Breathing Fire
Want to know what causes fire eaters' lung, what disease you can get from sitting in a hot tub, and how you can be poisoned by stealing gasoline?
This is the Pick Your Poison Podcast. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison.
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Want to know what causes fire eaters' lung, what disease you can get from sitting in a hot tub, and how you can be poisoned by stealing gasoline?
Grab your stethoscope and let's go to the emergency department.
Your patient is a 16-year-old boy with a chief complaint of cough. You enter the room and see the patient sleeping on the stretcher. Surprisingly there are no parents at the bedside. His vital signs are as follows: afebrile, with a temperature of 98.6 F or 37°C. heart rate 120 beats per minute. blood pressure 120/80. respiratory rate 25 and oxygen saturation 94% on room air.
You give him a gentle shake. He wakes up and opens his eyes. You ask what's brought him to the emergency department. He says the cough started an hour ago; it's been severe. He is now having chest tightness and came to the emergency department because he also has become short of breath. He denies other cold or flu symptoms like congestion or runny nose. He hasn't had a fever or chills and denies all other symptoms.
His chart says that he has no past medical history and when you ask him to confirm he says no prior history of asthma or lung disease. He doesn't take any medicines and hasn't been using any supplements or over-the-counter medicines. He doesn't have any allergies. He denies tobacco, alcohol, and illicit drug use. You ask about his parents. He says his dad is away on a business trip and his mom should be coming to the hospital shortly.
You take out your stethoscope to examine him. He falls asleep again. Other than the fast rate, his heart is normal. He doesn't have any abdominal tenderness. You have to shake him awake to get him to sit up so you can listen to his lungs. You hear crackles, but no wheezing. His extremities are normal without any swelling or edema and he has good muscle strength.
What are crackles in the lungs? It's a noise, just as described: a crackling. If you want to hear what it sounds like, you can rub your hair between your fingers next to your ear. Or think of the sound of crinkly paper, if it was quiet. There's something in his lungs that doesn't belong there.
Question number one. What do crackles indicate?
A. Asthma.
B. A heart valve problem
C. Fluid in the lungs.
The answer is C. Generally speaking it means fluid in the lungs. If someone has asthma you hear wheezing. If they have a heart valve problem you'd hear a heart murmur.
A common cause in the emergency department is pulmonary edema, meaning fluid in the lungs, for example from heart failure. Occasionally it can be due to pneumonia though often you hear rhonchi, a description of course lung sounds. It can indicate inflammation. In his case you hear it in both lungs so it's less likely to be a focal pneumonia and more likely widespread.
Essentially, we have a sleepy teenager with a rapid heart rate, rapid breathing, a borderline oxygen saturation with crackles in his lungs. How do we get to the bottom of this? the first and most useful step is going to be a chest X-ray. But we have another issue. In the United States if you're under 18, generally speaking, you need the permission of a parent to treat the child. There are some exceptions, in some states, like emancipated minors, if you have a pregnant teenager.
You ask the patient if he can call his parent. I like using the patient's phone better than using the hospital phone because these days people don't answer numbers they don't recognize.
Mom answers on the first ring. Wind is whipping in the background and she sounds very frazzled. She tells you she's on her way in but she's having some car problems and will be there as soon as possible. In the meantime, she gives you permission to treat and evaluate.
You order the chest X-ray. Basic lab work here is kind of 50/50. You could order it now or wait to see what the chest X-ray shows.
What about his mental status? Why is he so sleepy?
We've discussed in the past respiratory failure from things like asthma and COPD causing hypercapnia or an elevated carbon dioxide level, resulting in altered mentation from agitated to psychotic to completely unresponsive and comatose. Is that what's happening here? Do we need a blood gas to take a closer look?
It is odd he's a little sleepy but he doesn't seem truly altered or somnolent. He wakes up as soon as you shake him and he answers questions appropriately so I’d be doubtful it’s significant hypercapnia. But still I do wonder what's causing this.
The chest X-ray comes back showing bilateral interstitial infiltrates. What does this mean? It generally indicates fluid in the lungs. The cause of the fluid can be several different things. It's very common in the emergency department for this to be pulmonary edema, as I mentioned earlier, from congestive heart failure. That wouldn't be very likely in our otherwise healthy teenager and in addition he doesn't have other signs of volume overload on exam, like swelling in his ankles, etc.
Commonly, in patients without congestive heart failure it can be an atypical pneumonia. COVID can cause it. And yes he's had a cough and shortness of breath with rapid breathing with a low oxygen saturation, which can be pneumonia but he wouldn't have developed it or a significant COVID infection in the past hour, that takes days so I don't love either as an explanation. Also he hasn't had a fever.
