What is the appropriate management for a patient who has ingested phenol?

Management of Phenol Ingestion

Prioritize immediate airway protection, cardiovascular support, and rapid skin/GI decontamination with polyethylene glycol (PEG) or water, while avoiding gastric lavage, emesis, and substances that enhance absorption such as alcohol or mineral oil. 1

Immediate Stabilization and Assessment

Secure airway, breathing, and circulation first using standard resuscitation protocols, as phenol can cause rapid deterioration with respiratory arrest occurring within 30 minutes of ingestion. 1, 2

• Establish vascular access immediately for fluid resuscitation and medication administration. 1
• Intubate and provide assisted ventilation if respiratory depression or arrest occurs. 1
• Administer 100% oxygen, particularly if methemoglobinemia is suspected. 1
• Monitor continuously for cardiovascular collapse, as hypotension and ventricular arrhythmias are common. 1, 2

Contact your regional poison control center immediately (1-800-222-1222 in the United States) for case-specific guidance, but do not delay supportive care while awaiting consultation. 1

Critical "Do Not" List for Phenol Ingestion

Avoid the following interventions as they worsen outcomes:

• Do NOT induce emesis – increases aspiration risk and prolongs mucosal contact time. 1
• Do NOT perform gastric lavage – generally not recommended due to risk of aspiration and esophageal injury. 1
• Do NOT administer alcohol – enhances phenol absorption. 1
• Do NOT give oral mineral oil – increases phenol absorption. 1
• Do NOT attempt dilution with water orally – may increase absorption. 1

Gastrointestinal Decontamination

Administer olive oil followed by activated charcoal via small-bore nasogastric tube as the preferred GI decontamination method. 1, 2

• Olive oil should be given immediately after presentation. 1, 2
• Follow with activated charcoal (standard dose 1-2 g/kg body weight). 1
• This approach is supported by case reports demonstrating survival after severe ingestion. 2

Dermal Decontamination (Critical for All Exposures)

Healthcare personnel must wear gowns and rubber gloves to prevent secondary contamination. 1

Immediately decontaminate skin with copious amounts of water, followed by undiluted polyethylene glycol (PEG). 1, 3

• PEG is superior to water alone based on survival data from severe burns with high serum phenol concentrations (17,400 micrograms/L). 3
• After PEG treatment, wash thoroughly with soap and water. 1
• Water alone is acceptable if PEG is unavailable, but PEG provides better outcomes. 3

Ocular Decontamination

Irrigate eyes immediately with copious amounts of tepid water for at least 15 minutes. 1

• Perform follow-up examination with fluorescein stain to assess for corneal abrasion. 1

Management of Systemic Toxicity

Cardiovascular Complications

Treat shock with intravenous fluids and dopamine. 1

Manage ventricular arrhythmias with lidocaine – phenol specifically causes ventricular dysrhythmias distinct from its derivatives. 1, 2

• Bradycardia or tachycardia may occur; treat according to standard ACLS protocols. 1

Neurological Complications

Administer diazepam for seizures. 1

• CNS depression ranging from lethargy to coma develops 5-30 minutes post-ingestion or dermal application. 1

Metabolic Derangements

Correct metabolic acidosis with sodium bicarbonate 1-2 mEq/kg intravenously. 1

Treat methemoglobinemia if >30% or if respiratory distress is present with methylene blue 1-2 mg/kg of 1% solution given slowly IV. 1

• Note that methylene blue may be ineffective or cause hemolysis in patients with G6PD deficiency (present in ~2% of the US population). 4

Renal and Pulmonary Complications

Monitor for acute renal failure requiring hemodialysis – reported in cases of injectable phenol overdose. 5

Anticipate potential acute respiratory failure requiring mechanical ventilation, which may persist despite clinical improvement. 5

• Pulmonary infiltrates may persist for up to 6 months on imaging even after clinical recovery. 5

Lethal Dose and Risk Stratification

The lethal dose ranges from 3-30 grams, but may be as little as 1 gram. 1

Immediate medical evaluation is required for:

• Ingestion of >1 gram in adults 1
• Ingestion of >50 mg in infants 1
• Any symptomatic intoxication regardless of dose 1

Clinical Pitfalls to Avoid

• Do not delay airway management – respiratory arrest can occur within 30 minutes. 1, 2
• Do not underestimate dermal absorption – systemic toxicity develops rapidly from skin exposure. 1
• Do not assume initial painless white skin patches are benign – they progress to erythema and brown discoloration with deep tissue injury. 1
• Do not discharge patients prematurely – organ dysfunction may persist or develop over hours to days. 5
• Do not overlook the need for enforced diuresis or hemodialysis in severe cases with renal failure. 3

Prognosis

Roughly 50% of reported phenol poisoning cases have a fatal outcome, making this a life-threatening emergency requiring aggressive management. 3

Survival is possible even with severe burns (>20% TBSA) and extremely high serum concentrations when immediate PEG decontamination and supportive care are provided. 3