CLINICAL TOXICOLOGY, 29(2), 257-262 (1991)
MANAGEMENT OF OIL OF CITRONELLA POISONING
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
Wayne A. Temple, Ph.D.*; Nerida A. Smith, Ph.D.**; Michael Beasley, M.B. Ch.B., D.Com.H., M.Sc., DIH* New Zealand National Poisons and Hazardous Chemicals Information Centre* Department of Pharmacy** University of Otago Medical School, Dunedin, New Zealand
ABSTRACT The management for ingestion of oil of citronella, an essential oil, has traditionally been rigorous, including dilution with milk or oil, and gastric lavage or emesis, taking care to prevent aspiration. Recently our Centre handled five oil of citronella poisonings and their outcomes led us to review our management protocol which had been based on information from standard poisoning texts. The source data used to determine the human toxicity of oil of citronella and the appropriate management of poisoning included a case report of a fatal ingestion of oil of citronella in a child. On scrutiny, however, the management of this poisoning included now out-moded techniques, giving rise to uncertainties in establishing the true cause of the child’s death. Our own experiences indicate that advice given in standard texts based on poisoning cases managed with out-moded techniques should be carefully evaluated. (Key words: poisoning: essential oil; oil of citronella; clinical managemenr)
INTRODUCTION Recently, our Poison Control Centre handled a number of cases concerning oil of citronella ingestion and as a consequence we have reviewed our clinical management protocol for this substance.
257 Copyright
1991 by Marcel Dekker, he.
TEMPLE, SMITH, AND BEASLEY
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
25 8
CASE 1 In one of these recent cases, a male child of 18 months of age climbed up onto a chair and obtained a bottle containing oil of citronella from a table. He was subsequently discovered holding an empty bottle of oil of citronella after his mother had heard him coughing. Although there was a strong smell of citronella on the child’s breath, he did not vomit or appear distressed. After presentation to the Accident and Emergency Room, it was decided by the attendant physicians, upon consultation with our Centre, to perform gastric lavage. Unfortunately, an uncuffed endotracheal tube was used during this procedure since small cuffed tubes were not available at the health care facility involved. The child later exhibited mild signs of aspiration pneumonia and a chest x-ray showed increased markings of the right upper zone and right middle lobe; treatment included antibiotics. The child settled well over the next two days and was discharged home. On follow-up it was considered by attendant physicians that the child had suffered some iatrogenic illness following the intubation. CASES 2 and 3 A pediatrician at the health care facility commented that he had been involved with two previous episodes of oil of citronella ingestion by children. Although on each occasion our Poison Control Centre, when consulted, had advised that lavage be considered, he elected to manage the children by observation only, with no resulting untoward effects. In view of the differing outcomes of these three cases, we elected to review our management protocol for oil of citronella ingestion. CASE 4 An examination of our Centre’s previous case records of oil of
citronella poisoning revealed two further intoxications in young children. In Case 4 (January, 1967), a female child, age unspecified, presented to hospital half an hour post-ingestion of an unknown quantity of oil of citronella from a bottle that had contained approximately 80 mL before the incident. Although the bottle was found to be empty, no one had witnessed the child
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
OIL OF CITRONELLA POISONING
259
drinking from it. Prior to hospital attendance she had been given some soapy water at home as an emetic. Hospital treatment included a salt water emetic and castor oil, and the child vomited about one hour later with the vomitus smelling strongly of citronella (gastric lavage was considered but not attempted). A chest x-ray showed some prominence of the hilar markings and in the right lobe there was a little exaggerated peribronchial marking. She had scattered rales and rhonchi which were treated with penicillin, and she was discharged when this had resolved.
