Ammonia toxicity: Difference between revisions

Latest revision as of 17:11, 18 August 2019

Background

Liquid form common in cleaning products
Ammonia gas used as chemical weapon
Injury due to inhalation, skin/eye contact, and/or ingestion
Extent of injury contingent upon concentration and duration of exposure
- Even fairly low airborne concentrations (50 ppm) of ammonia produce rapid onset of eye, nose, and throat irritation; coughing; and narrowing of the bronchi.

Clinical Features

Routes of Exposure

Inhalation
- Nasopharyngeal and tracheal chemical burns, upper airway obstruction
- Bronchiolar/alveolar edema and narrowing
- Laryngospasm (can occur immediately upon exposure)
- Respiratory distress/failure, hypoxia
- Cough
Skin contact
- Dilute (e.g. household cleaners) rarely burn but may be irritating
- Corrosive injury if contact with concentrated (e.g. industrial cleaners >25%)
  - Skin chemical burns, blistering, pain, necrosis, particularly on moist skin areas
  - Contact with compressed liquid ammonia (stored at -28 °F) can cause frostbite injury and deep ulcerating burns
Eye contact
- Greater tendency to penetrate/damage eye than other alkali
- Temporary or permanent vision loss if contact with high concentrations of the gas or with concentrated ammonium hydroxide, due to swelling/sloughing of eye surface cells
  - Extent of damage may not be apparent for up to a week
Ingestion
- Corrosive damage/chemical burns to oropharynx, esophagus, stomach
  - --> Nausea/vomiting, chest pain, abdominal pain, drooling

Differential Diagnosis

Caustic Burns

Caustic ingestion
Caustic eye exposure (Caustic keratoconjunctivitis)
Caustic dermal burn
Airbag-related burns
Hydrofluoric acid
Tar burn
Cement burn

Chemical weapons

Blister chemical agents (Vesicants)
- Lewisite (L)
- Sulfur mustard (H)
- Phosgene oxime (CX)
Pulmonary chemical agents (Choking agents)
Incendiary agents
- Agent orange
- White phosphorus
Cyanide chemical weapon agents (Blood agents)
- Prussic acid (AKA hydrogen cyanide, hydrocyanic acid, or formonitrile)
Nerve Agents (organophosphates)
- Acetylcholinesterase inhibitors
- Household and commercial pesticides (diazinon and parathion)
- G-series (sarin, tabun, soman)
- V-series (VX)
Lacrimating or riot-control agents
- Pepper spray
- Chloroacetophenone
- CS

Evaluation

Decontaminate
Evaluate for extent of injury, co-intoxicants

Management

Diuretics and corticosteroids not shown to be effective
Inhaled beta agonists e.g. albuterol for bronchoconstriction
See caustic ingestion
See caustic burns

Disposition

Dependant on clinical severity

External Links

References

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-*Route of exposure:
+*Liquid form common in cleaning products
-**Inhalation of ammonia may cause nasopharyngeal and tracheal burns, bronchiolar and alveolar edema, and airway destruction resulting in respiratory distress or failure.
+*Ammonia gas used as chemical weapon
-**Skin/Eye Contact - the extent of injury produced by exposure to ammonia depends on the duration of the exposure and the concentration of the gas or liquid. Contact with concentrated ammonia solutions, such as some industrial cleaners (25%), may cause serious corrosive injury, including skin burns, permanent eye damage, or blindness. The full extent of damage to the eyes may not be clear until up to 1 week after the injury is sustained. Contact with liquefied ammonia can cause frostbite injury.
+*Injury due to inhalation, skin/eye contact, and/or ingestion
-**Ingestion - ingestion of ammonium hydroxide, while uncommon, results in corrosive damage to the mouth, throat, and stomach. Ingestion of ammonia does not normally result in systemic poisoning.
+*Extent of injury contingent upon concentration and duration of exposure
+**Even fairly low airborne concentrations (50 ppm) of ammonia produce rapid onset of eye, nose, and throat irritation; coughing; and narrowing of the bronchi.
 ==Clinical Features==
-*Respiratory
-**The extent of injury produced by exposure to ammonia depends on the duration of the exposure, the concentration of the gas, and the depth of inhalation
+===Routes of Exposure===
-**Even fairly low airborne concentrations (50 ppm) of ammonia produce rapid onset of eye, nose, and throat irritation; coughing; and narrowing of the bronchi.
+*Inhalation
-**More severe clinical signs include immediate narrowing of the throat and swelling, causing upper airway obstruction and accumulation of fluid in the lungs. This may result in low blood oxygen levels and an altered mental status. Mucosal burns to the tracheobronchial tree can also occur. Immediate onset of laryngospasm with respiratory arrest can occur.
+**Nasopharyngeal and tracheal [[chemical burns]], upper airway obstruction
-*Dermal
+**Bronchiolar/alveolar edema and narrowing
-**Dilute aqueous solutions (less than 5%) rarely cause serious burns but can be moderately irritating. **Exposure to concentrated vapor or solution can cause pain, inflammation, blisters, necrosis and deep penetrating burns, especially on moist skin areas.
+**Laryngospasm (can occur immediately upon exposure)
-**Skin contact with compressed, liquid ammonia (which is stored at -28 °F) causes frostbite injury, and may also result in severe burns with deep ulcerations.
+**[[Respiratory distress]]/failure, [[hypoxia]]
-*Ocular
+**[[Cough]]
-**Ammonia has a greater tendency to penetrate and damage the eyes than does any other alkali. Even low concentrations of ammonia vapor (100 ppm) produce rapid onset of eye irritation.
+*Skin contact
-**Contact with high concentrations of the gas or with concentrated ammonium hydroxide may cause swelling and sloughing of the surface cells of the eye, which may result in temporary or permanent blindness.
+**Dilute (e.g. household cleaners) rarely burn but may be irritating
-*Gastrointestinal
+**Corrosive injury if contact with concentrated (e.g. industrial cleaners >25%)
-**Nausea, vomiting, and abdominal pain are common symptoms following ingestion of ammonia. Ingestion of household ammonia (5-10%) has resulted in severe esophageal burns. Esophageal pain with swallowing, drooling and refusal of food suggest a more significant injury. Substernal chest pain, abdominal pain and rigidity suggest profound injury and potential perforation of the esophagus and/ or stomach.
+***Skin [[chemical burns]], blistering, pain, necrosis, particularly on moist skin areas
+***Contact with compressed liquid ammonia (stored at -28 °F) can cause [[frostbite]] injury and deep ulcerating burns
+*Eye contact
+**Greater tendency to penetrate/damage eye than other alkali
+**Temporary or permanent [[vision loss]] if contact with high concentrations of the gas or with concentrated ammonium hydroxide, due to swelling/sloughing of eye surface cells
+***Extent of damage may not be apparent for up to a week
+*Ingestion
+**[[Caustic ingestion|Corrosive damage]]/[[chemical burns]] to oropharynx, esophagus, stomach
+*** --> [[Nausea/vomiting]], [[chest pain]], [[abdominal pain]], drooling
 ==Differential Diagnosis==
+{{Caustic burn types}}
+{{Chemical weapon DDX}}
 ==Evaluation==
+*Decontaminate
+*Evaluate for extent of injury, co-intoxicants
 ==Management==
+*Diuretics and corticosteroids not shown to be effective
+*Inhaled beta agonists e.g. [[albuterol]] for bronchoconstriction
+*See [[caustic ingestion]]
+*See [[caustic burns]]
 ==Disposition==
+*Dependant on clinical severity
 ==See Also==