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Toxicity, Hydrogen Sulfide: Differential Diagnoses & Workup

Author: Sujal Mandavia, MD, FRCP(C), FACEP, Clinical Assistant Professor of Emergency Medicine, USC, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles County-University of Southern California Medical Center
Contributor Information and Disclosures

Updated: Mar 24, 2009

Differential Diagnoses

Lactic Acidosis
Smoke Inhalation
Toxicity, Carbon Monoxide
Toxicity, Cyanide
Toxicity, Hydrocarbons

Other Problems to Be Considered

Methemoglobinemia
Acute lung injury (ALI)

Workup

Laboratory Studies

  • Arterial blood gas
    • Arterial blood gas (ABG) usually reveals a marked uncompensated metabolic acidosis. Acidosis is associated with an elevation in serum lactate level.
    • Oxygen tension (pO2) and calculated oxygen saturation are within the reference range unless the patient has concomitant pulmonary edema.
    • As with other hemoglobinopathies, however, measured oxygen saturation often is low and indicates a saturation gap.
    • Venous blood gas may indicate abnormally high oxygen tension (because of decreased oxygen utilization) resulting in a decrease in the PO2 gradient between arterial and venous blood.
    • H2 S toxicity may be associated with carboxyhemoglobin or methemoglobinemia, depending on the source of H2 S and coexposure.

Imaging Studies

  • Chest radiography
    • Chest radiographic findings initially may be normal, but up to 20% of patients present with evidence of acute lung injury.
    • ARDS is viewed as a complication in H2 S poisoning.
  • CT scan or MRI of the head: Often only delayed findings, such as basal ganglia lesions, are found.

Other Tests

  • ECG may reveal ischemia or infarction patterns.
  • Sulfide (unstable metabolite) and thiosulfate blood levels rarely are available (especially on short notice) and may be elevated in cases of significant exposure. However, with significant acute exposure due to respiratory paralysis, the amount of actually absorbed hydrogen sulfide can be lower in comparison to low-level chronic exposure.
  • Measurement of sulfide and thiosulfate levels are more appropriate for the evaluation of low-level chronic exposures.

More on Toxicity, Hydrogen Sulfide

Overview: Toxicity, Hydrogen Sulfide
Differential Diagnoses & Workup: Toxicity, Hydrogen Sulfide
Treatment & Medication: Toxicity, Hydrogen Sulfide
Follow-up: Toxicity, Hydrogen Sulfide
References
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References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  2. Fuller DC, Suruda AJ. Occupationally related hydrogen sulfide deaths in the United States from 1984 to 1994. J Occup Environ Med. Sep 2000;42(9):939-42. [Medline].

  3. Truscott A. Suicide fad threatens neighbours, rescuers. CMAJ. Aug 12 2008;179(4):312-3. [Medline].

  4. Gregorakos L, Dimopoulos G, Liberi S, Antipas G. Hydrogen sulfide poisoning: management and complications. Angiology. Dec 1995;46(12):1123-31. [Medline].

  5. Hall AH, Rumack BH. Hydrogen sulfide poisoning: an antidotal role for sodium nitrite?. Vet Hum Toxicol. Jun 1997;39(3):152-4. [Medline].

  6. Hessel PA, Herbert FA, Melenka LS, et al. Lung health in relation to hydrogen sulfide exposure in oil and gas workers in Alberta, Canada. Am J Ind Med. May 1997;31(5):554-7. [Medline].

  7. Kilburn KH, Warshaw RH. Hydrogen sulfide and reduced-sulfur gases adversely affect neurophysiological functions. Toxicol Ind Health. Mar-Apr 1995;11(2):185-97. [Medline].

  8. Milby TH, Baselt RC. Hydrogen sulfide poisoning: clarification of some controversial issues. Am J Ind Med. Feb 1999;35(2):192-5. [Medline].

  9. Richardson DB. Respiratory effects of chronic hydrogen sulfide exposure. Am J Ind Med. Jul 1995;28(1):99-108. [Medline].

  10. Smilkstein MJ, Bronstein AC, Pickett HM, Rumack BH. Hyperbaric oxygen therapy for severe hydrogen sulfide poisoning. J Emerg Med. 1985;3(1):27-30. [Medline].

  11. Snyder JW, Safir EF, Summerville GP, Middleberg RA. Occupational fatality and persistent neurological sequelae after mass exposure to hydrogen sulfide. Am J Emerg Med. Mar 1995;13(2):199-203. [Medline].

  12. Watt MM, Watt SJ, Seaton A. Episode of toxic gas exposure in sewer workers. Occup Environ Med. Apr 1997;54(4):277-80. [Medline].

  13. Whitcraft DD, Bailey TD, Hart GB. Hydrogen sulfide poisoning treated with hyperbaric oxygen. J Emerg Med. 1985;3(1):23-5. [Medline].

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Further Reading

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Keywords

hydrogen sulfide toxicity, hydrogen sulfide exposure, hydrogen sulfide poisoning, rotten egg odor, H2 S toxicity, H2 S poisoning, H2 S, inhalation of hydrogen sulfide

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Contributor Information and Disclosures

Author

Sujal Mandavia, MD, FRCP(C), FACEP, Clinical Assistant Professor of Emergency Medicine, USC, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles County-University of Southern California Medical Center
Sujal Mandavia, MD, FRCP(C), FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

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.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

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, Department of Surgery, Section 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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