Sulfuryl Fluoride Poisoning

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

1. Background
   1. Sulfuryl Fluoride is a gas used to fumigate coastal structures for termites
   2. Gas is colorless and odorless and accumulates in low areas (heavier than air)
   3. Humans are exposed via inhalation of gas
      1. Exposure limit over short term is 10 ppm
      2. Toxic or lethal dose 200 ppm
2. Adverse Effects
   1. Electrolytes
      1. Hypocalcemia
      2. Hypomagnesemia
   2. Cardiovascular
      1. Arrhythmia
      2. QRS Widening
      3. QTc Prolongation
      4. Hemodynamic instability
   3. Gastrointestinal
      1. Nausea or Vomiting
      2. Diarrhea
      3. Abdominal Pain
   4. Respiratory
      1. Cough
      2. Dyspnea
      3. Pulmonary congestion
   5. Neurologic
      1. Paresthesias
      2. Agitation
      3. Seizures
      4. Altered Level of Consciousness to coma
3. Labs
   1. Serum Electrolytes and acid-base
      1. Serum Calcium Decreased
      2. Serum Magnesium decreased
      3. Serum Potassium decreased
      4. Acidosis
4. Diagnostics
   1. Electrocardiogram
      1. QRS Widening
      2. QTc Prolongation
5. Management
   1. Remove patient from exposure
   2. Decontamination
   3. ABC Management
   4. Electrolyte replacement
      1. Hypocalcemia Management
      2. Hypomagnesemia Management
      3. Hypokalemia Management
   5. Arrhythmia Management
      1. Consider Amiodarone for Ventricular Arrhythmia
   6. Seizure Management
      1. See Status Epilepticus
      2. Consider phenobarbital for refractory Seizures (after initial Benzodiazepines)
   7. Disposition - Emergency discharge indications (all others should remain for hospital observation)
      1. Observed for 4-6 hours without symptoms
      2. No acute EKG abnormalities (QTC normal, QRS width normal)
      3. No Hemodynamic instability
6. References
   1. Tomaszewski (2020) Crit Dec Emerg Med 34(11): 28