What is the first line of management for a patient with sulfur poisoning?

First-Line Management of Sulfur Poisoning

Immediately remove the patient from the contaminated environment, remove all contaminated clothing, and perform copious skin decontamination with large amounts of water and neutral soap or 0.5% sodium hypochlorite solution. 1

Immediate Decontamination (First Priority)

• Remove all contaminated clothing and jewelry immediately to prevent continued absorption and secondary exposure to healthcare workers 2, 1
• Flush exposed skin with copious amounts of water using neutral soap or 0.5% sodium hypochlorite solution as the most effective decontamination method 1
• Irrigate eyes immediately with tepid water for at least 15 minutes if ocular exposure occurred 2
• Healthcare workers must wear appropriate personal protective equipment (gloves, protective clothing) when handling the patient or contaminated materials to prevent secondary exposure 2, 3

Airway, Breathing, and Circulation Stabilization

• Secure airway, breathing, and circulation following standard advanced life support protocols as the absolute first priority before attempting specific toxin management 4, 5
• Provide early endotracheal intubation if respiratory distress develops, consciousness is depressed, or hemodynamic instability occurs 2
• Administer humidified oxygen for respiratory support as clinically indicated 1
• Treat hypotension with intravenous crystalloid resuscitation as first-line therapy 4

Early Antidote Administration

• Initiate sodium thiosulfate infusion (100-500 mg/kg/min) within 60 minutes of sulfur mustard exposure for maximum benefit 1
• Administer N-acetylcysteine (NAC) as a supportive measure, though neither acts as a specific or highly effective antidote 1

Gastrointestinal Management

• Do NOT induce vomiting with syrup of ipecac as this is no longer recommended and may worsen the condition 2
• Do NOT administer anything by mouth unless specifically advised by poison control 2
• Contact poison control center immediately (1-800-222-1222 in the US) while initiating treatment for expert guidance 2, 3

Respiratory Support Protocol

• Provide bronchodilators and NAC as mucolytic for pulmonary injuries 1
• Ensure adequate rehydration and provide mechanical ventilation as clinically indicated 1
• Administer appropriate antibiotics based on clinical presentation and respiratory physiotherapy 1

Ocular Management

• Start topical antibiotics immediately, preferably sulfacetamide eye drops 1
• Continue with lubricants and artificial tears for ongoing ocular protection 1

Cutaneous Injury Management

• Apply moist dressings, preferably with silver sulfadiazine cream 1
• Provide analgesics and anti-pruritics as needed 1
• Perform physical debridement followed by autologous split-thickness skin grafting as clinically indicated 1

Seizure and Agitation Management

• Administer benzodiazepines (diazepam first-line or midazolam) for seizures or severe agitation 2
• Treat dysrhythmias according to standard ACLS protocols 2

Critical Pitfalls to Avoid

• Do NOT delay treatment while waiting for confirmation of specific toxin type—treat based on clinical presentation and exposure history 4
• Do NOT forget healthcare worker protection during decontamination, as secondary exposure is a real risk 2, 3
• Do NOT use inappropriate polypharmacy—avoid unnecessary medications that may complicate management 1

Monitoring Requirements

• Observe all patients for at least 48-72 hours even if initially stable, due to potential for delayed toxic effects 4
• Perform serial monitoring of respiratory status and ability to protect airway 4
• Establish continuous hemodynamic monitoring with assessment of blood pressure, heart rate, and oxygen saturation 4