Morning Report: 1/9/2015 - The Original Kings of County

Dr. Waldman presents today’s Morning Report!

AMMONIA TOXICITY

Where can we find ammonia: glass cleaners, toilet bowel cleaners, metal polishes, floor strippers, wax removers, smelling salts, some refrigerants, explosives, pharmaceuticals, pesticides, textiles, leather, flame-retardants, plastics, pulp and paper, rubber, petroleum products, and cyanide

INHALATION INJURY:

Most common cause of injury
People who are capable of escaping their environment usually are not subject to severe exposures, because they flee upon detection of ammonia’s pungent odor
Signs/symptoms
- Rhinorrhea
- Scratchy throat
- Chest tightness
- Cough
- Dyspnea
- Eye irritation
Symptoms usually subside within 24-48 hours
Absence of symptoms following inhalational exposure to ammonia essentially rules out significant injury
Physical Exam
- HEENT: facial and oral burns and ulcerations
- RESP: Tachypnea, oxygen desaturation, stridor, drooling, cough, wheezing, rhonchi, and decreased air entry
- CNS: Loss of consciousness (if exposure is massive)
- Ocular: iritis, corneal edema, semi dilated fixed pupil (can eventually form cataracts)

TOPICAL INJURY: Burns

Gaseous ammonia mixes with water in eyes, skin, airways, forms ammonium (exothermic rxn)-> heat and chemical burns
Liquid ammonia freezes tissue on contact -> deep injuries
Physical Exam
- Mild skin burns -> yellow, soapy, soft in texture
- Severe skin burns -> black and leathery

INGESTION INJURY:

Ammonia ingestions in the home usually do not lead to significant damage; pH significantly higher in industrial strength products; however few case reports of injury with household products
Signs/Symptoms of ingestion:
- OP, epigastric and retrosternal pain
- Signs of perforated viscous (can occur up to 24-72 hrs after ingestion)
- Respiratory symptoms if aspiration PNA or pneumonitis

BLEACH + AMMONIA -> CHLORAMINE GAS:

Mild exposure: normal exam vs wheezing and decreased air entry
Moderate to severe exposure: dyspnea, pulmonary edema with secondary hypoxia, nausea, tracheobronchitis, toxic pneumonitis, intrapulmonary shunt, and/or pneumomediastinum

DIAGNOSIS:

Serum ammonia levels are of little value bc they do not correlate with clinical condition.
Labs: basic labs, co-ingestion labs, lactate
Eye: fluorescein staining, slit lamp exam, tonometry, conjunctival pH?
GI: advanced imaging for signs of perforation, endoscopy if significant ingestion
Pulmonary: PFTs, bronchoscopy if severe inhalation

MANAGEMENT:

Management is largely supportive
Decontaminate pt
Intubation
- When: resp distress, depressed MS, severe orofacial burns, stridor, hoarseness, burns identified on bronchoscopy or endoscopy
- How: consider procedural sedation rather than RSI (severe laryngeal edema)
- What: use large-size tubes to prevent plugging with sloughing mucosa
Burn management: irrigate copiously and frequently, apply silver sulfadiazine, tdap, BEWARE of aggressive fluid administration
Eyes: irrigate copiously, prompt optho consult
Ingestion: irrigate mouth with water or milk, do NOT induce emesis, prompt GI consult
Corticosteroids (very controversial)
- Increase mortality?
- May help with acute bronchospasm in pts with underlying RAD?
- May decrease airway edema?
- May decreased formation of esophageal strictures?

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital