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Accidental hydrocarbon ingestion cases telephoned to a regional poison center
ORIGINAL CONTRIBUTION ingestion, hydrocarbon, complications
Accidental Hydrocarbon Ingestion Cases Telephoned to a Regional Poison Center One hundred eighty-four telephone calls to the Texas State Poison Center concerning accidental hydrocarbon ingestion were reviewed in an attempt to define the risk of developing any subsequent medical problem requiring therapeutic intervention. Special attention was given to changing symptom severity in an attempt to evaluate its usefulness in predicting future complications. One hundred twenty patients (65%) had no initial symptoms and remained asymptomatic throughout an 18-hour follow-up period. Sixtytwo (34%) of patients had s y m p t o m s initially but quickly became asymptomatic. Two (1%) developed significant complications (one chemical pneumonitis, one death). These data suggest that the risk of significant complications after accidental hydrocarbon ingestion is low (approximately 1% of patients at risk). Patients who are asymptomatic or who quickly become asymptomatic can be watched safely at home, and referral of asymptomatic patients to a hospital may be unwarranted. [Machado B, Cross K, Snodgrass WR: Accidental hydrocarbon ingestion cases telephoned to a regional poison center. Ann Emerg Med August 1988;17:804-807.] INTRODUCTION The accidental ingestion of a hydrocarbon is a common emergency problem, and patients are often admitted for medical observation despite a lack of symptoms. Although early medical literature implies a high incidence of chemical pneumonitis in patients after hydrocarbon ingestion, 1-6 the experience of our regional poison control center supports previous studies 7 that find the incidence to be far lower. Our study attempted to define the risk of serious complications developing after the accidental ingestion of a hydrocarbon and to identify patients at risk of developing future complications. For our purposes, "complications" were defined as symptoms persistent or severe enough to require symptomatic or therapeutic intervention.
Bo Machado, MD* Columbia, South Carolina Kenneth CrosslWayne R Snodgrass, MD, PhDIGalveston, Texas From the Department of Emergency Medicine, Richland Memorial Hospital, Columbia, South Carolina;* and the Texas State Poison Center, The University of Texas Medical Branch, Galveston, Texas.t Received for publication September 11, 1987. Revision received March 14, 1988. Accepted for publication April 22, 1988. Address for reprints: Be Machado, MD, Department of Emergency Medicine, 3 Medical Park Road, Columbia, South Carolina 29203.
MATERIALS A N D METHODS The Texas State Poison Center is located at the University of Texas Medical Branch in Galveston, Texas, and receives more than 8,000 calls each month. The center is staffed with poison information specialists, most of whom have eight or more years of experience. All telephone calls are recorded on a case data sheet that includes exact product name, time of ingestion, estimate of amount ingested, initial signs and symptoms, medical hist o t and recommended treatment. In cases involving hydrocarbon ingestion, specific questioning is undertaken to establish whether symptoms are worsening or improving with time. Consecutive case data sheets involving hydrocarbon ingestion were collected over a five-month period. These calls were cross-checked to eliminate any duplication and then reviewed. All nonaccidental ingestions were exclude& In addition to the routine information previously described, specific review was undertaken to establish whether symptoms were worsening or improving with time as well as whether any therapeutic intervention was done and the patient's ultimate outcome. All cases received a follow-up call at 18 hours after ingestion, and symptomatic patients were called more fiequently to check for progression of symptoms. 17:8 August 1988
Annals of Emergency Medicine
804/69
ACCIDENTAL HYDROCARBON Machado, Cross & Snodgrass
INGESTION
RESULTS Two hundred eleven calls concerning hydrocarbon ingestion were received by the center. Of these 211 calls, 27 were discarded f r o m the study for insufficient documentation, mostly lack of follow-up. None of the patients whose calls were discarded had any initial symptoms at the time of their initial contact. The remaining 184 calls comprised the series. Of the 184 calls, 28% originated from physicians consulting the center regarding their patients, and the other 72% were calls from the general public. The ages of the patients included in the study ranged from five months to 77 years (Table). Seventy-one percent of the patients were less than 2 years old, 91% were less than 4 years old, and only 2.7% of the patient group was older than 18 years. This age