TY - JOUR
AU - MD, Leopoldo Cancio,
AB - Abstract Hydrocarbons are a wide-ranging group of flammable chemicals and are often used in suicide attempts either by ingestion or as an accelerant in self-immolation. In this case study, we present a 37-year-old female who suffered 6% TBSA partial-thickness burns to her perineum and buttocks, which she claims resulted from diarrhea after ingesting a bottle of lighter fluid. The patient underwent decontamination and medical treatment for her burns and during her inpatient stay, it became apparent that the burns were more likely sustained from an intentional rectal administration of lighter fluid. To our knowledge, this is one of the first reported cases of hydrocarbon enema. We review hydrocarbon poisoning, including both ingestion and dermal exposure, and discuss medical management. Hydrocarbons are a diverse group of chemicals derived from petroleum distillation and are ubiquitous in the home and workplace in the form of fuels, solvents, glues, cleaning agents, paints, and paint strippers (Table 1). In the United States in 2013, there were more than 33,000 human exposures reported to poison control centers, with approximately one third of the cases involving children 2 years of age or younger.1 A majority of these exposures, particularly in the pediatric population, are classified as unintentional.2 However, these chemicals are commonly subject to inhalant abuse, and there are numerous published reports of suicide attempts with intentional ingestions and even subcutaneous injections of hydrocarbons.3 Here we present an unusual chemical burn pattern most likely caused by a hydrocarbon enema. Table 1. Classes of common hydrocarbons View Large Table 1. Classes of common hydrocarbons View Large CASE REPORT An otherwise healthy, 37-year-old female presented to a community hospital one day after claiming to have ingested a bottle of lighter fluid in an effort to commit suicide. The presenting complaint was copious diarrhea and perianal burning that began several hours after her “ingestion.” She was subsequently transferred to the U.S. Army Institute of Surgical Research Burn Center for evaluation and treatment of suspected hydrocarbon ingestion and perineal chemical burn. On initial presentation, the patient stated that she “drank a bottle of lighter fluid” and then developed high volume, nearly continuous watery diarrhea that eventually soaked her undergarments and pants. She chose not to change her undergarments. She sought medical evaluation for unrelenting and severe perineal pain. At the time of admission to our facility, the patient confirmed the above history and continued to complain of “10/10” pain in the perineal region, on her buttocks, and posterior thighs. She denied headaches, changes in vision, shortness of breath, cough, dysphagia, odynophagia, chest pain, nausea, and vomiting. The patient's vital signs were significant for a fever of 102.5°F and tachycardia (100–123 beats per minute), which improved with administration of IV morphine. She was normotensive and had oxygen saturation ranging between 92 and 96% on room air. The patient's pupils were round, equal, and reactive to light. There was no scleral icterus. The patient's oropharynx was unremarkable, without ulcerations or erythema. Cardiovascular and pulmonary examination was likewise unremarkable. Physical examination was significant only for mild right upper quadrant tenderness to palpation and a 6% TBSA wound that was erythematous and blanched with palpation, consistent with superficial partial-thickness injury involving her perineal region, bilateral buttocks, and posterior thighs (Figure 1). Pertinent labs are presented in Table 2. A urine drug screen was positive for benzodiazepines, for which the patient had a prescription, and marijuana. Electrocardiogram showed only sinus tachycardia. A chest x-ray revealed bilateral-dependent lower lobe airspace opacities. An abdominal x-ray showed a normal bowel gas pattern (images not shown). Given the reported history of ingestion and concern for possible aspiration, the patient was admitted to the burn intensive care unit and put on close observation for suicidal behavior. The patient was showered for decontamination. Our decontamination protocol can be found in the Joint Trauma System Clinical Practice Guideline on Burn Care, which can be found at http://www.usaisr.amedd.army.mil/cpgs/Burn_Care_11May2016.pdf. As this was a chemical burn, pH testing was utilized to ensure adequate decontamination with washing continuing until the pH normalized. Silver sulfadiazine was applied to her burns and covered with gauze dressings. A fecal management system (FMS) was placed to reduce perirectal skin exposure to continued diarrhea and to protect the dressings, but approximately 2 hours after placement, the FMS was removed as it was noted by the nursing staff that the diarrheal fluid was disintegrating the tubing. The fluid in the collection bag was light yellow in color and had a strong odor of lighter fluid. Consultations were placed for gastroenterology and psychiatry, and the poison control center was called for management recommendations. Table 2. Pertinent