Arsenic Toxicity in Emergency Medicine Workup

  • Author: Steven Marcus, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 11, 2012
 

Laboratory Studies

  • Complete blood count
    • As with all heavy metals, microcytic hypochromic anemia is common.
    • Obtain a CBC with indices and a reticulocyte.
    • Acute hemolytic anemia is the rule with arsine exposure.
  • Serum electrolytes, including calcium and magnesium: Particularly in patients with severe vomiting and diarrhea
  • Type and screen or crossmatch blood for the transfusion in patients exposed to arsine gas.
  • A test for plasma arsenic concentrations is helpful but rarely available until after the decision to treat is made. Blood arsenic concentrations should not exceed 50 mcg/L. In patients with arsenic poisoning, blood arsenic concentrations commonly range from several hundred to several thousand micrograms per liter. The reported half-life of arsenic in blood immediately following ingestion is in hours, while whole-body clearance may be in days or months and is apparently dose-related.
  • Urine analyses
    • A urine spot test for arsenic can be helpful.
    • A 24-hour urine collection for total arsenic excretion can be diagnostic and useful following therapy. A 24-hour clearance of more than 50 mcg is unusual (be sure the patient has not consumed seafood for at least 3 days prior to urine collection). Because nutritional sources of arsenic are not unusual, the laboratory must "speciate" the arsenic into organic and inorganic moieties. The inorganic arsenic is responsible for symptoms and signs of arsenic toxicity. This point is extremely important, since using just the total arsenic level may lead to unnecessary treatment for many patients.
    • Various species of arsenic may be recovered in a urine specimen. The human body begins to metabolize inorganic arsenic into various organic forms after a short period of time. Metabolites include methylarsonic acid (MMA) and dimethylarsenic acid (DMA). It should be possible for the laboratory to separate these species from the usual dietary organic forms, but it is imperative that the laboratory be asked to insure that this has been done.
    • Obtain a urine pregnancy test in women of childbearing age.
  • Obtain serum acetaminophen level in every intentional exposure.
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Imaging Studies

An abdominal radiograph may reveal the presence of radio-opaque densities and may resemble an upper GI series.

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Other Tests

Nerve conduction studies may confirm the peripheral neuropathy. This may be particularly important because the classic stocking-glove distribution suggests another etiology.

Cardiac arrhythmias and, in rare cases, cardiac failure have been reported as resulting from arsenic toxicity. Electrocardiography would therefore be indicated.

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Procedures

Once arsenic distributes into the tissues, treatment may be unsuccessful. Clinical trials are not available, but attempting to remove arsenic from the plasma before it reaches the tissues makes sense. Because the clearance of arsenic by dialysis is substantial, hemodialysis may be indicated if available within a short time after exposure.

In arsine exposure, hemolysis may be severe and life threatening, and no data suggest that chelation therapy can alter this. Arsine appears to rapidly bind to the erythrocytes, making them likely to lyse and release more toxin to contaminate other cells. The use of multiple transfusions and perhaps exchange transfusion may be necessary.

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Contributor Information and Disclosures
Author

Steven Marcus, MD  Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center

Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Medical Society of New Jersey

Disclosure: Nothing to disclose.

Specialty Editor Board

David C Lee, MD  Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and 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.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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.

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Black water urine from a patient with massive hemolysis secondary to arsine exposure at a gas tank cleaning operation.
 
 
 
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