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    ZIRCONIUM




    WN Harrison PhD CChem MRSC
    SM Bradberry BSc MB MRCP
    JA Vale MD FRCP FRCPE FRCPG FFOM

    National Poisons Information Service
    (Birmingham Centre),
    West Midlands Poisons Unit,
    City Hospital NHS Trust,
    Dudley Road,
    Birmingham
    B18 7QH


    This monograph has been produced by staff of a National Poisons
    Information Service Centre in the United Kingdom.  The work was
    commissioned and funded by the UK Departments of Health, and was
    designed as a source of detailed information for use by poisons
    information centres.

    Peer review group: Directors of the UK National Poisons Information
    Service.


    ZIRCONIUM

    Toxbase summary

    Type of product

    Zirconium is used in a number of metal alloys, explosive primers and
    flash bulbs. Zirconium compounds have been used in deodorant and
    dermatitis treatments.

    Toxicity

    Most zirconium compounds have low systemic toxicity due to their poor
    solubility. However, some soluble compounds, such as zirconium
    tetrachloride, are irritants and may cause corrosive injury. In
    addition, skin and lung granulomas have been reported following
    repeated zirconium exposure.

    Features

    Dermal and inhalational exposure are reported most commonly.

    Dermal

         -    Most zirconium compounds are considered inert to the skin.
         -    Zirconium tetrachloride is irritant and may cause corrosive
              injury.
         -    Development of granulomas has been reported following
              application of zirconium-containing deodorants and
              dermatitis treatments to broken skin.

    Ocular

         -    Eye irritation, lacrimation, blurred vision and
              conjunctivitis may occur.
         -    Some soluble compounds may cause corrosive damage.

    Inhalation

         -    Most zirconium dusts and vapours will cause only mucosal
              irritation.
         -    Some corrosive compounds may cause hoarseness, dyspnoea and,
              in severe cases, stridor due to laryngeal oedema.
         -    Pulmonary oedema has been reported after exposure to
              zirconium tetrachloride (Cordasco and Stone, 1973) and may
              be delayed for up to 36 hours.
         -    Pulmonary granulomas have been reported in workers
              chronically exposed to zirconium dusts (Bartter et al, 1991;
              Liippo et al, 1993).

    Ingestion

         -    There are no reports of zirconium intoxication, although
              ingestion of a soluble salt may cause corrosive injury.

    Management

    Dermal

    1.   Irrigate with copious lukewarm water.
    2.   Zirconium-induced granulomas are managed most effectively by
         discontinuing exposure. Topical or systemic steroids may hasten
         resolution in severe cases.

    Ocular

    1.   Irrigate immediately with lukewarm water or preferably saline for
         at least 10 minutes.
    2.   Application of local anaesthetic may be required for pain relief
         and to overcome blepharospasm to allow thorough decontamination.
    3.   Ensure no particles remain lodged in the conjunctival recesses.
    4.   Corneal damage may be detected by the instillation of
         fluorescein.
    5.   If symptoms do not resolve rapidly or if there are abnormal
         examination findings, refer for an ophthalmological opinion.

    Inhalation

    1.   Remove from exposure and administer supplemental oxygen by
         face-mask if there is evidence of respiratory distress.
    2.   Intubation and assisted ventilation may be necessary.
    3.   Rarely tracheostomy may be required for life-threatening
         laryngeal oedema.
    4.   Corticosteroids in high dosage (prednisolone 60-80 mg/day) may be
         considered for laryngeal and pulmonary oedema but there is no
         confirmed evidence that they improve prognosis.
    5.   Chronic exposure may precipitate a pulmonary granulomatous
         reaction. Initial assessment involves chest X-ray and lung
         function tests. Specialist referral may be indicated.

    Ingestion

    1.   Ingestion of most common zirconium compounds will require
         symptomatic and supportive care as dictated by the patient's
         condition.
    2.   If corrosive injury is suspected management is as for acid
         ingestion (see Corrosives).

    References

    Anderson KD, Rouse TM, Randolph JG.
    A controlled trial of corticosteroids in children with corrosive
    injury of the esophagus.
    N Engl J Med 1990; 323: 637-40.

    Baler GR.
    Granulomas from topical zirconium in poison ivy dermatitis.
    Arch Dermatol 1965; 91: 145-8.