laboratory data on admission and hospital day 3 View Large Table 2. Pertinent laboratory data on admission and hospital day 3 View Large Figure 1. View largeDownload slide Photograph of chemical burn caused by hydrocarbon exposure following decontamination. Superficial partial-thickness burn covering approximately 6% TBSA and involving buttocks, perineum, and posterior thighs. Figure 1. View largeDownload slide Photograph of chemical burn caused by hydrocarbon exposure following decontamination. Superficial partial-thickness burn covering approximately 6% TBSA and involving buttocks, perineum, and posterior thighs. The following morning, a rigid proctoscopy examination was, surprisingly, largely unremarkable with no evidence of mucosal injury except for a few small foci of erythematous mucosa. She underwent a barium swallow followed by an esophagogastroduodenoscopy (EGD) with gastroenterology, which was both unremarkable with no evidence of perforation, irritation, or mucosal injury in the esophagus, stomach, or duodenum (Figure 2). By hospital day three, the patient's fever, leukocytosis, electrolyte abnormalities, and transaminitis had resolved without intervention. She remained hemodynamically normal with no respiratory distress and never required supplemental oxygen. She was transferred to the burn step-down unit on hospital day three. Once on the burn step-down unit, the patient was formally evaluated by the behavioral health service, who followed the patient during her inpatient stay. In addition to restarting her previously prescribed psychiatric medications, which included bupropion and temazepam, she was observed continuously by a healthcare aid due to persistent suicidal ideation. The patient was discharged to an inpatient psychiatric facility at the recommendation of behavioral health on hospital day eight. Figure 2. View largeDownload slide Esophagogastroduodenoscopy results. From left to right and top to bottom: Representative images of the esophagus, body of stomach (with residual gastrografin), antrum of stomach, and duodenum. Figure 2. View largeDownload slide Esophagogastroduodenoscopy results. From left to right and top to bottom: Representative images of the esophagus, body of stomach (with residual gastrografin), antrum of stomach, and duodenum. DISCUSSION Here we have presented what we believe to be the first report of a hydrocarbon enema. For our patient, the clinical presentation and history did not appear to be congruent. On arrival to the burn intensive care unit, the patient was still passing large volumes of lighter fluid per rectum despite the claimed ingestion occurring the previous day. Approximately 300 ml of the fluid was collected in the FMS before being removed due to tubing breakdown. One would expect if such a large volume of lighter fluid was orally ingested, the risk of aspiration would be extraordinarily high; however, the patient's respiratory status was uncompromised, and signs or symptoms of respiratory distress were never present during her admission. The patient's chest x-ray showed bilateral lower lobe opacities, but this could have been the result of being supine at the first hospital and then remaining supine during transport. Hydrocarbon ingestion also causes mucosal chemical burns and irritation of oropharynx and gastrointestinal tract and often induces nausea, vomiting, abdominal pain, and diarrhea.4 Despite the claim of a large volume ingestion, the patient denied nausea and vomiting, and no evidence of mucosal injury was noted on either EGD or proctoscopy. Cutaneous hydrocarbon injury and management is well-described in the literature, often related to motor vehicle accidents and prolonged skin exposure to leaking gasoline. It has been shown that dermal hydrocarbon exposure can dissolve lipids in the skin and induce inflammation, leading to epidermal sloughing, erythema, and potentially significant partial-thickness chemical burns.4,–7 With the presence of the chemical burns involving her perineum and buttocks, we believe that the patient attempted to administer a large volume of lighter fluid per rectum. Spillage of the lighter fluid onto her skin and subsequent and persistent leakage from her rectum resulted in the chemical burns. Given the size of the burns and the amount of fluid that drained in the FMS, it is difficult to imagine a scenario where an individual could orally ingest such a large volume of lighter fluid and not have nausea, vomiting, or respiratory symptoms secondary to aspiration. We believe that volume of lighter fluid administered per rectum was large enough to cause a degree of mucosal absorption, causing mild hepatic toxicity and the elevated liver enzymes that were found on presentation. The toxicological profile of hydrocarbons depends on chemical characteristics, namely viscosity, volatility, and surface tension and chemical structure; presence of additives, such as heavy metals or organophosphates; route of exposure; and volume of exposure. The volatility of hydrocarbons is utilized in substance abuse behaviors such as “huffing,” where hydrocarbon-soaked rags are placed over the mouth and nose, and “bagging,” where an individual