Toluene Toxicity Treatment & Management
- Author: Nathanael J McKeown, DO; Chief Editor: Asim Tarabar, MD more...
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).
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
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.
United States Department of Labor. Occupational Safety and Health Administration. Safety and Health topics: Toluene. Last revised March 17, 2004. Available at: http://www.osha.gov/dts/chemicalsampling/data/CH_272200.html.
Broberg K, Tinnerberg H, Axmon A, Warholm M, Rannug A, Littorin M. Influence of genetic factors on toluene diisocyanate-related symptoms: evidence from a cross-sectional study. Environ Health. 2008 Apr 30. 7:15. [Medline].
Shiomi S, Kuroki T, Kuroda T, et al. Absence of hepatic uptake of Tc-99m phytate in a man with chronic toluene hepatotoxicity. Clin Nucl Med. 1993 Aug. 18(8):655-6. [Medline].
Atay AA, Kismet E, Turkbay T, Kocaoglu M, Demirkaya E, Sarici SU, et al. Bone mass toxicity associated with inhalation exposure to toluene. Biol Trace Elem Res. 2005 Summer. 105(1-3):197-203. [Medline].
United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2012 National Survey on Drug Use and Health: National Survey. Sept 2008. Available at: http://oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.pdf. [Full Text].
Mowry JB, Spyker DA, Cantilena LR Jr, McMillan N, Ford M. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol (Phila). 2014 Dec. 52(10):1032-283. [Medline]. [Full Text].
Flanagan RJ, Ruprah M, Meredith TJ, Ramsey JD. An introduction to the clinical toxicology of volatile substances. Drug Saf. 1990 Sep-Oct. 5(5):359-83. [Medline].
Medina-Mora ME, Real T. Epidemiology of inhalant use. Curr Opin Psychiatry. 2008 May. 21(3):247-51. [Medline].
Chao TC, Lo DS, Koh J, et al. Glue sniffing deaths in Singapore--volatile aromatic hydrocarbons in post-mortem blood by headspace gas chromatography. Med Sci Law. 1993 Jul. 33(3):253-60. [Medline].
Seth R, Kotwal A, Ganguly KK. Street and working children of Delhi, India, misusing toluene: an ethnographic exploration. Subst Use Misuse. 2005. 40(11):1659-79. [Medline].
White V, Hayman J. Australian secondary students’ use of over-the-counter and illicit substances in 2002. 2004.
Bowen SE, Daniel J, Balster RL. Deaths associated with inhalant abuse in Virginia from 1987 to 1996. Drug Alcohol Depend. 1999 Feb 1. 53(3):239-45. [Medline].
Pearson MA, Hoyme HE, Seaver LH, Rimsza ME. Toluene embryopathy: delineation of the phenotype and comparison with fetal alcohol syndrome. Pediatrics. 1994 Feb. 93(2):211-5. [Medline].
Wick R, Gilbert JD, Felgate P, Byard RW. Inhalant deaths in South Australia: a 20-year retrospective autopsy study. Am J Forensic Med Pathol. 2007 Dec. 28(4):319-22. [Medline].
Toluene. Baselt RC, ed. Disposition of Toxic Drugs and Chemicals in Man. 7th ed. Foster City, CA: Biomedical Publications; 2004. 1120-24.
Cámara-Lemarroy CR, Gónzalez-Moreno EI, Rodriguez-Gutierrez R, González-González JG. Clinical presentation and management in acute toluene intoxication: a case series. Inhal Toxicol. 2012 Jun. 24(7):434-8. [Medline].
Ellenhorn MJ, Schonwald S, Ordog G. Inhalant abuse. Ellenhorn's Medical Toxicology. 2nd ed. Lipincott Williams & Wilkins: 1997. 1493-5.
Gagnaire F, Langlais C. Relative ototoxicity of 21 aromatic solvents. Arch Toxicol. 2005 Jun. 79(6):346-54. [Medline].
Siqueira LM, Crandall LA. Inhalant use in Florida youth. Subst Abus. 2006 Dec. 27(4):27-35. [Medline].
Yucel M, Takagi M, Walterfang M, Lubman DI. Toluene misuse and long-term harms: a systematic review of the neuropsychological and neuroimaging literature. Neurosci Biobehav Rev. 2008 Jul. 32(5):910-26. [Medline].