Rosen & Barkin's 5-Minute Emergency Medicine Consult (717 page)

• Detailed physical exam
  
• CXR for suspected pneumonitis
  

• Electrolytes, BUN, creatinine, glucose:
  
  • Hypokalemia
    
  • Normal or high anion gap metabolic acidosis
    
  • Hyperchloremia
    
  • Impaired renal function
    
  • Severe hypocalcemia/hypophosphatemia
    
• Urinalysis:
  
  • Check for myoglobin (rhabdomyolysis)
    
  • Hematuria and protein often present
    
• Creatinine kinase if suspect rhabdomyolysis
  
• Alcohol level—often coingestant
  
• Liver enzymes, prothrombin time (PT), partial thromboplastin time (PTT), INR, as may cause hepatotoxicity
  
• Urine for hippuric acid (metabolite of toluene):
  
  • Confirms exposure but does not correlate with systemic effects
    
• Serum levels only detectable for short time after exposure
  

• EKG:
  
  • For atrial and ventricular dysrhythmias
    
• CXR:
  
  • Indicated if dyspnea or low oxygen saturation
    
  • Chemical pneumonitis
    
• CT head:
  
  • For altered mental status/chronic exposure
    
  • Cerebral/cerebellar atrophy, white matter hypodensity
    

CSF often unremarkable but may be indicated for altered mental status to rule out other etiologies

• Alcohol intoxication
  
• Other hydrocarbon abuse
  
• Other inhalants (nitrous oxide, difluoroethane, butane, etc.)
  
• Methanol
  
• Ethylene glycol
  
• Salicylate
  
• Heavy metal exposure
  
• Guillain–Barré syndrome
  
• Metabolic abnormalities
  

TREATMENT

• Rapid onset of toxicity
  
• Death possible with sudden cardiac dysrhythmias (sudden sniffing death), often from catecholamine surge (e.g., eluding police)
  
• Topical decontamination as needed
  
• Forced emesis is not indicated:
  
  • Decreased level of consciousness may lead to aspiration.
    

• ABCs
  
• Supplemental oxygen
  
• Cardiac monitor
  
• 0.9% NS IV access
  
• Naloxone, thiamine, and check glucose if altered mental status
  

• Treat cardiac dysrhythmias in standard fashion:
  
  • Consider β-blocker for tachydysrhythmias.
    
• Monitor respiratory status with pulse oximetry, CXR, and ABG if significant inhalation.
  
• Steroids not recommended for pneumonitis.
  
• Correct metabolic abnormalities:
  
  • Potassium
    
  • Calcium
    
  • Phosphate
    
• Acidosis resolves with IV fluids.
  
• If rhabdomyolysis, maintain high urine output.
  
• Gastric decontamination for oral ingestion rarely useful and may cause harm:
  
  • Charcoal does not bind hydrocarbons well and stomach distention may predispose to vomiting and aspiration.
    

• Dextrose: D
  ₅₀
  W, 1 amp: 50 mL or 25 g (peds: D
  ₂₅
  W, 2–4 mL/kg) IV
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• Altered mental status
  
• Dysrhythmias
  
• Hepatic dysfunction
  
• Renal failure
  
• Rhabdomyolysis
  
• Severe metabolic derangements
  
• Refractory hypokalemia
  

After 4–6 hr of observation:

• Mental status at baseline
  
• No evidence of cardiac, metabolic, or neurologic derangement
  

• Psychiatry referral for intentional/repeated ingestions and addiction counseling
  
• Cessation of use is most important intervention
  

• Myocardial sensitization to catecholamines:
  
  • Possibility of sudden dysrhythmia/death
    
  • Cardiac dysrhythmias have poor prognosis
    
• Monitor and replete electrolyte abnormalities.
  

• Bowen SE, Hannigan JH. Developmental toxicity of prenatal exposure to toluene.
  AAPS J
  . 2006;8:E419–E424.
  
• Filley CM, Halliday W, Kleinschmidt-Demasters BK. The effects of toluene on the central nervous system.
  J Neuropathol Exp Neurol
  . 2004;63:1–12.
  
• Long H. Inhalants. In: Goldfrank LR, ed.
  Goldfrank’s Toxicologic Emergencies.
  9th ed. New York, NY: McGraw-Hill; 2011:1157–1165.
  
• Tang HL, Chu KH, Cheuk A, et al. Renal tubular acidosis and severe hypophosphataemia due to toluene inhalation.
  Hong Kong Med J
  . 2005;11(1):50–53.
  
• Yucel M, Takagi M, Walterfang M, et al. Toluene misuse and long-term harms: A systematic review of the neuropsychological and neuroimaging literature.
  Neurosci Biobehav Rev
  . 2008;32:910–926.
  

The author would like to provide special thanks to the author of the prior edition, Matthew Valento.

CODES

• 305.90 Other, mixed, or unspecified drug abuse, unspecified use
  
• 982.0 Toxic effect of benzene and homologues
  

BASICS

• Tooth pain is caused by irritation of the root nerves located in pulpal tissue:
  
  • The pulp is the tooth’s center and its neurovascular supply
    
• Other etiologies, both inside the mouth and referred to the oral cavity, may cause oral pain
  

• Dental:
  
  • Dental caries (hard structures demineralized by bacteria)
    
  • Pulpitis (inflamed pulp secondary to infection)
    
  • Reversible pulpitis is mild inflammation of the tooth pulp caused by caries encroaching on the pulp
    
  • Irreversible pulpitis is the result of an untreated carious lesion causing severe inflammation of the pulp and severe, persistent, poorly localized discomfort
    
  • Periapical abscess (necrotic pulp and subsequent abscess)
    
  • Postextraction pain (dry socket, infection)
    
  • Cracked-tooth syndrome (pain, cold sensitivity, crack difficult to visualize)
    
• Periodontal disease:
  
  • Gingivitis and periodontitis (gingivitis with loss of periodontal ligament attachment)
    
  • Periodontal abscess (gum boil)
    
  • Pericoronitis (gingival inflammation from malerupted tooth)
    
  • Acute necrotizing ulcerative gingivitis (gingival pain, ulcers with/without pseudomembranes)
    
  • Denture stomatitis
    
  • Herpetic gingivostomatitis
    
  • Aphthous ulcers (canker sores)
    
  • Traumatic ulcers
    

DIAGNOSIS

• Tooth pain:
  
  • May be referred to jaw, ear, face, eye, and neck (sensory distribution of 5th cranial nerve)
    
  • Pain often associated with chewing, changes in temperature, and recumbency
    
• Malodorous breath
  
• Fever and chills
  
• Foul taste in mouth
  
• Associated symptoms
  
• Duration of symptoms
  
• Treatments that have already been tried
  

• Dental decay
  
• Facial swelling or erythema
  
• Trismus:
  
  • Decreased maximal interincisal opening (normal opening, 35–50 mm)
    
• Inspect and palpate lips, salivary glands, floor of the mouth, lymph nodes of the neck
  
• Assess voice changes
  
• Identify periodontal abscess
  
• Evaluate for deep-space infection
  
• Examine face for swelling, redness, tenderness, and increased warmth
  
• Examine neck for adenopathy and stiffness
  
• Teeth should be percussed for tenderness and mobility
  
• Teeth should be examined for fracture and missing teeth
  
• Dental numeric system used in adults:
  
  • Maxillary: Right to left 1–16; mandibular: Left to right 17–32 (peds: A–J and K–T)
    
  • Alternatively identification of teeth by their location is also appropriate (i.e., left rearmost, upper molar)