Sulfuryl Fluoride Poisoning

Aka: Sulfuryl Fluoride Poisoning, Sulfuryl Fluoride Toxicity, Sulfuryl Fluoride

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II. Background

  1. Sulfuryl Fluoride is a gas used to fumigate coastal structures for wood boring Insects (termites, beetles)
    1. Only fumigant approved for whole-structure residential fumigation in the United States
  2. Sulfuryl Fluoride is also highly toxic to humans
    1. Requires treated structures be encased within a gas-tight tarpaulin tent before fumigation
    2. Also requires lacrimating agent use (chloropicrin) to be sprayed as a warning agent
  3. Gas is colorless and odorless and accumulates in low areas (heavier than air)
  4. Humans are exposed via inhalation of gas
    1. Exposure limit over short term is 10 ppm
    2. Toxic or lethal dose 200 ppm

III. Mechanism

  1. Triggers formation of insoluble Calcium fluoride and Magnesium fluoride
    1. Hypocalcemia
    2. Hypomagnesemia
  2. Sodium-Potassium ATPase pump inhibition (and increased Potassium efflux from cell)
    1. Hyperkalemia
  3. Myocardial adenylate cyclase effects
    1. Refractory ventricular Dysrhythmias

IV. Phamarmacokinetics

  1. Rapid respiratory system absorption
    1. Sulfuryl Fluoride is hydrolyzed to fluorosulfate which dissociates to fluoride and sulfate
  2. Peak plasma and red cell concentrations reached within 4 hours of inhalation
    1. High distribution to perfused tissue
  3. Elimination
    1. Renal

V. Adverse Effects

  1. Chloropicrin added to Sulfuryl Fluoride as warning agent causes Lacrimation and mucosal irritation
  2. Electrolytes
    1. Hypocalcemia
    2. Hypomagnesemia
  3. Cardiovascular
    1. Refractory Ventricular Arrhythmias
    2. QRS Widening
    3. QTc Prolongation
    4. Hemodynamic instability due to Cardiogenic Shock
  4. Gastrointestinal
    1. Nausea or Vomiting
    2. Diarrhea
    3. Abdominal Pain
  5. Respiratory
    1. Cough
    2. Dyspnea
    3. Pulmonary congestion
  6. Neurologic
    1. Paresthesias
    2. Agitation
    3. Seizures
    4. Altered Level of Consciousness to coma

VI. Labs

  1. Complete Blood Count
  2. Serum Electrolytes and acid-base
    1. Hypocalcemia
    2. Hypomagnesemia
    3. Hyperkalemia (delayed)
  3. Venous Blood Gas
    1. Metabolic Acidosis with Anion Gap

VII. Diagnostics

  1. Electrocardiogram
    1. QRS Widening
    2. QTc Prolongation

VIII. Management: General

  1. Remove patient from exposure into fresh air
  2. Decontamination
  3. ABC Management
  4. Electrolyte replacement
    1. Hypocalcemia Management
    2. Hypomagnesemia Management
    3. Hyperkalemia Management
  5. Cardiogenic Shock Management
    1. Careful Intravenous Fluids
    2. Vasopressors
    3. Inotropes
  6. Dysrhythmia Management
    1. Cardioversion
    2. Consider Amiodarone (or Quinidine) for Ventricular Arrhythmia
  7. Seizure Management
    1. See Status Epilepticus
    2. Consider Phenobarbital for refractory Seizures (after initial Benzodiazepines)
  8. Hemodialysis Indications
    1. Refractory Dysrhythmias
    2. Refractory Seizures

IX. Management: Disposition

  1. Asymptomatic patients with no symptoms (including no mucosal irritation, Lacrimation) may be discharged home
  2. Admit to ICU patients with neurologic, metabolic or cardiovascular findings
  3. Emergency discharge indications following Chloropicrin (warning agent) induced Lacrimation, mucosal irritation
    1. Observed for 4-6 hours without further symptoms (beyond chloropicrin induced Lacrimation, mucosal irritation)
    2. No acute EKG abnormalities (QTC normal, QRS width normal)
    3. No Hemodynamic instability

X. References

  1. Carroll and Yakey (2026) Crit Dec Emerg Med 40(10): 38
  2. Tomaszewski (2020) Crit Dec Emerg Med 34(11): 28

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