Mercury Toxicity Treatment & Management

  • Author: David A Olson, MD; Chief Editor: Tarakad S Ramachandran, MBBS, FRCP(C), FACP   more...
 
Updated: Dec 7, 2011
 

Approach Considerations

Notify state and local health officials to clarify the mechanism of exposure and to institute appropriate decontamination measures, should these be necessary.

Treatment of mercury toxicity consists of removal of the patient from the source of exposure, supportive care, and chelation therapy. Patients with cognitive and emotional sequelae may require psychotropic medications.

Although laboratory studies are important, acute treatment in critical situations should be based on the patient’s history and clinical presentation, without waiting for laboratory confirmation.

Little information is available about the treatment of mercury-induced tremulousness, but initiation of empiric treatment for patients who are functionally impaired with this complication would be reasonable.

Once the neurologic consequences of Minamata disease appear, they are, unfortunately, irreversible. The goal of medical management in Minamata disease is to reduce the total body burden of mercury and minimize further damage.

Prehospital care

Prehospital management includes gathering information on the time, type, and mode of mercury exposure, as well as the following:

  • Initial assessment - Airway, breathing, and circulation (ABCs)
  • Oxygen
  • Intravenous (IV) access
  • Removal from the contaminated area

Surgical care

Surgery does not have a role in the treatment of Minamata disease; however, in other forms of mercury exposure, surgical intervention is sometimes warranted. Surgery occasionally has been employed to remove ingested mercury that has become lodged in the intestine or colon.[79]

Surgical removal of subcutaneous deposits of self-injected elemental mercury has also been described.[80] Early, definitive surgical excisions of the mercury deposits resulted in good outcomes with minimal toxicity.

Inpatient care

All patients in unstable condition should be admitted to an intensive care unit (ICU). After the patient is admitted, supportive measures, decontamination, and careful monitoring should be continued. In cases of inorganic mercuric salt ingestion, carefully monitor the patient's renal function.

Transfer

Serious clinical manifestations due to mercury exposure should be managed in a tertiary care facility by physicians experienced with toxicologic emergencies.

Activity

Employment and driving should be restricted if patients have significant emotional or cognitive problems.

Consultations

Consult with the regional poison control center or a medical toxicologist (certified through the American Board of Medical Toxicology and/or the American Board of Emergency Medicine) for additional information and patient care recommendations.

Follow-up

Determine follow-up care on a case-by-case basis. Obtain laboratory measurements of toxicity in patients with possible continued sources of exposure.

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Emergency Department Care

Supportive care begins with the ABCs, especially when managing the inhalation of elemental mercury and the ingestion of caustic inorganic mercury, both of which may cause the onset of airway obstruction and failure. The next step in supportive care is the removal of contaminated clothing and copious irrigation of exposed skin. Aggressive hydration may be required for acute inorganic mercury poisoning because of its caustic properties. Do not induce emesis if the compound ingested is of the caustic inorganic form.

Gastric lavage is recommended for organic ingestion, especially if the compound is observed on an abdominal radiograph series.

Activated charcoal is indicated for GI decontamination because it binds inorganic and organic mercury compounds to some extent.

Whole bowel irrigation may be used until rectal effluent is clear and void of any radiopaque material. However, its effectiveness in decreasing the GI transit time of elemental mercury is doubtful because of the high density of elemental mercury and the low density of the whole bowel irrigant solutions. Likewise, whole bowel irrigation has no adsorptive effect on any type of mercury within the GI tract.

Use chelating agents if the patient is symptomatic, if systemic absorption is anticipated, or if increased blood or urinary mercury levels are present. Chelating agents contain thiol groups, which compete with endogenous sulfhydryl groups.

Hemodialysis is used in severe cases of toxicity when renal function has declined. The ability of regular hemodialysis to filter out mercury is limited because of mercury's mode of distribution among erythrocytes and plasma. However, hemodialysis with L-cysteine compound as a chelator has been successful.

Older literature indicates that neostigmine may help motor function in methylmercury toxicity as this toxicity may lead to acetylcholine deficiency.[81]

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Chelation

Because mercury binds to the body's ubiquitous cellular sulfhydryl groups, chelating agents should be administered early in treatment.

