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Arsine (AsH3)

                               

 
Clinical

  • After absorption by the lungs, arsine enters red blood cells (RBC) where different processes may contribute to hemolysis and impairment of oxygen transport. Arsine preferentially binds to hemoglobin, and is oxidized to an arsenic dihydride intermediate and elemental arsenic, both of which are hemolytic agents.
  • Pre-existing cardiopulmonary or renal conditions, iron deficiency, and/or pre-existing anemia may result in more severe outcomes if hemolysis occurs.

 

       Hematologic
  • Acute intravascular hemolysis develops within hours and may continue for up to 96 hours. Haptoglobin levels decline rapidly. Free hemoglobin levels in plasma rise (levels greater than 2 g/dL have been reported). Anemia develops; the peripheral smear shows variation in the size of the red blood cells, irregularly shaped blood cells, red-cell fragments, components that have an affinity for basic dyes, Heinz bodies, and ghost cells. The bone marrow usually shows no abnormalities. Coombs and Ham tests are
  • Methemoglobinemia can be of concern in infants up to 1 year old. Children may be more vulnerable to loss of effectiveness of hemoglobin because of their relative anemia compared to adults.

 

       Respiratory
  •  Difficult breathing is among the early symptoms of arsine poisoning. A garlic odor may be present on the breath. Delayed accumulation of fluid in the lungs may occur after massive exposure. Dyspnea may be due to lack of oxygen secondary to hemolysis.
  • Children may be more vulnerable because of increased minute ventilation per kg and failure to evacuate an area promptly when exposed.

 

      Renal
  • Kidney failure due to acute tubular destruction is a significant sequela of arsine exposure. Urinalysis shows large amounts of protein and free hemoglobin usually without intact RBCs. Urine may be colored (e.g., brown, red, orange, or greenish). Decreased urinary output may develop within 24 to 48 hours.

 

      Gastrointestinal
  • Nausea, vomiting, and crampy abdominal pain are among the first signs of arsine poisoning. Onset varies from a few minutes to 24 hours after exposure.

 

      Dermal
  • The characteristic bronze tint of the skin caused by arsine toxicity is induced by hemolysis and may be caused by hemoglobin deposits. This is not true jaundice which can occur in severe cases.
  • Contact with the liquid (compressed gas) can cause frostbite.

 

      Cardiovascular
  • Hypotension may occur with severe exposures. EKG changes and dysrhythmias associated with hypocalaemia can occur.

 

Hepatic
  • Right upper quadrant pain, hepatomegaly, elevated serum globulin, elevated liver enzymes and prolonged prothrombin time have been observed.

 

      Musculoskeletal

  • Skeletal muscle injury or necrosis have been reported. Muscle pain and twitches, myoglobinuria, elevated levels of serum creatine phosphokinase (CPK) and aldolase have been observed.

 

      Ocular
  • Red staining of the conjuctiva may be an early sign of arsine poisoning.

 

Laboratory Diagnosis
  • If significant exposure is a possibility and transfusion is considered, obtain a blood sample for type and screen.
  • Laboratory tests to determine hemolysis include CBC with peripheral smear, urinalysis, and plasma free hemoglobin and haptoglobin analyses.
  • Other useful studies include renal-function tests (e.g., BUN, creatinine), and determinations of serum electrolytes and bilirubin levels.

 

Exposure
  • Persons exposed to arsine pose no serious risks of secondary contamination to personnel outside the Hot Zone.

 

Treatment
  • If massive exposure is suspected or if the patient is hypotensive, ensure adequate hydration by infusing intravenous saline or lactated Ringer's solution. Monitor fluid balance and avoid fluid overload if renal failure supervenes; monitor plasma electrolytes to detect disturbances (particularly hyperkalemia) as early as possible. Monitor hematocrit.
  • Because of possible severe hemolysis ensure adequate oxygenation by arterial blood gas measurement or pulse oxygenation monitoring. The use of diuretics such as furosimide to maintain urinary flow is an important consideration and should be performed under medical base control.
  • EYE - In case of frostbite injury, ensure that thorough warming with lukewarm water or saline has been completed. Examine the eyes for corneal damage and treat appropriately. Immediately consult an ophthalmologist for patients who have corneal injuries.
  • SKIN - In case of frostbite injury, irrigate with lukewarm (42°C) water according to standard treatment.
  • INHALATION - Administer supplemental oxygen by mask to patients who have respiratory symptoms. Treat patients who have bronchospasm with aerosolized bronchodilators. Consider racemic epinephrine aerosol for children who develop stridor. If hemolysis develops, initiate urinary alkalinization. Consider hemodialysis if renal failure is severe.

 

Disposition/Followup
  • Decisions to admit or discharge a patient should be based on exposure history, physical examination, and test results.
  • Obtain the name of the patient's primary care physician so that the hospital can send a copy of the ED visit to the patient's doctor.
  • All patients should have repeat urine and blood laboratory tests in 12 to 24 hours. Patients who have corneal injuries should be reexamined within 24 hours.
  • If severe hemolysis has occurred, anemia may persist for several weeks.
  • Polyneuropathy and alteration in mental status are reported to have followed arsine poisoning after a latency of 1 to 6 months.
  • Patients should be evaluated periodically by their physician for several months; these examinations should include hematological and urinalysis tests.
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