Nickel Carbonyl

CAS RN:13463-39-3

Treatment Overview

0.4.2 ORAL/PARENTERAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Treat significant vomiting and/or dehydration with IV fluids and antiemetics in cases of severe vomiting. Administer supplemental oxygen for hypoxia and use bronchodilators and corticosteroids as needed for bronchospasm.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) ACUTE LUNG INJURY: Maintain ventilation and oxygenation and evaluate with frequent arterial blood gases or pulse oximetry monitoring. Early use of PEEP and mechanical ventilation may be needed. SEIZURES: Administer benzodiazepines as needed. Consider phenobarbital or propofol if seizures recur after large doses of benzodiazepines. Administer diethyldithiocarbonate or disulfiram.
  • C) DECONTAMINATION
    • 1) INGESTION: Ingestion of nickel carbonyl is UNLIKELY, because exposure are usually due to gas. Ingestion would most likely occur in persons having direct access to cylinders of condensed nickel carbonyl.
    • 2) OCULAR: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature water for at least 15 minutes.
    • 3) INHALATION: Move patient to fresh air. The first phase of nickel carbonyl inhalation is deceptive in its lack of severe symptoms. Monitor for respiratory distress.
    • 4) DERMAL: Remove contaminated clothing and wash exposed area thoroughly with soap and water. Treat dermal irritation or burns with standard topical therapy. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines. The degree to which nickel carbonyl is dermally absorbed is not known.
  • D) CHELATION
    • 1) Diethyldithiocarbamate (DDC) is the preferred chelating agent. Collect an 8 hour urine sample immediately after exposure. Results can be interpreted as follows: Less than 10 mcg/dL: delayed symptoms are not expected; DDC is unnecessary. If symptoms develop, treat as listed for urinary nickel levels of 10 to 50 mcg/dL. 10 to 50 mcg/dL: DDC should be administered orally (50 mg/kg/day on day 1, then 400 mg every 8 hours until the patient is symptom free and urine nickel is under 10 mcg/dL). Greater than 50 mcg/dL: the dose of DDC parenterally is 25 mg/kg. Additional DDC is based on clinical presentation and urinary nickel. Severe cases may use 100 mg/kg for the first 24 hours.
    • 2) If there is a doubt as to the severity of the exposure, give a course of 2 g of DDC orally until a urine nickel level can be obtained. Therapy should be not be delayed while awaiting for diagnostic data. If significant exposure is suspected or uncertain, parenteral DDC should be administered, urinary nickel concentrations levels monitored and the patient carefully evaluated for the development of delayed symptoms which may occur as much as a week after exposure.
    • 3) If DDC is not available, disulfiram may prove of some use. Although the optimal dose has not been established, one molecule disulfiram is metabolized to 2 molecules of DDC.. Avoid ethanol with disulfiram or DDC use given the risk of a disulfiram reaction.
    • 4) All patients with significant exposure should be admitted to a hospital and carefully observed and treated for possible delayed effects. Individuals with an 8-hour urinary nickel concentration of 10 mcg or greater/100 mL should be carefully followed for at least a week, even if they have received DDC.
  • E) ENHANCED ELIMINATION
    • 1) Hemodialysis and hemoperfusion are not known to be of benefit. High volume hemofiltration in conjunction with disulfiram therapy was used in one patient with severe pulmonary injury from nickel carbonyl.
  • F) PATIENT DISPOSITION
    • 1) HOME CRITERIA: All patients with exposure to nickel carbonyl should be monitored in a healthcare facility as it is an extremely toxic gas. Patients should not be managed at home if inhalation is suspected, the patient needs to be evaluated by monitoring either urine or plasma nickel levels.
    • 2) OBSERVATION CRITERIA: All patients with significant exposure should be admitted to a hospital and carefully observed and treated for possible delayed effects.
    • 3) ADMISSION CRITERIA: All patients with significant exposure irregardless of whether they are immediately symptomatic or not should be admitted for observation as clinical effects can be delayed.
    • 4) CONSULT CRITERIA: Consult a medical toxicologist for assistance with medical management.
  • G) TOXICOKINETICS
    • 1) ABSORPTION: Nickel carbonyl is readily absorbed via inhalation, dermal absorption is unknown. METABOLISM: The nickel is released from nickel carbonyl intracellular oxidation to Ni (II), then it is released into the blood and is bound to albumin and other substances. The carbon monoxide becomes bound to hemoglobin and is transported to the lungs. EXCRETION: Inhaled nickel carbonyl is excreted in the urine as nickel.
  • H) DIFFERENTIAL DIAGNOSIS
    • 1) Flu-like illness or infectious bronchopneumonia. Inhalation of other irritant or toxic gases (ie, acids, alkalia, phosgene).
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.
  • B) 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.
  • C) CHELATION
    • 1) DIETHYLDITHIOCARBAMATE
      • a) Diethyldithiocarbamate (DDC) is the preferred chelating agent.
      • b) Collect an 8 hour urine sample immediately after exposure.
    • 1) Urinary nickel levels of: 1. Less than 10 mcg/dL: Delayed, serious symptoms are not expected. DDC is usually unnecessary. If symptoms develop, treat as listed for urinary nickel levels of 10 to 50 mcg/dL. 2. 10 to 50 mcg/dL: Administered DDC orally in divided doses for a total of 35 to 45 mg/kg on day 1, then 400 mg every 8 hours until the patient is symptom free and urine nickel is under 10 mcg/dL. 3. Greater than 50 mcg/dL: Initial DDC dose parenterally is 25 mg/kg. Additional DDC based on clinical presentation and urinary nickel. Severe cases may need 100 mg/kg for the first 24 hours.
      • c) If there is doubt as to the severity of the exposure, give 2 g of DDC orally in divided doses. Base additional treatment on clinical presentation and urinary nickel levels.
    • 2) DISULFIRAM
      • a) DISULFIRAM (ANTABUSE(R)): It is metabolized to 2 molecules of DDC. If DDC is not available, disulfiram may prove of some use. Optimal dose has not been established. Doses of 500 mg every 12 hours and 750 mg every 8 hours orally or via NG tube have been used in adults.
  • D) DIURESIS
    • 1) Diuresis may be helpful to reduce the elimination half-life of serum nickel.
  • E) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).
    • 1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
    • 2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
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.
  • B) Treat ocular irritation or burns with standard topical therapy.
  • C) Observe patients with eye exposure carefully for development of systemic signs and symptoms, and follow treatment recommendations in the INHALATIONAL EXPOSURE section where appropriate.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) 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) Treat dermal irritation or burns with standard topical therapy. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines.
    • 3) Follow treatment recommendations listed under inhalational exposure.
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