Thallium Toxicity Treatment & Management
- Author: Chip Gresham, MD, FACEM; Chief Editor: Asim Tarabar, MD more...
The prehospital treatment should focus on 4 areas: (1) stabilizing acute life-threatening conditions, (2) initiating supportive therapy, (3) identifying the time and route of exposure, and (4) beginning the decontamination process.
- Establish ABCs.
- Administer oxygen as needed.
- Obtain intravenous access.
- Remove contaminated clothing as soon as possible. Avoid self-exposure and wear protective clothing that is appropriate to the type and degree of contamination. Wear air-purifying or supplied-air respiratory equipment as necessary.
- Activated charcoal should be considered in patients presenting within 1 hour of ingestion and have an intact or protected airway.
Emergency Department Care
The goals of treating a patient with thallium toxicity are initial stabilization, prevention of absorption, enhanced elimination, and antidotal therapy.
- Following the initial assessment and stabilization of the patient, if not performed in the prehospital setting, remove contaminated clothing while avoiding self-exposure. With dermal exposure, thoroughly wash exposed skin with soap and water. For eye exposure, irrigate exposed eyes with copious amounts of room temperature water for at least 15 minutes. Be sure to wear protective clothing appropriate to the type and degree of contamination.
- Gastrointestinal decontamination, activated charcoal, and Prussian blue (potassium ferric hexacyanoferrate) are recommended in thallium ingestions.
- Consider orogastric lavage in patients presenting within 1 hour postingestion if they have not vomited or if thallium is observed in the stomach on radiographs in patients who have vomited. In addition, whole-bowel irrigation with polyethylene glycol electrolyte lavage solution may be useful, especially when radiopaque material is visualized on an abdominal radiograph.
- Although both Prussian blue and activated charcoal absorb thallium, it appears that Prussian blue has absorptive superiority. In addition, because it has a far better safety profile than other proposed therapies, Prussian blue should be considered the drug of choice in acute thallium poisoning.
- Prussian blue is a crystal blue lattice of potassium ferric ferrocyanide. It acts as an ion exchanger for univalent cations, with its affinity increasing as the ionic radius of the cation increases. Prussian blue exchanges potassium ions from its lattice with thallium ions in the gut lumen. Removal of thallium from the gut creates a concentration gradient causing an increase in thallium exchange into the gut lumen. This interrupts its enterohepatic recirculation and increases its elimination. Prussian blue releases a negligible amount of cyanide (< 1.6 mg, minimal lethal dose of cyanide in humans is approximately 50 mg) and does not present a safety concern following its use.
- Prussian blue (Radiogardase) was approved by the Food and Drug Administration (FDA) in 2003 but is still difficult to obtain for pharmaceutical use in the United States. However, it has been obtained from The Oak Ridge Institute for Science and Education and the Radiation Emergency Assistance Center (REAC) in Oak Ridge, Tennessee. In addition, successful therapy using the laboratory reagent of Prussian blue has been documented in the United States.[24, 26]
- In patients in whom Prussian blue cannot be obtained and thallium poisoning is suspected, multidose activated charcoal may be effective. Because thallium undergoes enterohepatic and enteroenteric recirculation, repeated charcoal administration (0.25-0.5 g/kg q2-4h) may enhance fecal elimination.
- Forced diuresis with potassium loading was previously recommended to increase the renal clearance of thallium, but this may exacerbate the neurologic and cardiovascular symptoms and is no longer advised.
- Chelating agents such as EDTA, dimercaprol, and D-penicillamine have not been shown to be effective and should be avoided.
- The usefulness of hemodialysis and hemoperfusion is controversial, but they may be useful during early thallium poisoning before extensive distribution within the body tissues has occurred.[27, 28, 29]
- N -acetylcysteine and l-cysteine have not been shown to be effective in reducing mortality in animal models.
See the list below:
- Consultation with a regional poison control center or medical toxicologist may be of benefit.
Mercurio M, Hoffman RS. Thallium. Goldfrank's Toxicologic Emergencies. 9th ed. 2011. 1326-33.
Mulkey JP, Oehme FW. A review of thallium toxicity. Vet Hum Toxicol. 1993 Oct. 35(5):445-53. [Medline].
Saddique A, Peterson CD. Thallium poisoning: a review. Vet Hum Toxicol. 1983 Feb. 25(1):16-22. [Medline].
Rusyniak DE, Furbee RB, Kirk MA. Thallium and arsenic poisoning in a small midwestern town. Ann Emerg Med. 2002 Mar. 39(3):307-11. [Medline].
LaDou J. Metals. Occupational and Environmental Medicine. 2nd ed. 1997. 429-30.
Wang C, Chen Y, Liu J, Wang J, Li X, Zhang Y, et al. Health risks of thallium in contaminated arable soils and food crops irrigated with wastewater from a sulfuric acid plant in western Guangdong province, China. Ecotoxicol Environ Saf. 2013 Apr. 90:76-81. [Medline].
Turner A, Furniss O. An evaluation of the toxicity and bioaccumulation of thallium in the coastal marine environment using the macroalga, Ulva lactuca. Mar Pollut Bull. 2012 Dec. 64(12):2720-4. [Medline].
