eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Hydrogen Sulfide: Treatment & Medication

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

Treatment

Prehospital Care

  • Initial treatment of hydrogen sulfide exposure requires immediate removal of the victim from the contaminated area into a ventilated/fresh-air environment. Prehospital care providers should take hazardous materials precautions with respirator devices (SCBA) to avoid serious exposure.
  • In severe cases, intubation may be necessary for ventilatory support and airway protection.
  • Gain intravenous access or initiate other initial supportive care as necessary.
  • Search the patient's pockets for discolored copper coins, which can be an early diagnostic clue.
  • Protected rescue personnel can measure environmental concentration of hydrogen sulfide providing initial clue to the diagnosis.

Emergency Department Care

High-flow (100%) oxygen is the mainstay of therapy for hydrogen sulfide poisoning.

  • Supportive therapy includes aggressive ventilation and possible use of positive pressure ventilation for the patients with evidence of acute lung injury.
  • IV fluids and vasopressors should be administered to hypotensive patients.
  • Correction of acidosis based on ABG and serum lactate values is indicated.
  • Based on the similarities in cyanide and hydrogen sulfide toxicity, induced methemoglobinemia may be used for the treatment of hydrogen sulfide toxicity. Methemoglobin acts as a scavenger, and it is more attractive to hydrogen sulfide than cytochrome oxidase. Administer 10 mL of 3% sodium nitrite intravenously over 2-4 minutes (adult dose). Obtain methemoglobin level 30 minutes after administration of antidote.
  • Patients with persistent neurologic findings should be considered for hyperbaric oxygen therapy (HBO). Anecdotal reports indicate a salutary effect.

Consultations

Consultation with the local hyperbaric chamber facility may be necessary for patients who are unresponsive to nitrites.

Medication

Treatment of hydrogen sulfide (H2 S) poisoning is based on the creation of methemoglobinemia.

Nitrites

Nitrite administration leads to formation of methemoglobinemia. H2 S has a much greater affinity for methemoglobin than for cellular cytochromes, leading to lower metabolic toxicity.


Sodium nitrite

Initial DOC in hydrogen sulfide poisoning.

Adult

0.33 mL/kg of 3% solution slow IV push (2.5-5 mL/min) to maximum 10 mL

Pediatric

Administer as in adults

Methylene blue counteracts methemoglobin formation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May produce hypotension when administered intravenously in large doses or rapidly; high methemoglobin levels may exacerbate ischemia in patients with poor underlying cardiopulmonary reserve as they decrease oxygen-carrying capacity; adjust dose in severe anemia as outlined in package insert

Bronchodilators

These agents are effective in reversing acute bronchospasm of allergic or irritant origin through combined alpha-adrenergic and beta-adrenergic agonist action.

An additional option in the management of persistent bronchospasm involves anticholinergics. These agents block action of acetylcholine at parasympathetic sites in bronchial smooth muscle, causing bronchodilation.


Albuterol sulfate (Ventolin, Proventil)

Beta agonist useful in treatment of bronchospasm refractory to epinephrine. Relaxes bronchial smooth muscle by acting on beta2 receptors with little effect on heart rate.

Adult

2-4 mg/dose PO divided tid/qid; not to exceed 32 mg/d
Inhalant: 1-2 inhalations q4-6h; not to exceed 12 inhalations/d
Nebulizer: 0.5 mL (2.5 mg) of the 0.5% inhalation solution diluted in 1-2.5 mL of normal saline q4-6h; higher frequency may be used for intensive care patients

Pediatric

<2 years: Not established
2-6 years: 0.1-0.2 mg/kg/dose PO divided tid; not to exceed 12 mg/d
6-12 years: 2 mg/dose PO divided tid/qid; not to exceed 24 mg/d
>12 years: Administer as in adults
Inhalant dose for <12 years: Using a tube spacer, give 1-2 inhalations qid
Inhalant dose for >12 years: Administer as in adults
Nebulizer dose for <5 years: 0.25-0.5 mL (1.25-2.5 mg) of the 0.5% inhalation solution diluted in 1-2.5 mL of normal saline q4-6h in equally divided doses
Nebulizer dose for >5 years: Administer as in adults

Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders

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
[ CLOSE WINDOW ]

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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.