Medical Management Guidelines for Toluene
(C6H5CH3)
CAS# 108-88-3
UN# 1294
PDF Versionpdf icon[2.24 MB]
Synonyms include methyl benzene, methyl
benzol, phenyl methane, and toluol.
- Persons exposed only to toluene vapor do not pose substantial
risks of secondary contamination. Persons whose clothing
or skin is contaminated with liquid toluene can cause secondary
contamination by direct contact or through off-gassing vapor.
- Toluene is a colorless liquid with a sweet, pungent, benzene-like
odor which provides an adequate warning of hazardous concentrations.
Toluene is volatile, readily producing flammable and toxic
concentrations at room temperature. Its vapor is heavier
than air and may accumulate in low-lying areas.
- Toluene is absorbed rapidly after inhalation and ingestion.
It is absorbed slowly through intact skin; however, percutaneous
absorption may contribute to total body burden. Exposure
by ingestion or inhalation can cause systemic effects. No
information was found to suggest that the pharmacokinetics
of toluene in children is different than in adults. Toluene
crosses the placenta and is excreted in breast milk.
General Information
Description
Toluene is a clear, colorless, volatile
liquid with a sweet, pungent, benzene-like odor. It is flammable
at temperatures greater than 40°F (4.4°C); therefore,
it is a significant fire hazard at room temperature. Toluene
mixes readily with many organic solvents, but is poorly soluble
in water. Toluene is less dense than water and will float
on the surface of water. Toluene should be stored indoors
in a standard flammable liquids room or cabinet that is separate
from oxidizing materials.
Routes of Exposure
Inhalation
Toluene is readily absorbed from the
lungs, and most exposures to toluene occur by inhalation.
Toluene's odor is discernable at a concentration of 8 ppm,
which is 25 times less than the OSHA PEL (200 ppm); therefore,
odor generally provides adequate warning of acutely hazardous
concentrations. Its vapor is heavier than air and may cause
asphyxiation in enclosed, poorly ventilated, or low-lying
areas.
Children exposed to the same levels of
toluene vapor as adults may receive a larger dose because
they have greater lung surface area:body weight ratios and
increased minute volumes:weight ratios. In addition, they
may be exposed to higher levels than adults in the same location
because of their short stature and the higher levels of toluene
vapor found nearer to the ground.
Skin/Eye Contact
Toluene vapor is only mildly irritating
to mucous membranes; however, liquid toluene splashed in the
eyes can result in corneal injury. Repeated or prolonged skin
contact with liquid toluene can defat the skin, causing it
to crack and peel. Percutaneous absorption is slow through
intact skin; however, toluene absorbed through the skin may
contribute to total body burden.
Children are more vulnerable to toxicants
absorbed through the skin because of their relatively larger
surface area:body weight ratio.
Ingestion
Acute systemic toxicity can result from
ingestion of toluene.
Sources/Uses
Toluene is among the most abundantly
produced chemicals in the United States. It is obtained primarily
by distillation from crude petroleum. Toluene is an excellent
solvent for paints, lacquers, thinners, and adhesives. It
is used extensively in the rubber, chemical, paint, dye, glue,
printing, and pharmaceutical industries.
Standards and Guidelines
OSHA PEL (permissible exposure limit)
= 200 ppm (averaged over an 8-hour workshift)
OSHA ceiling = 300 ppm
OSHA STEL (short-term exposure limit)
= 500 ppm (10-minute exposure)
NIOSH IDLH (immediately dangerous to
life or health) = 500 ppm
ACGIH TLV (threshold limit value) = 50
ppm (averaged over an 8-hour workshift)
AIHA ERPG-2 (emergency response planning
guideline) (maximum airborne concentration below which it
is believed that nearly all individuals could be exposed for
up to 1 hour without experiencing or developing irreversible
or other serious health effects or symptoms which could impair
an individual's ability to take protective action) = 300 ppm
Physical Properties
Description: Clear, colorless
liquid
Warning properties: Adequate;
sweet, aromatic odor at 8 ppm
Molecular weight: 92.1 daltons
Boiling point (760 mm Hg): 232°F
(110.6°C)
Freezing point: -139°F (-9°C)
Specific gravity: 0.87 (water
= 1)
Vapor pressure: 21 mm Hg at 68°F
(20°C)
Gas density: 3.2 (air = 1)
Water solubility: Slightly water
soluble (0.07% at 74°F) (23°C)
Flammability: 40°F (4.4°C);
vapors may travel to a source of ignition and flash back.