I'd be very suspicious this is pneumonitis. What's pneumonitis? It's essentially inflammation in the lungs. As with any inflammation anywhere, you get fluid buildup. Think about a sprained ankle but in this case the fluid is in the lungs, seen as interstitial infiltrates. It can be caused by a lot of different things and definitely a lot of toxins are on the list.
Pneumonitis can be from hypersensitivity reactions, essentially an allergic reaction to things like mold or bird droppings. The bird one has a funny name called Bird Fancier's Lung. Autoimmune disease causes pneumonitis. I just learned about a new one doing this episode called "Hot Tub Lung," where patients get hypersensitivity pneumonitis from inhaling bacteria in contaminated hot tub water and steam. It appears to be a hypersensitivity reaction to the bacteria rather than a true infection because in many cases avoiding the hot tub is enough to prevent symptoms.
Occupational exposures are always on the list. These are given names like: Farmer's Lung, quartz worker’s lung, mushroom workers' lung. Farmer's lung is thought to occur from exposure to moldy hay, mushroom worker's lung, from dust and spores in the compost to grow the mushrooms.
Medicines can cause it. Chemotherapeutic agents are at the top of the list. Amiodarone, a drug for heart rhythm control. You ask the patient about hot tubs and bird watching. He gives you a funny look and says uh, no. He doesn't work and isn't taking any medicines.
There is one really common cause of Pneumonitis in teenagers. Well maybe "common" is the wrong word but incidence of this type of pneumonitis is definitely on the rise in this age group. That's question number 2. Is it do to?
A. Marijuana.
B. Synthetic marijuana, like K2
C. Alcohol.
D. Vaping
Answer: D. vaping. Listen to the Miasma episode for more details. I'm sure you know, Different substances can be vaped, including tobacco and marijuana. Pneumonitis doesn't seem to be directly related to either because smokers don't get it. The truth is we don't know exactly what's causing it but it's thought to be due to the diluent (i.e. the liquid inside the cartridges that the tobacco and marijuana are dissolved in so they can be vaped).
Pneumonitis caused by vaping is called EVALI meaning e-cigarette vaping-associated lung injury. It can be life-threatening. It's caused more than 50 deaths. Some, including teenagers, have survived but required double lung transplants due to the severity of the pneumonitis.
When you have a teenager with this disease, without risk factors like occupational exposure, my concern about vaping as the cause would be quite high. The patient initially denied tobacco and marijuana, but I'd go back and ask him again.
He's sleeping again when you get back to the room but as before is easily rousable. He adamantly denies vaping, saying he had a friend who had breathing problems as a result and would never use it himself. You notice his oxygen saturation is drifting down, now hovering around 92%. He's just above the cut-off where he needs oxygen. We administer it at 91% and below.
What's the treatment for pneumonitis? It's essentially supportive care. If there's an underlying cause like autoimmune disease, the first step would be to treat that. With a toxin of course the first step would be to withdraw exposure. You can give oxygen if the patient becomes hypoxic with a low oxygen saturation. Often patients get better with supportive care but pneumonitis can progress to ARDS. Or acute respiratory distress syndrome and respiratory failure. If that happens of course, you'd intubate them and put them on a ventilator. Some patients have gotten lung transplants, as I've mentioned earlier, though this is rare.
It's not clear what's causing the pneumonitis, it is clear he needs to be admitted to the hospital. His respiratory rate is now in the 30s and his oxygen rate is dropping in just the few hours he's been in the emergency department. It'd be worth doing a COVID and a flu swab. You order those and they come back negative. Some might treat with antibiotics just in case there was an infectious cause, which can be hard to know with 100% certainty during the initial workup.
You're in the room with the patient to discuss the findings, when the curtain whips open. A woman runs through saying breathlessly, "Hi I'm his mom. What's going on?" She has makeup smudges around her eyes and Her hair has escaped its bun in a halo of frizz. She rushes to the bedside.
You discuss what's happening with her, the finding of pneumonitis, the uncertainty as to the cause, and the definite need for hospital admission. She confirms that he's never vaped and doesn't smoke or have any prior history of lung disease, not even in childhood.
As you exit the room after the discussion, you hear her say, "What were you doing with my car. I slipped and almost fell in the huge puddle of gas on the ground. The tank was so empty the car wouldn't even start.”
You stop in your tracks with an idea about what might have caused the patient's pneumonitis. Question 3. And time to pick your poison. Are the patient's symptoms and pneumonitis caused by?
A. Motor oil.
B. Gasoline, i.e. fuel or petrol?
C. Windshield washer fluid
D. Anti-freeze
The answer is A. gasoline, i.e. engine fuel or petrol. Antifreeze is often a toxic alcohol, which, as you know from prior episodes, causes severe toxicity but not pneumonitis. Motor oil also really doesn't cause pneumonitis for reasons I'll come back to in a few minutes and windshield washer fluid ingredients vary, but it's often water and regular alcohol ie ethanol.
