Heavy Metal Toxicity Treatment & Management
- Author: Samara Soghoian, MD, MA; Chief Editor: Asim Tarabar, MD more...
Emergency Department Care
- Decontamination
- Removal of the patient from the source of exposure is critical to limiting dose.
- Treatment may include whole-bowel irrigation with polyethylene glycol electrolyte solution if radiographic evidence of retained metal (toys, coins, paint chips) is present.
- Resuscitation: Good supportive care is critical. Ensure airway patency and protection, provide mechanical ventilation where necessary, correct dysrhythmias, replace fluid and electrolytes (significant fluid losses generally occur and require aggressive rehydration), and monitor and treat the sequelae of organ dysfunction.
- Chelation: Chelation is rarely indicated in the emergent setting. A possible exception in lead encephalopathy. Consideration of chelation therapy for patients with suspected or confirmed metal exposures should be made in conjunction with a medical toxicologist or the local poison control center.
- Clinical guidelines on treatment of iron and mercury exposure are available from the American Association of Poison Control Centers.[8, 9]
Consultations
If intentional ingestion or overdose is suspected, place the patient in a closely monitored unit and consult a medical toxicologist and psychiatrist.
- Contact a certified poison control center or medical toxicologist.
- Consult a gastroenterologist if the possibility of corrosive GI effects is present.
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| Metal | Acute | Chronic | Toxic Concentration | Treatment |
| Arsenic | Nausea, vomiting, "rice-water" diarrhea, encephalopathy, MODS, LoQTS, painful neuropathy | Diabetes, hypopigmentation/ hyperkeratosis, cancer: lung, bladder, skin, encephalopathy | 24-h urine: ≥50 µg/L urine, or 100 µg/g creatinine | BAL (acute, symptomatic) Succimer DMPS (Europe) |
| Bismuth | Renal failure; acute tubular necrosis | Diffuse myoclonic encephalopathy | No clear reference standard | * |
| Cadmium | Pneumonitis (oxide fumes) | Proteinuria, lung cancer, osteomalacia | Proteinuria and/or ≥15 µg/ g creatinine | * |
| Chromium | GI hemorrhage, hemolysis, acute renal failure (Cr6+ ingestion) | Pulmonary fibrosis, lung cancer (inhalation) | No clear reference standard | NAC (experimental) |
| Cobalt | Beer drinker’s (dilated) cardiomyopathy | Pneumoconiosis (inhaled); goiter | Normal excretion: 0.1-1.2 µg/L (serum) 0.1-2.2 µg/L (urine) | NAC CaNa2 EDTA |
| Copper | Blue vomitus, GI irritation/ hemorrhage, hemolysis, MODS (ingested); MFF (inhaled) | vineyard sprayer’s lung (inhaled); Wilson disease (hepatic and basal ganglia degeneration) | Normal excretion: 25 µg/24 h (urine) | BAL D-Penicillamine Succimer |
| Iron | Vomiting, GI hemorrhage, cardiac depression, metabolic acidosis | Hepatic cirrhosis | Nontoxic: < 300 µg/dL Severe: >500 µg/dL | Deferoxamine |
| Lead | Nausea, vomiting, encephalopathy (headache, seizures, ataxia, obtundation) | Encephalopathy, anemia, abdominal pain, nephropathy, foot-drop/ wrist-drop | Pediatric: symptoms or [Pb] ≥45 µ/dL (blood); Adult: symptoms or [Pb] ≥70 µ/dL[1] | BAL CaNa2 EDTA Succimer |
| Manganese | MFF (inhaled) | Parkinson-like syndrome, respiratory, neuropsychiatric[2] | No clear reference standard | * |
| Mercury | Elemental (inhaled): fever, vomiting, diarrhea, ALI; Inorganic salts (ingestion): caustic gastroenteritis | Nausea, metallic taste, gingivo-stomatitis, tremor, neurasthenia, nephrotic syndrome; hypersensitivity (Pink disease) | Background exposure "normal" limits: 10 µg/L (whole blood); 20 µg/L (24-h urine) | BAL Succimer DMPS (Europe) |
| Nickel | Dermatitis; nickel carbonyl: myocarditis, ALI, encephalopathy | Occupational (inhaled): pulmonary fibrosis, reduced sperm count, nasopharyngeal tumors | Excessive exposure: ≥8 µg/L (blood) Severe poisoning: ≥500 µg/L (8-h urine) | * |
| Selenium | Caustic burns, pneumonitis, hypotension | Brittle hair and nails, red skin, paresthesia, hemiplegia | Mild toxicity: [Se] >1mg/L (serum); Serious: >2 mg/L | * |
| Silver | Very high doses: hemorrhage, bone marrow suppression, pulmonary edema, hepatorenal necrosis | Argyria: blue-grey discoloration of skin, nails, mucosae | Asymptomatic workers have mean [Ag] of 11 µg/L (serum) and 2.6 µg/L (spot urine) | Selenium, vitamin E (experimental) |
| Thallium | Early: Vomiting, diarrhea, painful neuropathy, coma, autonomic instability, MODS | Late findings: Alopecia, Mees lines, residual neurologic symptoms | Toxic: >3 µg/L (blood) | MDAC Prussian blue |
| Zinc[3] | MFF (oxide fumes); vomiting, diarrhea, abdominal pain (ingestion) | Copper deficiency: anemia, neurologic degeneration, osteoporosis | Normal range: 0.6-1.1 mg/L (plasma) 10-14 mg/L (red cells) | * |
| *No accepted chelation regimen; contact a medical toxicologist regarding treatment plan. MODS, multi-organ dysfunction syndrome; LoQTS, long QT syndrome; ALI, acute lung injury; ATN, acute tubular necrosis; ARF, acute renal failure; DMPS, 2,3-dimercapto-1-propane-sulfonic acid; CaNa2 EDTA, edetate calcium disodium; MDAC, multi-dose activated charcoal; NAC, N -acetylcysteine. | ||||
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