Flammable range: 1.2% to 7.1%
(concentration in air)
Incompatibilities
Toluene reacts with strong oxidizers.
Health Effects
- Toluene is irritating to the skin, eyes, and respiratory
tract. It can cause systemic toxicity by ingestion or inhalation
and is slowly absorbed through the skin. The most common
route of exposure is via inhalation. Symptoms of toluene
poisoning include CNS effects (headache, dizziness, ataxia,
drowsiness, euphoria, hallucinations, tremors, seizures,
and coma), ventricular arrythmias, chemical pneumonitis,
respiratory depression, nausea, vomiting, and electrolyte
imbalances.
- The mechanism by which toluene produces systemic toxicity
is not known. No information was found to suggest that the
health effects of toluene in children are different than
in adults. Toluene crosses the placenta and is excreted
in breast milk.
Acute Exposure
The mechanism by which toluene produces
systemic toxicity is not known. CNS toxicity may be due to
the liposolubility of toluene in the neuronal membrane. It
has been suggested that toluene interferes with the normal
function of neuronal proteins. It has also been suggested
that the toxicity of toluene may be due to some of its metabolic
intermediates. CNS toxicity is generally discernable within
a short time of exposure, but pulmonary effects may not appear
for up to 6 hours after exposure. No information was found
to suggest that the health effects of toluene in children
are different than in adults.
Children do not always respond to chemicals
in the same way that adults do. Different protocols for managing
their care may be needed.
CNS
Generally, symptoms of CNS toxicity are
apparent immediately after inhalation of high toluene concentrations
and 30 to 60 minutes after ingestion. Mild CNS effects include
headache, lightheadedness, dizziness, confusion, nausea, impaired
judgment, impaired gait, and blurred vision. More severe effects
include loss of consciousness, coma, and death. Coma may be
prolonged, although most victims regain consciousness rapidly
after they are removed from exposure.
Respiratory
Acute exposure to toluene vapor can irritate
the mucous membranes of the respiratory tract. With massive
exposure, accumulation of fluid in the lungs and respiratory
arrest may ensue. Pulmonary aspiration of toxic vomitus or
ingested liquid toluene may cause chemical pneumonitis.
Exposure to certain chemicals can lead
to Reactive Airway Dysfunction Syndrome (RADS), a chemically-
or irritant-induced type of asthma.
Children may be more vulnerable because
of relatively increased minute ventilation per kg and failure
to evacuate an area promptly when exposed.
Hydrocarbon pneumonitis may be a problem
in children.
Cardiovascular
Massive doses of toluene can cause cardiac
abnormalities. Toluene may lower the threshold of the heart
to the effects of epinephrine, potentially disrupting the
heart rhythm. Irregular heart rhythm leading to cardiac arrest
has been described in solvent abusers, often immediately after
intense physical activity.
Renal
Blood and protein in the urine can occur
after massive inhalation. These effects are usually reversible
if exposure is terminated. Renal tubular acidosis, glomerulonephritis, myoglobinuria, and renal failure have been observed (Poisondex, 2014).
Hematologic
Bone marrow dysplasia and anemia have occurred after exposure to toluene. Decreased prothrombin has been reported after occupational toluene exposure.
Metabolic
After high-level exposure, toluene may
cause an acid-base imbalance. In solvent abusers, electrolyte
and acid-base disturbances have resulted in renal tubular
acidosis, deficiency of potassium, and deficiency of phosphate.
Ethanol or aspirin may prolong the half-life of toluene in
the body.
Because of their relatively higher metabolic
rates, children may be more vulnerable to toxicants interfering
with basic metabolism.
