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Toxicity, Ammonia: Differential Diagnoses & Workup

Author: Steven Issley, MD, FRCPC, Assistant Professor of Emergency Medicine, Assistant Director of Medical Stimulation Center, Consulting Staff, Department of Emergency Medicine, SUNY-Downstate Medical Center, Kings County Hospital Center
Coauthor(s): Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Contributor Information and Disclosures

Updated: Oct 8, 2009

Differential Diagnoses

Acute Respiratory Distress Syndrome
Pediatrics, Reactive Airway Disease
Anaphylaxis
Pediatrics, Respiratory Distress Syndrome
Burns, Chemical
Respiratory Distress Syndrome, Adult
Burns, Ocular
Toxicity, Chlorine Gas
Burns, Thermal
Toxicity, Hydrogen Sulfide
Esophagitis
Toxicity, Phosgene
Hazmat
Iritis and Uveitis
Pediatrics, Anaphylaxis

Other Problems to Be Considered

Other toxic inhalations or ingestions
Concomitant trauma
Reactive airway dysfunction syndrome (RADS)

Workup

Laboratory Studies

  • Serum acetaminophen level in intentional exposures
  • Complete blood count (CBC)
  • Electrolytes, blood urea nitrogen (BUN), and creatinine
  • Serum lactic acid
  • Serial arterial blood gases (ABGs) in cases of significant respiratory distress
    • Metabolic acidosis
    • Respiratory alkalosis
    • Increased alveolar-arterial gradient
  • Note that serum ammonia levels are of little value because they do not correlate with clinical condition. However, patients with compromised hepatic function may show increased serum ammonia levels because of less efficient metabolism.

Imaging Studies

  • Chest radiography
    • Chest radiographic findings can vary from normal to diffuse micronodular interstitial infiltrates. However, abnormal radiographic findings may take up to 48 hours to develop, even following severe exposure.
    • Other findings to consider are acute lung injury (ALI), acute respiratory distress syndrome (ARDS), secondary bacterial bronchopneumonia, and pneumomediastinum.
  • Abdominal series (to rule out perforation following ingestion)

Other Tests

  • Cardiac monitor
  • Oxygen saturation monitor
  • Pulmonary capillary wedge pressure (PCWP) monitoring (in cases of severe ALI or ARDS)
  • Pulmonary function tests (PFTs) - Once acute emergency is controlled; useful to gauge severity and monitor progress and recovery
    • Obstructive lung disease (acute and chronic)
    • Restrictive lung disease (chronic)
  • Ventilation/perfusion (V/Q) scan - May be useful to gauge severity or progress of disease; unlikely to change acute management
    • Ventilation deficits generally are more pronounced in the larger airways.
    • The ventilation scan also may show abnormal air trapping in the setting of lower airway obstruction.
  • Slit-lamp examination with fluorescein staining, tonometry and conjunctival pH (see Physical: HEENT)

Procedures

  • Perform bronchoscopy to assess respiratory tract damage following acute inhalation injury (in severe cases).
    • Airway edema, obstruction, and necrosis
    • Epithelial sloughing
    • Laryngitis and tracheitis
    • Diffuse alveolar damage
  • Consider endoscopy for significant ingestion exposures (large volume and/or industrial concentrations). Indications are somewhat controversial; obtain a GI consultation if needed. Perform endoscopy on symptomatic patients and patients with intentional exposure within 48 hours following ingestion. The risk of perforation increases if endoscopy is performed more than 72 hours postingestion.
    • Laryngeal and epiglottic edema
    • Friable erythematous esophagus
    • Corrosive injury

More on Toxicity, Ammonia

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

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Further Reading

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Keywords

anhydrous ammonia, NH3, liquid ammonia, ammonia exposure, ammonia exposure symptoms, ammonia ingestion, ammonia inhalation, ammonium hydroxide, liquid anhydrous ammonia, toxic ammonia exposure, ammonia toxicity, ammonia poisoning, fertilizer

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Contributor Information and Disclosures

Author

Steven Issley, MD, FRCPC, Assistant Professor of Emergency Medicine, Assistant Director of Medical Stimulation Center, Consulting Staff, Department of Emergency Medicine, SUNY-Downstate Medical Center, Kings County Hospital Center
Disclosure: Nothing to disclose.

Coauthor(s)

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
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

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
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, 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.

 
 
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