Nathanael J McKeown, DO Assistant Professor, Department of Emergency Medicine, Oregon Health and Science University School of Medicine; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center [Full Text]. [Medline]. Pulmonary manifestations include the following: Gastrointestinal manifestations include the following: Dermatologic manifestations include the following: Musculoskeletal manifestations include the following: Profound muscle weakness due to hypokalemia. White V, Hayman J. Australian secondary students’ use of over-the-counter and illicit substances in 2002. Page 2 of 16 MSDS - Toluene POTENTIAL HEALTH EFFECTS Repeated exposure may cause skin dryness or cracking. NFPA Hazard ID: Health: 2 Flammability: 3 Reactivity: 0 United States Department of Health and Human Services. This is a free and confidential service. Subst Use Misuse. Identifying toluene exposure or risk of exposure admission is important, as well as the route of exposure, whether inhalation, ingestion, or transdermal absorption. 6-MP acted on by xanthine oxidase (XO), thiopurine methyltransferase (TPMT), leading to inactive metabolites. His temperature is 103°F (39.4°C), blood pressure is 167/105 mmHg, and pulse is 122/min. Procedures, 2002 2014. Glue sniffing is a form of addiction largely due to the effects of the substance toluene within these preparations. Here is a list of 15 common medical conditions from the ABIM Learning Objectives and their associated reflexes. This is seen among people working in may different occupations. In children this is largely seen as learning difficulties. Serious adverse behavioural effects are often associated with chronic occupational exposure and toluene abuse related to the deliberate inhalation of solvents. 2005 Jun. 21(3):247-51. Glue-sniffing and distal renal tubular acidosis: sticking to the facts. Shen … However, glue is often the preferred substance because it is easy to access and cheap. Efficacy and toxicity of 6-MP correlated with 6-TGN. 2007. 2007 Jun-Aug. 45(5):557-62. . [Medline]. It dissolves other substances easily and evaporates quickly into the air. The signs and symptoms of toluene depends on the quantity and duration of exposure. This website also contains material copyrighted by 3rd parties. 24(7):434-8. Neurosci Biobehav Rev. Deaths associated with inhalant abuse in Virginia from 1987 to 1996. Toluene specifically causes renal tubular acidosis. Broberg K, Tinnerberg H, Axmon A, Warholm M, Rannug A, Littorin M. Influence of genetic factors on toluene diisocyanate-related symptoms: evidence from a cross-sectional study. Defatting refers to the loss of fat tissue in an area leading to creasing, cracking and irritation of the skin (irritant contact dermatitis). Seth R, Kotwal A, Ganguly KK. Toluene misuse and long-term harms: a systematic review of the neuropsychological and neuroimaging literature. 2002 Effects of the abused inhalant toluene on the mesolimbic dopamine system. It involves voluntarily inhalation of glue or a rag soaked in glue to induce a sense of euphoria. Toluene embryopathy: delineation of the phenotype and comparison with fetal alcohol syndrome. The determination of toluene in air has consistently been one of the top analyses performed at the OSHA Salt Lake Technical Center (SLTC) for the last 25 years. 33(3):253-60. treatment of withdrawal. 1363-76. Cruz SL, Rivera-García MT, Woodward JJ. 2014. An occupational history should be taken, to identify workers whose occupation may result in nonintentional acute or chronic exposure. Mild to moderate exposure requires no significant measures and symptoms pass in a short period of time. Addiction may not be easily attributed to toluene if the abuser does not divulge their glue sniffing habits. Various diagnostic tests are conducted to monitor the effects of toluene exposure. Drug Saf. According to the police report, the patient had fallen several times during an altercation with another bar patron. [Medline]. Here it is: 14-year old boy has headaches for 2 months. 2012 Jun. Gagnaire F, Langlais C. Relative ototoxicity of 21 aromatic solvents. Firstly there may be dermatitis (a generalized skin rash as a result of skin inflammation) to chemical burns on the skin. 2008 Jul. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Diseases & Conditions, 2002 Inhalant deaths in South Australia: a 20-year retrospective autopsy study. Please confirm that you would like to log out of Medscape. Toluene is a colorless substance with a sweet odor. Cardiac toxicity encompasses myocardial edema, irreversible myocarditis, fibrosis, and congestive heart failure.8 Respiratory damage often is related to toluene … Acid-base disorders are a group of conditions characterized by changes in the concentration of hydrogen ions (H +) or bicarbonate (HCO 3-), which lead to changes in the arterial blood pH.These conditions can be categorized as acidoses or alkaloses and have a respiratory or metabolic origin, depending on the cause of the imbalance. Siqueira LM, Crandall LA. The hallmarks of toluene intoxication are distal renal tubular acidosis type 1 (RTA-1), classically described as hyperchloremic with a normal anion-gap, as well as hypokalemia and muscle paralysis [14]. Toluene (methyl benzene) is a chemical that is widely used in various substances within the home such as glue, paint and paint removers, and polish. 