SN7 SHORT NOTE 5M

Describe kerosene and hydrocarbon poisoning.

Forensic Medicine · 2nd Professional — Para-Clinical

Nature and Mechanism

Kerosene poisoning is among the commonest accidental poisonings of children in India, because kerosene is present in almost every household for cooking and lighting and is characteristically stored in used soft-drink or water bottles within easy reach
The hydrocarbons — kerosene, petrol, diesel, turpentine, furniture polish, thinners and lighter fluid; and they are also the solvent in most pesticide formulations, so that an organophosphate ingestion is simultaneously a hydrocarbon ingestion
The danger IS aspiration, not absorption. This is the single governing fact. Kerosene is poorly absorbed from the gut and relatively harmless if it stays there; but it has a low viscosity, low surface tension and high volatility, so that even a small quantity spreads rapidly over the airway surface and causes a severe chemical pneumonitis by destroying surfactant and damaging the alveolar membrane
Aspiration occurs at the moment of swallowing, during coughing and gagging, and again with any vomiting — which is why emesis and gastric lavage are so dangerous

System	Features
Respiratory — the dominant problem	Immediate coughing, choking and gagging; then tachypnoea, retractions, grunting, crepitations and wheeze; and chemical pneumonitis developing over hours, with hypoxia. Radiographic changes appear early, often within 30 minutes to 2 hours, and characteristically in the right lower and middle zones — and they lag behind clinical improvement, persisting for weeks after the child is well. Complications: pneumatocele, pleural effusion and secondary bacterial infection
Gastrointestinal	Burning of the mouth and throat, vomiting and abdominal pain — usually mild
Central nervous system	Drowsiness, irritability, ataxia and, in large ingestions or with inhalation, convulsions and coma — largely a consequence of the hypoxia rather than a direct effect
Cardiac	Hydrocarbons sensitise the myocardium to catecholamines, so ventricular arrhythmias may occur — the mechanism of sudden sniffing death in solvent abusers, characteristically on exertion or being startled
Skin	Defatting dermatitis and chemical burns with prolonged contact

CLINICAL PEARL

Do not make the child vomit and do not lavage — the poison is only dangerous if it reaches the lungs. Kerosene in the stomach does little; kerosene in the airway causes a severe pneumonitis. Every manoeuvre that brings it back up past the larynx converts a harmless ingestion into a dangerous one, which inverts the usual instinct to empty the stomach.

Management

DO not induce vomiting, and DO not perform gastric lavage — both greatly increase the risk of aspiration and are contraindicated. Lavage is considered only where a highly toxic additive is present in a large quantity (an organophosphate, a heavy metal, benzene or camphor), and then only with the airway protected by a cuffed tube
Activated charcoal is useless — hydrocarbons are among the "PHAILS" group it does not adsorb — and it adds vomiting risk
Remove contaminated clothing and wash the skin
Oxygen and respiratory support, with ventilation and positive end expiratory pressure where needed; this is the whole of the treatment
Do not give prophylactic antibiotics or steroids — neither is of proven benefit, antibiotics select resistant organisms, and steroids may worsen the outcome. Antibiotics are given only where secondary bacterial infection is demonstrated
Avoid adrenaline and other catecholamines where possible, because of myocardial sensitisation
Observe for at least 6 hours. A child who is asymptomatic with a normal chest radiograph at 6 hours may be discharged; any child with cough, tachypnoea or radiographic change is admitted

Applied Aspects

Never induce vomiting and never lavage a hydrocarbon ingestion; this single rule prevents most of the serious harm, and it runs against instinct
Do not give charcoal; it does not bind hydrocarbons and adds an aspiration risk for no benefit
Radiograph early and interpret with the clinical picture; the film changes within hours but clears long after the child has recovered, so it must not dictate the length of stay
Withhold prophylactic antibiotics and steroids; neither helps, and both are given routinely out of habit
Observe six hours and discharge the well child with a clear film; unnecessary admission of well children is common and displaces those who need the bed
Ask what was IN the kerosene; a pesticide dissolved in it changes the management completely, and the smell of kerosene may mask an organophosphate ingestion
Counsel on storage at discharge — never in a drink bottle, always labelled and out of reach; this is the only measure that prevents recurrence, and the same child often returns

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