CASE 5 In Case 5 (March, 1983), a 16 month-old male ingested approximately 25 mL of citronella oil. He was initially given ipecac syrup by the family physician half an hour post-ingestion with some success. Shortly thereafter he was examined in the Emergency Room and apart from some oral irritation and a strong odor of citronella oil was happy, content and normal to examination. He was given milk, a prophylactic antibiotic and a Dulcolax@enema, then discharged to his mother’s care. DISCUSSION
Oil of citronella is a fragrant, volatile oil obtained by distillation from fresh grass of Cymbopogan nardus Rendle or C. winterianus Jowitt (Fam. Graminae) or from varietal or hybrid forms of these species. The main constituents of citronella oil are geraniol and citronellol. Countries producing this oil include Sri Lanka, Indonesia and Taiwan. There are two main types of oil in commerce, differing in odor and composition, known as Ceylon oil (about 10%citronellol, 18% geraniol) and Java oil (about 35% citronellol, 21 % geraniol). Citronella oil is used in perfumery, as an active constituent in certain insect repellents, and as the active constituent of Antimatea, a preparation applied to bitches in heat to deter dogs. Animal toxicity studies have shown that citronella oil has an LD5* in mice of 4600 mg/kg and in rats of 7200 mg/kg (1). Gosselin et al. (2) reported that citronellol (an alcohol derived from citronellol) produced paralysis, coma, and death in doses of about 1 - 4 mL/kg given by stomach
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
260
TEMPLE, SMITH, AND BEASLEY
tube in rabbits. Furthermore, they also summarized a human exposure case reported by Mant (3) in which vomiting, shock, cyanosis and convulsions preceded death in a child who consumed an unknown quantity of a commercial preparation consisting largely of oil of citronella, Our Centre’s management protocol for oil of citronella poisoning was principally based upon Mant’s case together with the classical treatment for essential oil ingestions featured in standard poisoning management texts, e.g., Arena and Drew (4) and Dreisbach and Robertson (5). These sources concur that ingestion of volatile or essential oils in general necessitates rigorous management including dilution with milk or oil, and gastric lavage or emesis taking care to prevent aspiration. However, in light of the cases described above we reviewed our management protocol with emphasis on the degree of intervention required. Mant (3) reported that a female child of 21 months drank about three teaspoons of a preparation containing oil of citronella. She called her grandmother, who found her crying with her hand in her mouth. The grandmother believed that the child had swallowed something and put her fingers in the child’s mouth to investigate. The child began to vomit at once and the smell of citronella was apparent. The grandmother then noticed the bottle lying on the bed. An emetic of salt and water was immediately administered by the grandmother and this caused further vomiting. The child was admitted to hospital about an hour post-ingestion. Upon admission she was frothing at the mouth, very shocked, pulseless and retching continuously. She was lavaged and treated symptomatically. Despite the administration of adrenalin and nikethamide, she became cyanosed, had convulsions, vomited blood-stained fluid, and died 5 hours post-ingestion. At autopsy, the gastric mucosa was found to be severely damaged and there were numerous punctate hemorrhages in the brain. It is questionable whether the fatal outcome of this case was solely due to oil of citronella toxicity. One must query the role of the salt-water emetic administered by the grandmother, since salt intoxication in infants and children following the use of salt-water emetics has been well documented. Indeed, the cerebral hemorrhages found post-mortem in this case are
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
OIL OF CITRONELLA POISONING
261
consistent with salt intoxication (6). Furthermore, while nikethamide was formerly used as a respiratory stimulant, it is no longer recommended (7) since the effective dose is close to that causing toxic effects, especially convulsions, which occurred in the above case. Finally, it is not clear the extent to which pulmonary complications were a critical factor, although frothing at the mouth suggested that aspiration may have occurred. Given these uncertainties in establishing the cause of the child’s death, we question the use of these data to determine the human toxicity of oil of citronella and the appropriate management of poisoning. Although the management of essential oil ingestions such as eucalyptus, turpentine and penny royal has classically been aggressive, are such measures necessary in the case of oil of citronella? It would be tempting to conclude, for example, from the pediatrician’s experience that no decontamination is ever justified for this poisoning. However, the doses involved were unspecified and may have been quite small, and just two children (Cases 2 and 3) were involved. Although one might conclude from Case 1 that gastric lavage was responsible for the aspiration pneumonia due to complications from possible subsequent vomiting, the early presence of a cough suggests aspiration may have occurred at the time of ingestion. In a large controlled study of hydrocarbon ingestions (8), no significantly increased risk of pulmonary complications were observed in lavage patients. This study also noted that post-lavage vomiting was quite uncommon. However, it may be difficult to exclude the role of gastric lavage as a factor in aspiration pneumonitis in any individual case. While lavage may not pose a large additional aspiration risk the question remains whether it is justified, or whether a less invasive and more promptly available procedure such as induced emesis is acceptable or indeed indicated for large ingestions. Our experiences described in Cases 1 to 5 indicate that dilution may be sufficient for a significant proportion of ingestions and that for the remainder emesis may be induced with relatively low risk of major pulmonary complications. If spontaneous vomiting has occurred, and/or coughing or gagging has occurred at the outset, observation for respiratory symptoms is especially indicated. The evidence, however,
TEMPLE, SMITH, AND BEASLEY
262
suggests, that any aspiration pneumonia from this substance is relatively benign. Furthermore, we advocate the careful evaluation of long-held advice given in standard texts which may be based on cases managed with now out-moded techniques.