79(6):346-54. Arch Toxicol. J Drug Alcohol Res. The complete list of topics covered (chapter titles) is shown at the lef… High anion gap metabolic acidosis is a form of metabolic acidosis characterized by a high anion gap (a medical value based on the concentrations of ions in a patient's serum). overdose presents with somnolence, miosis, and bradycardia. Vasopressors, propanolol and esmolol to restore blood pressure and heart rhythm. September 9, 2012; Accessed: January 21, 2017. If you log out, you will be required to enter your username and password the next time you visit. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Specific Target Organ Toxicity – Repeated exposure, categories 1,2 Aspiration Hazard, category 1 . Snapshot: A 22-year-old male is brought in by police after being removed forcefully from a bar. It is not only toluene that has these host of effects on the body. These skin symptoms may not necessarily be due to toluene but instead caused by other chemicals also present in glue and pain. Medina-Mora ME, Real T. Epidemiology of inhalant use. 2004. Hello, I am trying to find the explanation for one question on the nbme but I cannot. Thiesen FV, Noto AR, Barros HM. Parental Occupational Exposure to Organic Solvents and Testicular Germ Cell Tumors in their Offspring: NORD-TEST Study. Toluene, also known as "methylbenzene", "phenylmethane" or "toluol" is a clear, colorless liquid with a sweet smell. Flanagan RJ, Ruprah M, Meredith TJ, Ramsey JD. In the long term, glue sniffing has a host of serious effects on every system of the body and can ultimately lead to death. Cámara-Lemarroy CR, Gónzalez-Moreno EI, Rodriguez-Gutierrez R, González-González JG. Pediatrics. His mother says that "he has not been himself" for the last few months. unpleasant but not life-threatening. Small amounts of toluene may have little to no noticeable effect. Toluene toxicity can also arise with skin contact and ingestion. The mechanism by which toluene produces systemic toxicity is not known. Levels of 50mg/L and above are often fatal but this also depends on the age, weight and health status of the person. 6-MP acted on by enzymes to make 6-thioguanine nucleotides (6-TGN). Milder symptoms pass within minutes to hours after exposure is discontinued. There is no specific medication for treating toluene toxicity. 1120-24. Toluene is a colorless substance with a sweet odor. Acute intoxication causes a variety of neurologic effects that depend on the amount of exposure. 2008 May. September 2015; Accessed: January 21, 2017. Review of toluene action: clinical evidence, animal studies and molecular targets. This arises with chemical exposure. 3:[Medline]. Start studying USMLE Step 1- Drug Abuse Cards. Other pertinent literature is also presented, but is described in less detail than the key studies. Toluene is one of the most widely abused inhaled drugs due to its acute neurologic effects including euphoria and subsequent depression. Levels of 50mg/L and above are often fatal but this also depends on the age, weight and health status of the person. Laboratory diagnosis of toluene-based inhalants abuse. [Medline]. 7th ed. Patients with chronic exposure may present with wide variety of complaints. More serious symptoms require immediate medical attention. The history should also identify other drugs that may be in the patient's system, including alcohol, cocaine or other stimulants. Ellenhorn's Medical Toxicology. ation [20]. 40(11):1659-79. A rag is soaked with glue or spray paint and then inhaled. Toluene is the main component of organic solvents and is blamed for the acute and chronic toxic neurologic effects of solvent inhalation. An introduction to the clinical toxicology of volatile substances. Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine and Medical Toxicology, Excela Health System Toluene may also cause significant renal damage especially with chronic use. Irrigation (“washing out”) of the skin at points of contact with toluene-containing substances. Absence of hepatic uptake of Tc-99m phytate in a man with chronic toluene hepatotoxicity. Available at https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Environ Health. Drug Alcohol Depend. This national hotline number will let you talk to experts in poisoning. Foster City, CA: Biomedical Publications; 2004. The skin also becomes more prone to secondary infections. It is more common among children and adolescents. Kidney damage Clin Nucl Med. Toluene. The typical metabolic profile is a normal anion gap hyperchloremic acidosis with hypokalemia and a urine pH of 5.5. Blood tests to measure the levels of toluene in the blood are often a long process and has to be done in specialized laboratories. Toluene Poisoning is the accidental or intentional intake of … Carlisle EJ, Donnelly SM, Vasuvattakul S, Kamel KS, Tobe S, Halperin ML. May cause central nervous system depression. The high anion gap is probably a consequence of its metabolism to hippuric acid. 3:[Medline]. Cocaine, or any sympathomimetic use, may increase risks of fatal dysrhythmias. Diagnosis is made by arterial blood gas interpretation. [Medline]. [Medline]. 