Respiratory complications following hydrocarbon aspiration in children

Utilizing extracorporeal membrane oxygenation and surfactant in the management of severe acute respiratory distress syndrome due to hydrocarbon pneumonitis

Severe cases of hydrocarbon aspiration requiring Extracorporeal Membrane Oxygenation (ECMO) are rarely reported in pediatrics, and 90% of hospitalized patients have a relatively benign clinical course. We describe a 14 month-old female with accidental hydrocarbon ingestion and aspiration due to organic makeup brush cleaner that suffered severe ARDS and multiorgan failure, successfully managed with ECMO and surfactant. She was decannulated after a total of 72 hours on ECMO, extubated on hospital day 15 (HD 15), and discharged home in her normal state of health after one month in the hospital. ECMO and adjunctive therapies such as surfactant may be helpful in the management of severe hydrocarbon pneumonitis and there are limited reports of ECMO as a supportive method for these pediatric patients.

The burden of poisoning in children hospitalised at a tertiary-level hospital in South Africa

Introduction

Globally, childhood poisoning, accounts for a significant proportion of emergency department admissions. There is a paucity of data from low- and middle-income countries on poisoning in children.

Objective

To describe the incidence, case fatality rate, and types of poisoning in children admitted to a tertiary-level hospital in Johannesburg, South Africa.

Methods

This was a retrospective descriptive study of children hospitalised with poisoning from January 2016 to December 2021 at Chris Hani Baragwanath Academic Hospital. Children were identified from a discharge summary database using ICD-10 codes that describe poisoning. Trends in incidence of poison exposure were reported.

Results

Of the 60,901 admissions during the study period, 2,652 (4.4%) children were diagnosed with poisoning. Most (71.3%) children were less than 5 years of age and 55% were male. The incidence of poisoning per 100,000 was highest at 108.4 (95% CI: 104.3-112.6) in 2019 and decreased to 77.3 (95% CI: 73.9-80.7) in 2020 and 59.6 (95% CI: 56.3-62.5) in 2021. Main causes of poisoning were organic solvents (37.6%), medications (32.9%), and pesticides (17.5%). The overall case fatality rate was 2.1%. In a multivariate analysis, poisoning secondary to pesticides (aOR: 13.9; 95% CI: 4.52-60.8; p < 0.001), and unspecified agents (aOR: 12.7; 95% CI: 3.27-62.8; p < 0.001) were associated with an increased odds of death.

Conclusion

We report a high prevalence of poisoning in children hospitalised in this tertiary-level hospital in South Africa. Public health measures to reduce the burden of organic solvents, medications and pesticide poisoning are urgently warranted.

Hydrocarbon ingestions among individuals younger than 20 years old reported to United States Poison Centers, 2000-2021

BACKGROUND

Hydrocarbon-based products have many household and commercial uses and exposure to these substances is common. Severe clinical effects can occur if these products are ingested. This study investigated the characteristics and trends of hydrocarbon ingestions reported to United States Poison Centers.

METHODS

Data from the National Poison Data System were analyzed for cases of hydrocarbon ingestion among individuals < 20 years old reported to United States Poison Centers from January 1, 2000 through December 31, 2021.

RESULTS

There were 284,085 hydrocarbon ingestions reported during the 22-year study period in which a hydrocarbon was the first-ranked substance. Most of these cases occurred among children < 6 years old (83.2%), males (64.6%), at a residence (96.5%), were single-substance exposures (98.3%), and were managed on-site rather than in a health care facility (74.9%). However, 4.5% of cases were associated with a serious medical outcome, including 34 deaths. Thirty-two deaths were among children < 6 years old and most were associated with aspiration. Gasolines accounted for 24.6% of total cases, followed by lubricating oils and/or motor oils (19.9%), other types of hydrocarbons (14.9%), lamp oils (11.3%), and lighter fluids and/or naphtha (10.3%). The rate of hydrocarbon ingestions among United States youth < 20 years old decreased significantly (p < 0.0001) by 66.5% from 2000 to 2021. The greatest rate decrease was observed among lamp oils (- 78.4%, p < 0.0001), followed by gasolines (- 75.9%, p < 0.0001).