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
REFERENCES 1.
2.
3. 4.
Sweet DV, ed. Registry of toxic eflects of chemical substances 1985 - 1986 edition. Volume 2. NIOSH Publication No. 87-114,1987. Gosselin RE, Smith RP, Hodge HC. ClinicaZ Toxicology of Commercial Products. Baltimore: Williams & Wilkins, 1984:II-231 Mant AK. Association Proceedings. VI. A case of poisoning by oil of citronella. Med Sci Law 1961;1/2:170-171. Arena JM, Drew RH, eds. Poisoning. Toxicology. Symptoms. Treatments. 5th Edition, Springfield, Illinois: Charles C. Thomas,
1986:1128. 5.
6. 7.
Dreisbach RH, Robertson WO. Handbook of Poisoning: Prevention, Diagnosis and Treatment. East Norwalk, Connecticut: Appleton & Lange, 1987589. Barer J, Leighton Hill L, Hill RM, Martinez WM. Fatal poisoning from salt used as an emetic. Am J Dis child 1973;125:889-890. BNF. British National Formulary. Number 19. British Medical Association and the Royal Pharmaceutical Society of Great Britain,
1990:559.
8.
AAP. American Academy of Pediatrics. Sub-committee on accidental poisoning, Co-operative Kerosene Study. Pediatrics 1962;29:648-674.
MANAGEMENT OF OIL OF CITRONELLA POISONING
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
Wayne A. Temple, Ph.D.*; Nerida A. Smith, Ph.D.**; Michael Beasley, M.B. Ch.B., D.Com.H., M.Sc., DIH* New Zealand National Poisons and Hazardous Chemicals Information Centre* Department of Pharmacy** University of Otago Medical School, Dunedin, New Zealand
ABSTRACT The management for ingestion of oil of citronella, an essential oil, has traditionally been rigorous, including dilution with milk or oil, and gastric lavage or emesis, taking care to prevent aspiration. Recently our Centre handled five oil of citronella poisonings and their outcomes led us to review our management protocol which had been based on information from standard poisoning texts. The source data used to determine the human toxicity of oil of citronella and the appropriate management of poisoning included a case report of a fatal ingestion of oil of citronella in a child. On scrutiny, however, the management of this poisoning included now out-moded techniques, giving rise to uncertainties in establishing the true cause of the child’s death. Our own experiences indicate that advice given in standard texts based on poisoning cases managed with out-moded techniques should be carefully evaluated. (Key words: poisoning: essential oil; oil of citronella; clinical managemenr)
INTRODUCTION Recently, our Poison Control Centre handled a number of cases concerning oil of citronella ingestion and as a consequence we have reviewed our clinical management protocol for this substance.
257 Copyright
1991 by Marcel Dekker, he.