distribution is comparable with that of p e d i a t r i c p o i s o n i n g s in general, s Of the 184 calls, 120 patients (65%) had no initial signs or symptoms; they remained a s y m p t o m a t i c throughout the 18-hour follow-up period (Figure). Sixty-four of the callers (35%) had initial symptoms, usually coughing (93%), dyspnea, nausea, vomiting, or malaise. Sixty-two of these patients (97%) quickly became asymptomatic and remained so over the next 18 hours. One child (1.5% of the symptomatic group) had progressing sympt o m s and was a d m i t t e d w i t h radiologic changes consistent with chemical p n e u m o n i t i s . He b e c a m e a s y m p t o m a t i c within 24 hours and was discharged after an additional five days of observation. He was reported to have ingested kerosene. A n o t h e r c h i l d (1.5% of s y m p t o m a t i c group, 0.5% of the total group) died. This 1-year-old was found in arrest at the scene and was initially resuscitated but died two days later. She was reported to have ingested Pine Sol ®. In our study, no initially asymptomatic patient developed later complications or exhibited a delayed onset of symptoms. No patients with regressing symptoms had a recurrence once they became asymptomatic. None received ipecac. DISCUSSION The term "hydrocarbon" is used to describe a vast number of aliphatic or aromatic organic molecules consisting mainly of hydrogen and carbon atoms that are usually, but not always, ob70/805
TABLE. Patient age Age (yr)
No. of Patients
0 - 0.5
%
1
0.5
0.5 - 1
8
4.3
1 - 2
122
66.3
3 - 4
36
19.6
5
2.7
2
1.1 2.7
5-8 9-
12
13 - 18
5
19 - 4 0
3
1.6
41 - 65
0
0.0
66 - 98
Total
tained f r o m the distillation of petroleum. Hydrocarbons are incorporated into a wide variety of commercial products that can typically be found in any household. Because they are so common, often within easy reach, and sometimes placed in bottles, toddlers will frequently drink these agents accidentally. The hydrocarbons m o s t likely to cause serious illnesses include kerosene, mineral seal oil, gasoline, and cigarette lighter fluid. 2 Hydrocarbon ingestions account for nearly 5% of all accidental poisonings in children less than 5 years of age. Ninety percent of the deaths caused by hydrocarbon ingestions occur in this age group. The Cooperative Kerosene Poisoning Study estimated the national mortality rate to be approximately 0.5 per million population. 2 Ingestions of hydrocarbons can lead to l i f e - t h r e a t e n i n g c o m p l i c a t i o n s , most notably chemical pneumonitis. The likelihood of developing chemical pneumonitis is related to the ingested hydrocarbon's viscosity. Generally, the lower the viscosity the higher the risk of aspiration and subsequent toxicity. 9 As little as 0.2 mL of a low-viscosity hydrocarbon directly aspirated into the trachea can produce severe pneumonitis in rats. lo Respiratory symptoms are the earliest and most serious medical abnormalities after hydrocarbon ingestion. If aspiration has occurred, coughing, shortness of breath, and various degrees of cyanosis, tachycardia, and retractions may be noted. The displacement of alveolar gases by vaporized hydrocarbons may lead to asphyxiationA 1 Neurologic changes usually inAnnals ofEmergency Medicine
2
1.1
184
100.0
clude lethargy; less commonly, seiz u r e s or c o m a occur. F e v e r or leukocytosis can be seen after aspiration but do not correlate directly with the severity of illness. 7 The bulk of the medical literature discussing hydrocarbon ingestions deals with kerosene ingestions and is biased toward hospitalized patients, u6 These studies do not address either the overall risk of developing complications or the risk to patients with minimal initial symptoms. Although this is n o t the current practice in emergency medicine, these early studies are still used by many physicians who call the poison center in support of their practice of admitting all such patients for observation. Most of the medical literature dealing with hydrocarbon ingestion was published before 1965, and only a few articles dealing with criteria for admission Or risk factors for subsequent complications exist. Our study found that less than 1% of hydrocarbon ingestion cases required physician intervention. This finding is in sharp contrast with the 1934 s t u d y by N u n n and Martin, which reported a m o r t a l i t y of 11% (eight of 72 patients). 1 Other studies have reported even higher mortality rates. 2-6 We feel Nunn and MartinM results are biased because they included only patients "admitted with signs of acute poisoning." For example, six of the eight patients described by Nunn and Martin s were already cyanotic or stuporous on presentation. Also, they did not specify whether cases involved intentional or accidental ingestions. Anas et al7 17:8 August 1988
184
!
