View source for Arsenic toxicity

==Background==
*[[Heavy metal]] 
*Readily absorbed via GI tract and inhalation, poorly via skin 
*Tasteless and odorless
*Organic trioxide form used as chemotherapeutic agent 
*Trivalent form, As3+, is toxic to over 200 intracellular enzymes 
*Known carcinogen: skin, lung, other 
*Ingestion fatal dose: 100-200mg

===Sources of Exposure===
*Poisoning
*Contaminated drinking water
*Eruptions
*Metal and semiconductor industry
*Wood preservatives 
*''seafood arsenic (felt to be organic form which is NONTOXIC and cleared from body in few days)''

==Clinical Features==
[[File:arsenicrash.png|thumb|Typical rash associated with chronic exposure]]
===Acute ingestion===
*Garlic smell of breath and tissues
*GI symptoms that can resemble [[cholera]]
**Vomiting may be bloody
**"Rice water" like diarrhea
*Dehydration
*[[Pulmonary Edema]] 
*[[Shock]] 
*[[Rhabdomyolysis]] 
*[[Altered mental status]]
*[[Seizure]]
*[[Coma]] 
*Death 
*Cardiovascular instability
[[File:Meeslines.png|thumb|"Mees lines"]]
===Arsine gas exposure===
*Hemolysis causing abdominal pain
*[[Hematuria]], urine often looks black
*[[Jaundice]]
*Shaking chills
*Can lead to [[altered mental status]]
*Immediately lethal at 250 ppm

===Subacute or chronic poisoning===
*[[Anemia]] 
*Peripheral neuropathy
**Typically symmetric "glove and stocking" distribution
*Skin changes 
*White lines on the finger nails known as "Mees lines"
*[[Ataxia]] 
*[[CNS Depression]]
*Risk factor for [[squamous cell carcinoma]]

==Differential Diagnosis==
{{Heavy metals list}}
{{Diarrhea DDX}}

==Evaluation==
===Workup===
*Urine arsenic level
*[[ECG]] to eval for [[QT Prolongation]] in acute exposure 
*CBC and retic count, expect hemolytic anemia 
*BMP, Mg, Phos, Ca,&nbsp;LFTs, CK
*Type and screen for possible transfusion in arsine gas exposure
*[[CXR]] if respiratory symptoms&nbsp;
*Consider other ingestion labs including acetaminophen and salicylate level in intentional ingestions

===Diagnosis===
*Urine arsenic level (usual normal level is <50mcg/L); both urine spot test and 24h urine collection 
**Lab must differentiate inorganic from organic arsenic (treat for inorganic exposure only)
*Blood arsenic level not helpful (cleared within 2 hrs of exposure)

==Management==
*Supportive care, ABCs, IV, O2, monitor 
*Removal from exposure 
*NO [[Charcoal]] if co-ingestion is not suspected - adsorbs poorly to arsenic
*Consider [[Whole Bowel Irrigation]] if large radiopaque material in GI tract on xray
*Airway management and mechanical [[ventilation]] if acute inhalation of arsine gas and respiratory distress 
*IV fluids 
*CHELATION therapy: if severe symptoms present
*[[Dimercaprol]] (BAL). 3-5mg/kg IM Q4-6h

==Disposition==
===Admission===
*Admit patient to intensive care setting if symptomatic from acute exposure
===Discharge===
*Asymptomatic/mildly symptomatic patients or those with suspected chronic exposures may be discharged w/ outpatient follow-up after initial ED observation.

==See Also==
*[[Toxicology (Main)]]
*[[Heavy Metals]]

==References==
<references/>
[[Category:Toxicology]]