Our patient's sleepiness and pneumonitis are consistent with gas exposure. And a quick word for those outside the US. We call fuel gas for sure. Here gas refers to fuel or petroleum you'd put in your car not something in the air.
What is gasoline? It's a hydrocarbon. We've talked about these several times. Ethanol itself is a hydrocarbon, as are things people use for huffing and snorting. Gasoline is a mixture of more than 500 hydrocarbons and additives.
You ask him about gas exposure, as does his mom, and he doesn't say anything. In fact he pretends he is asleep. As any practitioner of adolescent medicine knows, this is a not uncommon scenario when dealing with teenagers.
We've talked about sudden sniffing death, when hydrocarbons cause sudden cardiac arrest. Listen to the deadly breath equals Sudden Death episode. It doesn't fit here. Could this have been a suicide attempt? He opens his eyes to say no to that and Mom confirms his mood has been normal at home.
What happened? You have a good guess because this is actually a pretty common scenario. You ask if he was siphoning the gas. He squirms uncomfortably, closes his eyes for a few minutes, then opens them to look at his mom. Finally he says yes his car needed gas but he didn't have money to fill it up so he thought he could siphon some off the top of her tank to get where he needed to go.
Is siphoning gas dangerous? Actually yes. Let me explain first what I mean by siphoning. People stick a tube, like a hose for example, down into the gas tank of one car. They put the other end of the tube in their mouth and suck on it to start the gas flowing and quickly transfer the hose into a second car or gas tank. To transfer the gas from one to the other. The idea is to suck it up to get the flow started but to get it out of your mouth before any gas actually gets in. This doesn't work as well as people assume it will in many cases. Often the gas gets into their mouth.
Do they get sick from swallowing the gas? Actually no. If you drink gas, and I don't recommend this, it's not particularly dangerous in and of itself. It does cause nausea, vomiting, and diarrhea as you can imagine it’s a gross oily liquid, moving through your gastrointestinal tract. In and of itself, if it's only in your GI tract, it isn't otherwise toxic. The issue arises with aspiration into the lungs. It's pretty common because as you can imagine when the gas gets into your mouth, you start to cough and gag and spit it out because it tastes disgusting. In addition gas is volatile, so it's very easy for it to get into your lungs, where it is extremely toxic and causes pneumonitis.
When you ask what happened, he says, "Yeah I was trying to get the gas out with the hose. I started sucking on it exploded into my mouth, I tried to spit it out but it made me cough and gag. It was so gross.”
Now we know the cause of the pneumonitis. Does that change our treatment plan? No the treatment is the same. This is inflammation for sure rather than infection and the treatment will be supportive care. Specifically, oxygen if his saturation gets any lower. Some people have tried steroids to reduce the inflammation but it doesn't seem to help. You call the intern on the pediatric service to get him admitted to the hospital.
The intern asks, “Can you pump his stomach?” That's question number 4.
A. Yes
B. No
The answer here is definitely no for two reasons: First we've discussed before if you pump the stomach (gastric lavage in medical terms), you need a reasonable expectation the toxin is still in the stomach. The patient says that he tried to siphon the gas about four hours ago. Obviously, gas is a liquid and liquids are rapidly absorbed, staying in the stomach typically for less than an hour. It's doubtful there's any gas still in his stomach to pump out.
It's not uncommon for patients come in immediately after siphoning gas into their mouth.
Would this change your opinion? The answer is again no. Gastric lavage actually increases the risk of aspiration, i.e. getting the gas into the lungs. As I said earlier, gas in the stomach doesn't cause significant harm. If you try to pump it, you increase the risk of aspiration and thus increase the risk of or potentially worsen pneumonitis, doing more harm than good.
I strongly advise against siphoning gas with your mouth. If you need to transfer it, get a pump or use some other Method of Suction. That said, even after exposure most people are fine; only about 15% develop pneumonitis.
Let's change the scenario for a minute and say he rushed into the emergency department right after siphoning. If you did a chest X-ray, it was negative and he had normal vital signs, would you send him home?
Question 5.
A. Yes
B. No
Answer B No. Pneumonitis takes time to develop because it's inflammation and it takes time to be able to see it on the chest X-ray. Observation for 6 hours is recommended after hydrocarbon exposure. In patients who don't have symptoms, I will actually wait to get the chest X-ray at 6 hours, giving pneumonitis time to develop before you decide discharge is safe. Even then you want to give strict return precautions because it's possible for it to develop at 8 or even 12 hours.
How do hydrocarbons injure the lungs? First they directly injure the alveoli, these are sacs inside the lung which make up the lung surface. When the alveoli are injured, fluid leaks inside them and into the spaces in between them. Hydrocarbons inactivate surfactant, which helps keep alveoli open, making it easier to breathe. An inflammatory response is triggered, which is the pneumonitis we see on X-ray. If the fluid accumulates to a severe degree, then the lungs have a reduced ability to absorb oxygen, causing hypoxemia and ultimately respiratory failure.
