Acute ingestion causes CNS depression, oropharyngeal  and gastric discomfort, and vomiting.

      1.  Toluene can cause reversible superficial injury.
          Blepharospasm, conjunctivitis, corneal edema, and
          corneal abrasions usually resolve over 1-2 days.

      1.  Prolonged or repeated dermal exposure to the liquid
           may defat the skin.

         Fever in association with decreased pulse oximetry may
         herald the development of chemical pneumonitis.
         Bradycardia has been reported but is rare. Hypoventilation 
         secondary to both respiratory muscle weakness and CNS 
         depression may occur with chronic inhalational abuse.

Upper respiratory tract irritation, lacrimation, decreased color discrimination, decreased accuracy in visual perception, corneal burns, optic atrophy, blindness, and ototoxicity may occur.

Acute inhalation may result in bronchial and laryngeal irritation, acute bronchitis, bronchospasm, pulmonary edema, chemical aspiration pneumonitis, and asphyxia from narcosis and/or suffocation.  Chronic abusers have presented with respiratory failure after acute episodes of abuse.

      1.  CNS excitation (euphoria, giddiness, tremors,
          nervousness, insomnia) followed by CNS depression
          (headache, dizziness, fatigue, muscle weakness,
          drowsiness, confusion, vertigo, decreased reaction
          time), metallic taste, and nausea are common after
          exposure to 400 to 800 ppm.

      2.  Ataxia, severe fatigue, and seizures lasting up to
          several days has been reported after exposure to 800
          ppm.  Rapid general anesthesia follows exposure to
          10,000 ppm or greater.  Chemical pneumonitis and
          respiratory failure have occurred after sniffing paint
          or toluene.

      3.  Sudden death due to ventricular arrhythmias has been
          reported following acute inhalation in chronic abusers. 
          Arrthymogenesis may be related to sudden surges in 
          sympathetic outflow associated with a fight  or flight 
          response as well as hypoxia.  Electrolyte abnormalities 
          including severe hypokalemia and metabolic acidosis may 
          also contribute to arrthymogenesis.

 ACUTE INHALATION

Sudden death after acute inhalation  (usually in chronic abusers) is most often due to hypoxia during toluene narcosis, but occasionally is due to fatal arrhythmia secondary to sensitization to    endogenous catecholamines.  Sinus bradycardia, ventricular fibrillation, and myocardial infarction  have been reported.  Myocarditis occurred in a young  adult 1 week after exposure to a massive spill.

CHRONIC INHALATION 

Chronic paint or glue sniffers may  present with cardiac arrhythmias, including multifocal PVCs and supraventricular tachycardia; this may reflect  electrolyte disturbances and/or cardiac cell membrane toxicity.  Dilated cardiomyopathy has been reported after chronic inhalation abuse.

ACUTE INGESTION of toluene has been associated with the development of tachycardia and hypertension.

      1.  SYNDROMES - Muscular weakness due to id/electrolyte
           imbalance, gastrointestinal, renal tubular acidosis, and
           neuropsychiatric syndrome are common in toluene 
           sniffers.

      2.  SIGNS/SYMPTOMS may include hypokalemia, 
           hematuria,  proteinuria, oliguria, paresis (due to electrolyte
           disturbance) rhabdomyolysis, auditory or visual
           hallucinations, hyperactive reflexes, peripheral
           neuropathy, personality changes, tremors, recurrent
           headaches, emotional lability, and memory loss.

      3.  RARE EFFECTS - Optic atrophy and sensorineural 
           hearing  loss, myocarditis, congestive heart failure,
           hypothalamic dysfunction, central sleep apnea, grand
           mal seizures, choreoathetosis, opisthotonus,  hepatorenal 
           failure, and Bell's palsy have been  reported.

      4.  SEQUELAE - Progressive, irreversible mixed
          encephalopathy with cognitive difficulty and cerebellar 
          ataxia, and organic affective syndromes  have been 
          described in chronic workplace or abuse exposures.

ACUTE INGESTION
Toluene ingestion causes CNS depression.

ACUTE INHALATION 
CNS excitation (euphoria, giddiness, tremors, nervousness, insomnia) then CNS depression (headache, dizziness, fatigue, drowsiness, confusion, vertigo, decreased reaction time) common after exposure to 400 to 800 ppm; ataxia, severe fatigue, and seizures reported after 800 ppm.  Rapid general anesthesia occurs with 10,000 ppm or greater.

