Medical Care

For acute or emergency scenarios, symptomatic treatment is usually the mainstay of medical care. After emergency issues are addressed, reducing the intensity or eliminating exposure is the appropriate goal.

Reducing inhalation, ingestion, or dermatologic exposures may be accomplished by not eating or smoking in the workplace and by improving use of PPE, including masks and breathing apparatuses. Other protective measures are wearing gloves made of latex, Vicryl, or other impermeable material to limit skin absorption and by showering and changing clothes on completion of job tasks.
Changing the duration of exposure is also important. This may be accomplished by changing shifts and rotating jobs in a department.
Engineering controls, such as improving ventilation or shifting chemical processes to less-toxic substitutes, are other actions that the clinician might suggest.
Removal from exposure may follow a reduction of exposure if symptoms are severe, life threatening, or persistent. Reduction and/or removal are important diagnostic and treatment options. If symptoms abate after these steps, they better support the diagnosis of sequelae secondary to exposure than if they persist.
Clinicians should be willing to follow up their patients and to determine if their symptoms are improving compared with their relative exposure. A clinician must be willing to consider recommending a job change (eg, modified or restricted duty) to the employer. At that point, referral to appropriate specialists may be indicated.
Antidepressant medication, including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, have been helpful for managing the alterations of mood that may be part of the syndrome, as well as for reducing pain in patients with symptoms of peripheral neuropathy.
Psychological counseling, brain rehabilitation, and physical and occupational therapy may be appropriate.

Consultations

The patient may be referred to an internist, occupational medicine specialist, ophthalmologist, neuropsychologist, neuromuscular or behavioral neurologist, or other specialists depending on the specifics of the case.

Medication

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Table 1. Organic Solvents and Their Common Industrial Uses

Compound	Industrial Uses
Acetone	Cleaning solvent
Acrylamide	Mining and tunneling, adhesives, waste treatment, ore processing
Benzene	Fuel, detergents, paint removers, manufacture of other solvents
Carbon disulfide	Viscose rayon, explosives, paints, preservatives, textiles, rubber cement, varnishes, electroplating
Ethylene oxide (ETO)	Instrument sterilization
N- hexane	Glues and vegetable extraction, components of naphtha, lacquers, metal cleaning compounds
Hydrogen sulfide	Sulfur chemical manufacturing, by-product of petroleum processing, decay of organic matter
Methane	Industrial settings
Methyl mercaptan	Odorant in natural gas and fuels
Methyl-N- butyl ketone	Many industrial uses
Methylene chloride (dichloromethane)	Solvent, refrigerant, propellant
Organochlorine	Insecticides
Organophosphates	Insecticides
PCE	Dry cleaning, degreaser, textile industry
Styrene	Fiberglass component, ship building
Toluene	Paint, fuel oil, cleaning agents, lacquers, paints and paint thinners
1,1,1-Trichloroethane (methyl chloroform)	Degreaser and propellant
TCE	Cleaning agent, paint component, decaffeination, rubber solvents, varnish
Vinyl chloride	Intermediate for polyvinylchloride resins for plastics, floor coverings, upholstery, appliances, packaging
Xylene	Paint, lacquers, varnishes, inks, dyes, adhesives, cements, fixative for pathologic specimens

Table 2. Exposure levels Believed Safe for Workers

Compound	Urine	Blood	Expired Air
Acetone	Acetone, formic acid 100 mg/L	Acetone	Acetone
Benzene	Total phenol 50 mg/g at the end of the shift, trans-trans- muconic acid	Benzene	Benzene before shift, 0.08 ppm; end exhaled, 0.12 ppm
Carbon disulfide	2-TTCA 5 mg/g^*	Carbon disulfide	Carbon disulfide
ETO	None	None	None
N- hexane	2,5-hexanediol 5 mg/g at the end of the shift, 2-hexanol, total metabolites	N- hexane	N- hexane
Hydrogen sulfide	None	None	None
Methane	None	None	None
Methyl mercaptan	None	None	None
Methanol	Formic acid 80 mg/g at the start of the work week, methanol 15 mg/g at the end of the shift	None	Methanol
Methyl-N- butyl ketone	None	2,5-hexane dione	None
Methylene chloride	None	MeCl₂	MeCl₂
Organochlorine	None	None	None
Organophosphates	None	None	None
PCE	PCE, trichloroacetic acid	PCE 1 mg/L	PCE 10 ppm before the last shift of the week
Styrene	End of the shift: mandelic acid (MA) 800 mg, phenylglyoxylic acid (PGA) 240 mg/g) Before shift: MA 300 mg/g or PGA 100 mg/g	Styrene 0.02 mg/L at the start of the shift, 0.55 mg/L at the end of the shift	None
Toluene	Hippuric acid	Toluene	Toluene
1,1,1-Trichlorethane (methyl chloroform)	TCA 10 mg/L at the end of the work week; total trichloroethanol at the end of the shift and at the end of the work week, 30 mg/L	Total trichloroethanol 1 mg/L	Methyl chloroform 40 ppm before the last shift of the work week
TCE	TCE, TCA 100 mg/g at the end of the work week or TCA plus trichloroethanol 300 mg/g	TCE at the end of the work week 4 mg/L	TCE
Vinyl chloride	None	None	None
Xylene	Methylhippuric acid 1.5 g/g at the end of the shift	Xylene	Xylene
^* TTCA - 2-thiothiazolidine 4-carboxylic acid.