    Bartter T, Irwin RS, Abraham JL, Dascal A, Nash G, Himmelstein JS,
    Jederlinic PJ.
    Zirconium compound-induced pulmonary fibrosis.
    Arch Intern Med 1991; 151: 1197-201.

    Cordasco EM, Stone FD.
    Pulmonary edema of environmental origin.
    Chest 1973; 64: 182-5.

    Hadjimichael OC, Brubaker RE.
    Evaluation of an occupational respiratory exposure to a
    zirconium-containing dust.
    J Occup Med 1981; 23: 543-7.

    Jeng L-BB, Chen H-Y, Chen S-C, Hwang T-L, Jan Y-Y, Wang C-S, Chen M-F.
    Upper gastrointestinal tract ablation for patients with extensive
    injury after ingestion of strong acid.
    Arch Surg 1994; 129: 1086-90.

    Liippo KK, Anttila SL, Taikina-Aho O, Ruokonen E-L, Toivonen ST, Tuomi
    T.
    Hypersensitivity pneumonitis and exposure to zirconium silicate in a
    young ceramic tile worker.
    Am Rev Respir Dis 1993; 148: 1089-92.

    Marcus RL, Turner S, Cherry NM.
    A study of lung function and chest radiographs in men exposed to
    zirconium compounds.
    Occup Med 1996; 46: 109-13.

    Romeo L, Cazzadori A, Bontempini L, Martini S.
    Interstitial lung granulomas as a possible consequence of exposure to
    zirconium dust.
    Med Lav 1994; 85: 219-22.

    Rubin L, Slepyan AH, Weber LF, Neuhauser I.
    Granulomas of the axillas caused by deodorants.
    JAMA 1956; 162: 953-5.

    Shelley WB, Hurley HJ.
    The allergic origin of zirconium deodorant granulomas.
    Br J Dermatol 1958; 70: 75-101.

    Skelton HG, Smith KJ, Johnson FB, Cooper CR, Tyler WF, Lupton GP.
    Zirconium granuloma resulting from an aluminium zirconium complex: a
    previously unrecognized agent in the development of hypersensitivity
    granulomas.
    J Am Acad Dermatol 1993; 28: 874-6.

    Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK.
    Ingestion of corrosive acids. Spectrum of injury to upper
    gastrointestinal tract and natural history.
    Gastroenterology 1989; 97: 702-7.

    Substance name

         Zirconium

    Origin of substance

         Found in rare earth minerals, zircon, malacon, baddeleyite,
         zirkelite, eudialyte and in monazite sand. Invariably associated
         with hafnium.                           (MERCK, 1996)

    Synonyms

         Zircat                                  (HAZARDTEXT, 1997)

    Chemical group

         A group IV B (d block) transition metal.

    Reference numbers

         CAS            7440-67-7                (DOSE, 1994)
         RTECS          ZH7070000                (RTECS, 1997)
         UN             2858, 2009 (dry);
                        2008 (powder, dry);
                        1358 (powder, wetted)    (DOSE, 1994)
         HAZCHEM        NIF

    Physicochemical properties

    Chemical structure
         Zr                                      (DOSE, 1994)

    Molecular weight
         91.22                                   (DOSE, 1994)

    Physical state at room temperature
         Solid                                   (MERCK, 1996)

    Colour
         A grey-white metal or a blue-black powder.
                                                 (MERCK, 1996)

    Odour
         NIF

    Viscosity
         NA

    pH
         NIF

    Solubility
         Insoluble in hot or cold water.
         Slightly soluble in acids.
         Soluble in hydrogen fluoride and aqua regia.
                                                 (HSDB, 1997)

    Autoignition temperature
         NIF

    Chemical interactions
         Zirconium reacts with hydrofluoric acid, aqua regia and hot
         phosphoric acid.
         Zirconium is slightly attacked by hot concentrated sulphuric acid
         or hydrochloric acid and avidly attacked by fused potassium
         hydroxide or nitrate.
         Treatment of zirconium powder with hydrogen fluoride solution (1
         per cent) desensitizes it to electrostatic ignition.
         Zirconium dust may explode when mixed with alkali hydroxides,
         alkali metal chromates, dichromates, molybdates, sulphates,
         tungstates, borax, carbon tetrachloride, cupric oxide, lead, lead
         oxide, phosphorus, potassium chlorate, potassium nitrate and
         nitryl fluoride.
                             (MEDITEXT, 1997; SAX'S, 1996; MERCK, 1996)

