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Toluene Toxicity Treatment & Management

  • Author: Nathanael J McKeown, DO; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Feb 01, 2015
 

Prehospital Care

Administer supportive care, including supplemental oxygen, as soon as possible at the scene. If a patient is not breathing, administer ventilatory support with a bag valve mask. Avoid mouth-to-mouth breathing because 20% of toluene is expired unchanged, and the rescuer may be overcome by direct inhalation of fumes.

Upon discovery of the patient, remove the patient's clothing because the clothes may have additional solvent on them, which is harmful to the patient and rescue workers. Examine the skin for burns so that irrigation, if needed, can begin immediately.

Remove the patient from the area of contamination because toxic fumes may overcome rescue workers.

Immediate irrigation of the skin, eyes, and mucous membranes at the scene greatly reduces skin damage (eg, coagulation necrosis from prolonged contact).

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Emergency Department Care

Treatment is supportive, as follows:

  • Administer supplemental oxygen
  • Make certain that intubation equipment is available at the bedside; although often the patient's airway is not in jeopardy, consider intubation in patients with increasing respiratory distress, decreased level of consciousness, inability to protect their own airway, predicted worsening clinical course, and risk of aspiration from ingestion
  • Observe patients for tachypnea and obtain arterial blood gas levels to monitor for signs of metabolic acidosis, hypoxia, and hypercarbia
  • Follow advanced cardiac life support (ACLS) protocols for patients with arrhythmias, if needed; central line placement may be necessary for patients requiring ACLS interventions or defibrillation following ventricular fibrillation or significant hypotension
  • Cardioversion of dysrhythmias induced by toluene exposure may be necessary
  • Propranolol and esmolol have both been used successfully in treatment of ventricular dysrhythmias from inhalant abuse
  • Establish intravenous (IV) access for administration of fluids or medicines with two large-bore peripheral IV sites, or obtain central venous access, if needed.
  • Use fluid boluses, if necessary, to maintain blood pressure; use IV fluid boluses with normal saline or lactated Ringer solution at 20 mL/kg to maintain blood pressure and to ensure adequate urinary output
  • Careful use of vasopressors to support blood pressure can be considered, sympathomimetic agents may increase risk of developing dysrhythmias and should be used with caution
  • Replete potassium, calcium, and phosphorus losses caused by effects of toluene, if necessary; use sodium bicarbonate in cases of severe acidosis
  • Do not assume that adequate irrigation of contaminated skin was achieved in the field; copiously irrigate wounds to reduce potential burn damage and coagulation necrosis
  • Monitor urinary output and kidney functions to avoid acute kidney injury from myoglobinemia secondary to rhabdomyolysis
  • Facilitate gastric decontamination with nasogastric (NG) tube gastric lavage for patients who are symptomatic following ingestion of toluene
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Consultations

See the list below:

  • Consult the regional poison control center or local medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations.
  • Pursue pulmonary consultation for patients with respiratory compromise or complications from aspiration.
  • Consult cardiology department personnel for patients with ventricular dysrhythmias or cardiac arrest.
  • Consult with ear, nose, and throat (ENT) and/or plastic surgery specialists if significant burns or irritation of the mucous membranes are present on the face or significant dermal burns are observed on the rest of the body.
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Contributor Information and Disclosures
Author

Nathanael J McKeown, DO Assistant Professor, Department of Emergency Medicine, Oregon Health and Science University School of Medicine; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center

Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine, Excela Health System

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.

Additional Contributors

Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Kevin A Martin, MD, to the development and writing of this article.

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