Okay so back to our patient. What's his risk of developing complete respiratory failure with this type of pneumonitis? Fortunately it's only about 5%. Most patience do well. And why is he so sleepy? Did I hear you ask? Is that the gas or something else? Hydrocarbons can cause altered mental status. Gasoline doesn't cause as much alteration as other hydrocarbons so I wouldn't expect a coma. But this kind of sleepiness is definitely consistent.
As you can imagine there are many, many Different kinds of hydrocarbons people can be exposed to. I decided to use gas because it's so common but, in many places, a similar ingestion would be exposure to lamp oil.
What is lamp oil? Another hydrocarbon. The composition can vary, sometimes it’s kerosene, sometimes paraffin. Paraffin is essentially refined kerosene, meaning it burns cleaner and is better for inside use. The World Health Organization recommends kerosene not be used inside due to increased risk of asthma exacerbations and cancer. But it's fine for use outside in things like lanterns.
Who gets lamp oil exposures? Well they're not uncommon in the US, poison centers get tens of thousands of calls a year and they even more common worldwide. Most of the time it's a pediatric ingestion in children around two years old who mistake the liquid for a drink. Some lamp oils are very brightly colored and attractive to children as a result. Also we've talked before about storing things in Snapple bottles. Lamp oil can stored in Coca-Cola bottles or water bottles, confusing A Thirsty Child.
There are conservative religious groups in the US who don't use electricity at all or don't use it on certain days of the week and it's often in these populations that you see the lamp oil exposure. Around the world kerosene poisoning is one of the most common accidental poisonings, by some accounts representing 14 to 60% of admissions due to accidental poisoning in children.
Question number six. There is a very rare occupational exposure where patients get pneumonitis from hydrocarbons. Is it?
A. Fire eaters lung
B. Asphalt workers lung
C. Marina Workers Lung
D. Gas attendant lung
The answer is A: This risky occupation can result in fire-eaters' lungs. Performers who do shows with fire breathing use hydrocarbons. It's usually a mixture of things, sometimes kerosene as well as other different hydrocarbons. They are definitely at risk for aspirating the hydrocarbons and developing pneumonitis and the same symptoms as gasoline or lamp oil ingestion.
What happens with lamp oil ingestion? Essentially what happened to our patient. Drinking it isn't particularly toxic inside the GI tract other than vomiting or diarrhea. As with gasoline the risk is with potential aspiration. If a child does drink it, the recommendation is to go to the emergency department for vital signs including pulse ox monitoring, observation and then a chest X-ray at six hours to check for pneumonitis. If everything is fine they can be discharged if not they're treated supportively like our patient. If you do have an oil lamp or kerosene lamps or heaters in your house, please make sure to keep the oil away from children to prevent accidents.
Ingestion and aspiration isn't the only route of exposure that can cause pneumonitis interestingly enough. Several patients have injected gasoline intravenously or under the skin, leading to systemic toxicity and pneumonitis.
Oh and I mentioned that I would come back to motor oil. Motor oil is a hydrocarbon. It is, of course, pretty similar to gas or lamp oil, but it generally does not cause pneumonitis because it has a high viscosity, meaning it's thick and not likely to be aspirated. We used to use mineral oil, another hydrocarbon, to treat constipation and while it works pretty well for the reasons I mentioned above, it's fallen out of favor due to the risk of aspiration and lung injury.
How much does it take to cause pneumonitis? Not much. Aspiration of less than 1 mL of kerosene into the lungs is enough to cause it. There are some interesting radiology findings associated with kerosene ingestion. A double gastric fluid level was described in about 50% of X-rays after exposure. It's a visible layering in the stomach of the kerosene on top of the normal stomach acid.
Back to our patient, he gets admitted to the pediatric service where they continue to monitor his breathing and respirations. His oxygen saturations drop down into the 80s. He improves with supplemental oxygen and fortunately after a four-day hospital stay, he is weaned off the oxygen and discharged without further sequelae. This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings.
Gas siphoning is a timely topic as gas prices around the world are currently shooting up due to gas shortages from current political events. In 2002, when gas prices became high the Greek state government television got into trouble with a video showing people how to siphon gas. Gas siphoning is always on post-apocalyptic shows like The Walking Dead. If you want to be prepared for the end of the world, watch some YouTube videos showing you how to siphon it without your mouth so you don't end up with pneumonitis when there's no hospital or Supplemental oxygen. And please it should go without saying: do not steal gas.
Which brings us to the last question in today's podcast in the Pop Culture Consult. Which celebrity jokingly said that he went to jail for siphoning gas.
A. Tom Holland
B. Michael B. Jordan
C. Justin Timberlake
D. Justin Bieber
Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.