2018 Dec. 56 (12):1213-1415. All material on this website is protected by copyright, Copyright © 1994-2020 by WebMD LLC. Biol Trace Elem Res. Another common method of administration is to place glue into flimsy plastic bottles and inhaling through the mouth. Irregular heartbeat; Low blood pressure (shock) KIDNEYS. Safety and Health topics: Toluene. http://emedicine.medscape.com/article/818939-overview, Please note that any information or feedback on this website is not intended to replace a consultation with a health care professional and will not constitute a medical diagnosis. 2005. Acute Alcohol Intoxication. July 30, 2013 / SUNIRKUMAR, When preparing for the ABIM Internal Medicine board examination, realize that noting the reflexes mentioned in a clinical vignette can serve as a high-yield clue and often help narrow down the differential. Toluene’s metabolites, hippuric acid and benzoic acid, are possibly the cause for … Toluene exposure can be unintentional or intentional. Physical examination is an important aid in confirming a suspected diagnosis of toluene poisoning. Gastric lavage (“stomach pumping”) for patients who have ingested toluene-containing substances. Inhalation is the primary route of toluene exposure, but significant amounts can be absorbed through ingestion and dermal contact. Glue sniffing deaths in Singapore--volatile aromatic hydrocarbons in post-mortem blood by headspace gas chromatography. Yucel M, Takagi M, Walterfang M, Lubman DI. Clinical presentation and management in acute toluene intoxication: a case series. 1991 Feb. 1 (8):1019-27. J Am Soc Nephrol. Review toluene properties for your laboratory applications, and find HPLC toluene, ACS toluene, anhydrous toluene and other grades. Bowen SE, Daniel J, Balster RL. However, toluene also affects a host of other systems. However, long term exposure with addiction may lead to permanent complications. 0. Unintentional chronic exposure to toluene is mainly seen among workers handling substances that contain the chemical. IV administration of fluids and electrolytes as needed. 105(1-3):197-203. Generalized symptoms that may be noticeable to others include : More organ and system specific signs of toluene exposure includes : Many of the symptoms of acute and chronic toluene exposure can be attributed to various other, and more common, diseases. [Medline]. 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. Summary. Toxicities and risks vary with the route of exposure, as follows: Ingestion may cause hematemesis and abdominal pain, 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, Cutaneous exposure may result in coagulation necrosis unless copious skin irrigation is performed. 4-15 6-Mercaptopurine (6-MP) used to treat acute lymphoblastic leukemia (ALL). No information was found to suggest that the health effects of toluene in children are different than in adults. However, there is usually characteristic skin symptoms associated with touching and handling strong glues and paint that contains toluene. Race-, Sex-, and Age-related Demographics, https://www.osha.gov/dts/chemicalsampling/data/CH_272200.html, https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf, American Society of Health-System Pharmacists. 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 325574-overview Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. Inhalant use in Florida youth. Med Sci Law. Bloody stools; Abdominal pain (severe) Loss of appetite; Nausea; Vomiting (may be bloody) HEART AND BLOOD VESSELS. 1493-5. The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Kevin A Martin, MD, to the development and writing of this article. Toluene is also highly flammable and may catch on fire if exposed to heat or flames. On physical exam, the patient is highly alert, agitated, and diaphoretic. Due to its volatility, it passes into the atmosphere and is therefore easily inhaled. 