    Major products of combustion
         Zirconium oxide                         (SAX'S, 1996)

    Explosive limits
         0.16 g/L in air                         (SAX'S, 1996)

    Flammability
         Highly flammable. Dust may ignite spontaneously.
                                                 (SAX'S, 1996)

    Boiling point
         3577C                                  (DOSE, 1994)

    Density
         6.5 at 20C                             (DOSE, 1994)

    Vapour pressure
         NIF

    Relative vapour density
         NIF

    Flash point
         NIF

    Reactivity
         When exposed to heat and flame, zirconium dust is a very
         dangerous fire hazard. A 10 to 70 per cent zirconium lead alloy
         will ignite if hit by a hammer.
                                            (MEDITEXT, 1997; SAX'S, 1996)

    Uses

         Pure zirconium (hafnium free) is used in structural materials in
         nuclear reactors.
         In constructing rayon spinnerets in lamp filaments and flash
         bulbs.
         In explosive primers.
         As weighting agents, in welding rod manufacture and sandblasting
         applications.
         In moulds and furnaces in the aluminium, brass, steel and glass
         industries.
         As a reflective surface on satellites.
         In deodorants.           (MERCK, 1996; DOSE, 1994; PATTY, 1994)

    Hazard/risk classification

    Index no.
         Zirconium powder (pyrophoric) 040-001-00-3

    Risk phases
         R15-17 - Contact with water liberates extremely flammable gases.
         Spontaneously flammable in air.
    Safety phases
         S7/8 - 43 - Keep container tightly closed and dry. In case of
         fire, use (indicate in the space the precise type of fire
         fighting equipment). If water increases the risk add - Never use
         water.
    EEC no. 231 - 176 - 9                        (CHIP2, 1994)

    INTRODUCTION

    Zirconium is a transition metal usually existing in valence state +4,
    although it can form compounds in the +3 and +2 states (PATTY/Beliles,
    1994). It is believed to have low systemic toxicity due to the low
    solubility of many of its compounds (including the silicate, carbonate
    and oxide). Some soluble zirconium salts, such as zirconium
    tetrachloride, are irritants and may cause corrosive injury.
    Furthermore, zirconium may contain uranium and thorium presenting a
    potential radiation hazard to those exposed (Castello et al, 1992).

    EPIDEMIOLOGY

    Exposure to zirconium and its compounds is mainly as dust and fumes in
    the metallurgical industry. Although several studies have found no
    adverse health effects following occupational zirconium exposure
    (Hadjimichael and Brubaker, 1981; Marcus et al, 1996) a number of case
    reports have linked zirconium to respiratory disease (Bartter et al,
    1991; Liippo et al, 1993; Romeo et al, 1994).

    The use of zirconium compounds in deodorants (Rubin et al, 1956;
    Anon.,1958; Obermayer, 1969) and dermatitis treatments (Baler, 1965)
    has led to the development of "allergic" granulomas; Shelley and
    Hurley (1958) reported 70 cases between 1956 and 1958.

    Exposure of bare feet to zirconium-rich clay in Ethiopia has been
    associated with non-filarial elephantiasis (Frommel et al, 1993).

    MECHANISMS OF TOXICITY

     In vitro studies demonstrate zirconium induces lymphocyte
    proliferation and may augment the T-cell mediated immune response to
    other agents via interaction with macrophages (Price and Skilleter,
    1986). However, evidence that the development of lung granulomas in
    exposed individuals is a T- cell mediated delayed hypersensitivity
    response is inconclusive, unlike the case of beryllium
    hypersensitivity (Parkes, 1994).

    Some zirconium compounds, for example zirconium tetrachloride, have a
    direct irritant or corrosive effect on the skin, eyes and mucous
    membranes.

    TOXICOKINETICS

    Absorption

    Zirconium compounds are absorbed poorly following ingestion
    (PATTY/Beliles, 1994).

    The uptake of insoluble zirconium compounds following inhalation is
    low (PATTY/Beliles, 1994). Coal miners exposed to unstated zirconium
    concentrations had up to 14 ppm zirconium in heavily pigmented
    sections of lung and 22 ppm in pulmonary lymph nodes. Blood zirconium
    concentrations were up to 100 g/L and urine concentrations up to 12
    g/L (PATTY/Beliles, 1994).