Dermal
Liquid toluene can cause irritation and
defatting after prolonged or repeated contact with the skin.
Redness and blisters may occur.
Because of their relatively larger surface
area:body weight ratio, children are more vulnerable to toxicants
absorbed through the skin.
Hepatic
Liver damage has been reported in solvent
abusers.
Ocular
Eye irritation from toluene vapor begins
at concentrations of about 300 ppm. Inflammation is generally
slight. When splashed in the eyes, toluene may cause burning
pain, blepharospasm, conjuctivitis, and keratinitis.
Gastrointestinal
If swallowed, toluene can irritate the
stomach, causing nausea, vomiting, and diarrhea.
Potential Sequelae
During recovery, exposed persons may
continue to experience ataxia, depressed level of consciousness,
dilated and poorly responsive pupils, and decreased or absent
deep tendon reflexes. Anxiety, fatigue, and insomnia may last
several days. No long-term effects due to acute toluene exposure
have been reported.
Chronic Exposure
Chronic toluene exposures at less than
200 ppm have been associated with headache, fatigue, and nausea.
Workers repeatedly exposed at 200 to 500 ppm have reported
loss of coordination, memory loss, and loss of appetite. Some
workers have developed reversible disorders of the optic nerves
after chronic exposure in the workplace.
Chronic exposure due to solvent abuse
can result in permanent neuropsychiatric effects. Disorders
of the muscles, cardiovascular effects, renal tubular damage,
and sudden death have occurred in chronic abusers of toluene.
Chronic exposure may be more serious
for children because of their potential longer latency period.
Carcinogenicity
The International Agency for Research
on Cancer has determined that toluene is not classifiable
as to its carcinogenicity to humans. The EPA has determined
that toluene is not classifiable as to its human carcinogenicity.
Reproductive and Developmental Effects
Toluene has not been confirmed as a human
reproductive hazard. However, toluene is known to cross the
placenta and is excreted in breast milk. In animal studies
toluene has been shown to be fetotoxic, but not teratogenic.
Shepards Catalog of Teratogenic Agents reports five cases
of children whose mothers regularly used toluene recreationally
while pregnant. These children were born with small heads
(microcephaly); CNS dysfunction; and minor head, face, and
limb anomalies. Several of the mothers had also abused alcohol
during pregnancy. Toluene is included in Reproductive and
Developmental Toxicants, a 1991 report published by the
U.S. General Accounting Office (GAO) that lists 30 chemicals
of concern because of widely acknowledged reproductive and
developmental consequences.
Prehospital Management
- Victims exposed only to toluene vapor do not pose substantial
risks of secondary contamination to rescuers outside the
Hot Zone. Victims whose clothing or skin is contaminated
with liquid toluene can secondarily contaminate response
personnel by direct contact or through off-gassing vapor.
Toluene vapor may also off-gas from the toxic vomitus of
victims who have ingested toluene.
- Toluene is irritating to the skin, eyes, and respiratory
tract. It can cause systemic toxicity by ingestion or inhalation.
The most common route of exposure is via inhalation. Symptoms
of toluene poisoning include CNS effects (headache, dizziness,
ataxia, drowsiness, euphoria, hallucinations, tremor, seizures,
and coma), ventricular arrythmias, chemical pneumonitis,
respiratory depression, nausea, vomiting, and electrolyte
imbalances.
- There is no antidote for toluene. Treatment consists of
support of respiratory and cardiovascular functions.
Hot Zone
Rescuers should be trained and appropriately
attired before entering the Hot Zone. If the proper equipment
is not available, or if rescuers have not been trained in
its use, assistance should be obtained from a local or regional
HAZMAT team or other properly equipped response organization.
Rescuer Protection
Toluene vapor is absorbed well by inhalation
and is a mild respiratory-tract irritant. The liquid is a
mild skin and eye irritant with slow skin absorption.
Respiratory Protection: Positive-pressure,
self-contained breathing apparatus (SCBA) is recommended in
response situations that involve exposure to potentially unsafe
levels of toluene vapor.