÷ 35% (64) Had initial symptoms
65% (120) Initially asymptomatic
I 100% Remained asymptomatic
97% (62) Had regressing signs and symptoms
0% Worsened in any way
100% Soon became asymptomatic
t
100% Remained asymptomatic
reported 950 patients with hydrocarbon ingestion who presented for outpatient or e m e r g e n c y d e p a r t m e n t treatment. They reported an overall mortality of 0.7%, which is in agreement with our rate of 0.5%. Fortyseven percent of their patients were already asymptomatic at the time of their presentation. Ninety-one percent of their originally symptomatic patients "had no progression of their pulmonary disease and had uncomplicated hospitalizations." Ninety-five percent were a s y m p t o m a t i c by 24 hours. Only two (3%) of our initially symptomatic patients had persistent or progressive symptoms. One patient was totally asymptomatic by 24 hours despite p e r s i s t e n t r a d i o g r a p h i c changes. In the series of Anas et al, 7 9% of the initially symptomatic patients had persistent or progressive symptoms. However, half of these were asymptomatic by 24 hours, and they were discharged within 72 hours. Our study had a 0.5% overall proportional mortality rate and a 1.5% rate in the initially s y m p t o m a t i c group. This compares with the Anas et al 7 reported 0.2% overall mortality rate and 1.3% rate in initially symptomatic patients. Although Nunn and Martin 1 reported a mortality rate of 11%, this is suspect because they excluded "those showing little evidence of acute poisoning." 17:8August 1988
I
,
3% (2) Had persistent or progressive signs and symptoms
0% Worsened in any way
l
One patient slowly improved with observation; one patient died
t
0% Worsened in any way
Some potential weaknesses in our study were identified. We were concerned about excluding 27 of our 211 cases for insufficient documentation. Could these patients represent those who later developed complications? We feel this is unlikely because all of these patients were asymptomatic at the time of their telephone calls, and these patients appeared to be at low risk of complications based on the 120 asymptomatic cases included in the study and based on the study by Anas et al. 7 We also were concerned that patients ill from hydrocarbon ingestion might have been treated without involvement of the poison center by patient or physician. In defense of our data, nearly one-third of our cases came from physicians consulting the poison center. We chose not to report quantities ingested because they are usually uncertain estimates. The average 3-yearold's swallow is less than 10 mL; 12-13 therefore, it is probably unlikely that toddlers would ingest more than 30 mL of these bad-tasting substances. The Cooperative Kerosene Poisoning Study reported that only 27% of ingestions involved more than 30 mL. Anas et al 7 reported that most of their patients Ingested less than 30 mL.
SUMMARY In our study, the incidence of seAnnalsof Emergency Medicine
FIGURE. Total number of patients. quelae after telephone calls concerning accidental hydrocarbon ingestion was approximately 1%. We believe these telephone calls fall into one of the following four symptom patterns: patients who are initially asymptomatic, patients with regressing symptoms (ie, improving with time), patients with progressing symptoms (ie, worsening with time), and patients with severe, life-threatening symptoms. Initially asymptomatic patients have a negligible risk of becoming s y m p t o m a t i c and can be safely watched at home. Likewise, patients with minor initial symptoms that are regressing have a negligible risk; they can be followed for the persistence or progression of symptoms at home. Patients with progressive worsening of symptoms should be referred to a physician for observation and support. If these patients' symptoms subsequently resolve, they are unlikely to need further intervention, and hospitalization is probably unwarranted. Patients with severe or life-threatening s y m p t o m s require immediate (and often aggressive) medical intervention. The authors express their sincere gratitude to the poison information specialists and to Terry McHugh, MD, whose hard work and expertise made this paper possi806/71
ACCIDENTAL HYDROCARBON INGESTION Machado, Cross & Snodgrass
ble. T h e y a l s o t h a n k t h e c l e r i c a l staff, w h o s e d a t a p r o c e s s i n g a n d a s s e m b l i n g of t h e m a n u s c r i p t were i n v a l u a b l e .
