Part of the ICU Emergencies Hub — browse every related guide in one place.
Lead poisoning is usually thought of as a slow, chronic, pediatric problem — peeling paint in an old house, a rising blood lead level found on a screening test. But lead can also present acutely and land a patient in the ICU: a toddler with a swallowed fishing weight or a piece of jewelry, an adult with a heavy industrial or retained-bullet exposure, or a child from an imported cosmetic, spice, or folk-remedy source. When the blood lead level climbs high enough, the emergency is lead encephalopathy — a swelling, seizing brain — and the ICU nurse's job is to recognize it, protect the airway and the brain, and shepherd a patient through chelation.
Lead has no useful role in the body. It masquerades as calcium and other metals, jamming enzymes throughout the body — especially those that build heme (the oxygen-carrying molecule) and those the nervous system depends on. The result is a multi-system illness: a brain that swells and seizes at high levels, a gut that cramps, a marrow that cannot make normal red cells, and kidneys and nerves that suffer over time. Children absorb far more of an ingested dose than adults and have a more vulnerable, developing brain, which is why the same exposure is far more dangerous in a small child.
Acute, high-level lead poisoning is a story of the brain and the gut.
| System | What you may see |
|---|---|
| Neurologic (severe) | Headache, irritability, clumsiness, lethargy progressing to encephalopathy: vomiting, ataxia, altered mental status, seizures, coma, cerebral edema |
| GI | Anorexia, constipation, crampy abdominal pain ("lead colic"), nausea and vomiting |
| Hematologic | Anemia (often microcytic), basophilic stippling on the smear, pallor, fatigue |
| Other/chronic | Peripheral neuropathy (wrist drop in adults), renal injury, a "lead line" on the gums, developmental and behavioral effects in children |
The diagnosis rests on the blood lead level, but two other pieces matter at the bedside. An abdominal X-ray can reveal radio-opaque lead in the gut — paint chips, a swallowed object, a retained pellet cluster — which changes the plan, because chelating a patient who still has a lead depot in the bowel can backfire; the object or gut lead often needs to be removed (whole-bowel irrigation, endoscopy, or surgery) as part of care. The peripheral smear showing basophilic stippling and a microcytic anemia supports the picture while levels are pending. A careful exposure history — housing age, occupation, hobbies (bullet casting, stained glass, battery work), imported spices/cosmetics/remedies, retained bullets — often finds the source.
Chelators are drugs that bind lead so it can be excreted. The specific agent, route, and sequence are toxicology-guided and depend on the level and whether the patient has encephalopathy.
| Agent | Route | Typical use |
|---|---|---|
| Succimer (DMSA) | Oral | Moderate elevations without encephalopathy; outpatient-capable |
| CaNa2EDTA (edetate calcium disodium) | IV | Higher levels / severe poisoning, often paired with dimercaprol in encephalopathy |
| Dimercaprol (BAL) | Deep IM | Severe poisoning and encephalopathy; given first, before CaNa2EDTA |
Dimercaprol is a deep IM injection formulated in peanut oil (ask about peanut allergy) and can cause fever, hypertension, and a distinctive taste/pain; it is avoided in G6PD deficiency and with certain iron interactions. CaNa2EDTA is nephrotoxic — monitor renal function and urine output and ensure the patient is well hydrated and making urine. Do not confuse CaNa2EDTA (edetate calcium disodium) with plain edetate disodium (Na2EDTA), a look-alike name that has caused fatal hypocalcemia; verify the exact product. Oral succimer can cause GI upset, transaminase elevations, and a strong sulfur odor.
For the encephalopathic patient: neuro checks, seizure precautions, airway protection, and careful fluid management (enough to make urine for the kidneys and the chelator, but mindful of cerebral edema). For everyone on chelation: strict intake/output, renal function, and the metal level trend, plus watching for rebound after a course ends as lead redistributes from bone and tissue. Anemia may need treatment, and iron status is checked because lead and iron deficiency travel together. Above all, the exposure is removed — there is no point chelating a patient who goes home to the same source — and public health is notified, because a poisoned child usually means a poisoned environment and often other exposed people.
For other toxic exposures and the complications lead poisoning shares, see arsenic poisoning, mercury poisoning, hydrocarbon aspiration, and organophosphate poisoning. For the seizure and kidney threads, see seizure precautions and postictal care and acute kidney injury and CRRT.
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