Introduction

Kerosene is said to be one of the agent for poisoning in childhood period in India among others.Accidental kerosene ingestion is still a common problem in children. It causes considerable morbidity and occasionally mortality. The role and choice of antibacterial agents in its management remain unsettled. Pulmonary damage has been reported as resulting from aspiration. In aspiration pneumonia, anaerobic organisms may be important pathogens. Kerosene poisoning is said to occur when a child either swallows or inhales kerosene, intentionally or accidentally. Kerosene is a combustible hydrocarbon liquid, mainly used in paints, pesticides, fuel lamps and heating. Primarily, kerosene poisoning can be accidental or intentional. In India and other developing countries, most of the cases of kerosene poisoning are accidental due to its extensive use in cooking and lighting among people belonging to the lower socioeconomic groups and its inappropriate storage in soft drink/beer bottles.

Clinical features of kerosene poisoning

Acute exposure to kerosene by inhalation can result in headache, dizziness, drowsiness, euphoria, restlessness, ataxia, convulsions, coma and death. It can also provoke signs of pulmonary irritation like coughing and shortness of breath due to aspiration leading to aspiration pneumonia.

Throat swelling, Eyes, ears, nose, and throat Pain, Abdominal pain, Bloody stools, vomiting, possibly with blood, Heart and blood Collapse, Low blood pressure -- develops rapidly.

The defatting action (chemical dissolving of dermal lipids from the skin) of kerosene on the skin can result in local irritation as well as drying and cracking of skin. There may be transient pain with redness, blistering and superficial burns.

Kerosene poisoning in the eyes may result in irritation causing an immediate stinging and burning sensation with excessive tear production.

Intentional ingestion of kerosene can cause nausea, vomiting and occasionally diarrhoea.

Pathogenesis

• Pathogenesis is mainly due to aspiration either during ingestion.
• Systemic absorption is very small.
• Most children ingest less than 30ml.
• CNS symptoms are due to hypoxia and acidosis. These results from damage to the lungs.
• Respiratory problems are mainly due to development of atelectasis and pneumonitis.

Pathology

Changes in the Lungs

1. Atelectasis develops due to damage to surfactant, which increases surfacetension.
2. Bronchospasm, atelectasis, emphysema and signs of inflammation such as edema, hyperemia and infiltration of polymorphs, vascular thrombosis, hemorrhagic necrosis of bronchial,bronchiolar and alveolar tissue may develop.
3. Superseded secondary infection is rarely seen.

• GIT Changes- ulceration of stomach.
• Liver- fatty infiltration is seen.
• Heart- myocardial degeneration is present.
• Kidney- renal tubular lesions.
• Blood- intravascular haemolysis is due to damage to RBC membrane.

Diagnosis

It is based on the history of ingestion, radiological investigation in addition to above clinical features.

Investigations

• X-ray chest- Initially fine, punctate, mottled densities appear in the perihilar area and midlungfields. Ill defined, patchy densities develop subsequently. These commonly coalesce to form larger areas of consolidation.
•  Pnuemonitis typically is bilateral and generally involves multiple lobes, most severely the lower lobes.
•  Localised areas of atelectasis and obstructive emphysema are often present.
•  Pleural effusion, pneumatoceles, pneumothorax, pneumomediastinum and subcutaneous emphysema are infrequently noted.
•  Varying degrees of hypoxia and hypercarbia are present. Leucocytosis with shift to the left and ketonuria and glycosuria may occur.
•  Haemolytic anemia is an unusual finding.
• Respiratory symptoms sometimes develop within minutes of ingestion. It almost always begins with in the first 6 hrs.  If symptoms do not appear within 6 hours, the patients will be normal. Distress generally worsens within 24 to 48 hours

First Aid

Important Notes

•  Many patients remain well and need no treatment.
•  Ambulance staff, paramedics and emergency department staff treating chemically-contaminated casualties should be equipped with NHS approved liquid-tight PPE and blow-over respirators with an A2B2EK filter, where ever appropriate.

Dermal exposure

• Remove patient from exposure.
• Remove all soiled clothing.
• Wash the contaminated area thoroughly with soap and water.
• Treat symptomatically.

Ocular exposure

• Remove patient from exposure.
• Remove contact lenses if necessary and immediately irrigate the affected eye thoroughly with water or 0.9% saline for at least 10-15 minutes.

Inhalation

• Remove patient from exposure and give oxygen.
• Maintain a clear airway and adequate ventilation.
• Apply other measures as indicated by the patient’s clinical condition.

Ingestion

• Gastric lavage should not be undertaken. Consider gastric aspiration within 1 hour of ingestion, if very large amounts have been taken or there is concern about another toxin, provided the airway can be protected.
• Give oxygen if symptomatic.
• Patients who have ingested small amounts and have had no symptoms suggestive of aspiration (choking, coughing, vomiting) or other features since the exposure can be observed at home under supervision for 6 hours after ingestion, with advice to attend hospital if features develop.
• Patients who have had features of possible aspiration should be referred to hospital.
• Patients with persistent respiratory symptoms, drowsiness or convulsions should be admitted to hospital.
• Apply other measures as indicated by the patient’s condition.

Common treatment for kerosene poisoning

The first line of treatment for patients with kerosene poisoning is stabilization of the airways. For a patient who has severe respiratory distress or a decreased level of consciousness, early intubation and mechanical ventilation are required. Permanent lung damage can occur, if kerosene gets into the lungs.

Gastric lavage is avoided. In case of massive kerosene poisoning, a cuffed end tracheal tube is used. After lavage, small amount of magnesium or sodium sulphate is left behind in the stomach.

In case of dermal exposure, affected skin should be decontaminated as soon as possible.

When poisoning is via ocular exposure, the patient should be moved from the area of exposure, contact lenses removed and the affected eye should be irrigated immediately with water or 0.9% saline for at least 10-15 minutes.

Most commonly, in severe cases antibiotics like penicillin G and Kanamycin are prescribed.

Prevention of kerosene poisoning

As a primary preventive care following things should be taken into consideration:

• Contact numbers of the nearest hospitals and doctors should be maintained in contact list/diary.
• Household kerosene should be kept away from children’s reach.
• The word poison should be exhibited prominently on the containers of kerosene.
• Kerosene oil should not be stored in tumblers or beverage bottles.

Prognosis-

• Majority of these patients become normal.
• In a small number of patients, there is an increased incidence of respiratory infections and abnormal lung function.

Reference

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