4. Baldachin BJ, M e l m e d RN: Clinical and therapeutic aspects of kerosene poisoning. A series of 200 cases. Br Med J 1964;2:28-30.
REFERENCES
5. B r u n n e r 8, Rovsing H, Wulf H: Roentgenographic change in the lungs of children with kerosene poisoning. A m Rev Respir Dis 1964;89:250-254.
1. N u n n JA, Martin FM: Gasoline and kerosene poisoning in children. JAMA 1934;103:472-474. 2. Cooperative Kerosene Poisoning Study: Report of the Subcommittee on Accidental Poisonings. Pediatrics 1962;29:648-674. 3. Ng RC, Darwish H, Stewart DA: Emergency treatment of petroleum distillate and turpent i n e i n g e s t i o n . Can Med A s s o c J 1974;3: 537-538.
72/807
6. Bonte F], Reynolds J: Hydrocarbon pneumonitis. Radiology 1958;71:391-397. 7. Anas N, Namasonthi V, Ginsburg CM: Criteria for hospitalizing children who have ingested products containing hydrocarbons. JAMA 1981; 246:840-843. 8. Rosen P: Emergency Medicine. St Louis, CV
Annals of Emergency Medicine
Mosby Company, 1983. 9. Haddad LM: Poisoning and Drug Overdose. Philadelphia, WB 8aunders, 1983. 10. Bratton L, Haddow J: Ingestion of charcoal lighter fluid. J Pediatr 1975;87:633-636. 11. Klein BL, Simon JE: Hydrocarbon poisonings. Pediatr Clin North A m 1986;33:411-419. 12. Watson WA, Bradford DC, Veltri JC: The volume of a swallow: Correlation of deglutition with patient and container parameters. A m J Emerg Med 1983;1:278-281. 13. Jones DV~ Work CE: Volume of a swallovz Am J Dis Child 1961;102:427.
17:8 August 1988
Accidental Hydrocarbon Ingestion Cases Telephoned to a Regional Poison Center One hundred eighty-four telephone calls to the Texas State Poison Center concerning accidental hydrocarbon ingestion were reviewed in an attempt to define the risk of developing any subsequent medical problem requiring therapeutic intervention. Special attention was given to changing symptom severity in an attempt to evaluate its usefulness in predicting future complications. One hundred twenty patients (65%) had no initial symptoms and remained asymptomatic throughout an 18-hour follow-up period. Sixtytwo (34%) of patients had s y m p t o m s initially but quickly became asymptomatic. Two (1%) developed significant complications (one chemical pneumonitis, one death). These data suggest that the risk of significant complications after accidental hydrocarbon ingestion is low (approximately 1% of patients at risk). Patients who are asymptomatic or who quickly become asymptomatic can be watched safely at home, and referral of asymptomatic patients to a hospital may be unwarranted. [Machado B, Cross K, Snodgrass WR: Accidental hydrocarbon ingestion cases telephoned to a regional poison center. Ann Emerg Med August 1988;17:804-807.] INTRODUCTION The accidental ingestion of a hydrocarbon is a common emergency problem, and patients are often admitted for medical observation despite a lack of symptoms. Although early medical literature implies a high incidence of chemical pneumonitis in patients after hydrocarbon ingestion, 1-6 the experience of our regional poison control center supports previous studies 7 that find the incidence to be far lower. Our study attempted to define the risk of serious complications developing after the accidental ingestion of a hydrocarbon and to identify patients at risk of developing future complications. For our purposes, "complications" were defined as symptoms persistent or severe enough to require symptomatic or therapeutic intervention.
Bo Machado, MD* Columbia, South Carolina Kenneth CrosslWayne R Snodgrass, MD, PhDIGalveston, Texas From the Department of Emergency Medicine, Richland Memorial Hospital, Columbia, South Carolina;* and the Texas State Poison Center, The University of Texas Medical Branch, Galveston, Texas.t Received for publication September 11, 1987. Revision received March 14, 1988. Accepted for publication April 22, 1988. Address for reprints: Be Machado, MD, Department of Emergency Medicine, 3 Medical Park Road, Columbia, South Carolina 29203.
