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Low-level exposures to hydrogen sulfide usually produce local eye and mucous
membrane irritation, while high-level exposures rapidly produce fatal systemic
toxicity. Exposures of 700-800 ppm or greater can cause loss of consciousness and
cardiopulmonary arrest. Complications include the following:
Exposures can be subdivided into low-, high-, and very high-level categories. Lowlevel exposure often is more chronic in nature and usually is seen in industrial
settings. Chronic low-level exposure of hydrogen sulfide results primarily in irritation
to mucous membranes and the respiratory system. Other toxic effects are
headaches, asthenia, and bronchitis.
Cough, Dyspnea
Vertigo, Confusion
Nausea and vomiting
Possible loss of consciousness
Hemoptysis
Myocardial infarction
Sudden loss of consciousness ("knockdown")
Seizure
Cardiopulmonary arrest
Low-level exposure of hydrogen sulfide most often affects the mucous membranes
and may show:
Bradycardia
Tremulousness
Agitation
Cyanosis
Acute lung injury (patients may present with acute respiratory distress syndrome
[ARDS])
Perform a secondary survey to rule out traumatic injuries. Historically, these have
been found in about 10% of victims.
INVESTIGATIONS
Arterial blood gas (ABG)
testing usually reveals a marked uncompensated metabolic acidosis. Acidosis is
associated with an elevation in serum lactate level. Oxygen tension (pO2) and
calculated oxygen saturation are within the reference range unless the patient has
concomitant pulmonary edema. As with other hemoglobinopathies, however,
measured oxygen saturation often is low and indicates a saturation gap.
Venous blood gas may indicate abnormally high oxygen tension (because of
decreased oxygen utilization) resulting in a decrease in the PO2 gradient between
arterial and venous blood. Hydrogen sulfide toxicity may be associated with
carboxyhemoglobin or methemoglobinemia, depending on the source of the
hydrogen sulfide and co-exposure to other toxic gases.
Measurement of sulfide and thiosulfate levels is more appropriate for the evaluation
of low-level chronic exposures.
In severe cases, intubation may be necessary for ventilatory support and airway
protection. Establish intravenous (IV) access or initiate other initial supportive care
as necessary. Search the patient's pockets for discolored copper coins, which can be
an early diagnostic clue.
Patients who have suffered significant exposure (ie, anything other than chronic
low-level exposure with mucous membrane irritation) should be admitted to the
intensive care unit. Patients who are unresponsive to intravenous nitrites or who
have persistent or delayed neurologic sequelae should be considered for hyperbaric
oxygen therapy (HBO). Anecdotal reports indicate a salutary effect. All patients
should be discussed with the local poison center and/or a medical toxicologist.