begun and at monthly intervals for several months thereafter to monitor for blood dyscrasias; discontinue use if a rash appears and do not resume use if rash is exfoliative, bullous, or purpuric; rapid IV infusion may result in death from cardiac arrest, marked by QRS widening; caution in acute intermittent porphyria and diabetes (may elevate blood sugars); discontinue use if hepatic dysfunction occurs
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Important to monitor patient's blood pressure after administering dose. Adjust as necessary.
Adult
4 mg/dose IV slowly over 2-5 min and repeat in 10-15 min prn; cumulative dose of 8 mg/d typically considered maximum
1-10 mg/d PO/IV/IM divided bid/tid
Pediatric
Infants and children: 0.1 mg/kg IV slowly over 2-5 min; may repeat with dose of 0.05 mg/kg in 10-15 min if needed; not to exceed 4 mg/dose
Adolescents: 0.07 mg/kg IV slowly over 2-5 min and repeat in 10-15 min prn; not to exceed 4 mg/dose
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS depression, hypotension, and narrow-angle glaucoma; reversal agents (eg, flumazenil) contraindicated when lorazepam used for life-threatening conditions (eg, control of intracranial pressure or status epilepticus)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Antiarrhythmic agents
These agents may be required to treat tachycardias.
Amiodarone (Cordarone)
Class III antiarrhythmic. Has antiarrhythmic effects that overlap all 4 Vaughn-Williams antiarrhythmic classes. May inhibit AV conduction and sinus node function. Prolongs action potential and refractory period in myocardium and inhibits adrenergic stimulation. Only agent proven to reduce incidence and risk of cardiac sudden death, with or without obstruction to LV outflow. Very efficacious in converting atrial fibrillation and flutter to sinus rhythm and in suppressing recurrence of these arrhythmias.
Has low risk of proarrhythmia effects, and any proarrhythmic reactions are generally delayed. Used in patients with structural heart disease. Most clinicians are comfortable with inpatient or outpatient loading with 400 mg PO tid for 1 wk because of low proarrhythmic effect, followed by weekly reductions with goal of lowest dose with desired therapeutic benefit (usual maintenance dose for AF 200 mg/d). During loading, patients must be monitored for bradyarrhythmias. Before administration, control the ventricular rate and CHF (if present) with digoxin or calcium channel blockers.
PO efficacy may take weeks. With exception of disorders of prolonged repolarization (eg, LQTS), may be DOC for life-threatening ventricular arrhythmias refractory to beta blockade and initial therapy with other agents.
Adult
Loading dose: 800-1600 mg/d PO in 1-2 doses for 1-3 wk, and decrease to 600-800 mg/d in 1-2 doses for 1 mo Maintenance dose: 400 mg/d PO Alternatively, 150 mg (10 mL) IV over first 10 min, followed by 360 mg (200 mL) over next 6 h and, then, 540 mg over next 18 h
Pediatric
10-15 mg/kg/d or 600-800 mg/1.73 m2/d PO for 4-14 d or until arrhythmia controlled
Increases effect and blood levels of theophylline, quinidine, procainamide, phenytoin, methotrexate, flecainide, digoxin, cyclosporine, beta blockers, and anticoagulants; cardiotoxicity of amiodarone is increased by macrolide antibiotics, ritonavir, sparfloxacin, and disopyramide; coadministration with calcium channel blockers, may cause an additive effect and decrease myocardial contractility further; cimetidine may increase amiodarone levels; protease inhibitors (eg, indinavir, ritonavir, amprenavir, nelfinavir) inhibit amiodarone metabolism resulting in increased serum levels and may prolong QT interval; coadministration may increase myopathy/rhabdomyolysis risk; associated with HMG-CoA reductase inhibitors (eg, simvastatin); other drugs that prolong the QT interval (eg, fluoroquinolones, erythromycin, dofetilide, tricyclic antidepressants, thioridazine) may increase life-threatening arrhythmia risk
Documented hypersensitivity, complete AV block, and intraventricular conduction defects
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Known to cause serious (and at times fatal) toxicities, including pulmonary and liver toxicities; may cause prolonged proarrhythmic effects; may cause optic neuritis/neuropathy or hypothyroidism or hyperthyroidism; CNS and GI toxicity may occur and typically dissipates with dose reduction
More on Hydrocarbon Inhalation Injury |
| Overview: Hydrocarbon Inhalation Injury |
| Differential Diagnoses & Workup: Hydrocarbon Inhalation Injury |
 Treatment & Medication: Hydrocarbon Inhalation Injury |
| Follow-up: Hydrocarbon Inhalation Injury |
| References |
| Further Reading |
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References
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Further Reading
National Institute on Drug Abuse. NIDA Research Report - Inhalant Abuse. National Institutes of Health. Available at http://www.nida.nih.gov/researchreports/inhalants/Inhalants.html.
Keywords
hydrocarbon inhalation injury, volatile substance abuse, inhalant abuse, solvent abuse, sniffing, huffing, bagging, solvent, butane, toluene, sudden cardiac events, sudden sniffing death syndrome, ventricular dysrhythmias, sudden death, myocardial infarction, renal tubular acidosis, hypokalemia, hyperchloremia, frostbite, bone marrow damage, aplastic anemia, leukemia, toxic hepatitis, pulmonary injury, microcephaly, narrow bifrontal diameter, short palpebral fissures, hypoplastic mid face, wide nasal bridge, abnormal palmar creases, blunt fingertips, pulmonary hypertension, hydrocarbon aspiration, Parkinson disease, attention deficit, rhabdomyolysis, rhinitis, nasal mucosal erosions, epistaxis, hoarse voice, conjunctivitis, hypophosphatemia, hypercalcemia