CONCLUSIONS

Although the rate of hydrocarbon ingestions decreased during the study period and most reported cases resulted in non-serious outcomes, the number of cases remains high with a non-trivial minority (4.5%) of cases associated with a serious medical outcome, including death. Most deaths were among children < 6 years old. This underscores the need to increase primary prevention efforts, especially for young children.

Initial clinical and laboratory parameters triaging non-pharmaceutical acute pediatric poisoned patients for potential adverse outcomes: a three-year retrospective study

Identifying high-risk pediatric patients with non-pharmaceutical poisoning is crucial to avoid prospective complications and decrease the evident hospital economic burden. Although the preventive strategies have been well studied, determining the early predictors for poor outcomes remains limited. Therefore, this study focused on the initial clinical and laboratory parameters as a triage of non-pharmaceutical poisoned children for potential adverse outcomes taking the causative substance effects into account. This retrospective cohort study included pediatric patients admitted to Tanta University Poison Control Center from January 2018 to December 2020. Sociodemographic, toxicological, clinical, and laboratory data were retrieved from the patient's files. Adverse outcomes were categorized into mortality, complications, and intensive care unit (ICU) admission. Out of enrolled 1,234 pediatric patients, preschool children constituted the highest percentage of the patients investigated (45.06%), with a female predominance (53.2%). The main non-pharmaceutical agents included pesticides (62.6%), corrosives (19%), and hydrocarbons (8.8%), mainly associated with adverse consequences. The significant determinants for adverse outcomes were pulse, respiratory rate, serum bicarbonate (HCO3), Glasgow Coma Scale, O2 saturation, Poisoning Severity Score (PSS), white blood cells (WBCs), and random blood sugar. The cutoffs of serum HCO3 < 17.55 mmol/l, WBCs >8,650 cells/microliter, and PSS > 2 points were the best discriminators for mortality, complications, and ICU admission, respectively. Thus, monitoring these predictors is essential to prioritize and triage pediatric patients who require high-quality care and follow-up, particularly in aluminum phosphide, sulfuric acid, and benzene intoxications.

A case report of recreational use of inhaled Freon leading to acute hypoxemic respiratory failure salvaged by veno-venous extracorporeal membrane oxygenation

BACKGROUND

Freon™ is a halogenated hydrocarbon often used as a refrigerant. When inhaled recreationally, it has the desired effects of euphoria and intoxication. Toxic effects include cardiovascular and neurologic insults such as arrhythmias and seizures, and less well-described toxicities include airway and lung injury. The treatment in general is primarily supportive.

CLINICAL FEATURES

We present the case of a 42-yr-old previously healthy male who developed acute bronchiolitis and pneumonitis following inhalation of Freon leading to severe respiratory failure. He was supported by veno-venous extracorporeal membrane oxygenation and managed with high-dose corticosteroids.

CONCLUSION

To our knowledge, this is the first case report of an inhaled Freon exposure resulting in acute lung injury refractory to conventional therapy that was salvaged by vv-ECMO as a bridge towards a full recovery.

Extracorporeal Membrane Oxygenation for Pediatric Toxin Exposures: Review of the Extracorporeal Life Support Organization Registry