325451-overview [Full Text]. [Medline]. Review Topic. (Ref. 1011549-overview [Medline]. Sometimes these substances may be unintentionally ingested, which is mainly seen among infants and young children. It is a toxic chemical that is sometimes used illegally as a recreational inhalant. Toluene, the main component of volatile glues, lacquer thinners and aerosol paints is the chemical responsible for most clinical toxicity. Model airplane glues and rubber cements are sources of toluene. It is also widely used for various industrial purposes. Chao TC, Lo DS, Koh J, et al. 814701-overview (EEG) studies performed during acute toluene intoxication, demonstrated low amplitude slow wave activity in the bilat-eral parieto-occipital regions, which resolved several days. Toluene naturally occurs in crude oil at low levels and, as such, toluene is typically generated during the process of making fuels from crude oil. 5.1) Samples were collected by drawing air through glass tubes 4th ed. 2008 Apr 30. [Medline]. Gummin DD, Mowry JB, Spyker DA, Brooks DE, Osterthaler KM, Banner W. 2017 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 35th Annual Report. When addiction is suspected, various tests to detect the use of other more commonly abused substances are often conducted. [Medline]. Your local poison control center can be reached directly by calling the national toll-free Poison Help hotline (1-800-222-1222) from anywhere in the United States. Due to its ability to cross the blood brain barrier and affect the central nervous system, it is an important chemical in everyday substances that can induce as sense of euphoria among other neurological disruption. Toluene is added to gasoline, used to produce benzene, and used as a solvent. clonidine. In the ED, he is agitated and cannot follow questions. Small amounts of toluene may have little to no noticeable effect. Glue sniffing is a global problem mainly among children. Some specific hydrocarbons also are associated with hematologic disorders, including benzene and naphthalene. 1993 Aug. 18(8):655-6. Alcohol intoxication and toluene intoxication have a similar presentations. Baselt RC, ed. Damian Apollo 0 % Topic. Head, eyes, ears, nose, and throat (HEENT) manifestations include the following: "Huffer's eczema": Perioral defatting dermatitis secondary to contact of solvent vapors with skin may be noted, Mucosal irritation (eg, burning mouth, eyes, throat). In the acute setting, there is usually no permanent consequences. Disposition of Toxic Drugs and Chemicals in Man. [Medline]. Inhal Toxicol. [Full Text]. 1994 Feb. 93(2):211-5. Identifying toluene exposure or risk of exposure admission is important, as well as the route of exposure, whether inhalation, ingestion, or transdermal absorption. Wick R, Gilbert JD, Felgate P, Byard RW. John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System PharmacistsDisclosure: Nothing to disclose. 1993 Jul. General /vital sign manifestations include the following: Patients may be tachypneic, tachycardic, and hypoxic on initial evaluation, Fever may be present, secondary to aspiration pneumonitis, Sweet smelling odor: Hair, breath, and clothing may smell of solvent; 20% of inhaled toluene is expired from the lungs unchanged, Paint or oil stains may be seen on clothing. Sniffing glue is one of the more dangerous forms of getting a high, with several life-threatening side effects and many short- and long-term health … Varnishes may affect people refinishing wooden furniture. PDF Version, 13MB Toxicological Profile Information The ATSDR toxicological profile succinctly characterizes the toxicologic and adverse health effects information for the hazardous substance described here. Am J Forensic Med Pathol. Lipincott Williams & Wilkins: 1997. Occupational Safety and Health Administration. It includes workers handling glue, paint, show polish, gasoline, carpenters and artists. Blurred vision; Burning pain; Hearing loss; STOMACH AND INTESTINES. Toluene is metabolized by cytochrome p-450 into benzoic acid and hippuric acid, these are excreted by the kidney [8, 9]. J Drug Alcohol Res. In high doses, it can be toxic. Available at https://www.osha.gov/dts/chemicalsampling/data/CH_272200.html. 53(3):239-45. Other toluene-containing substances could be used for a similar purpose. Examples of workers who may be at risk include the following: Hobbies or activities that lead to nonintentional or intentional exposure should be reviewed. Below are symptoms of toluene and xylene poisoning in different parts of the body. Peak blood concentrations occur 15 to 30 minutes after inhalation. [Medline]. Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. Bone mass toxicity associated with inhalation exposure to toluene. 1999 Feb 1. Neurologic manifestations are as follows: Decreased level of consciousness leading to coma, Paresthesias (Toluene has anesthetic effects.). Toxicity usually starts at blood levels around 2.5mg/L. They will give you further instructions. 2006 Dec. 27(4):27-35. Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency MedicineDisclosure: Nothing to disclose. Toluene is volatile meaning that it disperses into the air and can thereby be inhaled. Toluene is a hydrocarbon that is present as a clear, colorless liquid at room temperature, with a characteristic smell. United States Department of Labor. Fred Harchelroad, MD, FACMT, FAAEM, FACEP is a member of the following medical societies: American College of Medical ToxicologyDisclosure: Nothing to disclose. Atay AA, Kismet E, Turkbay T, Kocaoglu M, Demirkaya E, Sarici SU, et al. Clinical features of acute intoxication with toluene were first described in 1963 . 