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Chromium Toxicity
How Should Patients Exposed to Chromium Be Treated and Managed?

Course: WB 1466
CE Original Date: December 18, 2008
CE Renewal Date: December 18, 2011
CE Expiration Date: December 18, 2013
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Learning Objectives

Upon completion of this section, you will be able to

  • describe the principal treatment strategy for managing chromium poisoning.

Introduction

No matter what route of exposure, the initial approach to an affected individual includes a brief assessment of clinical status followed by support of basic cardiopulmonary functions.

Once the airway has been stabilized and cardiopulmonary support has been instituted as indicated, further measures can be considered [Geller 2001].

Acute Exposure

No proven antidote is available for chromium poisoning. Acute poisoning is often fatal regardless of therapy. Treatment in cases of acute high-level chromium exposure is usually supportive and symptomatic.

Fluid and electrolyte balance is critical.

Affected patients should be monitored carefully for evidence of

  • gastrointestinal bleeding,
  • hemolysis,
  • coagulopathy,
  • seizures, and
  • pulmonary dysfunction [Geller 2001].

Appropriate supportive measures may include ventilatory support, cardiovascular support, and renal and hepatic function monitoring.

When renal function is compromised, maintenance of adequate urine flow is important. Progression to anuria is associated with poor prognosis [Meditext 2005].

Induction of vomiting is contraindicated, owing to the potential corrosive effects of the chromium compounds and the potential for rapid deterioration of the patient [Geller 2001; Meditext 2005].

Gastric lavage with magnesium hydroxide or another antacid might be useful in cases of chromium ingestion.

The efficacy of activated charcoal has not been proven.

Orally administered ascorbic acid was found to be protective in experimental animals and was reported beneficial in at least one patient after chromium ingestion; however, no clinical trials have been conducted to confirm the efficacy of this treatment [Bradberry and Vale 1999].

Exchange transfusion was effective in reducing blood chromium levels 67% in one case of chromium poisoning, using 10.9 L of blood [Kelly, Ackrill et al. 1982]. Existing evidence does not allow the conclusion that exchange transfusion generally should be employed, however [Geller 2001].

Hemodialysis and charcoal hemoperfusion do not substantially enhance chromium removal from the body if renal function remains normal [Ellis, Brouhard et al. 1982]. However, if renal failure ensues, hemodialysis may be necessary for management of the renal failure itself [Schiffl, Weidmann et al. 1982; Geller 2001].

Chelation with ethylenediaminetetraacetic acid (EDTA) does not seem to be of clinical benefit [Geller 2001].

If the eyes and skin are directly exposed, flush with copious amounts of water.

Several case reports suggest that topical ascorbic acid is effective in the management of chromium dermatitis but this has not been confirmed in controlled clinical trials [Bradberry and Vale 1999]. The ulcers heal in several weeks without specific treatment.

Ethylenediaminetetraacetic acid (EDTA) ointment 10% might facilitate removal of chromate scabs [Geller 2001; Lewis 2004].

Weeping dermatitis can be treated with 1% aluminum acetate wet dressings, and chrome ulcers can be treated with topical ascorbic acid [Geller 2001; Meditext 2005].

Chronic Exposure

In most patients with chronic low-dose exposure, no specific treatment is needed.

The mainstay of management is removing the patient from further exposure and relying on the urinary and fecal clearance of the body burden.

Although normal urinary excretion is quite rapid, forced diuresis has been used.

Except in the lungs, only small amounts of chromium are retained several weeks after exposure has ceased.

Dermatitis, liver and renal injury will not progress after removal from exposure, and, in most cases, the patient will recover.

If the exposure has been to high levels or lengthy, the increased risk of lung cancer should be discussed with the patient.

Although no reliable tests are currently available to screen patients for lung cancer, the physician can provide advice and patient education regarding smoking cessation, avoiding or minimizing exposure to other known pulmonary carcinogens, and general preventive health measures.

Annual chest radiographs might be advisable in carefully selected cases [HSDB 2000; Meditext 2005].

Key Points

  • No proven antidote is available for chromium poisoning.
  • Treatment in cases of acute high-level chromium exposure is usually supportive and symptomatic.
  • Treatment consists of removal of the patient from further chromium exposure, reliance on the body's naturally rapid clearance of the metal and symptomatic management.
  • The physician can provide advice and patient education regarding smoking cessation, how to avoid or minimize exposure to other known pulmonary carcinogens, and general preventive health measures.
   

Progress Check

13. Which of following measures is incorrect when managing patients with acute chromium poisoning:

A. Ventilatory and cardiovascular support.
B. Maintenance of adequate urine.
C. Induction of vomiting.
D. Hepatic function monitoring.

Answer:

To review relevant content, see Acute Exposure in this section.

14. Which of the following statements is incorrect?

A. Except in the lungs, only small amounts of chromium are retained several weeks after exposure has ceased.
B. Dermatitis, liver, and renal injury will not progress after removal from exposure.
C. If the exposure has been lengthy (i.e., 2 years to 3 years), the increased risk of lung cancer should be discussed with the patient.
D. The mainstay of management for chronic exposure is relying on chromium clearance techniques, such as hemodialysis, exchange transfusions, or chelating agents such as dimercaprol or EDTA.

Answer:

To review relevant content, see Chronic Exposure in this section.

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