    Zirconium-induced skin granulomas are associated typically with areas
    of damaged skin indicating that absorption through intact skin is
    poor.

    Distribution

    Zirconium was found to be widely distributed in specimens from four
    autopsies of non-poisoned patients with particularly high
    concentrations in liver and body fat (Schroeder and Balassa, 1966).

    Excretion

    There are very little data available but most absorbed zirconium
    appears to be eliminated in bile with only small amounts appearing in
    urine (HSDB, 1997).

    CLINICAL FEATURES: ACUTE EXPOSURE

    Dermal exposure

    Most commonly used zirconium compounds are insoluble and considered
    inert to the skin, although some salts, such as zirconium
    tetrachloride, are skin irritants. The severity of injury will depend
    on concentration or extent of exposure.

    Development of axillary granulomas has been reported rarely following
    a single application of a zirconium-containing deodorant. However,
    prior sensitization, possibly from inhalation of zirconium compounds,
    is believed to have occured (Shelley and Hurley, 1958).

    Ocular exposure

    Ocular exposure to zirconium compounds may cause eye irritation,
    lacrimation, blurred vision and conjunctivitis. More severe damage may
    be expected following exposure to a corrosive salt such as zirconium
    tetrachloride. There are no clinical case data.

    Inhalation

    Most zirconium compounds cause only irritation when inhaled as dusts
    or vapours although pulmonary oedema has been reported following
    exposure to zirconium tetrachloride which is corrosive (Cordasco and
    Stone, 1973).

    Early features following corrosive inhalation include cough and
    retrosternal discomfort. Hoarseness, dyspnoea and, in severe cases,
    stridor due to laryngeal oedema may follow. Where pulmonary oedema
    ensues its onset may be delayed for up to 36 hours.

    Ingestion

    There are no reports of zirconium poisoning by ingestion. Most
    zirconium compounds are absorbed poorly from the gastrointestinal
    tract although some salts such as zirconium tetrachloride may cause
    corrosive injury.

    Gastrointestinal toxicity

    Common early features of corrosive ingestion include immediate pain in
    the mouth, pharynx and abdomen, intense thirst, vomiting, haematemesis
    and diarrhoea. Gastric and oesophageal perforation and chemical
    peritonitis may also occur.

    Late features include antral or pyloric stenosis, jejunal stricture
    formation, achlorhydria, protein-losing gastroenteropathy and gastric
    carcinoma.

    Pulmonary toxicity

    Features associated with corrosive ingestion include hoarseness,
    stridor, respiratory distress and, in severe cases, laryngeal or
    epiglottal oedema. Chemical pneumonitis and adult respiratory distress
    syndrome (ARDS) are recognized.

    Nephrotoxicity

    Renal failure secondary to acute tubular necrosis may complicate
    ingestion of a corrosive zirconium salt.

    Cardiovascular toxicity

    Circulatory collapse is likely in patients with extensive
    gastrointestinal burns.

    Haemotoxicity

    Disseminated intravascular coagulation and haemolysis may complicate
    concentrated corrosive ingestions.

    Injection

    Two individuals developed vertigo following intravenous administration
    of 50 mg zirconium malate (Hathaway et al, 1991).

    CLINICAL FEATURES: CHRONIC EXPOSURE

    Dermal

    The use of soluble zirconium salts, notably sodium zirconium lactate,
    in deodorants (Rubin et al, 1956; Anon.,1958; Shelley and Hurley,
    1958) has been associated with the development of axillary granulomas.
    These appear as red-brown or flesh coloured, mildly or non-pruritic
    papules which may form linear streaks, often associated with shaving
    and restricted to areas of deodorant application. Histologically they
    resemble sarcoid granulomas with epithelioid and multinucleate giant
    cells. Onset of the lesions is usually delayed for days to weeks after
    exposure with complete recovery within six to twelve months if
    exposure ceases.

    A more recent report linked the use of an aluminium zirconium complex
    to granuloma formation (Skelton et al, 1993). A 27 year-old woman
    developed a right axillary mass after some two years use of an
    antiperspirant containing aluminium zirconium tetrachlorohydrex
    glycerine. A year after its development the mass became acutely
    inflamed and was excised. Histological examination showed typical
    features of zirconium-induced granulomas and chemical analysis
    confirmed the presence of zirconium. The use of the antiperspirant was
    discontinued and no recurrence was reported after one year (Skelton et
    al, 1993).

