2,4,6-Trinitrotoluene

CAS RN:118-96-7

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Patients with mild to moderate toxicity can be treated with supportive care. The offending agent should be withdrawn. Intravenous fluids should be given to maintain urine output and supplemental oxygen applied.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Patients with evidence of end-organ ischemia should be treated with methylene blue regardless of the methemoglobin concentration. However, patients are unlikely to have end-organ ischemia with concentrations less than 20%. Treatment with methylene blue should result in resolution of all symptoms attributable to methemoglobinemia within 2 hours. The administration of cimetidine may also shorten the course of dapsone-induced methemoglobinemia. Patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency or children younger than 3 months may require exchange transfusion or treatment with hyperbaric oxygen as they may not respond to methylene blue. Treat seizures with IV benzodiazepines or barbiturates.
  • C) DECONTAMINATION
    • 1) PREHOSPITAL: Patients should be placed on oxygen. Following dermal exposure, skin should be thoroughly washed with soap and water. Contaminated clothing and shoes should be discarded. Otherwise, no field decontamination is required.
    • 2) HOSPITAL: Overdose of drug tablets implicated in causing methemoglobinemia can be treated with 50 grams of activated charcoal, if the patient presents early and the patient's mental status is amenable to taking the charcoal. However, this is rarely necessary as patients generally do not develop methemoglobinemia until hours after an acute ingestion. Following dermal exposure, skin should be thoroughly washed with soap and water. Contaminated clothing and shoes should be discarded.
  • D) AIRWAY MANAGEMENT
    • 1) Patients with severe dyspnea, tachypnea, seizure, or evidence of end-organ ischemia may require intubation for airway protection or to minimize excessive work of breathing.
  • E) ANTIDOTE
    • 1) Initiate oxygen therapy. Treat with methylene blue if patient is symptomatic (usually at methemoglobin concentrations greater than 20% to 30% or at lower concentrations in patients with anemia, underlying pulmonary or cardiovascular disease). METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg. DAPSONE: See dapsone management for treatment of patients with significant methemoglobinemia following dapsone overdose. CONTRAINDICATIONS: Known hypersensitivity to methylene blue and methemoglobin reductase deficiency. Patients with G-6-PD deficiency may develop hemolysis, however, enzyme deficiency is usually not complete and most toxicologists would still recommend methylene blue for severely symptomatic patients.
  • F) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Patients with any degree of cyanosis should be referred to a health care facility. Patients with mild headache or nausea may be managed at home.
    • 2) OBSERVATION CRITERIA: Patients should be observed for 8 hours after methylene blue administration to rule out recurrence of methemoglobinemia or adverse reaction to the antidote. Some chemicals (eg, aniline, nitrobenzene) may require biochemical transformation before causing methemoglobinemia. Observation of asymptomatic or mildly symptomatic individuals following exposure to these chemicals may be advisable. Slow absorption of some chemicals may also contribute to delayed methemoglobinemia. When doubt exists, it is probably best to admit the patient for continued observation.
    • 3) ADMISSION CRITERIA: Patients with recurrent methemoglobinemia should be admitted. Patients exposed to etiologic agents with a slow clearance, such as dapsone, should be admitted.
    • 4) CONSULT CRITERIA: A medical toxicologist or poison control center should be consulted for patients with methemoglobin concentrations above 30% or for symptomatic patients with lower concentrations. Consultation is recommended for patients with familial methemoglobinemia or G-6-PD deficiency.
  • G) PITFALLS
    • 1) Failure of the patient to improve following two doses of methylene blue suggests: inadequate decontamination, NADPH dependent methemoglobin reductase deficiency, hemoglobin M, sulfhemoglobinemia, or G-6-PD deficiency. Failure to stabilize and treat the sequelae of end-organ ischemia can lead to significant morbidity and mortality. Patients with methemoglobinemia from agents such as dapsone may require repeated doses or continuous infusion of methylene blue.
  • H) TOXICOKINETICS
    • 1) Dependent on the etiologic agent. The elimination half-life of methemoglobin averages 15 to 20 hours. Following treatment with methylene blue, the half-life decreases to 40 to 90 minutes. Methemoglobinemia due to dermal exposure to local anesthetics generally resolves within several hours depending upon the clearance of the parent compound. Dapsone may cause symptoms for more than 24 hours due to the formation of an active metabolite.