Evidence for the use of extracorporeal membrane oxygenation (ECMO) in children with refractory respiratory failure or shock following ingestion or toxin exposure, has been confined to single-center experiences, individual case reports, and extrapolated from adult cohorts; no pediatric multicenter cohorts exist. The objective of this retrospective review of the Extracorporeal Life Support Organization registry is to describe pediatric ECMO use following ingestion or toxin exposure, and define factors associated with mortality. Twenty-eight children between the ages of 30 days and 18 years met inclusion criteria between January 1, 2008 and December 31, 2017. The primary outcome measure was mortality before hospital discharge, which occurred in 32% of patients. Factors associated with in-hospital mortality included pre-ECMO use of inhaled nitric oxide (44.4% vs. 5.3%, p = 0.026), lower pre-ECMO arterial blood gas pH (6.97 [6.80-7.17] vs. 7.20 [7.15-7.32], p = 0.034), and higher pre-ECMO PaCO2 (79 [57-85] vs. 49 [38-63], p = 0.014). Receipt of inotropic support during ECMO was more common in nonsurvivors (66.7% vs. 21.1%, p = 0.035). Extracorporeal membrane oxygenation should be considered in the most severe pediatric toxin exposures as a bridge to recovery, providing time for both toxin elimination and end-organ recovery.

Pneumatocele formation in a fatal adult pneumonia patient coinfected with Streptococcus pyogenes emm-type 3 and influenza A: a case report

Background

A pneumatocele is a transient thin-walled lesion and rare complication in adult pneumonia.

A variety of infectious pathogens have been reported in children with pneumatoceles. We report the first case of adult pneumonia with pneumatocele formation that is likely caused by Streptococcus pyogenes and coinfection with influenza A virus.

Case presentation

A 64-year-old Japanese man presented with a one-week history of fever, sore throat, and arthralgia. He was referred to our university hospital for respiratory distress. He required mechanical ventilation in the intensive care unit (ICU). Bacterial culture detected S. pyogenes in the bronchoscopic aspirates, which was not detected in blood. Although a rapid influenza antigen test was negative, an influenza A polymerase chain reaction (PCR) test was positive. Therefore, he was diagnosed with coinfection of influenza A and group A streptococcus (GAS) pneumonia complicated by probable streptococcal toxic shock syndrome. A chest radiograph on admission showed diffuse patchy opacification and consolidation in the bilateral lung fields.

Multiple thin-walled cysts appeared in both middle lung fields on computed tomography (CT). On the following day, the bilateral cysts had turned into a mass-like opacity. The patient died despite intensive care. An autopsy was performed. The pathology investigation revealed multiple hematomas formed by bleeding in pneumatoceles.

Conclusions

There have been no previous reports of a pneumatocele complicated by S. pyogenes in an adult patient coinfected with influenza A. Further molecular investigation revealed that the S. pyogenes isolate had the sequence type of emm3.

Liquid Mosquito Repellent Ingestion in Children

OBJECTIVES

Hydrocarbons are a common cause of accidental poisoning in children, with kerosene being the most implicated agent in rural parts of India. However, lately, liquid mosquito repellent ingestion is emerging as an important cause of hydrocarbon (kerosene) poisoning in urban households.

METHODS

This is a retrospective case series over a 5-y period (January 2013 - December 2017) of children with accidental liquid mosquito repellent ingestion presenting to the pediatric emergency. Epidemiology, clinical profile, management and outcomes are discussed.

RESULTS

Twenty-three children with median (IQR) age of 24 (18.8-32) mo presented after mean (SD) interval of 6 (3) h from ingestion. Majority (20, 87%) were seen during summer months (March-June) and all were from urban background. Sixteen (70%) had mild-moderate acute respiratory distress syndrome (ARDS) requiring supplemental oxygen with or without positive airway pressure for a mean (SD) duration of 3.3 (1.9) d. All except one survived.

CONCLUSIONS

Children with accidental liquid mosquito repellent ingestion had predominant aspiration pneumonitis due to hydrocarbon content rather than neurological complications attributable to synthetic pyrethroids. Ensuring child-proof containers, appropriate storage, regulatory surveillance and parental awareness are must for prevention.

