What is the management of pine oil (essential oil) poisoning?

From the Guidelines

Management of pine oil poisoning requires immediate supportive care as there is no specific antidote, prioritizing airway management, hemodynamic support, and correction of critical vital sign and metabolic derangements, as emphasized in the 2023 American Heart Association guidelines 1. The primary goal is to ensure the patient's airway, breathing, and circulation are stable.

• Do not induce vomiting as pine oil can cause aspiration pneumonitis if inhaled into the lungs during vomiting.
• Activated charcoal (1 g/kg orally) may be administered if the patient presents within one hour of ingestion and is alert with an intact gag reflex, as suggested by general principles of toxicology management 1.
• Gastric lavage is generally not recommended due to aspiration risk.
• Provide IV fluids to maintain hydration and electrolyte balance.
• Monitor vital signs, oxygen saturation, and respiratory status closely as pine oil can cause central nervous system depression and respiratory distress.
• Oxygen therapy should be provided if hypoxemia develops.
• For seizures, administer benzodiazepines such as diazepam (5-10 mg IV for adults) or lorazepam (2-4 mg IV for adults).
• Severe cases may require intubation and mechanical ventilation.
• Laboratory tests should include complete blood count, electrolytes, liver and kidney function tests, and arterial blood gases.
• Chest X-ray is indicated if respiratory symptoms develop. Pine oil poisoning can be dangerous because it contains terpenes that are rapidly absorbed and can cause CNS depression, respiratory distress, and hepatotoxicity, highlighting the importance of timely and effective supportive care, as outlined in the 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1. Most patients recover with supportive care within 24-48 hours if complications like aspiration pneumonia are avoided.

From the FDA Drug Label

When Activated Charcoal is indicated for use, give 3 to 4 heaping tablespoonfulls (20 to 30 g) mixed in a minimum of 8 ounces of liquid or as directed by a health professional. If an emergency, fill this bottle with water. Mix well and have poison victim drink all of this mixture. Repeat dose immediately, if possible. If possible, call a Poison Control Center, emergency facility, or health professional for help before using this product. If help cannot be reached quickly, follow the directions in this label.

For the management of pine oil poisoning, activated charcoal (PO) can be considered as a treatment option. The recommended dose is 3 to 4 heaping tablespoonfuls (20 to 30 g) mixed in a minimum of 8 ounces of liquid. It is crucial to:

• Contact a Poison Control Center (1-800-222-1222) or a health professional for guidance before administration, if possible.
• Follow the directions provided in the label if help cannot be reached quickly.
• Repeat the dose immediately, if possible, in emergency situations 2, 2.

From the Research

Management of Pine Oil Poisoning

• The management of pine oil poisoning is primarily supportive, with a focus on addressing the clinical effects of the exposure 3, 4.
• Patients who ingest pine oil may develop CNS depression, respiratory failure, and GI dysfunction, and may require intubation and mechanical ventilation 3.
• Gastrointestinal decontamination and minimal supportive care are often sufficient for patients who ingest pine oil cleaner 4.
• In cases of severe poisoning, patients may develop acute hydrocarbon pneumonitis, which can be fatal if not treated promptly 4, 5.
• Treatment for pneumonitis typically involves supportive care, supplemental oxygen, and may require intubation and admission to an intensive care unit in severe cases 5.
• Extracorporeal treatments, such as hemodialysis, may be necessary in cases of severe toxicity or when the poison is not being adequately eliminated by the body 6.
• The decision to use extracorporeal treatments should be based on the severity of the poisoning, the anticipated duration of toxicity, and the potential for removal of the poison by the treatment 6.

Clinical Features and Treatment

• Clinical features of pine oil ingestion include depressed mentation, respiratory failure, and GI dysfunction 3.
• Ataxia is a frequent presenting sign of intoxication in children who ingest pine oil cleaner 4.
• Central nervous system depression is a common effect of hydrocarbon exposure, and can range from mild depression to coma 7, 5.
• Treatment for CNS depression is typically supportive, and may involve the use of antidotes or other medications to manage symptoms 7, 6.

Prevention and Prognosis

• Prevention of pine oil poisoning involves careful handling and storage of household cleaning solutions that contain pine oil 3.
• The prognosis for patients who ingest pine oil is generally good, with most patients recovering fully with supportive care 3, 4.
• However, severe cases of poisoning can be fatal, particularly if patients develop acute hydrocarbon pneumonitis or other complications 3, 5.