  • I) DIFFERENTIAL DIAGNOSIS
    • 1) Sulfhemoglobinemia is clinically indistinguishable from methemoglobinemia. This diagnosis should be considered if a patient is unresponsive to 2 doses of methylene blue. Sulfhemoglobin is a very stable entity and may require exchange transfusion, although patients usually have minimal symptoms and often require no treatment. Other medical conditions that lead to cyanosis, such as emphysema, congestive heart failure, pulmonary shunts, as well as, other primary lung pathologies, must be considered.
    • 2) The following list also includes the differential diagnosis of low oxygen saturation by pulse oximetry: Hypoxia, IV dyes (methylene blue/indocyanine green), hemoglobinopathies, methemoglobin (acquired/congenital), carboxyhemoglobin, abnormal hemoglobin variants (Hemoglobin M), ambient light contamination, dark nail polish, low perfusion/poor signal/venous pulsations, or motion artifact.
0.4.3 INHALATION EXPOSURE
  • A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
0.4.4 EYE EXPOSURE
  • A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) Some methemoglobinemia-producing chemicals are readily absorbed through the skin to produce adverse systemic effects. Aniline and related compounds may be rapidly absorbed by all routes. Skin contact with contaminated clothing or shoes may result in adverse systemic effects.
      • a) Skin should be thoroughly washed with soap and water. Contaminated clothing and shoes should be discarded. Seek medical attention. Administer 100% humidified supplemental oxygen with assisted ventilation as required. Treat for methemoglobinemia and sequelae. Signs and symptoms of methemoglobinemia may be delayed.
0.4.2 ORAL EXPOSURE
  • A) GASTRIC LAVAGE
    • 1) Significant esophageal or gastrointestinal tract irritation or burns may occur following ingestion. The possible benefit of early removal of some ingested material by cautious gastric lavage must be weighed against potential complications of bleeding or perforation.
    • 2) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.
      • a) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
  • B) ACTIVATED CHARCOAL
    • 1) Activated charcoal binds most toxic agents and can decrease their systemic absorption if administered soon after ingestion. In general, metals and acids are poorly bound and patients ingesting these materials will not likely benefit from activated charcoal administration.
      • a) Activated charcoal should not be given to patients ingesting strong acidic or basic caustic chemicals. Activated charcoal is also of unproven value in patients ingesting irritant chemicals, where it may obscure endoscopic findings when the procedure is justified.
    • 2) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
  • C) DILUTION -
    • 1) Immediate dilution with milk or water may be of benefit in caustic or irritant chemical ingestions.
    • 2) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting.
  • D) IRRITATION -
    • 1) Observe patients with ingestion carefully for the possible development of esophageal or gastrointestinal tract irritation or burns. If signs or symptoms of esophageal irritation or burns are present, consider endoscopy to determine the extent of injury.
  • E) OBSERVATION CRITERIA -
    • 1) Carefully observe patients with ingestion exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    • 2) Patients symptomatic following exposure should be observed in a controlled setting until all signs and symptoms have fully resolved.
0.4.3 INHALATION EXPOSURE
  • A) DECONTAMINATION -
    • 1) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
  • B) IRRITATION -
    • 1) Respiratory tract irritation, if severe, can progress to pulmonary edema which may be delayed in onset up to 24 to 72 hours after exposure in some cases.
  • C) ACUTE LUNG INJURY -
    • 1) ACUTE LUNG INJURY: Maintain ventilation and oxygenation and evaluate with frequent arterial blood gases and/or pulse oximetry monitoring. Early use of PEEP and mechanical ventilation may be needed.
  • D) BRONCHOSPASM -
    • 1) If bronchospasm and wheezing occur, consider treatment with inhaled sympathomimetic agents.
  • E) OBSERVATION CRITERIA -
    • 1) Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    • 2) Patients symptomatic following exposure should be observed in a controlled setting until all signs and symptoms have fully resolved.
0.4.4 EYE EXPOSURE
  • A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) DERMAL DECONTAMINATION -
      • a) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    • 2) PESTICIDES -
      • a) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    • 3) IRRITATION -
      • a) Treat dermal irritation or burns with standard topical therapy. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines.
    • 4) DERMAL ABSORPTION -
      • a) Some chemicals can produce systemic poisoning by absorption through intact skin. Carefully observe patients with dermal exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
Find more information on this substance at: Hazardous Substances Data Bank , TOXNET , PubMed