Ammonia Toxicity Workup

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

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.

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Imaging Studies

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 are performed to rule out perforation following ingestion.

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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)
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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
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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.

References

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