Toluene Toxicity Treatment & Management

Administer supportive care, including supplemental oxygen, as soon as possible at the scene. If a patient is not breathing, administer ventilatory support with a bag valve mask. Avoid mouth-to-mouth breathing because 20% of toluene is expired unchanged, and the rescuer may be overcome by direct inhalation of fumes.

Upon discovery of the patient, remove the patient's clothing because the clothes may have additional solvent on them, which is harmful to the patient and rescue workers. Examine the skin for burns so that irrigation, if needed, can begin immediately.

Remove the patient from the area of contamination because toxic fumes may overcome rescue workers.

Immediate irrigation of the skin, eyes, and mucous membranes at the scene greatly reduces skin damage (eg, coagulation necrosis from prolonged contact).

Treatment is supportive, as follows:

• Administer supplemental oxygen.

• Make certain that intubation equipment is available at the bedside; although the patient's airway is usually not in jeopardy, consider intubation in patients with increasing respiratory distress, decreased level of consciousness, inability to protect their own airway, predicted worsening clinical course, and risk of aspiration from ingestion.

• Observe patients for tachypnea and obtain arterial blood gas levels to monitor for signs of metabolic acidosis, hypoxia, and hypercarbia.

• Follow advanced cardiac life support (ACLS) protocols for patients with arrhythmias, if needed; central line placement may be necessary for patients requiring ACLS interventions or defibrillation following ventricular fibrillation or significant hypotension.

• Cardioversion of dysrhythmias induced by toluene exposure may be necessary.

• Propranolol and esmolol have both been used successfully in treatment of ventricular dysrhythmias from inhalant abuse.

• Establish intravenous (IV) access for administration of fluids or medicines with two large-bore peripheral IV sites, or obtain central venous access, if needed.

• Use fluid boluses, if necessary, to maintain blood pressure; use IV fluid boluses with normal saline or lactated Ringer solution at 20 mL/kg to maintain blood pressure and to ensure adequate urinary output.

• Careful use of vasopressors to support blood pressure can be considered, sympathomimetic agents may increase risk of developing dysrhythmias and should be used with caution.

• Replete potassium, calcium, and phosphorus losses caused by effects of toluene, if necessary; use sodium bicarbonate in cases of severe acidosis or in patients identified to have non–anion gap acidosis due to renlal tubular acidosis.

• Do not assume that adequate irrigation of contaminated skin was achieved in the field; copiously irrigate wounds to reduce potential burn damage and coagulation necrosis.

• Monitor urinary output and kidney functions to avoid acute kidney injury from myoglobinemia secondary to rhabdomyolysis.

• Consider gastric decontamination with nasogastric (NG) tube gastric lavage for patients who are symptomatic and who present soon after ingestion of toluene

Consider admitting patients with toluene exposure or abuse for observation and treatment if they have any of the following:

• Electrolyte abnormalities
• ECG abnormalities such as dysrhythmia or prolonged QT interval
• Hypoxia
• Seizures
• Rhabdomyolysis
• Persistent mental status changes

Patients with continuing respiratory, cardiac, and renal problems may need to be admitted to a critical care unit. Transfer patients to a facility with critical care if they require critical care monitoring and are admitted to a hospital without sufficient ICU facilities.

Patients who have no laboratory abnormalities and who demonstrate improved mental status (asymptomatic, back to baseline) may be discharged from the ED after 4-6 hours of observation, with the following instructions:

• Arrange for follow-up care with the primary care physician within 1-3 days
• Advise patients and families to return to the ED if changes in mental status, decreased urine output, abdominal pain, muscle pain or weakness, shortness of breath, chest pain, or choking sensation occur
• Arrange substance abuse counseling for abusers, although the relapse rate is extremely high
• Refer long-term abusers with no laboratory abnormalities and improved mental status to a drug rehabilitation program

Consult the regional poison control center or local medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations.

Pursue pulmonary consultation for patients with respiratory compromise or complications from aspiration. Consult cardiology department personnel for patients with ventricular dysrhythmias or cardiac arrest. Consult with ear, nose, and throat (ENT) and/or plastic surgery specialists if significant burns or irritation of the mucous membranes are present on the face or significant dermal burns are observed on the rest of the body. Consult neurology for patients with neurological or cognitive deficits from chronic exposure.

Advise workers with occupational exposure not to work in poorly ventilated enclosed rooms.

Inform chronic glue sniffers of the long-term sequelae and consequences associated with abuse.