repeatedly inhales from a plastic bag filled with a hydrocarbon.4,8 In addition to high volatility, aliphatic hydrocarbons, such as gasoline, kerosene, and lighter fluid, have low viscosity and decreased surface tension and are more likely to cause aspiration and induce pulmonary injury after oral ingestion.9 Supporting this idea, Joliff et al2 found in a 10-year study of hydrocarbon exposure in children that clinically significant pulmonary complications were strongly associated with ingestion of the volatile and low viscosity aliphatic hydrocarbons, the most common ingestions being kerosene, lighter fluid, and lamp oil. Aspiration and the subsequent development of chemical pneumonitis is the main cause of morbidity and mortality with hydrocarbon exposure whether intentional or accidental.10 In terms of hydrocarbon ingestion, an important and worrisome feature is that very small volume ingestions often induce lung injury. In one study, more than 50% of patients who had ingested only 30 ml or more of hydrocarbons developed chemical pneumonitis, highlighting the fact that aspiration of these chemicals is extremely common even with small ingestions.11 Aspiration of hydrocarbons directly injures lung parenchyma, impairs the production of surfactant, and results in increased vascular permeability, edema, and hypoxia.8 Signs and symptoms of aspiration develop rapidly and are the result of oropharyngeal and bronchial irritation and inflammation. Other symptoms include fever, nausea, vomiting, cough, gasping, dyspnea, oral irritation, tachypnea, grunting, wheezing, and retractions with severe pneumonitis.9,12 Pneumonitis develops quickly following aspiration and can be visualized with chest radiography often within hours of ingestion. A wide range of radiographic findings, including effusions, pulmonary infiltrates, pneumatoceles, and pneumothorax, are associated with hydrocarbon aspiration. Findings are bilateral and typically involve the lower and middle lobes.8 In summary, we present a patient who we believe administered lighter fluid per rectum. Suicide attempts by rectal administration of drugs or other substances are rare, with few reports in the literature.13 The patient claimed that she intentionally ingested the fluid, however, in the absence of pulmonary complications, the extent and distribution of her burns, with concomitant minimal mucosal injury seen on EGD and proctoscopy, and volume of lighter fluid removed after placement of the FMS, an ingestion seems unlikely. Patients who present with suggested hydrocarbon ingestion should have their respiratory status closely monitored; intubation and mechanical ventilation should be considered early for patient with respiratory distress and/or depressions in neurologic status. In addition, laboratory studies to assess hepatic and renal function should be obtained. Decontamination can result in exposure to healthcare workers, thus protective equipment should be worn at all times. Treatment for hydrocarbon chemical burns is similar to other partial-thickness burns and involves liberal irrigation of the exposed areas with water, debridement as necessary, application of antimicrobial ointments, and regular dressing changes. Gastrointestinal decontamination remains controversial.9 Toxicological studies have demonstrated that aliphatic compounds have limited gastrointestinal absorption,9,14 thus the risk of pulmonary aspiration and pneumonitis secondary to gastrointestinal decontamination likely outweighed any benefit that could be derived. Finally, while rectal administration of chemicals is rare, there is an increasing number of reports of such behaviors, particularly with ethanol.15 Healthcare workers should be cognizant of this route of administration and the potential consequences thereof. REFERENCES 1. 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Medicine (Baltimore  2001; 80: 291– 7. Google Scholar CrossRef Search ADS PubMed  11. Press E. Cooperative kerosene poisoning study: evaluation of gastric lavage and other factors in the treatment of accidental ingestion of petroleum distillation products. Pediatrics  1962; 28: 648– 674. 12. Sen V Kelekci S Selimoglu Sen H. An evaluation of cases of pneumonia that occurred secondary to hydrocarbon exposure in children. Eur Rev Med Pharmacol Sci  2013; 17(Suppl 1): 9– 12. Google Scholar PubMed  13. Corbett J Meier G. Suicide attempted by rectal administration of drug. JAMA  1968; 206: 2320– 1. Google Scholar CrossRef Search ADS PubMed  14. Gerade HW. Toxicological studies on hydrocarbons: V. Kerosene. Toxicol Appl Pharmacol  1959; 1: 462– 474. Google Scholar CrossRef Search ADS PubMed  15. Peterson T Rentmeester L Judge BS Cohle SD Jones JS. Self-administered ethanol enema causing accidental death. Case Rep Emerg Med  2014; 2014: 191237. Google Scholar PubMed  Copyright © 2017 by the American Burn Association
TI - Hydrocarbon Enema: An Unusual Cause of Chemical Burn
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000509
DA - 2017-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/hydrocarbon-enema-an-unusual-cause-of-chemical-burn-stuulzKPhB
SP - e872
EP - e876
VL - 38
IS - 5
DP - DeepDyve
ER -