Arsenic Trichloride

CAS RN: 7784-34-1

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) DILUTION
    • 1) ADMINISTER MILK (preferred) OR WATER (one or two glassfuls) to dilute the hydrofluoric acid in the oropharynx, esophagus and stomach. Milk provides calcium ions which will bind the fluoride ion and decrease the penetrability.
  • B) EMESIS/NOT RECOMMENDED
    • 1) Because of the corrosive effects of hydrofluoric acid released following contact with moisture, EMESIS should NOT be induced.
  • C) 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) There may be slow absorption of ingested arsenic trichloride and lavage may be effective even after several hours.
    • 3) 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.
  • D) NASOGASTRIC SUCTION
    • 1) Consider nasogastric suction or lavage with a soft tube in patients with significant ingestions who present within 90 minutes of exposure and have not spontaneously vomited. Calcium gluconate 10 percent may be added to the lavage fluid.
      • a) The risk of systemic fluoride toxicity from absorption of fluoride in the stomach may outweigh the risk of gastric perforation secondary to the procedure.
  • E) ACTIVATED CHARCOAL
    • 1) As there is little risk in using activated charcoal, it is recommended until further data are available.
    • 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.
  • F) DEMULCENTS
    • 1) ADMINISTER MILK OF MAGNESIA after oral dilution with milk or water, for its soothing effect.
  • G) EVALUATE BURNS
    • 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.
  • H) MONITORING PATIENT
    • 1) Monitor liver, renal and cardiac functions. Maintain high urine output.
  • I) ALKALINIZATION OF THE URINE - May prevent deposition of
    • 1) red cell breakdown products from hemolysis in the renal tubules.
  • J) URINE ALKALINIZATION
    • 1) Administer 1 to 2 mEq/kg sodium bicarbonate bolus. Add 132 milliequivalents (3 ampules) sodium bicarbonate and 20 to 40 milliequivalents potassium chloride (as needed) to one liter of dextrose 5 percent in water and infuse at approximately 1.5 times the maintenance fluid rate. Adjust as needed to achieve a urine pH of at least 7.5 and a urine output of 1 to 3 mL/kg/hr.
    • 2) Assure adequate hydration and renal function. Monitor fluid balance, serum electrolytes, and blood pH. Obtain hourly intake/output and urine pH.
  • K) Chelation therapy may be indicated at a urine arsenic level of 200 mcg/liter or higher. Dimercaprol (BAL), D-PENICILLAMINE and DMSA are effective arsenic chelators.
    • 1) DIMERCAPROL (BAL) - Usual dosage range is 3 to 5 milligrams/kilogram intramuscularly every 4 to 12 hours until symptoms resolve or another chelator is substituted. The dose and frequency used depend on the degree of toxicity seen. Dose dependent side effects may occur.
    • 2) D-PENICILLAMINE - The usual dose is 25 milligrams/kilogram/dose given four times daily up to one gram per day; adults may require larger doses (ie, up to 2 grams/day).
    • 3) DMSA - 2,3-Dimercaptosuccinic acid (DMSA) is an investigational drug. It has the advantage of being an oral agent as well as being relatively non-toxic.
    • 4) N-acetylcysteine (NAC) cannot presently be recommended for the treatment of arsenic poisoning.
    • 5) THERAPEUTIC END-POINT - Repeat five-day courses of chelation therapy should be prescribed in severe poisonings until the 24-hour urine arsenic level falls below 50 micrograms/liter.
  • L) A MOBILIZATION TEST - has been suggested to aid the diagnosis of mild or chronic exposure. Its usefulness has been questioned because of the relatively rapid excretion of absorbed arsenic. Refer to TREATMENT/INHALATION EXPOSURE section in the main body of this document for more information.
  • M) Physical therapy may be helpful for patients with established arsenical neuropathies.
  • N) HEMODIALYSIS - should be performed in the presence of any degree of renal failure.
  • O) 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.
  • P) VENTRICULAR DYSRHYTHMIAS
    • 1) Institute continuous cardiac monitoring, obtain an ECG, and administer oxygen. Evaluate for hypoxia, acidosis, and electrolyte disorders. Lidocaine and amiodarone are generally first line agents for stable monomorphic ventricular tachycardia, particularly in patients with underlying impaired cardiac function. Because arsenic can cause torsades de pointes and QTc prolongation, amiodarone should only be used with extreme caution. Unstable rhythms require immediate cardioversion.
  • Q) TORSADES DE POINTES
    • 1) Treat with magnesium; atrial overdrive pacing may also be necessary. Correct electrolyte abnormalities.
  • R) 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.
  • S) X-RAY: Arsenic is radiopaque. Obtain abdominal film and repeat as necessary to insure that gastric emptying maneuvers have been effective.
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) If bronchospasm and wheezing occur, consider treatment with inhaled sympathomimetic agents.
  • D) Alkalinization of the urine may prevent deposition of red cell breakdown products from hemolysis in renal tubular cells.