Kerosene, Camphor, and Naphthalene Poisoning in Children

Kerosene poisoning is one of the most common accidental poisoning in children in developing countries due common use of kerosene in house-hold and unsafe storage practices. Aspiration pneumonitis is the most common manifestation of kerosene ingestion due to its low viscosity, high volatility, and low surface tension. The treatment of aspiration pneumonitis due to kerosene poisoning is symptomatic including oxygen support, respiratory monitoring, and careful monitoring of fluid balance. Children with severe respiratory distress and hypoxemia unresponsive to supplemental oxygen and/or severe central nervous system involvement require early intubation and mechanical ventilation. Transfer to the pediatric intensive care unit (PICU) is required at this stage. Emesis, gastric lavage, and administration of activated charcoal are contraindicated due to risk of aspiration. There is no clear benefit of using corticosteroids or prophylactic antibiotics. Asymptomatic children should be kept under observation for atleast 6 hours after exposure. The mortality rate is low and death occurs due to pneumonitis. Camphor is used in house-hold items including vaporized or topical cold preparations, liniments, moth repellents, for performing rituals in religious ceremonies, and in antimicrobial preparations. Camphor poisoning is not very common in childhood. Even small doses of camphor can cause serious toxicity and is potentially fatal. The onset of action is very rapid (5–15 minutes). The common manifestations are confusion, restlessness, delirium, and hallucinations, muscle twitching, myoclonus, ataxia, hyperreflexia, fasciculations, and seizures. Seizures are common and serious complication in camphor toxicity. The treatment is supportive including decontamination, gastric lavage, activated charcoal, and seizure control. Naphthalene is a major constituent of mothballs which are commonly used in household to protect clothes from moths. Though the poisoning with naphthalene is uncommon in children, most of the cases with naphthalene poisoning occur in developing countries where mothballs are still commonly used. The manifestations of naphthalene toxicity are predominantly due to acute intravascular hemolysis leading to anemia, hemoglobinuria, methemoglobinemia, and acute kidney injury (AKI). The treatment of naphthalene toxicity is supportive in form of transfusion of the packed red blood cells, monitoring of fluid and electrolyte balance, administration of alkalis in presence of hemoglobinuria, and renal replacement therapy. Prevention is better than cure. The strategies should be adopted to prevent children being exposed to these toxic compounds in the house-hold. Safe storage of toxic compounds away from the reach of children, avoiding storing kerosene in cold drink and beverage bottles, community education, provision of electricity in rural areas, safe cooking practices, and parental supervision are important interventions to prevent accidental poisoning among children.

Successful treatment of canine acute respiratory distress syndrome secondary to inhalant toxin exposure

OBJECTIVE

To describe the successful management of a dog with acute respiratory distress syndrome secondary to inhalant toxin exposure.

CASE SUMMARY

An 8-year-old male neutered Greyhound was referred with severe respiratory distress 56 hours after exposure to an aerosol toxicant. The patient developed respiratory difficulties requiring veterinary attention within 12 hours of initial exposure. Treatment at the referral hospital included mechanical ventilation and supportive care. The patient was discharged 5 days after admission to the referral hospital.

NEW OR UNIQUE INFORMATION

This is the first report, to the authors' knowledge, of canine acute respiratory distress syndrome secondary to inhalant toxin exposure not associated with smoke inhalation. The report summarizes the provided care and subsequent successful outcome.

Prophylactic Use of Steroids and Antibiotics in Acute Hydrocarbon Poisoning in Children

Ingestion of hydrocarbons is a common cause of childhood poisoning in low and middle-income countries. Although mild ingestions are usually devoid of complications, the morbidity and mortality associated with such poisoning are primarily related to pulmonary aspiration. Subsequent complications, most importantly, secondary bacterial infections can worsen the clinical condition. Standard treatment protocol for acute accidental hydrocarbon poisoning does not advocate routine use of steroids or antibiotics. However, some studies have demonstrated beneficial effects of prophylactic steroid and antibiotic to prevent chemical pneumonitis. In this article, we have summarized the findings of the clinical studies from literature, which have evaluated the advantages of early administration of steroids and antibiotics to prevent chemical pneumonitis in acute hydrocarbon poisoning in children. From these studies, we have found that there is no convincing evidence for initiating steroid and antibiotic to improve outcome in these children.