Skin Protection: Chemical-protective
clothing is not generally required when only vapor exposure
is expected because toluene vapor is neither irritating nor
absorbed well through the skin.
Chemical-protective clothing should be
worn when repeated or prolonged contact with the liquid is
anticipated because skin irritation and dermal absorption
may occur.
ABC Reminders
Quickly access for a patent airway, ensure
adequate respiration and pulse. If trauma is suspected, maintain
cervical immobilization manually and apply a cervical collar
and a backboard when feasible.
Victim Removal
If victims can walk, lead them out of
the Hot Zone to the Decontamination Zone. Victims who are
unable to walk may be removed on backboards or gurneys; if
these are not available, carefully carry or drag victims to
safety.
Consider appropriate management of chemically
contaminated children, such as measures to reduce separation
anxiety if a child is separated from a parent or other adult.
Decontamination Zone
Patients exposed only to toluene vapor
who have no skin or eye irritation may be transferred immediately
to the Support Zone. Other patients will require decontamination
(as described below).
Rescuer Protection
If exposure levels are determined to
be safe, decontamination may be conducted by personnel wearing
a lower level of protection than that worn in the Hot Zone
(described above).
ABC Reminders
Quickly access for a patent airway, ensure
adequate respiration and pulse. Stabilize the cervical spine
with a collar and a backboard if trauma is suspected. Administer
supplemental oxygen as required. Assist ventilation with a
bag-valve-mask device if necessary.
Basic Decontamination
Victims who are able may assist with
their own decontamination. Quickly remove and double-bag contaminated
clothing and personal belongings.
Flush liquid-exposed skin and hair with
plain water for 2 to 3 minutes, then wash with mild soap.
Rinse thoroughly with water. Use caution to avoid hypothermia
when decontaminating children or the elderly. Use blankets
or warmers when appropriate.
Flush exposed or irritated eyes with
plain water or saline for at least 15 minutes or until pain
resolves. Remove contact lenses if easily removable without
additional trauma to the eye. If a corrosive material is suspected
or if pain or injury is evident, continue irrigation while
transferring the victim to the Support Zone.
In cases of ingestion, do not induce
emesis. The use of activated charcoal for hydrocarbon
absorption is limited, but it may have some effect, especially
in cases of mixed overdose. If the victim is alert, asymptomatic,
and has a gag reflex, administer a slurry of activated charcoal
at 1 gm/kg (usual adult dose 60-90 g, child dose 25-50 g).
A soda can and a straw may be of assistance when offering
charcoal to a child.
Consider appropriate management of chemically contaminated
children at the exposure site. Provide reassurance to the
child during decontamination, especially if separation from
a parent occurs.
Transfer to Support Zone
As soon as basic decontamination is complete,
move the victim to the Support Zone.
Support Zone
Be certain that victims have been decontaminated
properly (see Decontamination Zone above). Victims
who have undergone decontamination or who have been exposed
only to vapor generally pose no serious risks of secondary
contamination. In such cases, Support Zone personnel require
no specialized protective gear.
ABC Reminders
Quickly access for a patent airway. If
trauma is suspected, maintain cervical immobilization manually
and apply a cervical collar and a backboard when feasible.
Ensure adequate respiration and pulse. Administer supplemental
oxygen as required and establish intravenous access if necessary.
Place on a cardiac monitor. Observe for cardiac arrhythmias.
Additional Decontamination
Continue irrigating exposed skin and
eyes, as appropriate.
In cases of ingestion, do not induce
emesis. The use of activated charcoal for hydrocarbon
absorption is limited, but it may have some effect, especially
in cases of mixed overdose. If activated charcoal has not
been given previously and if the patient is alert, asymptomatic,
and has a gag reflex, administer a slurry of activated charcoal
at 1 gm/kg (usual adult dose 60-90 g, child dose 25-50 g).
A soda can and a straw may be of assistance when offering
charcoal to a child.
Advanced Treatment
In cases of respiratory compromise secure
airway and respiration via endotracheal intubation. If not
possible, perform cricothyroidotomy if equipped and trained
to do so.