    • 1) URINE ALKALINIZATION
      • a) Administer 1 to 2 mEq/kg sodium bicarbonate bolus. Add 132 milliequivalents (3 ampules) sodium bicarbonate and 20 to 40 milliequivalents potassium chloride (as needed) to one liter of dextrose 5 percent in water and infuse at approximately 1.5 times the maintenance fluid rate. Adjust as needed to achieve a urine pH of at least 7.5 and a urine output of 1 to 3 mL/kg/hr.
      • b) Assure adequate hydration and renal function. Monitor fluid balance, serum electrolytes, and blood pH. Obtain hourly intake/output and urine pH.
  • E) Chelation therapy may be indicated at a urine arsenic level of 200 mcg/liter or higher. Dimercaprol (BAL), D-PENICILLAMINE and DMSA are effective arsenic chelators.
    • 1) DIMERCAPROL (BAL) - Usual dosage range is 3 to 5 milligrams/kilogram intramuscularly every 4 to 12 hours until symptoms resolve or another chelator is substituted. The dose and frequency used depend on the degree of toxicity seen. Dose dependent side effects may occur.
    • 2) D-PENICILLAMINE - The usual dose is 25 milligrams/kilogram/dose given four times daily up to one gram per day, adults may require larger doses (ie, up to 2 grams/day).
    • 3) DMSA - 2,3-Dimercaptosuccinic acid (DMSA) is an investigational drug. It has the advantage of being an oral agent as well as being relatively non-toxic.
    • 4) N-acetylcysteine (NAC) is not presently recommended for the treatment of arsenic poisoning.
    • 5) THERAPEUTIC END-POINT - Repeat five-day courses of chelation therapy should be prescribed in severe poisonings until the 24-hour urine arsenic level falls below 50 micrograms/liter.
  • F) A MOBILIZATION TEST - has been suggested to aid the diagnosis of mild or chronic exposure. Its usefulness has been questioned because of the relatively rapid excretion of absorbed arsenic. Refer to TREATMENT/INHALATION EXPOSURE section in the main body of this document for more information.
  • G) Physical therapy may be helpful for patients with established arsenical neuropathies.
  • H) HEMODIALYSIS - should be performed in the presence of any degree of renal failure.
  • I) 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.
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) No cases of systemic arsenic poisoning following only eye exposure have been reported.
  • C) If significant eye irritation is present, prolonged initial flushing and early ophthalmologic consultation are advisable.
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) Treatment of CHEMICAL BURNS may be required. Refer to TREATMENT/DERMAL EXPOSURE section in the main body of this document for more information.
    • 4) Alkalinization of the urine may prevent deposition of red cell breakdown products from hemolysis in renal tubular cells.
      • a) URINE ALKALINIZATION
    • 1) Administer 1 to 2 mEq/kg sodium bicarbonate bolus. Add 132 milliequivalents (3 ampules) sodium bicarbonate and 20 to 40 milliequivalents potassium chloride (as needed) to one liter of dextrose 5 percent in water and infuse at approximately 1.5 times the maintenance fluid rate. Adjust as needed to achieve a urine pH of at least 7.5 and a urine output of 1 to 3 mL/kg/hr.
    • 2) Assure adequate hydration and renal function. Monitor fluid balance, serum electrolytes, and blood pH. Obtain hourly intake/output and urine pH.
    • 5) Chelation therapy may be indicated at a urine arsenic level of 200 mcg/liter or higher. Dimercaprol (BAL), D-PENICILLAMINE and DMSA are effective arsenic chelators.
      • a) DIMERCAPROL (BAL) - Usual dosage range is 3 to 5 milligrams/kilogram intramuscularly every 4 to 12 hours until symptoms resolve or another chelator is substituted. The dose and frequency used depend on the degree of toxicity seen. Dose dependent side effects may occur.
      • b) D-PENICILLAMINE - The usual dose is 25 milligrams/kilogram/dose given four times daily up to one gram per day, adults may require larger doses (ie, up to 2 grams/day).
      • c) DMSA - 2,3-Dimercaptosuccinic acid (DMSA) is an investigational drug. It has the advantage of being an oral agent as well as being relatively non-toxic.
      • d) N-acetylcysteine (NAC) cannot presently be recommended for the treatment of arsenic poisoning.
      • e) THERAPEUTIC END-POINT - Repeat five-day courses of chelation therapy should be prescribed in severe poisonings until the 24-hour urine arsenic level falls below 50 micrograms/liter.
    • 6) A MOBILIZATION TEST - has been suggested to aid the diagnosis of mild or chronic exposure. Its usefulness has been questioned because of the relatively rapid excretion of absorbed arsenic. Refer to TREATMENT/DERMAL EXPOSURE section in the main body of this document for more information.
    • 7) Physical therapy may be helpful for patients with established arsenical neuropathies.
    • 8) 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.
    • 9) HEMODIALYSIS - should be performed in the presence of any degree of renal failure. 1
    • 0) Restriction from further exposure may be necessary for workers with significant arsenical dermatitis, ulcerations, or dermatoses. 1
    • 1) 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.
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