History
Identifying toluene exposure or risk of exposure admission is important, as well as the route of exposure, whether inhalation, ingestion, or transdermal absorption. Any history of "huffing" or "bagging" before presentation, or a history of previous abuse of inhalants, should be elicited.
An occupational history should be taken, to identify workers whose occupation may result in nonintentional acute or chronic exposure. Examples of workers who may be at risk include the following:
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Painters
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Chemists
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Textile workers
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Gasoline refinery workers
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Rubber industry workers
Hobbies or activities that lead to nonintentional or intentional exposure should be reviewed. Model airplane glues and rubber cements are sources of toluene. Varnishes may affect people refinishing wooden furniture.
Toxicities and risks vary with the route of exposure, as follows:
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Ingestion may cause hematemesis and abdominal pain
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Inhalation is a risk for airway compromise secondary to aspiration and induction of bronchospasm; subsequent hypoxemia from chemical pneumonitis and acute lung injury also may occur
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Cutaneous exposure may result in coagulation necrosis unless copious skin irrigation is performed
The history should also identify other drugs that may be in the patient's system, including alcohol, cocaine or other stimulants. Alcohol intoxication and toluene intoxication have a similar presentations. Alcohol inhibits the metabolism of toluene and raises the concentration of toluene in the blood twofold. Cocaine, or any sympathomimetic use, may increase risks of fatal dysrhythmias.
Physical Examination
Physical examination is an important aid in confirming a suspected diagnosis of toluene poisoning. Patients with acute toluene poisoning may present with a range of pulmonary and central nervous system (CNS) symptoms, depending on duration of exposure, route of exposure, and level of toluene in the air or liquid.
Patients with chronic exposure may present with wide variety of complaints.
General /vital sign manifestations include the following:
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Patients may be tachypneic, tachycardic, and hypoxic on initial evaluation
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Hypotension may be present
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Fever may be present, secondary to aspiration pneumonitis
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Sweet smelling odor: Hair, breath, and clothing may smell of solvent; 20% of inhaled toluene is expired from the lungs unchanged
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Paint or oil stains may be seen on clothing
Head, eyes, ears, nose, and throat (HEENT) manifestations include the following:
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"Huffer's eczema": Perioral defatting dermatitis secondary to contact of solvent vapors with skin may be noted
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Mucosal irritation (eg, burning mouth, eyes, throat)
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Injected sclera
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Nystagmus
Neurologic manifestations are as follows:
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Decreased level of consciousness leading to coma
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Dizziness and headaches
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Confusion
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Hallucinations
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Amnesia
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Seizure activity
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Paresthesias (Toluene has anesthetic effects.)
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Decreased deep tendon reflexes
Cerebellar signs include the following:
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Decreased motor coordination
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Impaired fine motor movements
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Ataxia
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Balance problems
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Anesthesia
Pulmonary manifestations include the following:
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Respiratory distress
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Dyspnea
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Chest pain (with aspiration)
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Tachypnea
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Cyanosis
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Wheezing from bronchospasm
Gastrointestinal manifestations include the following:
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Nausea
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Vomiting
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Abdominal pain
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Hematemesis
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Jaundice
Dermatologic manifestations include the following:
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Itching or burns from skin contact
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Glue sniffer's rash (see in HEENT)
Musculoskeletal manifestations include the following:
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Profound muscle weakness due to hypokalemia
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Muscle pain
