What is the management approach for camphor ingestion in children with liver damage?

Management of Camphor Ingestion in Children with Pre-existing Liver Damage

Children with liver damage who ingest camphor require immediate emergency department referral regardless of dose, as camphor is hepatotoxic and can cause severe liver injury even with dermal application, making these patients at extremely high risk for acute hepatic decompensation. 1

Immediate Triage and Referral

• Any child with pre-existing liver disease who ingests camphor should be referred to an emergency department immediately, even if asymptomatic, as the combination of baseline hepatic dysfunction and camphor's known hepatotoxicity creates unacceptable risk 1, 2

• Standard camphor ingestion guidelines recommend emergency department referral for ingestions >30 mg/kg or any symptomatic patient, but children with liver damage should be referred at ANY dose due to compromised hepatic reserve 2

• Transport by emergency medical services is mandatory if seizures occur, with benzodiazepines as first-line anticonvulsant therapy 2

Clinical Manifestations Requiring Urgent Attention

Neurological toxicity:

• Seizures typically occur within 5-15 minutes of ingestion and represent the most serious acute complication 3, 4
• Confusion, restlessness, delirium, hallucinations, muscle twitching, myoclonus, ataxia, and hyperreflexia may develop rapidly 3
• Doses as low as 500 mg can cause mortality in children, with 750-1000 mg commonly associated with seizures and death 4

Hepatotoxicity (critical in children with pre-existing liver damage):

• Elevated hepatic enzymes can occur even with dermal application, not just ingestion 1
• The combination of camphor hepatotoxicity and baseline liver dysfunction significantly increases risk of acute liver failure 5, 1

Other manifestations:

• Respiratory insufficiency, severe acidosis, renal insufficiency, electrolyte imbalances, and elevated amylase levels 5
• Vomiting with risk of chemical pneumonitis from aspiration 3, 5

Emergency Department Management

Supportive care is the cornerstone, as no antidote exists 5, 2:

• Seizure control: Benzodiazepines are first-line therapy for camphor-induced seizures 2
• Respiratory support: Early intubation and mechanical ventilation for severe respiratory distress, hypoxemia unresponsive to supplemental oxygen, or severe CNS depression 3
• Intensive care monitoring: Transfer to pediatric intensive care unit for severe cases with respiratory compromise, seizures, or signs of hepatic decompensation 3
• Hepatic monitoring: Serial liver function tests, coagulation studies, and ammonia levels given the dual insult of camphor toxicity and pre-existing liver disease 5, 1

Critical Contraindications in Management

Do NOT perform the following 3, 2:

• Emesis induction with ipecac - contraindicated due to aspiration risk and rapid onset of seizures 3, 2
• Gastric lavage - contraindicated due to aspiration risk 3
• Activated charcoal - should not be used for camphor alone, though may be considered if co-ingestions are present 2

Observation Period and Monitoring

• Minimum 4-hour observation period for asymptomatic patients in the emergency department setting 2
• However, children with pre-existing liver disease require extended observation (minimum 24 hours) with serial liver function monitoring given their compromised hepatic reserve and camphor's documented hepatotoxicity 1
• Monitor for delayed hepatic decompensation including worsening coagulopathy, encephalopathy, hypoglycemia, and acidosis 6

Special Considerations for Liver Disease Patients

Baseline hepatic assessment is critical 6:

• Document baseline liver function tests, coagulation parameters (INR), albumin, and ammonia levels
• Assess for signs of chronic liver disease complications including ascites, portal hypertension, and baseline encephalopathy 6
• Children with cirrhosis or decompensated liver disease are at highest risk for acute-on-chronic liver failure 6

Nutritional support considerations:

• Children with chronic liver disease already have increased caloric requirements (20-80% above normal) and are prone to malnutrition 6, 7
• Camphor toxicity with associated vomiting and potential ICU admission further compromises nutritional status 6

Common Pitfalls to Avoid

• Do not rely on standard dose thresholds (30 mg/kg) for emergency department referral in children with liver disease - refer at any dose 2
• Do not assume asymptomatic status at 4 hours means safety in liver disease patients - hepatotoxicity may be delayed and more severe 1
• Do not use prophylactic antibiotics or corticosteroids - no proven benefit in camphor poisoning 3
• Do not underestimate the rapid onset - serious toxicity including seizures can occur within 5-15 minutes 3, 4
• Do not attempt decontamination procedures that increase aspiration risk in a patient population already at risk for rapid neurological deterioration 3, 2

Prognosis and Follow-up

• Mortality rate is generally low with appropriate supportive care in children with normal liver function 3
• However, children with pre-existing liver damage face significantly elevated mortality risk due to compromised ability to metabolize camphor and increased susceptibility to hepatotoxicity 1
• Liver function tests should return to baseline after camphor elimination if acute liver failure does not develop 1
• Long-term neurological sequelae including memory loss have been reported even after clinical recovery 5