Sodium Hydrosulfide

CAS RN:16721-80-5

Treatment Overview

    • 1) Perform early (within 12 hours) endoscopy in patients with stridor, drooling, vomiting, significant oral burns, difficulty swallowing or abdominal pain, and in all patients with deliberate ingestion. If burns are absent or grade I severity, patient may be discharged when able to tolerate liquids and soft foods by mouth. If mild grade II burns, admit for intravenous fluids, slowly advance diet as tolerated. Perform barium swallow or repeat endoscopy several weeks after ingestion (sooner if difficulty swallowing) to evaluate for stricture formation.
    • 1) Resuscitate with 0.9% saline; blood products may be necessary. Early airway management in patients with upper airway edema or respiratory distress. Early (within 12 hours) gastrointestinal endoscopy to evaluate for burns. Early bronchoscopy in patients with respiratory distress or upper airway edema. Early surgical consultation for patients with severe grade II or grade III burns, large deliberate ingestions, or signs, symptoms or laboratory findings concerning for tissue necrosis or perforation.
    • 1) Dilute with 4 to 8 ounces of water may be useful if it can be performed shortly after ingestion in patients who are able to swallow, with no vomiting or respiratory distress; then the patient should be NPO until assessed for the need for endoscopy. Neutralization, activated charcoal, and gastric lavage are all contraindicated.
    • 1) Aggressive airway management in patients with deliberate ingestions or any indication of upper airway injury.
    • 1) Should be performed as soon as possible (preferably within 12 hours, not more than 24 hours) in any patient with deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after inadvertent ingestion. Endoscopy should also be considered in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion. Children and adults who are asymptomatic after inadvertent ingestion do not require endoscopy. The grade of mucosal injury at endoscopy is the strongest predictive factor for the occurrence of systemic and GI complications and mortality. The absence of visible oral burns does NOT reliably exclude the presence of esophageal burns.
    • 1) The use of corticosteroids to prevent stricture formation is controversial. Corticosteroids should not be used in patients with grade I or grade III injury, as there is no evidence that it is effective. Evidence for grade II burns is conflicting, and the risk of perforation and infection is increased with steroid use.
    • 1) A barium swallow or repeat endoscopy should be performed several weeks after ingestion in any patient with grade II or III burns or with difficulty swallowing to evaluate for stricture formation. Recurrent dilation may be required. Some authors advocate early stent placement in these patients to prevent stricture formation.
    • 1) Immediate surgical consultation should be obtained on any patient with grade III or severe grade II burns on endoscopy, significant abdominal pain, metabolic acidosis, hypotension, coagulopathy, or a history of large ingestion. Early laparotomy can identify tissue necrosis and impending or unrecognized perforation, early resection and repair in these patients is associated with improved outcome.
    • 1) OBSERVATION CRITERIA: Patients with alkaline corrosive ingestion should be sent to a health care facility for evaluation. Patients who remain asymptomatic over 4 to 6 hours of observation, and those with endoscopic evaluation that demonstrates no burns or only minor grade I burns and who can tolerate oral intake can be discharged home.
    • 2) ADMISSION CRITERIA: Symptomatic patients, and those with endoscopically demonstrated grade II or higher burns should be admitted. Patients with respiratory distress, grade III burns, acidosis, hemodynamic instability, gastrointestinal bleeding, or large ingestions should be admitted to an intensive care setting.
    • 1) The absence of oral burns does NOT reliably exclude the possibility of significant esophageal burns.
    • 2) Patients may have severe tissue necrosis and impending perforation requiring early surgical intervention without having severe hypotension, rigid abdomen, or radiographic evidence of intraperitoneal air.
    • 3) Patients with any evidence of upper airway involvement require early airway management before airway edema progresses.
    • 4) The extent of eye injury (degree of corneal opacification and perilimbal whitening) may not be apparent for 48 to 72 hours after the burn. All patients with corrosive eye injury should be evaluated by an ophthalmologist.
    • 1) Acid ingestion, gastrointestinal hemorrhage, or perforated viscus.
    • 1) Administer oxygen as necessary. Monitor for respiratory distress.
    • 1) Manage airway aggressively in patients with significant respiratory distress, stridor or any evidence of upper airway edema. Monitor for hypoxia or respiratory distress.
    • 1) Treat with oxygen, inhaled beta agonists and consider systemic corticosteroids.
    • 1) Exposed eyes should be irrigated with copious amounts of 0.9% saline for at least 30 minutes, until pH is neutral and the cul de sacs are free of particulate material.
    • 2) An eye examination should always be performed, including slit lamp examination. Ophthalmologic consultation should be obtained. Antibiotics and mydriatics may be indicated.
      • a) Remove contaminated clothes and any particulate matter adherent to skin. Irrigate exposed skin with copious amounts of water for at least 15 minutes or longer, depending on concentration, amount and duration of exposure to the chemical. A physician may need to examine the area if irritation or pain persist.
    • 1) For mild to moderate toxicity, remove the patient from the exposure and administer oxygen. Symptomatic and supportive care is the mainstay of treatment. Treat ocular injury with normal saline irrigation and perform an ocular exam (including visual acuity and slit lamp). Treat dermal injury by removing clothing and performing copious soap and water decontamination.