    Similar lesions were reported in a 15 year old girl following
    treatment of poison ivy dermatitis with four per cent zirconium oxide
    cream. No granulomas appeared on intact skin areas indicating dermal
    damage is necessary for zirconium penetration. Oral prednisone (dose
    not stated), topical fluocinolone and intralesional injection of
    triamcinolone (6 mg/mL) each cleared the lesions leaving only areas of
    pigmentation. However, there was a complete recurrence on cessation of
    treatment and untreated granulomas showed no evidence of improvement
    over 20 months (Baler, 1965). The author noted that although cutaneous
    reactions to zirconium seemed less common following exposure to
    insoluble (e.g. zirconium oxide) than soluble (e.g. zirconium lactate)
    salts, once initiated reactions to insoluble salts were more likely to
    persist due to prolonged retention in dermal tissue.

    The development of lymph node sclerosis, leading to non-filarial
    elephantiasis has been associated with increased soil concentrations
    of zirconium and beryllium in Southwest Ethiopia (Frommel et al,
    1993). The exposure of bare feet to zirconium rich soil is thought to
    be exacerbated by the corrosive nature of the clay particles.

    Inhalation

    Epidemiological studies of industrial exposure to zirconium compounds
    have found no evidence of impaired pulmonary function although
    individual cases of zirconium-induced lung disease have been reported.

    No zirconium-attributed abnormalities were reported in 22 workers
    exposed to fumes in a zirconium reduction plant for one to five years
    (Reed, 1956).

    A group of 32 male metal handfinishers exposed to zirconium dust for
    one to 17 years were examined for any adverse pulmonary function
    compared to a control group matched for age, sex, payroll status and
    smoking history. No significant difference in self-reported symptoms,
    chest X-rays or expiratory lung function tests were found
    (Hadjimichael and Brubaker, 1981).

    The pulmonary function of 178 men exposed to zirconium dust (mainly
    less than 10 mg/m3; maximum measured concentration 30.0 mg/m3) was
    monitored between 1975 and 1988 (Marcus et al, 1996). No abnormal
    chest X-ray findings (in 1975, 1978 and 1982) or impaired pulmonary
    function were found to have resulted from zirconium exposure.

    Conversely, Bartter et al (1991) described a 62 year-old man with
    apparent zirconium-induced pulmonary fibrosis. He was employed for 39
    years at a lens grinding company where he was responsible for mixing a
    powder containing 90 per cent zirconium dioxide. He was a smoker and
    wore no respiratory protection during the course of his work. Over 25
    years he became increasingly dyspnoeic, and was originally diagnosed
    with emphysema. Examination revealed clubbing of the fingers and toes
    with diffuse crackles and wheeze in both lungs. A series of X-rays
    taken between 1969 and 1988 showed progressive interstitial fibrosis
    with honeycombing in the lower zones bilaterally. Pulmonary function
    tests showed a restrictive picture with total lung capacity 56 per
    cent predicted, carbon monoxide diffusing capacity 37 per cent
    predicted and modest hypoxia (pO2 9.3 kPa; pCO2 normal). An open
    lung biopsy showed end-stage fibrosis and honeycombing but no
    granulomas. Polarizing light microscopy revealed a moderate number of
    birefringent particles. Further scanning electron microscope analysis
    revealed 69 x 106 particles/cm3, 60 x 106 of which contained
    zirconium oxide, zirconium silicate or zirconium aluminium silicate
    (normal < 1 x 106/cm3). Zirconium-specific proliferation studies
    on peripheral lymphocytes and pulmonary lymphocytes obtained via
    bronchoalveolar lavage were negative. The patient died of pneumonia
    with sepsis two years after initial examination (Bartter et al, 1991).

