Ammonia Toxicity Treatment & Management

  • Author: Steven Issley, MD, FRCPC; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Jun 27, 2011
 

Prehospital Care

  • Immediately remove the patient from the contaminated environment.
  • Remove all the patient's clothing.
  • Support airway, breathing, and circulation (ABCs) as per advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) guidelines. (ACLS and ATLS guidelines may vary by region, according to training and legal responsibilities of prehospital care providers.)
  • If the patient is sufficiently stable, begin copious skin and eye irrigation immediately following exposure. Continue irrigation for at least 20 minutes. Patients then can be covered with a dry, clean dressing and sheet.
  • Provide a container for patients with ingestion exposure.
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Emergency Department Care

Decontaminate the patient (if not previously performed) and support ABCs as necessary. Provide warmed humidified oxygen.

As with all burns, patients with facial or oral lesions are at high risk for developing laryngeal edema. Airway intervention should be aggressive.

Indications for intubation include severe respiratory distress (hypoxemia, hypercapnia), stridor, hoarseness, deep facial burns, burns identified by bronchoscopy or endoscopy, and depressed mental status. If intubation is necessary, use large size tube to prevent plugging by sloughed mucosa. Some consider procedural sedation preferable to rapid sequence intubation (RSI) because paralysis is risky with a difficult and edematous airway. Furthermore, ventilation cannot be predicted as successful if intubation fails in this context. Positive end respiratory pressure (PEEP) generally is useful (5 cm water minimum).

Beware of fluid over-resuscitation. Patients may have or may be developing acute lung injury (ALI).

Follow standard initial burn management. (Discussion is beyond the scope of this article.) Once the patient is adequately stable, irrigate skin with tepid water for at least 15 minutes. Continue frequent regular irrigation for the first 24 hours, in addition to conventional burn management. Debride wounds and dress with 1% silver sulfadiazine (avoid using on face). Administer tetanus prophylaxis.

Irrigate eye injuries with copious amounts of tepid water for at least 30 minutes or until conjunctival pH is 6.8-7.4; use pH indicator paper to monitor. Examine eye with slit-lamp and fluorescein staining. Perform tonometry to determine if intraocular pressure is elevated. Consult ophthalmology promptly because of risk of perforation and/or permanent eye damage.

Treat ingestions using the following steps:

  • Rinse mouth and dilute ingestion with approximately 250 mL of water or milk.
  • Do not induce emesis, so as not to reproduce injury with a second pass of toxin.
  • Consult gastroenterology promptly for subsequent endoscopic evaluation (not often performed before 12 hours postingestion).
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Consultations

When appropriate, immediately consult an intensivist, medical toxicologist, ophthalmologist (all eye injuries), gastroenterologist, and general and plastic surgeons.

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Contributor Information and Disclosures
Author

Steven Issley, MD, FRCPC  Attending Physician, Trauma Team Leader, Department of Emergency Medicine, Hotel Dieu Grace Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

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.

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.

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.

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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