What is the immediate management of a patient who has ingested diesel (hydrocarbon)?

Management of Diesel Ingestion

Do not induce vomiting, do not perform gastric lavage, and do not administer activated charcoal—these interventions are contraindicated and increase the risk of aspiration pneumonitis, which is the primary cause of morbidity and mortality in hydrocarbon ingestion. 1, 2, 3

Immediate Actions and Contraindications

What NOT to Do (Critical)

• Never induce vomiting with ipecac or any other method, as this dramatically increases aspiration risk and provides no clinical benefit 1, 2, 3
• Never perform gastric lavage, as manipulation increases the risk of aspiration and subsequent chemical pneumonitis 1, 3
• Never administer activated charcoal, as hydrocarbons are poorly adsorbed and administration may provoke vomiting 2, 3
• Do not give anything by mouth (water, milk, or neutralizing agents) unless specifically directed by poison control, as this increases emesis and aspiration risk 4, 2

First Response Protocol

• Contact Poison Control Center immediately (1-800-222-1222 in the United States) for agent-specific guidance on systemic toxicity management 4, 1, 2
• Activate EMS immediately if the patient exhibits altered mental status, seizures, respiratory difficulty, vomiting, or reduced consciousness 1, 2
• Remove all contaminated clothing to prevent continued dermal exposure, using personal protective equipment to avoid self-contamination 4, 2

Clinical Assessment and Monitoring

Initial Evaluation

• Immediately assess airway, breathing, and circulation while monitoring for signs of aspiration pneumonitis including cough, dyspnea, hypoxemia, and tachypnea 1, 3
• Monitor for respiratory symptoms that typically evolve over the first 6-8 hours after ingestion, with symptom zenith reached within 48 hours 5, 3
• Perform focused physical examination for respiratory distress, altered mental status, oral/pharyngeal mucosal injury, and abdominal tenderness 1, 3

Emergency Department Observation

• Observe all patients for 6-8 hours in the emergency department, even if initially asymptomatic, as approximately 15% will develop aspiration pneumonitis 5, 3
• Obtain chest radiograph at the end of the observation period (4-8 hours post-ingestion), as radiographic abnormalities may be delayed but typically appear by this time 5, 3
• Note that chest radiographic abnormalities are not always predictive of clinical pneumonitis, so clinical assessment remains paramount 5

Hospital Management and Supportive Care

Treatment Approach

• Treatment is entirely symptomatic and supportive with no specific antidote existing for diesel or hydrocarbon poisoning 1, 3
• Administer supplemental oxygen for hypoxemia, escalating to mechanical ventilation if hypoxemia is unresponsive to supplemental oxygen or if severe CNS involvement develops 5, 3
• Provide cardiorespiratory monitoring for all symptomatic patients admitted to the hospital 5, 3

Intensive Care Unit Indications

• Admit to ICU if increased work of breathing, altered sensorium, seizures, or severe respiratory distress develops, as approximately 5% of pneumonitis cases progress rapidly to acute respiratory failure 5, 3
• Consider systemic corticosteroids for ARDS, though evidence for routine use in uncomplicated aspiration pneumonitis is limited 6
• Administer antibiotics only for documented bacterial superinfection, not prophylactically, as most cases are chemical pneumonitis without bacterial involvement 5, 3

Complications and Follow-Up

Expected Clinical Course

• Approximately 90% of hospitalized patients have a benign clinical course with progressive improvement after the 48-hour symptom zenith 5
• Pneumatoceles may develop after 6-10 days and typically resolve within 6 months on follow-up chest radiographs 5
• Severe cases can develop pneumomediastinum, extensive oral and esophageal erosion, and nosocomial infections requiring prolonged hospitalization 7, 6

Psychiatric Evaluation

• Obtain psychiatric evaluation before discharge for all intentional ingestions, as these patients require further evaluation and treatment for underlying psychiatric disease 1

Common Pitfalls to Avoid

• Do not assume asymptomatic patients are safe for immediate discharge—the 6-8 hour observation period is mandatory as symptoms evolve over this timeframe 5, 3
• Do not delay chest radiography—obtain it at the end of the observation period even if the patient appears clinically well 5
• Do not routinely prescribe corticosteroids or antibiotics—these are reserved for specific complications (ARDS and bacterial superinfection, respectively) 5, 6
• Do not overlook the potential for multi-organ toxicity including CNS depression, metabolic acidosis, and cardiac arrhythmias, though respiratory complications predominate 3