    Zirconium-induced hypersensitivity pneumonitis was considered the
    underlying cause of death in a 25 year old female ceramic tile worker
    (Liippo et al, 1993) who had a history of atopy. The patient had
    worked for 1.5 years as a glazier where she was exposed to
    0.8-5.8 mg/m3 dust containing 10-30 per cent zirconium silicate. She
    previously had worked for two years as a sorter where dust
    concentrations were 0.5 - 2.6 mg/m3 and one month with special
    shaped ceramics where dust concentrations were as high as 8.6 mg/m3.
    At presentation she gave a two month history of dry cough and
    exertional breathlessness. Examination revealed crackles in both lungs
    with bilateral interstitial fibrosis and small discrete nodules on
    chest X-ray. Respiratory function was markedly decreased with FEV1 32
    per cent predicted, FVC 34 per cent predicted and carbon monoxide
    diffusing capacity 36 per cent predicted. Oral prednisolone 1 mg/kg
    for nine months gave no improvement. An open lung biopsy was performed
    but was complicated by pneumothorax which precipitated acute right
    heart failure and fatal splenic rupture one week later. At autopsy the
    lungs showed features compatible with hypersensitivity pneumonitis
    with widespread interstitial lymphocytic inflammation, mild fibrosis
    and multiple noncaseating epithelioid granulomas with some
    multinucleate cells. Scanning electron microscopy revealed 1.3 x 109
    zirconium silicate particles per gram dry weight of lung (Liippo et
    al, 1993).

    Zirconium-induced lung disease has been implicated also in a 29 year
    old male worker with suspected pneumoconiosis following eight years
    exposure to 1.1 mg/m3 inhalable dust containing zirconium silicate.
    Pulmonary function tests were normal though chest X-ray showed diffuse
    interstitial reticular opacities. A transbronchial biopsy revealed

    small interstitial granulomas which histologically contained
    epithelioid and giant cells with no central necrosis (Romeo et al,
    1994).

    A recent review has concluded that while prolonged zirconium dust
    inhalation undoubtedly may cause a benign pneumoconiosis, there is
    insufficient evidence to confirm zirconium as a cause of a delayed
    (type IV) granulomatous hypersensitivity reaction as seen among
    beryllium workers (Parkes, 1994).

    Ingestion

    There are no reports of chronic ingestion of zirconium or its
    compounds.

    MANAGEMENT

    Dermal exposure

    Ensure adequate self protection before attempting treatment. If
    possible the patient should remove any contaminated clothing
    him/herself. Affected areas of skin should be washed with copious
    quantities of water. Pay special attention to skin folds, fingernails
    and ears. Burns should be treated conventionally as for thermal burns
    (e.g. silver sulphadiazine dressing). Surgery may be required for deep
    burns.

    Dermal granulomas usually clear spontaneously six to twelve months
    after removal from exposure (PATTY/Beliles, 1994; Obermayer, 1969),
    although they may remain for longer periods in individuals exposed to
    insoluble zirconium compounds (Baler, 1965). Topical and/or systemic
    steroids may hasten granuloma resolution.

    Ocular exposure

    Irrigate immediately with lukewarm water or preferably saline for at
    least 10-15 minutes. A local anaesthetic may be indicated for pain
    relief and to overcome blepharospasm. Specialist ophthalmic advice
    should be sought if any abnormality is detected or suspected on
    examination and in those whose symptoms do not resolve rapidly.

    Inhalation

    Immediate management involves removal from exposure, establishment of
    a clear airway and administration of supplemental oxygen if necessary.
    Rarely mechanical ventilation may be required or tracheostomy if there
    is life-threatening laryngeal oedema. The administration of
    prednisolone 60-80 mg daily may be considered if laryngeal or
    pulmonary oedema are present but there is no confirmed evidence that
    their use alters prognosis. Discussion with a NPIS physician is
    recommended.

    Ingestion

    Decontamination

    Ingestion of most common zirconium compounds will require only
    symptomatic and supportive care as dictated by the patient's
    condition. However, if ingestion is of a corrosive salt a more
    aggressive approach may be required.

    Gastric aspiration/lavage following corrosive ingestion is
    contraindicated. There may be some benefit of attempting oral dilution
    with milk or water, if performed immediately, though this is
    controversial.

    Fluids should not be offered if the patient is not fully conscious, is
    unable to swallow or protect his/her own airway, has respiratory
    difficulty or severe abdominal pain. Possible complications of fluid
    administration include vomiting, aspiration, perforation of the
    gastrointestinal tract and worsening of oesophageal or gastric
    injuries.

    Supportive measures

    Airway support and analgesia should be provided as required. Treat
    shock with intravenous colloid/crystalloid and/or blood. Monitor
    biochemical and haematological profiles and acid/base status.
    Administer antibiotics for established infection only.

    Symptoms and signs are unreliable predictors of the extent of injury
    following corrosive ingestion (Zargar et al, 1989) and therefore in
    symptomatic patients panendoscopy should be carried out, ideally
    within 12-24 hours to gauge the severity of injury.