Patients who have bronchospasm may be
treated with aerosolized bronchodilators. However, the use
of sympathomimetic agents such as epinephrine and isoproterenol
could precipitate fatal arrhythmias and should be avoided.
Selective beta-2 agonists would be preferred, but clinical
reports of their use are lacking. Theophylline derivatives
have not been studied. Use all catecholamines with caution
because of the enhanced risk of cardiac arrhythmias. Also
consider the health of the myocardium before choosing which
type of bronchodilator should be administered.
Patients who are comatose, hypotensive, or having seizures
or cardiac arrhythmias should be treated according to advanced
life support (ALS) protocols.
Monitor fluid and electrolyte status
carefully. Correct hypokalemia with potassium phosphate (phosphate
levels are also generally low). Hypocalcemia may occur following
fluid and electrolyte replenishment. Do not administer bicarbonate
therapy until potassium and calcium are adequately replaced.
Transport to Medical Facility
Only decontaminated patients or patients
not requiring decontamination should be transported to a medical
facility. "Body bags" are not recommended.
Report to the base station and the receiving
medical facility the condition of the patient, treatment given,
and estimated time of arrival at the medical facility.
If toluene has been ingested, prepare
the ambulance in case the victim vomits toxic material. Have
ready several towels and open plastic bags to quickly clean
up and isolate vomitus.
Multi-Casualty Triage
Consult with the base station physician
or the regional poison control center for advice regarding
triage of multiple victims.
Patients with evidence of substantial
inhalation exposure (e.g., confusion, syncope, or coma) and
all patients who have ingested toluene should be transported
to a medical facility for evaluation. Others may be discharged
at the scene after their names, addresses, and telephone numbers
are recorded. Those discharged should be advised to seek medical
care promptly if symptoms develop (see Patient Information
Sheet below).
Emergency Department Management
- Hospital personnel can be secondarily contaminated by
direct contact or vapor off-gassing from heavily soaked
skin or clothing. Patients do not pose contamination risks
after clothing is removed and the skin is washed. Toxic
vomitus from patients who have ingested toluene may also
off-gas toluene vapor.
- Toluene is irritating to the skin, eyes, and respiratory
tract. It can cause systemic toxicity by ingestion or inhalation.
The most common route of exposure is via inhalation. Symptoms
of toluene poisoning include CNS effects (headache, dizziness,
ataxia, drowsiness, euphoria, hallucinations, tremor, seizures,
and coma), ventricular arrythmias, chemical pneumonitis,
respiratory depression, nausea, vomiting, and electrolyte
imbalances.
- There is no antidote for toluene. Treatment consists of
support of respiratory and cardiovascular functions.
Decontamination Area
Unless previously decontaminated, all
patients suspected of contact with liquid toluene and all
victims with skin or eye irritation require decontamination
as described below. All other patients may be transferred
to the Critical Care area.
Be aware that use of protective equipment
by the provider may cause fear in children, resulting in decreased
compliance with further management efforts.
Because of their relatively larger surface
area:body weight ratio, children are more vulnerable to toxicants
absorbed through the skin. Also emergency room personnel should
examine children's mouths because of the frequency of hand-to-mouth
activity among children.
ABC Reminders
Evaluate and support airway, breathing,
and circulation. In cases of respiratory compromise secure
airway and respiration via endotracheal intubation. If not
possible, surgically create an airway.
Patients who have bronchospasm may be
treated with aerosolized bronchodilators. However, the use
of sympathomimetic agents such as epinephrine and isoproterenol
could precipitate fatal arrhythmias and should be avoided.
Selective beta-2 agonists would be preferred, but clinical
reports of their use are lacking. Theophylline derivatives
have not been studied. Use all catecholamines with caution
because of the enhanced risk of cardiac arrhythmias. Also
consider the health of the myocardium before choosing which
type of bronchodilator should be administered.
