eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Ammonia: Follow-up

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

Follow-up

Further Inpatient Care

  • The majority of patients with unintentional household ammonia exposure will have very mild symptoms and could be discharged safely if asymptomatic and able to tolerate oral intake.
  • Admit patients to observation for at least 24 hours if they show significant and persistent signs, symptoms, or abnormalities in laboratory findings attributable to ammonia exposure.
  • Admit unstable or potentially unstable patients to the intensive care unit.
  • Following ingestion, patients may be discharged if endoscopy results are normal and oral intake is tolerated.
  • Intentional ingestions require psychiatric evaluation.

Complications

  • Patients can develop chronic respiratory sequelae, particularly with severe ammonia exposures. In a case series by Close et al, exposed patients experienced gradual deterioration of pulmonary function during the first 2-6 months following exposure.6 A period of slight improvement was then observed, followed by stabilization of symptoms.
  • Long-term effects of ammonia inhalation injury include the following:
    • Cough
    • Hoarseness
    • Obstructive and/or restrictive lung disease
    • Hyper-reactive airway disease and reactive airway dysfunction syndrome (RADS)
    • Impaired gas exchange
    • Residual parenchymal damage
    • Bronchiectasis and bronchiolitis obliterans (following massive exposure)
    • Pulmonary fibrosis
  • It is postulated that chronic obstructive disease is secondary to airway lesions more than hyper-reactivity and, therefore, often minimally improved by bronchodilators.

Prognosis

  • Most individuals with ammonia inhalation who survive the first 24 hours will recover.
  • Patients begin showing improvement within 48-72 hours and may recover fully during this time if exposure was mild.
  • For patients with more significant respiratory symptoms, recovery can be expected within several weeks to months.
  • Interestingly, Arwood et al found that initial chest x-ray and PaO2 poorly correlate with outcome and that physical examination on arrival is a more sensitive prognosticating factor.7
  • Montague and MacNeil, however, note that patients who do not develop chest x-ray findings are less likely to have chronic respiratory sequelae.

Patient Education

Miscellaneous

Special Concerns

  • Chloramine gas
    • Chloramines (NH2 Cl, NHCl2) are highly water-soluble irritant gases formed when household bleach [(5.25% sodium hypochlorite (NaOCl)] is mixed with 5-10% ammonia solutions (usually cleaning products). Fumes contact moist mucous membranes, reacting with water to produce free ammonia gas (see Inhalation injury), hypochloric acid, and hypochlorous acid. The latter then reacts with water to form hydrochloric acid and nascent oxygen, a strong oxidizing agent with corrosive effects.
    • At low concentration, symptoms include tearing, rhinorrhea, oropharyngeal burning, and cough. Although chloramine gases produce rapid onset of symptoms, these symptoms are mild enough that patients often do not remove themselves promptly from the toxic environment; thus, patients often present after a prolonged exposure time.
    • The physical examination following mild exposure reveals only mild wheezing and decreased air entry or may be entirely unremarkable.
    • Patients with more significant exposure may present with dyspnea, pulmonary edema with secondary hypoxia, nausea, tracheobronchitis, toxic pneumonitis, intrapulmonary shunt, and/or pneumomediastinum. Note that pulmonary edema may ensue within minutes or be delayed for up to 24 hours following exposure.
    • Pulmonary function tests may reveal obstructive, restrictive, or combined patterns, and pulmonary artery occlusive pressure may be less than 17 mm Hg.
  • Treat chloramine gas exposure as described under Emergency Department Care.
    • Nebulized sodium bicarbonate (3.75%) has been suggested to be an adjunct to supportive treatment, but little clinical experience with this treatment exists.
    • In Thomas and Storrow's case series of 22 patients with chloramine toxicity, treatment with sodium bicarbonate resulted in no clinical or statistical improvement.
 


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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  2. Watson WA, Litovitz TL, Rodgers GC. 2002 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2003;21(5):353-421. [Medline].

  3. de la Hoz RE, Schlueter DP, Rom WN. Chronic lung disease secondary to ammonia inhalation injury: a report on three cases. Am J Ind Med. 1996;29(2):209-14. [Medline].

  4. Caplin M. Ammonia-gas poisoning: 47 cases in a London shelter. Lancet. 1941;2:958-61.

  5. Klein J, Olson KR, McKinney HE. Caustic injury from household ammonia. Am J Emerg Med. Jul 1985;3(4):320. [Medline].

  6. Close LG, Catlin FI, Cohn AM. Acute and chronic effects of ammonia burns on the respiratory tract. Arch Otolaryngol. Mar 1980;106(3):151-8. [Medline].

  7. Arwood R, Hammond J, Ward GG. Ammonia inhalation. J Trauma. May 1985;25(5):444-7. [Medline].

  8. Am J Respir Crit Care Med. Respiratory health hazards in agriculture. Am J Respir Crit Care Med. Nov 1998;158(5 Pt 2):S1-S76. [Medline].

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  10. Burgess JL, Pappas GP, Robertson WO. Hazardous materials incidents: the Washington Poison Center experience and approach to exposure assessment. J Occup Environ Med. Aug 1997;39(8):760-6. [Medline].

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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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