Galván-Arzate S, Santamaría A. Thallium toxicity. Toxicol Lett. 1998 Sep 30. 99(1):1-13. [Medline].
Hasan M, Ali SF. Effects of thallium, nickel, and cobalt administration of the lipid peroxidation in different regions of the rat brain. Toxicol Appl Pharmacol. 1981 Jan. 57(1):8-13. [Medline].
Hultin T, Näslund PH. Effects of thallium (I) on the structure and functions of mammalian ribosomes. Chem Biol Interact. 1974 May. 8(5):315-28. [Medline].
Hazardous Substances Data Bank [Internet]. Bethesda (MD): National Library of Medicine (US); [Last Revision Date 2005 Jun 23; cited 2005 Nov 17]. Thallium, Elemental; Hazardous Substances Databank Number: 4496.
Atsmon J, Taliansky E, Landau M, et al. Thallium poisoning in Israel. Am J Med Sci. 2000 Nov. 320(5):327-30. [Medline].
Cvjetko P, Cvjetko I, Pavlica M. Thallium toxicity in humans. Arh Hig Rada Toksikol. 2010 Mar. 61(1):111-9. [Medline].
Al Hammouri F, Darwazeh G, Said A, Ghosh RA. Acute thallium poisoning: series of ten cases. J Med Toxicol. 2011 Dec. 7(4):306-11. [Medline].
Li JM, Wang W, Lei S, Zhao LL, Zhou D, Xiong H. Misdiagnosis and long-term outcome of 13 patients with acute thallium poisoning in China. Clin Toxicol (Phila). 2014 Mar. 52(3):181-6. [Medline].
McMillan TM, Jacobson RR, Gross M. Neuropsychology of thallium poisoning. J Neurol Neurosurg Psychiatry. 1997 Aug. 63(2):247-50. [Medline].
Tabandeh H, Thompson GM. Visual function in thallium toxicity. BMJ. 1993 Jul 31. 307(6899):324. [Medline].
Tromme I, Van Neste D, Dobbelaere F, et al. Skin signs in the diagnosis of thallium poisoning. Br J Dermatol. 1998 Feb. 138(2):321-5. [Medline].
Saha A, Sadhu HG, Karnik AB. Erosion of nails following thallium poisoning: a case report. Occup Environ Med. 2004 Jul. 61(7):640-2. [Medline].
Lu CI, Huang CC, Chang YC, Tsai YT, Kuo HC, Chuang YH, et al. Short-term thallium intoxication: dermatological findings correlated with thallium concentration. Arch Dermatol. 2007 Jan. 143(1):93-8. [Medline].
Moore D, House I, Dixon A. Thallium poisoning. Diagnosis may be elusive but alopecia is the clue. BMJ. 1993 Jun 5. 306(6891):1527-9. [Medline].
Liu CH, Lin KJ, Wang HM, Kuo HC, Chuang WL, Weng YH, et al. Brain fluorodeoxyglucose positron emission tomography (¹8FDG PET) in patients with acute thallium intoxication. Clin Toxicol (Phila). 2013 Mar. 51(3):167-73. [Medline].
Shamshinova AM, Ivanina TA, Yakovlev AA, et al. Electroretinography in the diagnosis of thallium intoxication. J Hyg Epidemiol Microbiol Immunol. 1990. 34(2):113-21. [Medline].
Hoffman RS. Thallium toxicity and the role of Prussian blue in therapy. Toxicol Rev. 2003. 22(1):29-40. [Medline].
Yang Y, Brownell C, Sadrieh N, et al. Quantitative measurement of cyanide released from Prussian Blue. Clin Toxicol (Phila). 2007 Oct-Nov. 45(7):776-81. [Medline].
Miller MA, Patel MM, Coon T. Prussian blue for treatment of thallium overdose in the US. Hosp Pharm. 2005. 40:796-7.
Misra UK, Kalita J, Yadav RK, et al. Thallium poisoning: emphasis on early diagnosis and response to haemodialysis. Postgrad Med J. 2003 Feb. 79(928):103-5. [Medline].
Huang C, Zhang X, Li G, Jiang Y, Wang Q, Tian R. A case of severe thallium poisoning successfully treated with hemoperfusion and continuous veno-venous hemofiltration. Hum Exp Toxicol. 2013 Jul 30. [Medline].
Ammendola A, Ammendola E, Argenzio F, et al. Clinical and electrodiagnostic follow-up of an adolescent poisoned with thallium. Neurol Sci. 2007 Aug. 28(4):205-8. [Medline].
Montes S, Soriano L, Ríos C, et al. Endogenous thiols enhance thallium toxicity. Arch Toxicol. 2007 Oct. 81(10):683-7. [Medline].
Sharma AN, Nelson LS, Hoffman RS. Cerebrospinal fluid analysis in fatal thallium poisoning: evidence for delayed distribution into the central nervous system. Am J Forensic Med Pathol. 2004 Jun. 25(2):156-8. [Medline].
Talas A, Wellhöner HH. Dose-dependency of Tl+ kinetics as studied in rabbits. Arch Toxicol. 1983 May. 53(1):9-16. [Medline].