MATERIALS A N D METHODS The Texas State Poison Center is located at the University of Texas Medical Branch in Galveston, Texas, and receives more than 8,000 calls each month. The center is staffed with poison information specialists, most of whom have eight or more years of experience. All telephone calls are recorded on a case data sheet that includes exact product name, time of ingestion, estimate of amount ingested, initial signs and symptoms, medical hist o t and recommended treatment. In cases involving hydrocarbon ingestion, specific questioning is undertaken to establish whether symptoms are worsening or improving with time. Consecutive case data sheets involving hydrocarbon ingestion were collected over a five-month period. These calls were cross-checked to eliminate any duplication and then reviewed. All nonaccidental ingestions were exclude& In addition to the routine information previously described, specific review was undertaken to establish whether symptoms were worsening or improving with time as well as whether any therapeutic intervention was done and the patient's ultimate outcome. All cases received a follow-up call at 18 hours after ingestion, and symptomatic patients were called more fiequently to check for progression of symptoms. 17:8 August 1988
Annals of Emergency Medicine
804/69
ACCIDENTAL HYDROCARBON Machado, Cross & Snodgrass
INGESTION
RESULTS Two hundred eleven calls concerning hydrocarbon ingestion were received by the center. Of these 211 calls, 27 were discarded f r o m the study for insufficient documentation, mostly lack of follow-up. None of the patients whose calls were discarded had any initial symptoms at the time of their initial contact. The remaining 184 calls comprised the series. Of the 184 calls, 28% originated from physicians consulting the center regarding their patients, and the other 72% were calls from the general public. The ages of the patients included in the study ranged from five months to 77 years (Table). Seventy-one percent of the patients were less than 2 years old, 91% were less than 4 years old, and only 2.7% of the patient group was older than 18 years. This age distribution is comparable with that of p e d i a t r i c p o i s o n i n g s in general, s Of the 184 calls, 120 patients (65%) had no initial signs or symptoms; they remained a s y m p t o m a t i c throughout the 18-hour follow-up period (Figure). Sixty-four of the callers (35%) had initial symptoms, usually coughing (93%), dyspnea, nausea, vomiting, or malaise. Sixty-two of these patients (97%) quickly became asymptomatic and remained so over the next 18 hours. One child (1.5% of the symptomatic group) had progressing sympt o m s and was a d m i t t e d w i t h radiologic changes consistent with chemical p n e u m o n i t i s . He b e c a m e a s y m p t o m a t i c within 24 hours and was discharged after an additional five days of observation. He was reported to have ingested kerosene. A n o t h e r c h i l d (1.5% of s y m p t o m a t i c group, 0.5% of the total group) died. This 1-year-old was found in arrest at the scene and was initially resuscitated but died two days later. She was reported to have ingested Pine Sol ®. In our study, no initially asymptomatic patient developed later complications or exhibited a delayed onset of symptoms. No patients with regressing symptoms had a recurrence once they became asymptomatic. None received ipecac. DISCUSSION The term "hydrocarbon" is used to describe a vast number of aliphatic or aromatic organic molecules consisting mainly of hydrogen and carbon atoms that are usually, but not always, ob70/805
TABLE. Patient age Age (yr)
No. of Patients
0 - 0.5
%
1
0.5
0.5 - 1
8
4.3
1 - 2
122
66.3
3 - 4
36
19.6
5
2.7
2
1.1 2.7
5-8 9-
12
13 - 18
5
19 - 4 0
3
1.6
41 - 65
0
0.0
66 - 98
Total
tained f r o m the distillation of petroleum. Hydrocarbons are incorporated into a wide variety of commercial products that can typically be found in any household. Because they are so common, often within easy reach, and sometimes placed in bottles, toddlers will frequently drink these agents accidentally. The hydrocarbons m o s t likely to cause serious illnesses include kerosene, mineral seal oil, gasoline, and cigarette lighter fluid. 2 Hydrocarbon ingestions account for nearly 5% of all accidental poisonings in children less than 5 years of age. Ninety percent of the deaths caused by hydrocarbon ingestions occur in this age group. The Cooperative Kerosene Poisoning Study estimated the national mortality rate to be approximately 0.5 per million population. 2 Ingestions of hydrocarbons can lead to l i f e - t h r e a t e n i n g c o m p l i c a t i o n s , most notably chemical pneumonitis. The likelihood of developing chemical pneumonitis is related to the ingested hydrocarbon's viscosity. Generally, the lower the viscosity the higher the risk of aspiration and subsequent toxicity. 9 As little as 0.2 mL of a low-viscosity hydrocarbon directly aspirated into the trachea can produce severe pneumonitis in rats. lo Respiratory symptoms are the earliest and most serious medical abnormalities after hydrocarbon ingestion. If aspiration has occurred, coughing, shortness of breath, and various degrees of cyanosis, tachycardia, and retractions may be noted. The displacement of alveolar gases by vaporized hydrocarbons may lead to asphyxiationA 1 Neurologic changes usually inAnnals ofEmergency Medicine
