What is the emergency management of acute copper sulfate (CuSO4) ingestion?

Emergency Management of Acute Copper Sulfate (CuSO₄) Poisoning

Copper sulfate poisoning is a life-threatening emergency requiring immediate supportive care with aggressive fluid resuscitation, early gastric decontamination, and chelation therapy with D-penicillamine or dimercaprol (BAL), while preparing for potential multi-organ failure including intravascular hemolysis, methemoglobinemia, acute kidney injury, and hepatotoxicity. 1, 2, 3

Immediate Resuscitation and Stabilization

• Secure the airway, establish breathing support, and stabilize circulation immediately, as copper sulfate is a corrosive agent that can cause severe gastrointestinal hemorrhage and systemic toxicity leading to cardiovascular collapse 4, 2
• Obtain IV access and begin aggressive fluid resuscitation to address severe dehydration from hemorrhagic gastroenteritis and to prevent acute kidney injury 2, 3
• Initiate continuous cardiac monitoring and obtain vital signs, as systemic copper toxicity can cause cardiovascular failure and dysrhythmias 2, 5
• Contact the Poison Control Center immediately for guidance on agent-specific management and chelation protocols 4, 6

Early Decontamination

• Perform early gastric lavage if the patient presents within 1-2 hours of ingestion, as this has been associated with improved outcomes in case reports 2
• Do NOT induce vomiting with ipecac, as copper sulfate is corrosive and vomiting increases risk of aspiration and further esophageal injury 4, 6
• Do NOT administer activated charcoal, as it is ineffective for metal poisoning and may obscure endoscopic visualization 6

Initial Laboratory and Imaging Evaluation

• Obtain complete blood count with peripheral smear to assess for intravascular hemolysis (the hallmark complication), checking for anemia, elevated reticulocyte count, and schistocytes 1, 2, 7
• Measure serum copper levels (though normal levels do NOT exclude severe toxicity, as seen in reported cases), liver enzymes (AST, ALT, bilirubin), renal function (creatinine, BUN), and creatine kinase for rhabdomyolysis 2, 3, 7
• Check methemoglobin level, as copper sulfate commonly causes methemoglobinemia requiring specific antidotal therapy 2, 3
• Obtain arterial blood gas, serum lactate, and electrolytes (sodium, potassium, calcium, magnesium) to assess for metabolic acidosis and electrolyte derangements 4, 2
• Perform chest and abdominal radiographs to evaluate for aspiration pneumonitis or gastrointestinal perforation 4

Specific Antidotal Therapy

Chelation Therapy

• Initiate chelation with D-penicillamine 250 mg orally four times daily OR dimercaprol (BAL) 3-5 mg/kg IM every 4 hours for the first 2 days, then every 6-12 hours, as these agents have been used successfully in severe copper poisoning 2, 3, 5
• Consider 2,3-dimercaptopropane-1-sulphonate (DMPS) as an alternative chelating agent if available, as it has shown benefit in case reports 2
• The evidence for chelation benefit is limited and based primarily on case reports; however, in severe poisoning with multi-organ failure, chelation should be attempted as adjunctive therapy 1, 5

Methemoglobinemia Treatment

• Administer methylene blue 1-2 mg/kg IV over 5 minutes if methemoglobin level exceeds 20-30% or if patient is symptomatic with cyanosis, altered mental status, or respiratory distress 2, 3
• Repeat methylene blue dosing every 30-60 minutes as needed, up to a total dose of 7 mg/kg 2

Management of Specific Complications

Intravascular Hemolysis

• Monitor hemoglobin closely (every 4-6 hours initially) and prepare for blood transfusion if severe anemia develops 1, 2, 7
• Maintain aggressive hydration and consider alkalinization of urine with sodium bicarbonate to prevent hemoglobin precipitation in renal tubules 2, 7
• Consider plasmapheresis (therapeutic plasma exchange) for severe, refractory cases not responding to chelation and supportive care, as it has been shown to rapidly remove protein-bound copper and improve clinical outcomes 1

Acute Kidney Injury

• Maintain urine output >0.5 mL/kg/hr with aggressive fluid resuscitation and diuretics (furosemide) as needed 2, 3
• Initiate hemodialysis for severe renal failure, though copper itself is not dialyzable; dialysis addresses uremia, fluid overload, and electrolyte abnormalities 1, 2
• Monitor for rhabdomyolysis with serial creatine kinase measurements and treat with aggressive hydration 3, 7

Hepatotoxicity

• Monitor liver enzymes daily, as acute severe hepatic failure can develop within 24-48 hours 2, 7
• Assess coagulation parameters (PT/INR) and provide vitamin K or fresh frozen plasma if coagulopathy develops 2
• Consider N-acetylcysteine as hepatoprotective therapy, though evidence is limited in copper poisoning 2

Adrenal Insufficiency

• Administer hydrocortisone 100 mg IV every 6-8 hours if adrenal insufficiency develops (hypotension refractory to fluids and vasopressors, hyponatremia, hyperkalemia), as this has been reported in severe cases 2

Gastrointestinal Management

• Administer proton pump inhibitors or H₂-blockers (ranitidine) to reduce gastric acid secretion and protect damaged mucosa 2
• Provide antiemetic therapy (ondansetron) for severe nausea and vomiting 2
• Consider early upper endoscopy within 12-48 hours to assess extent of corrosive injury to esophagus and stomach, though this should be performed cautiously by experienced practitioners 4, 8
• Obtain surgical consultation if there are signs of perforation, peritonitis, or uncontrolled bleeding 4, 8

Supportive Care and Monitoring

• Admit all patients with copper sulfate ingestion to intensive care unit for close monitoring, as the lethal dose can be as small as 10 grams 7
• Monitor for cardiovascular failure requiring vasopressor support (norepinephrine, vasopressin) 2, 5
• Provide respiratory support including supplemental oxygen or mechanical ventilation if respiratory failure develops from aspiration or pulmonary edema 2
• Monitor fluid balance closely and adjust resuscitation based on urine output, hemodynamics, and signs of fluid overload 2

Critical Pitfalls to Avoid

• Do NOT rely on serum copper levels to guide management, as normal levels have been documented in severely poisoned patients; clinical presentation and complications are more important 2
• Do NOT delay chelation therapy while waiting for copper levels, as early initiation may improve outcomes 2, 3
• Do NOT perform gastric lavage if patient presents >2 hours post-ingestion or has signs of perforation 4
• Do NOT underestimate the severity based on initial presentation, as multi-organ failure can develop rapidly over 24-48 hours 2, 7
• Recognize that the evidence for chelation is based on case reports and observational data; the primary treatment remains aggressive supportive care 1, 5

Disposition and Follow-Up

• All patients require ICU admission for minimum 48-72 hours to monitor for delayed complications 2, 7
• Obtain psychiatric evaluation for all intentional ingestions before discharge 4, 8
• Monitor renal and hepatic function for weeks after discharge, as mild impairment may persist 2
• Arrange follow-up endoscopy at 3-6 weeks if corrosive injury was documented, to assess for stricture formation 8