8.6.4 Toluene toxicity Inhalation of toluene (eg by 'glue-sniffing') may cause either a high anion-gap or a normal anion gap acidosis. 0. Pearson MA, Hoyme HE, Seaver LH, Rimsza ME. Toluene Safety in the Workplace. 7:15. Learn vocabulary, terms, and more with flashcards, games, and other study tools. However, dangerous metabolic abnormalities are associated to acute toluene intoxication. Woodward JJ, Beckley J. fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms) yawning. The symptoms also depend on duration of exposure and development of complications. Once it enters the bloodstream, either through the respiratory organs, alimentary tract and transdermal absorption, toluene can reach the brain by crossing the blood-brain barrier. With acute unintentional exposure from toluene-containing household products, symptoms may include dizziness, rapid breathing, shortness of breath, headaches, hallucinations, seizures and even unconsciousness. Intentional or deliberate exposure is largely associated with an addiction to glue or paint. Toluene, an aromatic hydrocarbon, has a propensity to cause renal tubular acidosis or severe hypokalemia, similar to hypokalemic periodic paralysis. Toxicity usually starts at blood levels around 2.5mg/L. (M1.PY.15.27) A 25-year-old man presents to the emergency department after paramedics picked him up from an electronic music festival. John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals Share cases and questions with Physicians on Medscape consult. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODE4OTM5LWNsaW5pY2Fs. In true Knowmedge style, let\\ The amount of toluene absorbed by inhalation depends on the respiratory minute volume; thus, exercise affects the absorption rate of toluene. 32(5):910-26. 125 (6):067023. Cardioversion (electric “shock”) to restore normal heart rhythm. Environ Health Perspect. [Medline]. 1990 Sep-Oct. 5(5):359-83. By affecting the transmission of nerve impulses and neurotransmitters (brain hormones), it has a host of central nervous system effects. α2 agonist that decreases NE and sympathetic output making autonomic symptoms less intense. Subst Abus. Ellenhorn MJ, Schonwald S, Ordog G. Inhalant abuse. Headaches are described as a bilateral aching in the temples. [Medline]. Exposure to toluene may occur from breathing ambient or indoor air affected by such sources. Toluene, or methylbenzene, is a lipid-soluble aromatic hydrocarbon that is commonly used as an organic solvent in many industrial and domestic products such as thinners, glues, and spray paints. Chronic toluene exposure is mainly due to a “glue sniffing” addiction or occupational exposure. Procedures, encoded search term (Toluene Toxicity) and Toluene Toxicity, Botulinum Toxin Injections in Plastic Surgery, Pathophysiology and Etiology of Lead Toxicity, Recent Advances in Targeted Drug Delivery for Treatment of Osteoarthritis, Novel Approaches to Management of Hyperkalaemia in Kidney Transplantation, Incident Type 2 Diabetes Mellitus After Initiation of Common HIV Antiretroviral Drugs, Don't Use N95 Masks for More Than 2 Days, Research Suggests, A 30-Year-Old Man With Hallucinations After a House Party, Lower Back Pain: NSAID + Muscle Relaxant No Better Than NSAID + Placebo, Add Delirium to Checklist of COVID-19 Symptoms in Seniors. Curr Opin Psychiatry. Long-term toluene exposure is often associated with effects such as: psychoorganic syndrome; visual evoked potential (VEP) abnormality; toxic polyneuropathy, cerebellar, cognitive, and pyramidal dysfunctions; optic atrophy; hearing disorders and brain lesions. Any history of "huffing" or "bagging" before presentation, or a history of previous abuse of inhalants, should be elicited. 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 MedicineDisclosure: Nothing to disclose. [Full Text]. Secondly, there may “huffer’s eczema” which is defatting eczema around the mouth. Other chemicals within glue, pain and other household solvents may have a similar effect but toluene is by far the main component responsible for the neurological effects. Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine [Medline]. At relatively low levels of ambient toluene, just exceeding 200 ppm, fatigue, headache, paresthesias, and slowed reflexes are seen . Severe acute and chronic exposure requires supportive measures such as : With proper supportive measures, most patients will recover after acute exposure usually without any complications. The central nervous system (CNS) is the primary target organ for toluene toxicity in both humans and animals for acute (short-term) and chronic (long-term) exposures. May be irritating to the eyes, nose, throat, and lungs. EYES, EARS, NOSE, AND THROAT. Shiomi S, Kuroki T, Kuroda T, et al. This includes testing for alcohol abuse, prescription medication and cocaine use. Clin Toxicol (Phila).