    Grade 0:  Normal examination
          1:  Oedema, hyperaemia of mucosa
          2a: Superficial, localized ulcerations, friability, blisters
          2b: Grade 2a findings and circumferential ulcerations
          3:  Multiple, deep ulceration, areas of necrosis (Zargar et al,
              1989).

    Following corrosive acid ingestion endoscopic findings within the
    first 36 hours have been successfully used to guide management. In a
    series of 41 patients (Zargar et al, 1989) those with grade 0 to 1
    burns were discharged within one or two days, those with grade 2a
    burns required only supportive care for a little longer, whereas those
    with 2b and 3 burns required nutritional support via jejunostomy
    feeding (total parenteral nutrition is an alternative). All patients
    with grade 0, 1 and 2a injury recovered without sequelae. Acute
    complications and death were confined to those with grade 3 burns
    although several patients with grade 2b burns developed oesophageal or
    gastric strictures.

    In view of the high morbidity associated with corrosive-induced upper
    gastrointestinal perforation and the high incidence of later
    complications requiring surgery, an aggressive surgical approach is
    recommended (Jeng et al, 1994). Surgery should therefore be
    considered:

    1.   If symptoms or signs of gastrointestinal tract perforation are
         evident at initial presentation.

    2.   When endoscopy reveals evidence of grade 3 burns with full-
         thickness necrosis (black, ulcerated mucosa) of the stomach or
         oesophagus.

    Corticosteroids

    In a controlled trial of steroid use among 60 children with
    oesophageal burns following corrosive ingestion (alkalis in the
    majority) the use of steroids (intravenous prednisolone 2 mg/kg within
    24 hours and daily until oral intake was resumed then prednisolone 2.5
    mg/kg orally daily for at least three weeks) did not influence outcome
    (Anderson et al, 1990). Smaller case series have also concluded that
    systemic corticosteroids confer no benefit following acid ingestion
    and may exacerbate or mask symptoms of pending perforation (Hawkins et
    al, 1980).

    MEDICAL SURVEILLANCE

    Ensure adequate ventilation and air concentrations below the
    occupational exposure standard.

    Appropriate respiratory and dermal protective equipment should be
    available. In particular, the exposure of broken skin to zirconium
    compounds must be avoided.

    People with respiratory disease should be identified prior to
    employment if inhalational exposure is likely.

    Normal zirconium concentrations in biological fluids

    NIF

    OCCUPATIONAL DATA

    Occupational exposure standard

    Short-term exposure limit (15 minute reference period) 3.8 mg/m3.
    Long term exposure limit 1.3 mg/m3 (8 hour TWA reference period)
    (Health and Safety Executive, 1997).

    OTHER TOXICOLOGICAL DATA

    Carcinogenicity

    There is no evidence regarding the carcinogenicity of zirconium in
    humans (REPROTEXT, 1997). However, there is an increased risk of
    gastric cancer following severe mucosal damage after corrosive
    ingestion.

    Reprotoxicity

    There is no conclusive evidence that zirconium is reprotoxic in man
    (REPROTEXT, 1997).

    Genotoxicity

     Salmonella typhimurium TA98, TA100, TA102, TA1537, TA2637 negative.
    When tested in combination with 9-aminoacridine, the mutation rate was
    higher than that for 9-aminoacridine alone (zirconium tetrachloride)
    (DOSE, 1994).

    Fish toxicity

    LC50 (96hr) fish (unspecified) bioassay >20 mg/L (DOSE, 1994).

    EC Directive on Drinking Water Quality 80/778/EEC

    NIF

    WHO guidelines for drinking water quality

    NIF

    AUTHORS

    WN Harrison PhD CChem MRSC
    SM Bradberry BSc MB MRCP
    JA Vale MD FRCP FRCPE FRCPG FFOM

    National Poisons Information Service (Birmingham Centre),
    West Midlands Poisons Unit,
    City Hospital NHS Trust,
    Dudley Road,
    Birmingham
    B18 7QH
    UK

    This monograph was produced by the staff of the Birmingham Centre of
    the National Poisons Information Service in the United Kingdom. The
    work was commissioned and funded by the UK Departments of Health, and
    was designed as a source of detailed information for use by poisons
    information centres.

    Date of last revision
    28/1/98

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    See Also:
       Toxicological Abbreviations
       Zirconium (ICSC)