Patients who are comatose, hypotensive,
or have seizures or ventricular arrhythmias should be treated
in the conventional manner. Avoid sympathomimetics or catecholamines
or use them with caution. Beta-blockers may be more effective
than lidocaine in cases of prolonged or resistant arrhythmias.
Monitor fluid and electrolyte status
carefully. Correct hypokalemia with potassium phosphate (phosphate
levels are also generally low). Hypocalcemia may occur following
fluid and electrolyte replenishment. Do not administer bicarbonate
therapy until potassium and calcium are adequately replaced.
Basic Decontamination
Patients who are able may assist with
their own decontamination. Remove and double-bag contaminated
clothing and personal belongings.
Flush liquid-exposed skin and hair with
plain water for 2 to 3 minutes, then wash with mild soap.
Rinse thoroughly with water. Use caution to avoid hypothermia
when decontaminating children or the elderly. Use blankets
or warmers when appropriate.
Flush exposed or irritated eyes with
plain water or saline for at least 15 minutes or until pain
resolves. Remove contact lenses if present and easily removable
without additional trauma to the eye. If a corrosive material
is suspected or if pain or injury is evident, continue irrigation
while transferring the victim to the Critical Care Area.
In cases of ingestion, do not induce
emesis. The use of activated charcoal for hydrocarbon
absorption is limited, but it may have some effect, especially
in cases of mixed overdose. If the victim is alert, asymptomatic,
and has a gag reflex, administer a slurry of activated charcoal
at 1 gm/kg (usual adult dose 60-90 g, child dose 25-50 g).
A soda can and a straw may be of assistance when offering
charcoal to a child.
Critical Care Area
Be certain that appropriate decontamination
has been carried out (see Decontamination Area above).
ABC Reminders
Evaluate and support airway, breathing,
and circulation as in ABC Reminders above. Establish intravenous
access in seriously ill patients if this has not been done
previously. Continuously monitor cardiac rhythm. To avoid
inducing ventricular fibrillation, use sympathomimetics or
catecholamines with caution. Beta-blockers may be more effective
than lidocaine in treating patients who have arrhythmia.
Patients who are comatose, hypotensive,
or have seizures or ventricular arrhythmia should be treated
in the conventional manner. Avoid sympathomimetics or catecholamines
or use them with caution. Beta-blockers may be more effective
than lidocaine in cases of prolonged or resistant arrhythmia.
Inhalation Exposure
Administer supplemental oxygen by mask
to patients who have respiratory complaints. Patients who
have bronchospasm may be treated with aerosolized bronchodilators.
However, the use of sympathomimetic agents such as epinephrine
and isoproterenol could precipitate fatal arrhythmia and should
be avoided. Selective beta-2 agonists would be preferred,
but clinical reports of their use are lacking. Theophylline
derivatives have not been studied. Use all catecholamines
with caution because of the enhanced risk of cardiac arrhythmia.
Also consider the health of the myocardium before choosing
which type of bronchodilator should be administered.
Skin Exposure
If the skin was in prolonged contact
with liquid toluene, chemical burns may result; treat as thermal
burns.
Because of their larger surface area:body
weight ratio, children are more vulnerable to toxicants absorbed
through the skin.
Eye Exposure
Ensure that adequate eye irrigation has
been completed. Examine the eyes for corneal damage and treat
appropriately. Immediately consult an ophthalmologist for
patients who have corneal injuries.
Ingestion Exposure
Do not induce emesis.
The use of activated charcoal for hydrocarbon
absorption is limited, but it may have some effect, especially
in cases of mixed overdose. If activated charcoal has not
been given previously and if the patient is alert, asymptomatic,
and has a gag reflex, administer a slurry of activated charcoal
at 1 gm/kg (usual adult dose 60-90 g, child dose 25-50 g).
A soda can and a straw may be of assistance when offering
charcoal to a child.
Consider endoscopy to evaluate the extent
of gastrointestinal-tract injury. Extreme throat swelling
may require endotracheal intubation or cricothyroidotomy.