CHRONIC INHALATION may cause hyperactive reflexes,        peripheral neuropathy, personality changes, tremors, recurrent headaches, emotional lability, and memory loss.  Rarely, hypothalamic dysfunction, central sleep apnea, grand mal seizures, choreoathetosis, opisthotonus, and Bell's palsy have been reported.

Oral ingestion may cause vomiting, abdominal cramps,and  diarrhea.  One of the major presenting syndromes in chronic toluene abusers is gastrointestinal, with abdominal pain, nausea, vomiting and/or hematemesis.

Isolated cases of hepatorenal failure have been attributed to toluene abuse or occupational exposure. Hepatomegaly and impaired liver function has also been  reported in a toluene sniffer.  Fatty liver and  increased ALT/AST ratio has been associated with chronic workplace exposure; alcoholism increased risk  of severe effects in animal studies.

Transient distal renal tubular acidosis (RTA), with        hyperchloremic metabolic acidosis, hypokalemia, and urine pH >5.5, may be found in up to 44% of hospitalized paint sniffers; usually accompanied by rapidly reversible renal insufficiency.  Urinalysis often show proteinuria, hematuria, pyuria, or hyaline      casts; cultures usually negative. Proximal RTA or Fanconi's syndrome is less common (urine ph >5.5, uricosuria, hypophosphatemia,  hypocalcemia).  Isolated cases of irreversible renal insufficiency, glomerulonephritis, focal segmental glomerulosclerosis, acute interstitial nephritis, and renal failure        secondary to myoglobinuria have been reported.

Toluene inhalation causes metabolic acidosis due to  tissue hypoxia, distal renal tubular acidosis, and  accumulation of its metabolites, benzoic and hippuric acids.  Hyperchloremic metabolic acidosis is a common  presenting finding in hospitalized toluene abusers.

Hypokalemia, metabolic acidosis, and hypophosphatemia are typical; hypercalcemia and hypouricemia less frequent.  Hypocalcemia and precipitation of tetany has  occurred during correction of acidemia.Patients presenting with the muscular weakness are likely to have severe fluid/electrolyte imbalance.

Two cases of bone marrow dysplasia have been reported         following exposure to toluene proven to have no benzene         contamination; most older studies linking toluene to blood dyscrasias involved heavy benzene contamination. Exposed workers were found to have decreased  prothrombin levels in one study.

After prolonged contact with the skin, toluene may cause drying and defatting, leading to fissured dermatitis.  Superficial burns were reported after 18  hour contact in one case.

Rhabdomyolysis is present in as many as 40% of chronic     toluene abusers, secondary to hypokalemia, hypophosphatemia, compression, ischemia in comatose  patients, or direct muscle toxicity.  One of the common  presenting syndrome in chronic abusers is severe muscle weakness, sometimes misdiagnosed as Guillain-Barre syndrome.

Inhalation abuse has resulted in fatal adrenal hemorrhage.

sychiatric disorders are commonly found in chronic toluene abusers; including bizarre behavior, acute  paranoid psychosis, confusion, hallucinations, and  decreased IQ test scores.  In some cases, the psychosis resolves after the acute episode, but the majority require prolonged neuroleptic therapy.

Multiple physical deformities, with signs similar to fetal alcohol syndrome, microencephaly, CNS dysfunction, and variable growth deficiencies have occurred in infants born to mothers who chemically abused toluene during pregnancy. Toluene enhances the embryotoxic effect of acetylsalicylic acid.

Conflicting study results regarding the carcinogenic  potential of toluene have been reported; however, when BENZENE contamination is NOT present, it is unlikely  that toluene exposure alone can be carcinogenic.

There is conflicting information in the literature regarding the potential of toluene to cause DNA strand breaks.  Toluene was not mutagenic in the Ames assay.

Chromosome damage has been reported.

Toluene may be measured in the breath and blood; hippuric  acid and cresol metabolites may be measured in the urine. Obtain a baseline CBC and monitor renal and hepatic  function tests, urinalysis (including urine pH) electrolytes, and CPK.  Monitor arterial blood gases in  symptomatic patients.

Emesis is not indicated due to possible aspiration and rapid onset of toxicity. Consider gastric lavage if the patient has ingested a
large quantity of toluene or there is a high benzene     contamination; weigh potential toxicity of the amount ingested against the risk of aspiration.  Charcoal adsorption has not been studied, but other hydrocarbons  are adsorbed; charcoal may induce vomiting and increase aspiration risk.