2
1.1
184
100.0
clude lethargy; less commonly, seiz u r e s or c o m a occur. F e v e r or leukocytosis can be seen after aspiration but do not correlate directly with the severity of illness. 7 The bulk of the medical literature discussing hydrocarbon ingestions deals with kerosene ingestions and is biased toward hospitalized patients, u6 These studies do not address either the overall risk of developing complications or the risk to patients with minimal initial symptoms. Although this is n o t the current practice in emergency medicine, these early studies are still used by many physicians who call the poison center in support of their practice of admitting all such patients for observation. Most of the medical literature dealing with hydrocarbon ingestion was published before 1965, and only a few articles dealing with criteria for admission Or risk factors for subsequent complications exist. Our study found that less than 1% of hydrocarbon ingestion cases required physician intervention. This finding is in sharp contrast with the 1934 s t u d y by N u n n and Martin, which reported a m o r t a l i t y of 11% (eight of 72 patients). 1 Other studies have reported even higher mortality rates. 2-6 We feel Nunn and MartinM results are biased because they included only patients "admitted with signs of acute poisoning." For example, six of the eight patients described by Nunn and Martin s were already cyanotic or stuporous on presentation. Also, they did not specify whether cases involved intentional or accidental ingestions. Anas et al7 17:8 August 1988
184
!
÷ 35% (64) Had initial symptoms
65% (120) Initially asymptomatic
I 100% Remained asymptomatic
97% (62) Had regressing signs and symptoms
0% Worsened in any way
100% Soon became asymptomatic
t
100% Remained asymptomatic
reported 950 patients with hydrocarbon ingestion who presented for outpatient or e m e r g e n c y d e p a r t m e n t treatment. They reported an overall mortality of 0.7%, which is in agreement with our rate of 0.5%. Fortyseven percent of their patients were already asymptomatic at the time of their presentation. Ninety-one percent of their originally symptomatic patients "had no progression of their pulmonary disease and had uncomplicated hospitalizations." Ninety-five percent were a s y m p t o m a t i c by 24 hours. Only two (3%) of our initially symptomatic patients had persistent or progressive symptoms. One patient was totally asymptomatic by 24 hours despite p e r s i s t e n t r a d i o g r a p h i c changes. In the series of Anas et al, 7 9% of the initially symptomatic patients had persistent or progressive symptoms. However, half of these were asymptomatic by 24 hours, and they were discharged within 72 hours. Our study had a 0.5% overall proportional mortality rate and a 1.5% rate in the initially s y m p t o m a t i c group. This compares with the Anas et al 7 reported 0.2% overall mortality rate and 1.3% rate in initially symptomatic patients. Although Nunn and Martin 1 reported a mortality rate of 11%, this is suspect because they excluded "those showing little evidence of acute poisoning." 17:8August 1988
I
,
3% (2) Had persistent or progressive signs and symptoms
0% Worsened in any way
l
One patient slowly improved with observation; one patient died
t
0% Worsened in any way
Some potential weaknesses in our study were identified. We were concerned about excluding 27 of our 211 cases for insufficient documentation. Could these patients represent those who later developed complications? We feel this is unlikely because all of these patients were asymptomatic at the time of their telephone calls, and these patients appeared to be at low risk of complications based on the 120 asymptomatic cases included in the study and based on the study by Anas et al. 7 We also were concerned that patients ill from hydrocarbon ingestion might have been treated without involvement of the poison center by patient or physician. In defense of our data, nearly one-third of our cases came from physicians consulting the poison center. We chose not to report quantities ingested because they are usually uncertain estimates. The average 3-yearold's swallow is less than 10 mL; 12-13 therefore, it is probably unlikely that toddlers would ingest more than 30 mL of these bad-tasting substances. The Cooperative Kerosene Poisoning Study reported that only 27% of ingestions involved more than 30 mL. Anas et al 7 reported that most of their patients Ingested less than 30 mL.