Gastric lavage is useful in certain circumstances to remove
toxic material and prepare for endoscopic examination. Consider
gastric lavage with a small nasogastric tube if: (1) a large
dose has been ingested; (2) the patient's condition is evaluated
within 30 minutes; (3) the patient has oral lesions or persistent
esophageal discomfort; and (4) the lavage can be administered
within one hour of ingestion. Care must be taken when placing
the gastric tube because blind gastric-tube placement may
further injure the chemically damaged esophagus or stomach.
Because children do not ingest large
amounts of toxic materials, and because of the risk of perforation
from NG intubation, lavage is discouraged in children unless
performed under endoscopic guidance.
Toxic vomitus or gastric washings should
be isolated, e.g., by attaching the lavage tube to isolated
wall suction or another closed container.
Antidotes and Other Treatments
There is no antidote for toluene. Hemodialysis
and hemoperfusion are ineffective.
Monitor fluid and electrolyte status
carefully. Correct hypokalemia with potassium phosphate (phosphate
levels are also generally low). Hypocalcemia may occur following
fluid and electrolyte replenishment. Do not administer bicarbonate
therapy until potassium and calcium are adequately replaced.
Laboratory Tests
Routine laboratory studies for all exposed
patients include CBC, glucose, and electrolyte determinations.
Additional studies for patients exposed to toluene include
ECG monitoring, renal-function tests, and liver-function tests.
Chest radiography and pulse oximetry (or ABG measurements)
are also recommended for severe inhalation exposure or if
pulmonary aspiration is suspected.
Blood levels of toluene may be useful
in documenting exposure, but are not useful clinically. Toluene
is metabolized to hippuric acid, which is excreted in urine
with a biologic half-life of about 3 hours. Results of urinary
hippuric acid tests do not correlate well with systemic effects
and are not available on an emergency basis; however, they
can help confirm the diagnosis or etiology. The ACGIH suggests
that levels exceeding 0.5 mg/L of o-cresol or 1.6 g of hippuric
acid/g creatinine in urine, or 0.05 mg/L of toluene in blood
indicate potential overexposure to toluene, but these are
not useful clinically.
Disposition and Follow-up
Consider hospitalizing symptomatic patients
who have significant inhalation or ingestion exposure with
symptoms of CNS depression or respiratory distress.
Delayed Effects
Observe hospitalized patients for signs
of acute tubular necrosis, encephalopathy, and arrhythmia.
In addition, patients who have inhaled large amounts of toluene
should be observed for signs of pulmonary edema, and those
who have ingested toluene should be watched for signs of aspiration
pneumonitis.
Patient Release
Patients who remain asymptomatic for
6 to 12 hours after exposure may be discharge with instructions
to seek medical care promptly if symptoms develop (see the
Toluene-Patient Information Sheet below).
Follow-up
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.
Patients who have corneal injuries should
be reexamined within 24 hours. No long-term sequelae due to
a single acute exposure to toluene have been reported.
Reporting
If a work-related incident has occurred,
you may be legally required to file a report; contact your
state or local health department.
Other persons may still be at risk in
the setting where this incident occurred. If the incident
occurred in the workplace, discussing it with company personnel
may prevent future incidents. If a public health risk exists,
notify your state or local health department or other responsible
public agency. When appropriate, inform patients that they
may request an evaluation of their workplace from OSHA or
NIOSH. See Appendices III and IV for a list of agencies that
may be of assistance.
Patient Information Sheet
This handout provides information and
follow-up instructions for persons who have been exposed to
toluene.
Print this handout only.pdf icon[45.9 KB]
What is toluene?
Toluene is a clear, colorless liquid
with a sweet odor. It is obtained from crude petroleum and
is highly flammable. Toluene is used in a variety of industries
and is a common solvent for products such as paints, thinners,
and glues. It is found in small amounts in gasoline.
What immediate health effects can result from toluene exposure?
Breathing toluene vapors in small amounts
may cause a mild headache, dizziness, drowsiness, or nausea.
With more serious exposure, toluene may cause sleepiness,
stumbling, irregular heartbeat, fainting, or even death. Toluene
vapor is mildly irritating to the skin, eyes, and lungs. If
liquid toluene contacts the skin, it may cause irritation
and a rash. Liquid toluene splashed in the eyes can damage
the eyes. Generally, the more serious the exposure, the more
severe the symptoms.