Small amounts can be handled at  home if asymptomatic, follow-up can be done, and no indication of child abuse or suicidal intent.  Observe for six hours.  Admit if symptomatic.

Monitor for respiratory distress.  If symptomatic, obtain chest x-ray; if severe monitor arterial blood gases.  Positive end-expiratory  pressure (PEEP), CPAP, or ECMO may be necessary.  If CNS depressed, intubation, assisted ventilation, or  supplemental oxygen may be required.  Monitor cardiac function and avoid epinephrine.

Evaluate hepatic, renal, CPK, fluid, acid-base, and electrolyte status.  Correct hypokalemia  with intravenous potassium.

Emesis is probably not indicated due to the possibility for aspiration of gastric contents.

1.  GASTRIC LAVAGE:  May be indicated if a patient has
     ingested a potentially life-threatening amount of a poison and it 
     can be performed soon after ingestion, or  in patients who     
     are comatose or at risk of convulsing. Protect airway by
     placement in Trendelenburg and left lateral decubitus position 
     or by cuffed endotracheal intubation.

      a.  After control of any seizures present, perform gastric
          lavage.  Volume of lavage return should approximate
          fluid given.

      b.  CONTRAINDICATIONS:  Loss of airway protective 
           reflexes or decreased level of consciousness if patient is 
           not intubated, following ingestion of corrosive
          substances, hydrocarbons (high aspiration potential),
          patients at risk of hemorrhage or gastrointestinal
          perforation, and trivial or non-toxic ingestion.

 1.  GASTRIC LAVAGE:  May be indicated if a patient has     ingested a potentially life-threatening amount of a poison and it can be performed soon after ingestion, or in patients who are comatose or at risk of convulsing. Protect airway by placement in Trendelenburg and left  lateral decubitus position or by cuffed endotracheal  intubation.

      a.  After control of any seizures present, perform gastric
          lavage.  Volume of lavage return should approximate
          fluid given.

      b.  CONTRAINDICATIONS:  Loss of airway protective
           reflexes or decreased level of consciousness if patient is 
           not  intubated, following ingestion of corrosive
          substances, hydrocarbons (high aspiration potential),
          patients at risk of hemorrhage or gastrointestinal
          perforation, and trivial or non-toxic ingestion.

Administer charcoal as slurry.  The FDA suggests 240 mL diluent/30 g charcoal.  Usual  charcoal dose:  25 to 100 g in adults and adolescents, 25 to 50 g in children (1 to 12 years old), and 1 g/kg  in infants less than 1 year old.

MONITOR FLUID and ELECTROLYTE STATUS CAREFULLY.  Correct  hypokalemia with intravenous potassium.

MONITOR PATIENT for RESPIRATORY DISTRESS.

MONITOR EKG and VITAL SIGNS REGULARLY.  Use epinephrine cautiously if indicated.

CHRONIC EXPOSURE - Evaluate renal and liver function.

DECONTAMINATION:  Move patient to fresh air.  Monitor      for respiratory distress.  If cough or difficulty in  breathing develops, evaluate for respiratory tract  irritation, bronchitis, or pneumonitis.  Administer 100  percent humidified supplemental oxygen with assisted ventilation as required.

MONITOR FLUID and ELECTROLYTE STATUS CAREFULLY.  Correct  hypokalemia with potassium.  CAUTION - Hypocalcemia may ensue following fluid and electrolyte replenishment.

MONITOR for RESPIRATORY DISTRESS, assure airway patency and adequacy of ventilation and oxygenation.

MONITOR EKG and VITAL SIGNS REGULARLY.  Use epinephrine cautiously if indicated.

CHRONIC - Evaluate renal and liver function.

DECONTAMINATION:  Exposed eyes should be irrigated with copious amounts of tepid water for at least 15 minutes.  If irritation, pain, swelling, lacrimation, or  photophobia persist, the patient should be seen in a  health care facility.

DECONTAMINATION:  Wash exposed area extremely thoroughly with soap and water.  A physician may need to examine  the area if irritation or pain persists.

Ingestion - 60 mL caused death within 30 minutes in an adult    Some subjects exposed to toluene concentrations of 600 to  800 ppm for 3 hours developed fatigue, nausea, confusion, and a staggering gait.