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Organic Solvents (Acute Exposure to Solvents, Anesthetics, or Sedatives (SAS) Toxidrome)

Concise toxidrome definition: A decreased level of consciousness (progressing to coma in some cases), depressed respirations, and in some cases ataxia (difficulty balancing and walking) from acute exposure to solvents, inhalational anesthetics, or sedative-hypnotic compounds.

Rationale or reasoning for toxidrome decisions: The basis for creating this toxidrome is the existence of a similar clinical presentation in casualties exposed to any of the members of these groups (solvents, inhalational anesthetics, and sedative-hypnotic compounds) following acute exposure. The delayed effects of solvent exposure do not form part of this toxidrome.

Issues or concerns about this toxidrome:  Because several different compounds form a part of this toxidrome, subtle differences among the clinical presentations may be missed; however, the signs and symptoms of exposure to each of these chemicals or drugs is similar enough to warrant inclusion in a combined toxidrome. It will be important to emphasize the difference between acute effects and delayed effects (primarily neurotoxicity) from solvent exposure.

SAS examples of industrial chemicals and potential chemical warfare/terrorism agents: Gasoline, benzene, toluene, xylene, carbon tetrachloride, methylene chloride, Freon, nitrous oxide, halothane, isoflurane, benzodiazepines (e.g., diazepam, alprazolam, midazolam), barbiturates (e.g., phenobarbital, pentobarbital), and miscellaneous compounds (e.g., chloral hydrate, methaqualone, etomidate, and propofol).

The clinically relevant routes of exposure and types of sources: Inhalation, ingestion, and dermal.

The organ systems generally affected: Central nervous system (CNS), peripheral nervous system (PNS), cardiac (secondary effects), skin, GI, hepatic, renal, and hematological.

The initial signs and symptoms: CNS agitation or (more commonly) depression, behavioral changes, slurred speech, nystagmus (abnormal eye movements), ataxia (difficulty walking and balancing), secondary cardiac arrest from release of catecholamines [solvents]; chemical dermatitis (chemical burns) and defatting from skin exposure to solvents.

A progression of signs and symptoms includes: a) possible initial agitation [solvents] progressing to confusion, slurred speech, ataxia, and loss of consciousness and b) subsequently sometimes progressing to coma, convulsions, respiratory arrest, cardiac dysrhythmias (irregular heartbeat), and cardiac arrest; cardiac arrest may be the first sign with high inhaled doses of solvents.

The underlying pathology, biological processes, or modes of action include: a) unclear [acute effects of solvents], b) release of catecholamines (acute effects of solvents), c) effects on ion channels (including GABA receptors) in the brain (inhalational anesthetics), and d) effects on GABA receptors (sedatives).

Common treatment protocol, specific antidotes and key supportive measures: Removal from exposure, airway management, artificial ventilation, flumazenil (not recommended if other toxicants may be involved).

Report to the Toxic Chemical Syndrome Definitions and Nomenclature Workshop (PDF - 2.01 MB) (DHS, NLM, May, 2012)

Information from Other Resources

Resource Comparison Table of Resource Comparison
Information from CDC, WISER, and CAMEO
Emergency Response Safety and Health Database (CDC/NIOSH) arrow WISER (NIH/NLM) arrow CAMEO (EPA, NOAA) arrow Medical Management Guidelines for Acute Chemical Exposures (CDC/ATSDR) arrow Chemical Emergencies (CDC) arrow

Additional Resources:

ChemIDplus - Chemical dictionary, structures, and links to many Internet resources (NIH/NLM)
Gasoline, Benzene, Toluene, Xylene, Carbon tetrachloride, Methylene chloride, Freon, Nitrous oxide, Halothane, Isoflurane, Benzodiazepines (e.g., Diazepam, Alprazolam, Modazolam), Barbiturates (e.g., Phenobarbital, Pentobarbital), Miscellaneous compounds (e.g., Chloral hydrate, Methaqualone, Etomidate, and Propofol)

Hazardous Substances Data Bank - Comprehensive, peer-reviewed toxicology data (NIH/NLM)
Gasoline, Benzene, Toluene, Xylenes, Carbon tetrachloride, Methylene chloride, Freon 22, Nitrous oxide, Halothane, Isoflurane, Benzodiazepines (e.g., Diazepam, Alprazolam, Midazolam), Barbiturates (e.g., Phenobarbital, Pentobarbital), Miscellaneous compounds (e.g., Chloral hydrate, Methaqualone, and Propofol)

Report on Toxic Chemical Syndromes: Definitions and Nomenclature (PDF - 2.01 MB)

An Interagency Agreement between the Department of Homeland Security (DHS) Office of Health Affairs (OHA) and the National Library of Medicine led to a workshop to discuss and develop a consistent lexicon to describe toxic chemical syndromes, or toxidromes. This workshop included practitioners and experts in emergency response, emergency medicine, and medical toxicology developed names and definitions for twelve unique toxidromes that describe and differentiate the clinical signs and symptoms from exposures to chemicals. These toxidromes focus on acute signs and symptoms caused by inhalation and dermal exposures, and each toxidrome is characterized by exposure routes and sources, organs/systems affected, initial signs and symptoms, underlying mode of action, and treatment/antidotes. The toxidrome names and definitions are designed to be readily understood and remembered by users since communication in a crisis requires accurate and succinct terms that can quickly convey the health conditions of patients. These toxidromes lay the foundation for a consistent lexicon for use in CHEMM and for other uses that, if adopted widely, will improve response to chemical mass exposure incidents.

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