Can toluene poisoning be treated?
There is no antidote for toluene, but
its effects can be treated, and most exposed persons get well.
Persons who have experienced serious symptoms may need to
be hospitalized.
Are any future health effects likely to occur?
A single small exposure from which a
person recovers quickly is not likely to cause delayed or
long-term effects. After a serious exposure to toluene, some
symptoms may take a few days to develop.
Repeated sniffing of toluene can cause
permanent damage to the brain, muscles, heart, and kidneys.
What tests can be done if a person has been exposed to toluene?
Specific tests for the presence of toluene
in blood or urine generally are not useful to the doctor.
Hippuric acid, a breakdown product of toluene, can be measured
in urine if the toluene dose was high. If a severe exposure
has occurred, blood and urine analyses and other tests may
show whether the brain, heart, or kidneys have been injured.
Testing is not needed in every case.
Where can more information about toluene be found?
More information about toluene can be
obtained from your regional poison control center; your state,
county, or local health department; the Agency for Toxic Substances
and Disease Registry (ATSDR); your doctor; or a clinic in
your area that specializes in occupational and environmental
health. If the exposure happened at work, you may wish to
discuss it with your employer, the Occupational Safety and
Health Administration (OSHA), or the National Institute for
Occupational Safety and Health (NIOSH). Ask the person who
gave you this form for help in locating these telephone numbers.
Follow-up Instructions
Keep this page and take it with you to
your next appointment. Follow only the instructions
checked below.
Print instructions only.pdf icon[45.9 KB]
[ ] Call your doctor or the Emergency
Department if you develop any unusual signs or symptoms within
the next 24 hours, especially:
- fatigue, headache, dizziness, tremor or seizures.
- coughing, shortness of breath or wheezing
- chest pain or tightness
- increased pain or a discharge from injured eyes
- increased redness or pain or a pus-like discharge in the
area of a skin burn
- fever
[ ] No follow-up appointment is necessary
unless you develop any of the symptoms listed above.
[ ] Call for an appointment with Dr.____
in the practice of ________.
When you call for your appointment, please
say that you were treated in the Emergency Department at _________
Hospital by________and were advised to be seen again in ____days.
[ ] Return to the Emergency Department/Clinic
on ____ (date) at _____ AM/PM for a follow-up examination.
[ ] Do not perform vigorous physical
activities for 1 to 2 days.
[ ] You may resume everyday activities
including driving and operating machinery.
[ ] Do not return to work for _____days.
[ ] You may return to work on a limited
basis. See instructions below.
[ ] Avoid exposure to cigarette smoke
for 72 hours; smoke may worsen the condition of your lungs.
[ ] Avoid drinking alcoholic beverages
for at least 24 hours; alcohol may worsen injury to your stomach
or have other effects.
[ ] Avoid taking the following medications:
________________
[ ] You may continue taking the following
medication(s) that your doctor(s) prescribed for you: _______________________________
[ ] Other instructions:
____________________________________
_____________________________________________________
- Provide the Emergency Department with the name and the
number of your primary care physician so that the ED can
send him or her a record of your emergency department visit.
- You or your physician can get more information on the
chemical by contacting: ____________ or _____________, or by
checking out the following Internet Web sites:
___________;__________.
Signature of patient _______________ Date ____________
Signature of physician _____________ Date ____________
Where can I get more information?
If you have questions or concerns, please contact your community or state health or environmental quality department or:
For more information, contact:
Agency for Toxic Substances and Disease Registry
Division of Toxicology and Human Health Sciences
4770 Buford Highway
Chamblee, GA 30341-3717
Phone: 1-800-CDC-INFO 888-232-6348 (TTY)
Email: Contact CDC-INFO
ATSDR can also tell you the location of occupational and environmental health clinics. These clinics specialize in recognizing, evaluating, and treating illnesses resulting from exposure to hazardous substances.