TEMPLE, SMITH, AND BEASLEY
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
25 8
CASE 1 In one of these recent cases, a male child of 18 months of age climbed up onto a chair and obtained a bottle containing oil of citronella from a table. He was subsequently discovered holding an empty bottle of oil of citronella after his mother had heard him coughing. Although there was a strong smell of citronella on the child’s breath, he did not vomit or appear distressed. After presentation to the Accident and Emergency Room, it was decided by the attendant physicians, upon consultation with our Centre, to perform gastric lavage. Unfortunately, an uncuffed endotracheal tube was used during this procedure since small cuffed tubes were not available at the health care facility involved. The child later exhibited mild signs of aspiration pneumonia and a chest x-ray showed increased markings of the right upper zone and right middle lobe; treatment included antibiotics. The child settled well over the next two days and was discharged home. On follow-up it was considered by attendant physicians that the child had suffered some iatrogenic illness following the intubation. CASES 2 and 3 A pediatrician at the health care facility commented that he had been involved with two previous episodes of oil of citronella ingestion by children. Although on each occasion our Poison Control Centre, when consulted, had advised that lavage be considered, he elected to manage the children by observation only, with no resulting untoward effects. In view of the differing outcomes of these three cases, we elected to review our management protocol for oil of citronella ingestion. CASE 4 An examination of our Centre’s previous case records of oil of
citronella poisoning revealed two further intoxications in young children. In Case 4 (January, 1967), a female child, age unspecified, presented to hospital half an hour post-ingestion of an unknown quantity of oil of citronella from a bottle that had contained approximately 80 mL before the incident. Although the bottle was found to be empty, no one had witnessed the child
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
OIL OF CITRONELLA POISONING
259
drinking from it. Prior to hospital attendance she had been given some soapy water at home as an emetic. Hospital treatment included a salt water emetic and castor oil, and the child vomited about one hour later with the vomitus smelling strongly of citronella (gastric lavage was considered but not attempted). A chest x-ray showed some prominence of the hilar markings and in the right lobe there was a little exaggerated peribronchial marking. She had scattered rales and rhonchi which were treated with penicillin, and she was discharged when this had resolved.
CASE 5 In Case 5 (March, 1983), a 16 month-old male ingested approximately 25 mL of citronella oil. He was initially given ipecac syrup by the family physician half an hour post-ingestion with some success. Shortly thereafter he was examined in the Emergency Room and apart from some oral irritation and a strong odor of citronella oil was happy, content and normal to examination. He was given milk, a prophylactic antibiotic and a Dulcolax@enema, then discharged to his mother’s care. DISCUSSION
Oil of citronella is a fragrant, volatile oil obtained by distillation from fresh grass of Cymbopogan nardus Rendle or C. winterianus Jowitt (Fam. Graminae) or from varietal or hybrid forms of these species. The main constituents of citronella oil are geraniol and citronellol. Countries producing this oil include Sri Lanka, Indonesia and Taiwan. There are two main types of oil in commerce, differing in odor and composition, known as Ceylon oil (about 10%citronellol, 18% geraniol) and Java oil (about 35% citronellol, 21 % geraniol). Citronella oil is used in perfumery, as an active constituent in certain insect repellents, and as the active constituent of Antimatea, a preparation applied to bitches in heat to deter dogs. Animal toxicity studies have shown that citronella oil has an LD5* in mice of 4600 mg/kg and in rats of 7200 mg/kg (1). Gosselin et al. (2) reported that citronellol (an alcohol derived from citronellol) produced paralysis, coma, and death in doses of about 1 - 4 mL/kg given by stomach
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
260
TEMPLE, SMITH, AND BEASLEY
tube in rabbits. Furthermore, they also summarized a human exposure case reported by Mant (3) in which vomiting, shock, cyanosis and convulsions preceded death in a child who consumed an unknown quantity of a commercial preparation consisting largely of oil of citronella, Our Centre’s management protocol for oil of citronella poisoning was principally based upon Mant’s case together with the classical treatment for essential oil ingestions featured in standard poisoning management texts, e.g., Arena and Drew (4) and Dreisbach and Robertson (5). These sources concur that ingestion of volatile or essential oils in general necessitates rigorous management including dilution with milk or oil, and gastric lavage or emesis taking care to prevent aspiration. However, in light of the cases described above we reviewed our management protocol with emphasis on the degree of intervention required. Mant (3) reported that a female