What is the treatment for bromide toxicity?

Treatment of Bromide Toxicity

The cornerstone of treatment for bromide toxicity is aggressive hydration with chloride-containing intravenous fluids to enhance bromide elimination. 1, 2

Clinical Presentation

Bromide toxicity (bromism) presents with a spectrum of neuropsychiatric symptoms:

• Sedative-hypnotic-like intoxication with altered mental status, confusion, and hallucinations 1, 3
• Ataxic gait, decreased sensation, and hyperactive reflexes 4
• Tremor, convulsions, and unconsciousness in severe cases 4
• Skin manifestations (bromoderma) may occur, especially in children 2

Diagnostic Approach

• Suspect bromism in patients with sedative-hypnotic-type intoxication and a history of exposure to bromide-containing products 1
• Laboratory findings often include:
  • Elevated serum chloride levels (pseudohyperchloremia) 2
  • Negative anion gap (highly suggestive of diagnosis) 2
  • Note: Normal chloride levels and anion gap do not rule out bromism 1

Treatment Algorithm

First-line Treatment

• Administer aggressive intravenous hydration with chloride-containing solutions (normal saline) 1, 2
  • Chloride competes with bromide for renal tubular reabsorption, enhancing bromide elimination

Adjunctive Therapies

• Consider diuretics to enhance bromide elimination:
  • Thiazide diuretics 3
  • Loop diuretics 3
  • Mercurial diuretics (historical use) 3

Severe Cases

• Hemodialysis should be considered for severe bromide intoxication or cases not responding to hydration therapy 2, 5
  • Hemodialysis has been shown to be effective in removing bromide from the blood 5

Supportive Care

• Discontinue the source of bromide exposure 1, 2
• Provide symptomatic management for neurological manifestations 4
• Monitor serum bromide levels if available 2

Special Considerations

• Pediatric patients may require dose adjustments for fluid therapy based on weight 1
• Pregnant women should be treated with caution, prioritizing maternal stabilization 2
• Elderly patients may be more susceptible to fluid overload during aggressive hydration 3

Monitoring and Follow-up

• Monitor neurological status throughout treatment 4
• Follow serum bromide levels until normalization, if testing is available 2
• Be aware that neuropsychiatric sequelae may persist despite successful bromide elimination 5

Prevention

• Thorough medication, dietary, herbal supplement, and cultural histories are essential to identify potential sources of bromide 1
• Education about the risks of bromide-containing products is important for prevention 4

Bromism is less common than in the past but should still be considered in the differential diagnosis of patients presenting with unexplained neuropsychiatric symptoms, especially when there is a history of exposure to potential bromide sources 3, 2.