Arsenic toxicity: Difference between revisions

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==Background==
==Background==
*[[Heavy metal]]  
*[[Heavy metal]]  
*sources of exposure: poisoning, contaminated drinking water, eruptions, metal and semiconductor industry, wood preservatives
*Readily absorbed via GI tract and inhalation, poorly via skin  
*seafood arsenic felt to be organic form which is NONTOXIC and cleared from body in few days
*Tasteless and odorless
*readily absorbed via GI tract and inhalation, poorly via skin  
*Organic trioxide form used as chemotherapeutic agent  
*organic trioxide form used as chemotherapeutic agent  
*Trivalent form, As3+, is toxic to over 200 intracellular enzymes  
*trivalent form, As3+, is toxic to over 200 intracellular enzymes  
*Known carcinogen: skin, lung, other  
*known carcinogen: skin, lung, other  
*Ingestion fatal dose: 100-200mg
*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==
==Clinical Features==
[[File:arsenicrash.png|thumb|Typical rash associated with chronic exposure]]
===Acute ingestion===
===Acute ingestion===
*GI symptoms that can resemble cholera
*Garlic smell of breath and tissues
*GI symptoms that can resemble [[cholera]]
**Vomiting may be bloody
**Vomiting may be bloody
**"rice water" like diarrhea
**"Rice water" like diarrhea
*dehydration
*Dehydration
*[[Pulmonary Edema]]  
*[[Pulmonary Edema]]  
*[[Shock]]  
*[[Shock]]  
*[[Rhabdomyolysis]]  
*[[Rhabdomyolysis]]  
*[[altered mental status]]
*[[Altered mental status]]
*[[Seizure]]
*[[Seizure]]
*[[coma]]  
*[[Coma]]  
*death
*Death
*cardiovascular instability  
*Cardiovascular instability
 
[[File:Meeslines.png|thumb|"Mees lines"]]
===Arsine gas exposure===
===Arsine gas exposure===
*hemolysis causing abdominal pain
*Hemolysis causing abdominal pain
*[[hematuria]]
*[[Hematuria]], urine often looks black
*[[jaundice]]
*[[Jaundice]]
*Shaking chills
*Can lead to [[altered mental status]]
*Immediately lethal at 250 ppm


[[File:arsenicrash.png|thumb|Typical rash associated with chronic exposure]]
===Subacute or chronic poisoning===
===Subacute or chronic poisoning===
*[[Anemia]]  
*[[Anemia]]  
*peripheral neuropathy
*Peripheral neuropathy
**typically symmetric "glove and stocking" distribution
**Typically symmetric "glove and stocking" distribution
*skin changes  
*Skin changes  
*White lines on the finger nails known as "Mees lines"[[File:Meeslines.png|thumb|"Mees lines"]]
*White lines on the finger nails known as "Mees lines"
*[[ataxia]]  
*[[Ataxia]]  
*[[CNS Depression]]
*[[CNS Depression]]
*Risk factor for [[squamous cell carcinoma]]


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


==Diagnosis==
==Evaluation==
*urine arsenic level (usual normal level is <50mcg/L); both urine spot test and 24h urine collection
===Workup===
*blood arsenic level not helpful (cleared within 2 hrs of exposure)
*Urine arsenic level
*ECG to eval for [[QT Prolongation]] in acute exposure  
*[[ECG]] to eval for [[QT Prolongation]] in acute exposure  
*CBC to eval for hemolysis
*CBC and retic count, expect hemolytic anemia
*BMP, Mg, phos, Ca, LFTs, CK, type and screen  
*BMP, Mg, Phos, Ca, LFTs, CK
*CXR if respiratory symptoms 
*Type and screen for possible transfusion in arsine gas exposure
*[[CXR]] if respiratory symptoms 
*Consider other ingestion labs including acetaminophen and salicylate level in intentional ingestions


==Treatment==
===Diagnosis===
*supportive care, ABCs, IV, O2, monitor  
*Urine arsenic level (usual normal level is <50mcg/L); both urine spot test and 24h urine collection
*removal from exposure  
**Lab must differentiate inorganic from organic arsenic (treat for inorganic exposure only)
*NO [[Charcoal]] - adsorbs poorly to arsenic
*Blood arsenic level not helpful (cleared within 2 hrs of exposure)
*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 resp distress  
==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  
*IV fluids  
*CHELATION therapy: if severe symptoms present
*CHELATION therapy: if severe symptoms present
*Dimercaprol (BAL). 3-5 mg/kg IM Q4-6h
*[[Dimercaprol]] (BAL). 3-5mg/kg IM Q4-6h


==Disposition==
==Disposition==
*admit pt's with significant symptoms
===Admission===
*ED observation and discharge with follow-up for mildly symptomatic
*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==
==See Also==
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==References==
==References==
 
<references/>
[[Category:Tox]]
[[Category:Toxicology]]

Latest revision as of 01:24, 16 September 2021

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

Typical rash associated with chronic exposure

Acute ingestion

"Mees lines"

Arsine gas exposure

Subacute or chronic poisoning

Differential Diagnosis

Heavy metal toxicity

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

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, LFTs, CK
  • Type and screen for possible transfusion in arsine gas exposure
  • CXR if respiratory symptoms 
  • 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

References

  1. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
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