    • 1) Severe toxicity usually manifests as CNS depression. Patients should be immediately removed from the offending environment, aggressive airway management including intubation, oxygen supplementation and crystalloid/pressor support should ensue. For patients with severe poisoning who are already receiving good supportive care, consider the administration of sodium nitrite. DOSE: Sodium Nitrite: Adult: 300 mg of 3% sodium nitrite (10 mL of a 3% solution) administered over 2.5 to 5 minutes; Pediatric: 0.12 to 0.33 mL/kg. There are anecdotal reports suggesting hyperbaric oxygen treatment may be useful if provided immediately after exposure. Hyperbaric oxygen therapy and nitrite therapy should only be instituted after maximum supportive measures have been instituted for severely ill patients, as there is no rigorous human evidence supporting either treatment.
    • 1) PREHOSPITAL: Maximum personal protective gear (self-contained breathing apparatus) should be utilized for rescuers removing the victim from the toxic environment (would-be rescuers entering a contaminated environment often become victims). Administer high flow oxygen, and assist ventilation with a bag-valve-mask or perform endotracheal intubation, if necessary.
    • 2) HOSPITAL: Minimal off-gassing usually occurs in the hospital environment after the patient has been removed from the exposure. Administer high-flow oxygen. Irrigate eyes if there is evidence of irritation. Wash skin if there is evidence of irritation.
    • 1) Early endotracheal intubation and mechanical ventilation with high oxygen concentrations is recommended in patients with mental status depression or respiratory distress.
    • 1) Animal studies suggest that inducing methemoglobinemia reduces hydrogen sulfide toxicity, as hydrogen sulfide has a greater affinity for methemoglobin than for cytochrome oxidase. There are no clinical studies in human as hydrogen sulfide poisoning is rare. For patients with severe poisoning who are already receiving aggressive supportive care. Consider administration of sodium nitrite (Adult: 300 mg of 3% sodium nitrite (10 mL of a 3% solution) administered over 2.5 to 5 minutes; Pediatric: 0.12 to 0.33 mL/kg). Be aware that nitrites can induce hypotension and hypoxia and excessive methemoglobin formation can worsen tissue hypoxia in an unstable patient. There are anecdotal reports suggesting that hyperbaric oxygen treatment may be beneficial if provided immediately after exposure. Hyperbaric oxygen therapy and nitrite therapy should only be instituted after maximum supportive measures have been instituted for severely ill patients.
    • 1) HOME CRITERIA: All significant exposures should be sent to a hospital.
    • 2) OBSERVATION CRITERIA: Patients who are minimally symptomatic may be observed until resolution of symptoms in a healthcare facility.
    • 3) ADMISSION CRITERIA: Any severely ill patient should be admitted to an intensive care unit.
    • 4) CONSULT CRITERIA: Consult a medical toxicologist or a poison center for any severely poisoned patient. Data are controversial regarding hyperbaric therapy; however, if a hyperbaric center is readily available, contact a hyperbaric specialist to consult on a patient with severe poisoning. Consult an ophthalmologist for patients with keratoconjunctivitis or corneal ulceration.
    • 1) At high concentrations the ability to perceive the odor of hydrogen sulfide is rapidly lost because of olfactory nerve paralysis; this may be misinterpreted as dissolution of the gas. Rescuers should wear personal protective equipment (self-contained breathing apparatus) as they often become victims when they attempt to rescue other victims in environments with high concentrations of hydrogen sulfide. Victims often fall due to rapid loss of consciousness, evaluate for traumatic injuries. Hydrogen sulfide is an irritant; therefore, evaluate exposed patients for ocular or dermal injury.
    • 1) In severe cases, onset is rapid, duration depends upon continued exposure and environmental concentration. Hydrogen sulfide is oxidized to thiosulfate and polysulfides.
    • 1) Cyanide, and other mitochondrial poisons.
  • A) Immediately move the patient to fresh air and administer 100% oxygen. Prevent self-exposure and possible death by wearing a self-contained breathing apparatus to rescue the victim.
  • B) 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.
  • C) HYPOTENSION: Infuse 10 to 20 mL/kg isotonic fluid. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (ADULT: begin infusion at 0.5 to 1 mcg/min; CHILD: begin infusion at 0.1 mcg/kg/min); titrate to desired response.
  • D) NITRITE THERAPY: IV sodium nitrite may be beneficial by forming sulfmethemoglobin, thus removing sulfide from combination in tissue. Do NOT use sodium thiosulfate. The antidotal efficacy of nitrite therapy is controversial; it should be considered in patients with severe symptoms who present soon after exposure.
    • 1) SODIUM NITRITE: Adult: 10 mL (300 mg) of a 3% solution IV at a rate of 2.5 to 5 mL/minute; Child (with normal hemoglobin concentration): 0.2 mL/kg (6 mg/kg) of a 3% solution IV at a rate of 2.5 to 5 mL/minute, not to exceed 10 mL (300 mg).
    • 2) Repeat one-half of initial sodium nitrite dose one-half hour later if there is inadequate clinical response. Calculate pediatric doses precisely to avoid potentially life-threatening methemoglobinemia. Use with caution if carbon monoxide poisoning is also suspected. Monitor blood pressure carefully. Reduce nitrite administration rate if hypotension occurs.
  • E) 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.
    • 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).
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