Table 3. Recommended Exposure Limits, Organic Solvents

Compound	ppm, mg/m,³
Compound	OSHA PEL as TWAs	NIOSH REL as TWAs, IDLH	ACGIH TLV, STEL
Acetone	1000 (2400)	250 (590), 2500	750 (1780) ceiling, 1000 (2380)
Acrylamide	0.3	(0.03), 60 level for carcinogenicity	None
Benzene	10, 25 ceiling, 50 for 10 min	0.1, STEL 1, 500	10 (32)
Carbon disulfide	20, 30, 100 for 30 min	1 (3), 10 STEL (30), 500	10 (31)
ETO		< 0.1, < 0.18, 5 ceiling, 800	1 (1.8)
N- hexane	500 (1800)	50 (180), 1100	50 (176)
Hydrogen sulfide	20 ceiling, 50 for 10 min once only	10 ceiling, (15) for 10 min, 100	None
Methyl mercaptan	10 ceiling (20)	0.5 ceiling, (1) for 15 min, 150	None
Methanol	200 (260)	200 (260), 250 STEL (325), 6000	262 (200), 328 (250)
Methyl-n- butyl ketone	100 (410)	None	5 (20)
Methylene chloride	25, 15 STEL for 15 min	2300 level for carcinogenicity	50 (174) ceiling
Perchloroethylene	100, 200 ceiling, 300 for 5 min in 3 h	150 level for carcinogenicity	25 (170), 100 (685)
Styrene	100, 200 ceiling, 600 for 5 min in 3 h	50 (215), 100 ST (425), 700	50 (213), 100 (428)
Toluene	200, 300, 500 for 10 min	100 (375), 150 STEL (560), 500	50 (188)
1,1,1-Trichlorethane (methyl chloroform)	350 (1900)	Ceiling 350 (1900) for 15 min, 700	350 (1910), 450 (2460)
Trichloroethylene	100, 200 ceiling, 300 for 5 min in 2 h	1000 level for carcinogenicity	50 (269), 100 (1070)
Vinyl chloride	1, 5 for 15 min	Not determined	None
Xylene	100 (435)	100 (435), 150 STEL (655)	100 (434),150 (651)
Abbreviations—ACGIH = American Congress of Governmental Industrial Hygienists, IDLH = Immediately dangerous to life or health; NIOSH = National Institute for Occupational Safety and Health, OSHA = Occupational Safety and Health Administration, PEL = permissible exposure limit, REL = recommended exposure limit; STEL = short-term exposure limit; TWA = time-weighted average.

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Author

Jonathan S Rutchik, MD, MPH, FACOEM Associate Clinical Professor, Division of Occupational Medicine, Department of Medicine, University of California, San Francisco, School of Medicine; Neurology, Environmental and Occupational Medicine Associates (www.neoma.com)

Jonathan S Rutchik, MD, MPH, FACOEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Occupational and Environmental Medicine, International Parkinson and Movement Disorder Society, Society of Toxicology, Western Occupational and Environmental Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University in St Louis School of Medicine; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS † Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, American College of International Physicians, American College of Physicians, American Heart Association, American Stroke Association, National Association of Managed Care Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Roberta J Seidman, MD Associate Professor of Pathology, Director of Neuropathology, Department of Pathology, Renaissance School of Medicine at Stony Brook University, Stony Brook Medicine

Roberta J Seidman, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuropathologists, New York Association of Neuropathologists (The Neuroplex)

Disclosure: Nothing to disclose.

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