What is the step‑by‑step emergency management of acute urea (fertilizer) poisoning in a male patient?

Emergency Management of Acute Urea (Fertilizer) Poisoning

Urea fertilizer poisoning is primarily managed with aggressive supportive care focused on airway protection, breathing support, and circulatory stabilization, as no specific antidote exists and the toxicity is generally low compared to other agricultural chemicals.

Immediate Stabilization (First Priority)

Airway and Breathing Management

• Secure the airway immediately if the patient exhibits respiratory depression, loss of protective airway reflexes, or altered mental status requiring bag-mask ventilation or endotracheal intubation 1, 2
• Provide rescue breathing or bag-mask ventilation until spontaneous breathing returns in patients with respiratory arrest 1
• Administer supplemental oxygen to maintain oxygen saturation ≥94% or when saturation cannot be confirmed 3
• Standard BLS/ACLS protocols take absolute priority over any other intervention 1, 4

Circulatory Support

• Treat hypotension with careful intravenous fluid administration to restore hemodynamic stability 3
• Monitor for signs of shock including prolonged capillary refill (≥2 seconds), altered consciousness, and cool peripheries 5
• Recognize that cardiovascular effects may include tachycardia and altered peripheral pulse volume 5

Emergency Response Activation

• Activate emergency medical services immediately—do not delay while attempting any home or field interventions 1, 4, 5
• Contact Poison Control Center (1-800-222-1222 in the United States) for expert guidance on management 4, 5

Decontamination Protocol

Dermal Exposure

• Remove all contaminated clothing and jewelry immediately to prevent continued exposure, ensuring you do not contaminate yourself in the process 5
• Irrigate affected skin areas with copious amounts of water 5
• Use warmed water to prevent hypothermia during prolonged decontamination 5
• Apply heat lamps, blankets, and other warming mechanisms to prevent hypothermia, especially in cold environments 5

Ocular Exposure

• Rinse eyes immediately with copious amounts of water for at least 15 minutes of continuous irrigation 5

Ingestion Management

• Do NOT administer anything by mouth (water, milk, or activated charcoal) unless specifically advised by poison control, as it may cause emesis and aspiration 5
• Do NOT induce vomiting or administer ipecac—this is contraindicated and provides no clinical benefit while potentially causing harm 5
• Do NOT attempt dilution with water or milk, as no human studies demonstrate clinical benefit and administration may cause vomiting and aspiration 5

Clinical Monitoring and Assessment

Vital Signs and Organ Function

• Monitor vital signs continuously, as stable vitals can deteriorate rapidly in poisoning situations 4
• Continuously monitor core temperature because hypothermia is a frequent complication; initiate passive or active rewarming measures as needed 3
• Evaluate for multi-organ toxicity requiring intensive supportive care 5

Renal Function Monitoring

• Assess blood urea nitrogen (BUN) and creatinine levels, as urea is eliminated primarily through the kidneys and renal function evaluation is critical 6
• Monitor urine output and fluid balance closely 6

Neurological Assessment

• Systematically evaluate for altered mental status, seizures, or neurologic changes 5
• Assess level of consciousness using standardized scales 2

Key Clinical Context for Urea Poisoning

Toxicity Profile

• Urea has relatively low acute toxicity compared to other agricultural chemicals, with no toxicity observed at levels as high as 2000 mg/kg in acute oral studies 7
• Urea is the end product of mammalian protein metabolism and is normally present in the body 6, 7
• High-dose exposure can cause gastrointestinal irritation, nausea, vomiting, and potential metabolic disturbances 7
• Urea can increase percutaneous absorption of other chemicals, so consider co-exposures 7

Distribution and Elimination

• Urea diffuses readily through tissues and has a half-life of several hours 7
• The permeability of urea across skin is significant, with absorption rates of 9.5% ±2.3% across normal skin and 67.9% ±5.6% across abraded skin 7

Critical Pitfalls to Avoid

• Do not delay EMS activation while attempting field interventions or awaiting response to supportive measures 1, 4, 5
• Do not assume dilution helps—this is not evidence-based for urea ingestion and may worsen outcomes by inducing vomiting 5
• Do not overlook hypothermia risk during decontamination, especially in pediatric or elderly patients 5
• Do not contaminate yourself while removing the patient's clothing or during decontamination procedures 5
• Do not administer gastric lavage or induce vomiting in any poisoned patient, as these interventions increase aspiration risk 3

Disposition and Observation

• Observe all symptomatic patients for at least 2 hours after initial stabilization 4
• Longer observation periods are needed if the patient develops significant gastrointestinal symptoms, metabolic disturbances, or renal dysfunction 4
• Most patients with isolated urea exposure and mild symptoms can be managed with supportive care and observation 7
• Admit patients with significant ingestions, persistent symptoms, or evidence of organ dysfunction for continued monitoring and supportive care 4