Toluene poisoning

Substance

Toluene

Common name or Trade name

- 甲苯 C7H8

- 從原油中提煉出來

- 用於油漆類, 黏著劑, 指甲油, 塗料, 清潔劑裡 [1]

 Involving system

- heart : life-threatening dysrhythmias, such as ventricular tachycardia and ventricular fibrillation. Bradycardia [2] , longer QT in chronic poisoning [3]

- hematopoietic: aplastic anemia, acute myelogenous leukemia, and multiple myeloma. [4]

- liver: hepatitis [5].

- kidney: metabolic acidosis. [6]

- neurology : headache, and causes euphoria followed by depression

- pulmonary system: destroying alveolar and capillary membranes. This results in vascular permeability and edema.

- muscle: causes hypokalemia leading to muscle weakness and if low enough, muscle paralysis. Rhabdomyolysis is a common complication (80%). [3]

Presentation 

 - 頭痛、恍惚與喪失記憶, ataxia, lethargy and coma. Dizziness, confusion, [1]

 - SOB, Wheezing . 

 - Ventricular arrhythmias. [2] 

 - Nausea, abdominal pain, vomiting.

 - Muscle weakness and paralysis, and rhabdomyolysis 

Antidote and Treatment

- no specific antidote 

- No benefit to gastric lavage or activated charcoal 

- 20%直接由肺的呼吸而排出，有些甲苯會代謝成更具水溶性、且毒性較低的馬尿酸 (hippuric acid) 經由尿液排出 

- Secure airway. 

- oxygen if SOB, wheezing. 

- Broncho-dilator. Beta-2 agonist. 

- MV support if respiratory failure. 

- IVF for hypotension / observation. 

- treat arrhythmia according to ACLS

 Disposition 

- depends on intoxicated dose.

- ICU when altered mental state, renal failure, severe acidemia [3]

- female gender could be associated with a poor outcome [3]

References

[1]. Filley CM. Toluene abuse and white matter: a model of toxic leukoencephalopathy. Psychiatr Clin North Am. 2013;36(2):293‐302. doi:10.1016/j.psc.2013.02.008

[2]Einav S, Amitai Y, Reichman J, Geber D. Bradycardia in toluene poisoning. J Toxicol Clin Toxicol. 1997;35(3):295‐298. doi:10.3109/15563659709001214

[3]. Peckham T, Kopstein M, Klein J, Dahlgren J. Benzene-contaminated toluene and acute myeloid leukemia: a case series and review of literature. Toxicol Ind Health. 2014;30(1):73‐81. doi:10.1177/0748233712451764

[4]. Park CK, Kwon KT, Lee DS, et al. Taehan Kan Hakhoe Chi. 2003;9(4):332‐336.

[5]. Kamijima M, Nakazawa Y, Yamakawa M, et al. Metabolic acidosis and renal tubular injury due to pure toluene inhalation. Arch Environ Health. 1994;49(5):410‐413. doi:10.1080/00039896.1994.9954994

[6]. Camara-Lemarroy CR, Rodríguez-Gutiérrez R, Monreal-Robles R, González-González JG. Acute toluene intoxication--clinical presentation, management and prognosis: a prospective observational study. BMC Emerg Med. 2015;15:19. Published 2015 Aug 18. doi:10.1186/s12873-015-0039-0

~~ May 22, 2020 Yu-Jang Su