Arsenic toxicity: Difference between revisions
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==Background== | ==Background== | ||
*[[Heavy metal]] | *[[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== | ==Clinical Features== | ||
| Line 15: | Line 22: | ||
*GI symptoms that can resemble [[cholera]] | *GI symptoms that can resemble [[cholera]] | ||
**Vomiting may be bloody | **Vomiting may be bloody | ||
**" | **"Rice water" like diarrhea | ||
* | *Dehydration | ||
*[[Pulmonary Edema]] | *[[Pulmonary Edema]] | ||
*[[Shock]] | *[[Shock]] | ||
*[[Rhabdomyolysis]] | *[[Rhabdomyolysis]] | ||
*[[ | *[[Altered mental status]] | ||
*[[Seizure]] | *[[Seizure]] | ||
*[[ | *[[Coma]] | ||
* | *Death | ||
* | *Cardiovascular instability | ||
[[File:Meeslines.png|thumb|"Mees lines"]] | [[File:Meeslines.png|thumb|"Mees lines"]] | ||
===Arsine gas exposure=== | ===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=== | ===Subacute or chronic poisoning=== | ||
*[[Anemia]] | *[[Anemia]] | ||
* | *Peripheral neuropathy | ||
** | **Typically symmetric "glove and stocking" distribution | ||
* | *Skin changes | ||
*White lines on the finger nails known as "Mees lines" | *White lines on the finger nails known as "Mees lines" | ||
*[[ | *[[Ataxia]] | ||
*[[CNS Depression]] | *[[CNS Depression]] | ||
*Risk factor for [[squamous cell carcinoma]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Heavy metals list}} | |||
{{Diarrhea DDX}} | |||
==Evaluation== | ==Evaluation== | ||
===Workup=== | |||
*Urine arsenic level | |||
* | *[[ECG]] to eval for [[QT Prolongation]] in acute exposure | ||
*ECG to eval for [[QT Prolongation]] in acute exposure | |||
*CBC and retic count, expect hemolytic anemia | *CBC and retic count, expect hemolytic anemia | ||
*BMP, Mg, | *BMP, Mg, Phos, Ca, LFTs, CK | ||
* | *Type and screen for possible transfusion in arsine gas exposure | ||
*[[CXR]] if respiratory symptoms | *[[CXR]] if respiratory symptoms | ||
*Consider other ingestion labs including acetaminophen and salicylate level in intentional ingestions | *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== | ==Management== | ||
* | *Supportive care, ABCs, IV, O2, monitor | ||
* | *Removal from exposure | ||
*NO [[Charcoal]] if co-ingestion is not suspected - adsorbs poorly to arsenic | *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). 3-5mg/kg IM Q4-6h | *[[Dimercaprol]] (BAL). 3-5mg/kg IM Q4-6h | ||
==Disposition== | ==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== | ==See Also== | ||
| Line 120: | Line 91: | ||
==References== | ==References== | ||
<references/> | |||
[[Category:Toxicology]] | [[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
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
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 metal toxicity
- Aluminum toxicity
- Antimony toxicity
- Arsenic toxicity
- Barium toxicity
- Bismuth toxicity
- Cadmium toxicity
- Chromium toxicity
- Cobalt toxicity
- Copper toxicity
- Gold toxicity
- Iron toxicity
- Lead toxicity
- Lithium toxicity
- Manganese toxicity
- Mercury toxicity
- Nickel toxicity
- Phosphorus toxicity
- Platinum toxicity
- Selenium toxicity
- Silver toxicity
- Thallium toxicity
- Tin toxicity
- Zinc toxicity
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
Watery Diarrhea
- Enterotoxigenic E. coli (most common cause of watery diarrhea)[1]
- Norovirus (often has prominent vomiting)
- Campylobacter
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
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
- ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.