Bismuth | Antidiarrheals (bismuth subsalicylate), impregnated surgical packing paste | Abdominal pain, acute renal failure | Myoclonic encephalopathy | Dimercaprol (limited evidence) |
Cadmium | Contaminated soil in cadmium-rich areas; alloys used in welding, soldering, jewelry, and batteries | Ingestion: hemorrhagic gastroenteritis Inhalation: pneumonitis, acute lung injury | Proteinuria, osteomalacia, lung cancer (questionable) | Ingestion: succimer (limited evidence; not generally indicated) Pneumonitis: chelation not indicated |
Chromium | Corrosion inhibitors (eg, heating systems), pigment production | Skin irritation and ulceration, contact dermatitis; GI irritation, renal and pulmonary failure | Mucous membrane irritation, perforation of nasal septum, chronic cough, contact dermatitis, skin ulcers (“chrome holes”), lung cancer | Acetylcysteine (animal studies suggest efficacy as chelator) |
Cobalt | “Hard metal dust” (tungsten–cobalt mixture), flexible magnets, drying agents | Contact dermatitis, asthma | Hard metal lung disease (spectrum ranging from alveolitis to fibrosis), cardiomyopathy, thyroid hyperplasia | Acetylcysteine (animal studies suggest efficacy as chelator) |
Copper | Leaching from copper pipes and containers; fungicide (copper sulfate); welding (copper oxide) | Ingestion: resembles iron poisoning; blue vomitus (copper salts), hepatotoxicity, hemolysis, methemoglobinemia Inhalation: metal fume fever (self-limited fever, chills, cough, dyspnea) | Hepatotoxicity (Indian childhood cirrhosis) | Dimercaprol for hepatic or hematologic toxicity Succimer in mild poisoning |
Silver | Colloidal (metallic) silver used for medicinal purposes as oral solutions, aerosols, and douches; cauterizing and antiseptic agent (silver nitrate); jewelry, wire | Mucosal irritation (silver oxide and nitrate) | Argyria (permanent skin discoloration due to silver deposition and melanocyte stimulation) | Selenium (possible role) |
Thallium | Rodenticides (use prohibited in the U.S.); contaminated herbal products; medical radioisotope (miniscule dose); most poisonings related to homicide | Early: nausea, vomiting, abdominal pain, tachycardia Intermediate (>24 h): painful ascending neuropathy, cardiac dysrhythmias, altered mental status Delayed (2 wk): alopecia | Sensorimotor neuropathy, psychosis, dermatitis, hepatotoxicity | Multidose activated charcoal Prussian blue, 125 milligrams/kilogram PO every 12 h |
Zinc | Smelting, electroplating, military smoke bombs, zinc lozenges, welding/galvanizing (zinc oxide) | Ingestion: nausea, vomiting, abdominal pain (resembles iron poisoning) Inhalation: mucosal irritation, metal fume fever (zinc oxide) | Copper deficiency, sideroblastic anemia, neutropenia | Edetate calcium disodium Supportive care for metal fume fever |