SUMMARY In our study, the incidence of seAnnalsof Emergency Medicine
FIGURE. Total number of patients. quelae after telephone calls concerning accidental hydrocarbon ingestion was approximately 1%. We believe these telephone calls fall into one of the following four symptom patterns: patients who are initially asymptomatic, patients with regressing symptoms (ie, improving with time), patients with progressing symptoms (ie, worsening with time), and patients with severe, life-threatening symptoms. Initially asymptomatic patients have a negligible risk of becoming s y m p t o m a t i c and can be safely watched at home. Likewise, patients with minor initial symptoms that are regressing have a negligible risk; they can be followed for the persistence or progression of symptoms at home. Patients with progressive worsening of symptoms should be referred to a physician for observation and support. If these patients' symptoms subsequently resolve, they are unlikely to need further intervention, and hospitalization is probably unwarranted. Patients with severe or life-threatening s y m p t o m s require immediate (and often aggressive) medical intervention. The authors express their sincere gratitude to the poison information specialists and to Terry McHugh, MD, whose hard work and expertise made this paper possi806/71
ACCIDENTAL HYDROCARBON INGESTION Machado, Cross & Snodgrass
ble. T h e y a l s o t h a n k t h e c l e r i c a l staff, w h o s e d a t a p r o c e s s i n g a n d a s s e m b l i n g of t h e m a n u s c r i p t were i n v a l u a b l e .
4. Baldachin BJ, M e l m e d RN: Clinical and therapeutic aspects of kerosene poisoning. A series of 200 cases. Br Med J 1964;2:28-30.
REFERENCES
5. B r u n n e r 8, Rovsing H, Wulf H: Roentgenographic change in the lungs of children with kerosene poisoning. A m Rev Respir Dis 1964;89:250-254.
1. N u n n JA, Martin FM: Gasoline and kerosene poisoning in children. JAMA 1934;103:472-474. 2. Cooperative Kerosene Poisoning Study: Report of the Subcommittee on Accidental Poisonings. Pediatrics 1962;29:648-674. 3. Ng RC, Darwish H, Stewart DA: Emergency treatment of petroleum distillate and turpent i n e i n g e s t i o n . Can Med A s s o c J 1974;3: 537-538.
72/807
6. Bonte F], Reynolds J: Hydrocarbon pneumonitis. Radiology 1958;71:391-397. 7. Anas N, Namasonthi V, Ginsburg CM: Criteria for hospitalizing children who have ingested products containing hydrocarbons. JAMA 1981; 246:840-843. 8. Rosen P: Emergency Medicine. St Louis, CV
Annals of Emergency Medicine
Mosby Company, 1983. 9. Haddad LM: Poisoning and Drug Overdose. Philadelphia, WB 8aunders, 1983. 10. Bratton L, Haddow J: Ingestion of charcoal lighter fluid. J Pediatr 1975;87:633-636. 11. Klein BL, Simon JE: Hydrocarbon poisonings. Pediatr Clin North A m 1986;33:411-419. 12. Watson WA, Bradford DC, Veltri JC: The volume of a swallow: Correlation of deglutition with patient and container parameters. A m J Emerg Med 1983;1:278-281. 13. Jones DV~ Work CE: Volume of a swallovz Am J Dis Child 1961;102:427.
17:8 August 1988