Chelating agents contain thiol groups, which bind to mercury. For acute, inorganic toxicity, dimercaprol (British antilewisite [BAL]) has traditionally been recommended, but oral agents are gaining prominence. Chelation with 2,3-dimercaptosuccinic acid (DMSA or succimer) has been shown to result in increased mercury excretion, compared with N -acetyl-D,L-penicillamine, in adults with acute mercury vapor exposure. DMSA is generally well tolerated and has also demonstrated efficacy in children exposed to mercury. Chelation treatment may be administered in the outpatient setting with an oral chelator, such as DMSA.[82]

Polythiol is a nonabsorbable resin that can theoretically help in facilitating the removal of methylmercury (short chain alkyl organic mercury), which is then excreted in the bile after enterohepatic circulation.

Exchange transfusion has been used as a treatment of last resort. Because mercury-chelating agent complexes are large molecules, they may fail to be filtered out by standard hemodialysis membranes, rendering conventional hemodialysis ineffective.[83]

Despite the increased excretion of mercury with chelating agents, chelation removes only a small portion of the body's mercury stores. Furthermore, the efficacy of chelating agents in treating neurologic complications has not been established; however, among patients with amalgam fillings, placebo responses to chelation treatment have been reported.[84]

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Diet

Seafood rich in organic mercury should of course be avoided. Predators such as sharks and tuna typically have increased mercury concentrations compared with herbivorous fishes.

In some studies, the levels of mercury in shark, swordfish, and large tuna steaks exceeded the Food and Drug Administration (FDA) safety limit of 1 part per million. However, most other fish sold in the United States have clearly lower levels of approximately 0.3 part per million.

Because of the high morbidity and mortality rates associated with methyl mercury poisoning, especially in utero, pregnant women and nursing mothers should avoid consuming larger fish, because their mercury concentrations tend to be higher than those in smaller fish.

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Deterrence and Prevention

Workplace hygiene and careful monitoring and disposal of industrial waste are equally important in the prevention of mercury poisoning.

Because of the high morbidity and mortality rates associated with methyl mercury poisoning, especially in utero, pregnant women and nursing mothers should avoid consuming larger fish because their mercury concentrations tend to be higher than those in smaller fish.

Minamata disease can be prevented by reducing or eliminating one's consumption of fish caught from bodies of water that are contaminated with high concentrations of mercury.

Other forms of mercury exposure, such as elemental mercury vapor inhalation, occur when people vacuum or sweep mercury spills in an enclosed space. The proper authorities must handle any spill with the appropriate mercury decontamination kits and procedures.

Significant oral ingestion of elemental mercury may lead to significant environmental contamination as the mercury is passed, essentially unabsorbed, through the GI tract and expelled in the feces.

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Contributor Information and Disclosures
Author

David A Olson, MD  Clinical Neurologist, Dekalb Neurology Associates, Decatur, Georgia

David A Olson, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP  Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine

Disclosure: Abbott Labs None None; Teva Marion None None; Boeringer-Ingelheim Honoraria Speaking and teaching

Additional Contributors

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York AcademyofSciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Barry M Diner, MD, MPH, FACEP Assistant Clinical Professor, Department of Emergency Medicine, Emory University School of Medicine; Attending Physician, St Luke's Episcopal Hospital, Houston, Texas

Barry M Diner, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Chair, Department of Emergency Medicine, Director of Medical Toxicology, Allegheny General Hospital; Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Michael E Mullins, MD Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David K Tan, MD, EMT-T, FAAEM Assistant Professor and Chief, EMS Section, Division of Emergency Medicine, Medical Director, Washington University EMS, Washington University in St Louis School of Medicine

David K Tan, MD, EMT-T, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and National Association of EMS Physicians

Disclosure: Nothing to disclose.

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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This is a 1-view, abdominal, upright radiograph in a male patient who intentionally ingested 8 ounces of elemental mercury. Notice how the mercury outlines the large intestine from ascending to descending. Image courtesy of Fred P. Harchelroad, MD, and Ferdinando L. Mirarchi, DO.
Patient with intentional ingestion of mercury from blood pressure instrument. Note how mercury beads can be seen deposited in lung fields. Image courtesy of Shuchi Vyas, MD.
 
 
 
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