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Table. Typical Presentation of the Most Commonly Encountered Metals and Their Treatment

Table. Typical Presentation of the Most Commonly Encountered Metals and Their Treatment

Metal	Acute	Chronic	Toxic Concentration	Treatment
Arsenic	Nausea, vomiting, "rice-water" diarrhea, encephalopathy, MODS, LoQTS, painful neuropathy	Diabetes, hypopigmentation/ hyperkeratosis, cancer: lung, bladder, skin, encephalopathy	24-h urine: ≥50 µg/L urine, or 100 µg/g creatinine	BAL (acute, symptomatic) DMSA (succimer) DMPS (Europe)
Bismuth	Acute kidney injury; acute tubular necrosis	Diffuse myoclonic encephalopathy	No clear reference standard	*
Cadmium	Pneumonitis (oxide fumes)	Proteinuria, lung cancer, osteomalacia	Proteinuria and/or ≥15 µg/ g creatinine	*
Chromium	GI hemorrhage, hemolysis, acute renal failure (Cr⁶⁺ ingestion)	Pulmonary fibrosis, lung cancer (inhalation)	No clear reference standard	NAC (experimental)
Cobalt	Beer drinker’s (dilated) cardiomyopathy	Pneumoconiosis (inhaled); goiter	Normal excretion: 0.1-1.2 µg/L (serum) 0.1-2.2 µg/L (urine)	NAC CaNa₂ EDTA
Copper	Blue vomitus, GI irritation/ hemorrhage, hemolysis, MODS (ingested); MFF (inhaled)	vineyard sprayer’s lung (inhaled); Wilson disease (hepatic and basal ganglia degeneration)	Normal excretion: 25 µg/24 h (urine)	BAL D-Penicillamine DMSA (succimer)
Iron	Vomiting, GI hemorrhage, cardiac depression, metabolic acidosis	Hepatic cirrhosis	Nontoxic: < 300 µg/dL Severe: >500 µg/dL	Deferoxamine
Lead	Nausea, vomiting, encephalopathy (headache, seizures, ataxia, obtundation)	Encephalopathy, anemia, abdominal pain, nephropathy, foot-drop/ wrist-drop	Pediatric: symptoms or [Pb] ≥45 µ/dL (blood); Adult: symptoms or [Pb] ≥70 µ/dL	BAL CaNa₂ EDTA DMSA (succimer)
Manganese	MFF (inhaled)	Parkinson-like syndrome, respiratory, neuropsychiatric	No clear reference standard	*
Mercury	Elemental (inhaled): fever, vomiting, diarrhea, ALI; Inorganic salts (ingestion): caustic gastroenteritis	Nausea, metallic taste, gingivo-stomatitis, tremor, neurasthenia, nephrotic syndrome; hypersensitivity (Pink disease)	Background exposure "normal" limits: 10 µg/L (whole blood); 20 µg/L (24-h urine)	BAL DMSA (succimer) DMPS (Europe)
Nickel	Dermatitis; nickel carbonyl: myocarditis, ALI, encephalopathy	Occupational (inhaled): pulmonary fibrosis, reduced sperm count, nasopharyngeal tumors	Excessive exposure: ≥8 µg/L (blood) Severe poisoning: ≥500 µg/L (8-h urine)	*
Selenium	Caustic burns, pneumonitis, hypotension	Brittle hair and nails, red skin, paresthesia, hemiplegia	Mild toxicity: [Se] >1 mg/L (serum); Serious: >2 mg/L	*
Silver	Very high doses: hemorrhage, bone marrow suppression, pulmonary edema, hepatorenal necrosis	Argyria: blue-grey discoloration of skin, nails, mucosae	Asymptomatic workers have mean [Ag] of 11 µg/L (serum) and 2.6 µg/L (spot urine)	Selenium, vitamin E (experimental)
Thallium	Early: Vomiting, diarrhea, painful neuropathy, coma, autonomic instability, MODS Late: Alopecia, Mees lines, residual neurologic symptoms	Alopecia, neuropathy	Toxic: >3 µg/L (blood)	MDAC Prussian blue
Zinc	MFF (oxide fumes); vomiting, diarrhea, abdominal pain (ingestion)	Copper deficiency: anemia, neurologic degeneration, osteoporosis	Normal range: 0.6-1.1 mg/L (plasma) 10-14 mg/L (red cells)	*
*No accepted chelation regimen; contact a medical toxicologist regarding treatment plan. MODS, multi-organ dysfunction syndrome; LoQTS, long QT syndrome; ALI, acute lung injury; ATN, acute tubular necrosis; ARF, acute renal failure; DMPS, 2,3-dimercapto-1-propane-sulfonic acid; CaNa₂ EDTA, edetate calcium disodium; MDAC, multi-dose activated charcoal; NAC, N-acetylcysteine; DMSA (succimer), dimercaptosuccinic acid.

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Author

Adefris Adal, MD, MS Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Samara Soghoian, MD, MA Clinical Assistant Professor of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center

Samara Soghoian, MD, MA is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.