child of 21 months drank about three teaspoons of a preparation containing oil of citronella. She called her grandmother, who found her crying with her hand in her mouth. The grandmother believed that the child had swallowed something and put her fingers in the child’s mouth to investigate. The child began to vomit at once and the smell of citronella was apparent. The grandmother then noticed the bottle lying on the bed. An emetic of salt and water was immediately administered by the grandmother and this caused further vomiting. The child was admitted to hospital about an hour post-ingestion. Upon admission she was frothing at the mouth, very shocked, pulseless and retching continuously. She was lavaged and treated symptomatically. Despite the administration of adrenalin and nikethamide, she became cyanosed, had convulsions, vomited blood-stained fluid, and died 5 hours post-ingestion. At autopsy, the gastric mucosa was found to be severely damaged and there were numerous punctate hemorrhages in the brain. It is questionable whether the fatal outcome of this case was solely due to oil of citronella toxicity. One must query the role of the salt-water emetic administered by the grandmother, since salt intoxication in infants and children following the use of salt-water emetics has been well documented. Indeed, the cerebral hemorrhages found post-mortem in this case are
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
OIL OF CITRONELLA POISONING
261
consistent with salt intoxication (6). Furthermore, while nikethamide was formerly used as a respiratory stimulant, it is no longer recommended (7) since the effective dose is close to that causing toxic effects, especially convulsions, which occurred in the above case. Finally, it is not clear the extent to which pulmonary complications were a critical factor, although frothing at the mouth suggested that aspiration may have occurred. Given these uncertainties in establishing the cause of the child’s death, we question the use of these data to determine the human toxicity of oil of citronella and the appropriate management of poisoning. Although the management of essential oil ingestions such as eucalyptus, turpentine and penny royal has classically been aggressive, are such measures necessary in the case of oil of citronella? It would be tempting to conclude, for example, from the pediatrician’s experience that no decontamination is ever justified for this poisoning. However, the doses involved were unspecified and may have been quite small, and just two children (Cases 2 and 3) were involved. Although one might conclude from Case 1 that gastric lavage was responsible for the aspiration pneumonia due to complications from possible subsequent vomiting, the early presence of a cough suggests aspiration may have occurred at the time of ingestion. In a large controlled study of hydrocarbon ingestions (8), no significantly increased risk of pulmonary complications were observed in lavage patients. This study also noted that post-lavage vomiting was quite uncommon. However, it may be difficult to exclude the role of gastric lavage as a factor in aspiration pneumonitis in any individual case. While lavage may not pose a large additional aspiration risk the question remains whether it is justified, or whether a less invasive and more promptly available procedure such as induced emesis is acceptable or indeed indicated for large ingestions. Our experiences described in Cases 1 to 5 indicate that dilution may be sufficient for a significant proportion of ingestions and that for the remainder emesis may be induced with relatively low risk of major pulmonary complications. If spontaneous vomiting has occurred, and/or coughing or gagging has occurred at the outset, observation for respiratory symptoms is especially indicated. The evidence, however,
TEMPLE, SMITH, AND BEASLEY
262
suggests, that any aspiration pneumonia from this substance is relatively benign. Furthermore, we advocate the careful evaluation of long-held advice given in standard texts which may be based on cases managed with now out-moded techniques.
Clinical Toxicology Downloaded from informahealthcare.com by ThULB Jena on 11/13/14 For personal use only.
REFERENCES 1.
2.
3. 4.
Sweet DV, ed. Registry of toxic eflects of chemical substances 1985 - 1986 edition. Volume 2. NIOSH Publication No. 87-114,1987. Gosselin RE, Smith RP, Hodge HC. ClinicaZ Toxicology of Commercial Products. Baltimore: Williams & Wilkins, 1984:II-231 Mant AK. Association Proceedings. VI. A case of poisoning by oil of citronella. Med Sci Law 1961;1/2:170-171. Arena JM, Drew RH, eds. Poisoning. Toxicology. Symptoms. Treatments. 5th Edition, Springfield, Illinois: Charles C. Thomas,
1986:1128. 5.
6. 7.
Dreisbach RH, Robertson WO. Handbook of Poisoning: Prevention, Diagnosis and Treatment. East Norwalk, Connecticut: Appleton & Lange, 1987589. Barer J, Leighton Hill L, Hill RM, Martinez WM. Fatal poisoning from salt used as an emetic. Am J Dis child 1973;125:889-890. BNF. British National Formulary. Number 19. British Medical Association and the Royal Pharmaceutical Society of Great Britain,
1990:559.
8.
AAP. American Academy of Pediatrics. Sub-committee on accidental poisoning, Co-operative Kerosene Study. Pediatrics 1962;29:648-674.
