The Journal of Emergency Medicine, Vol 14. No 4.

pp 4355437, 1996
Copyright 0 1996 Elsevier Science Inc.
Printed in the USA. All rights reserved
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ELSEVIER PI1 SO736-4679( 96) 00080.7

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-. Selected Topics:
Toxicology

COMA AND RESPIRATORY ARREST AFTER EXPOSURE TO BUTYROLACTONE

Thomas F. Higgins, Jr., MD and Stephen W. Borron, MD, MS, FACEP

De lartment of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
Reprint Address: Thomas F. Higgins, MD, MetroHealth Medical Center, Department of Emergency Medicine,
2500 MetroHealth Drive, Cleveland, OH 44109-i 998

C hhstract-A 2-year-old male was found unresponsive
apijroximately 40 min after oral exposure to butyrolac-
tone (Figure l), a solvent used to remove metbacrylate
glues. The patient was apneic, bradycardic, and flaccid.
He was given atropine and orally intubated, and his heart
raie increased and blood pressure remained normal. He
remained unresponsive to deep painful stimuli. Six hours
after admission, the patient was alert and breathing spon-
taneously. He was extubated and discharged home the
foil owing day. Previous cases of serious toxicity following
or:%1 exposure to butyrolactone reported in Denmark
halie shown a similar propensity to bradycardia and
coma. The use of butyrolactone is likely to increase, par-
alleling the popularity of acrylate adhesives. Emergency
physicians should be aware of its potential for life-threat-
ening toxicity.
0 Keywords-butyrolactone; solvents, organic; poison-
ing; asphyxia, coma
INTRODUCTION
Butyrolactone (Bullet@ and others) is a substituted fu-
ralone used as a solvent for acrylate polymers (e.g.,
Super Glue@) and polyacrylonitrile and in the synthesis
of piperidine and methionine. It is a constituent of paint
removers and drilling oils. Butyrolactone is a clear oily
liquid that is miscible with water and has a slight ketone
odor. Its vapor pressure is low (0.16 mmHg) , resulting
in a slow rate of evaporation. A material safety data sheet
provided for this product (MSDS: Butyrolactone, ISP
Technologies Inc., Wayne, NJ) states that the product
“may dull senses, if significant quantity ingested” and
that no effects are expected after inhalation, “although
if exposed to high concentrations or for long period of
time, it may cause varying degrees of narcosis.” There
ils no mention of effects on heart rhythm, or of respiratory
compromise. This case illustrates the potential for sig-
nificant toxicity after oral exposure to a small amount of
the product.
CASE REPORT
A previously healthy 2-year-old male was brought to the
emergency department by paramedics after the reported
ingestion of 1 ounce or less of Bullet@ (Figure 2)) a
solvent composed of 100% butyrolactone, approximately
40 min earlier. The patient was found unconscious with
agonal respirations. Paramedics established a peripheral
IV line and initiated bag-valve-mask ventilation.
Vital signs upon arrival in the Emergency Department
were as follows: blood pressure 87152 torr, pulse rate 56
beats/min, respiratory rate 3 breaths/min, and tempera-
ture 36.3”C rectal. The Glasgow coma score was 3. Pupils
were 2-3 mm, equal, and sluggishly reactive. Rhonchi
were noted in all lung fields. Heart sounds were normal.
Cyanosis was absent. Capillary refill was greater than 3
sec. A slight gag reflex was present. The child very
quickly became apneic and required intubation.

Toxicology is coordinated by Kenneth Kulig, MD, of Denver, Colorado

RECEIVED : 21 November 1994; FINAL SUBMISSION RECEIVED : 3 January 1996;
ACCEPTED: 19 January 1996
435
 T. F. Higgins, Jr. and S. W. Borron

about the specific toxicity of butyrolactone, however,

is lacking. Material safety data sheets obtained from
two manufacturers suggest that the toxicity from inges-
tion or inhalation is minimal. The treatment recom-
mended by the manufacturer for ingestion is induction
of vomiting “by giving two glasses of water and stick-
ing finger down throat,” a methodology that is clearly
incorrect (5). Major textbooks of clinical toxicology
fail to mention butyrolactone (6-g)) and only one
previous case series involving human poisonings could
Y-Butyrolactone be located (9). Andersen and Netterstrom reported on
Figure 1. Structure of butyrolactone.
three patients brought to the Rigshospitalet in Copen-
hagen, including two males in their twenties and a
young female whose age was not disclosed. Each of
the males had ingested about 50 ml of a product con-
The patient was given 0.2 mg of intravenous atropine taining 50% butyrolactone and 50% ethanol. The fe-
and was intubated without difficulty. Mild vocal cord male had ingested a very small amount, and was
edema was noted during laryngoscopy. A nasogastric asymptomatic. Both male patients were unconscious
tube was placed to suction. A postintubation arterial on arrival. One patient had respiratory depression re-
blood gas on 100% oxygen revealed a pH of 7.32, pC0, quiring bag-valve-mask ventilation. Both males re-
38 torr, pOZ 241 ton-, HC03 19.6 ton-, and O2 saturation quired atropine for sinus bradycardia. One developed
of 99.8%. The patient remained flaccid and unresponsive. transient atria1 fibrillation after treatment with atropine,
He was admitted to the pediatric intensive care unit. which resolved spontaneously. Each awoke within 5
A chest radiograph obtained approximately 2 l/2 1I2 hours and suffered no lasting sequelae. Laboratory
hours after the ingestion demonstrated a small left lower
lobe infiltrate, consistent with aspiration pneumonitis.
The patient received intravenous dexamethasone 2 mg
every 6 h for 24 h.
Laboratory abnormalities included a hemoglobin of
9.8 and a hematocrit of 29.8, with an MCV of 79. The
serum calcium was low at 8.4 mg/dl, as were the total
protein at 5.1 g/dl, and the albumin at 3.3 g/dl. Serum
phosphorous was slightly low at 2.3 mg/dl. A mild
metabolic acidosis persisted during the first 4 h after
admission.
Approximately 6 h after admission, the child was
alert with spontaneous respirations. He was extubated
without problem. A room air arterial blood gas re-
vealed pH 7.32, pCOp 32 torr, pOZ83 torr, and HC03 20
torr, and 0, saturation 95%. A repeat chest radiograph
demonstrated no change in the left lower lobe infiltrate.
He was discharged home in good condition the follow-
ing day. The child was noted to be doing well with no
postingestion sequelae 1 mo after discharge.

DISCUSSION

A vast array of organic solvents remains available to

the general public in spite of restrictions on certain
compounds, such as carbon tetrachloride and benzene.
Often, as in the case described above, the containers
fail to have child-protective caps. The toxicity of or- Figure 2. Bullet@ brand of butyrolactone. Note the absence
ganic solvents is well described ( l-4). Information of child-resistant packaging.
Butyrolactone Exposure
studies of hemoglobin, hematocrit, albumin, and cal-
cium were normal in both cases. Serum ethanol levels
were not obtained in these cases.
The case described here closely parallels the find-
ings of Andersen and Netterstrom, namely, coma, re-
spiratory depression, and bradycardia following inges-
tion of a small amount of butyrolactone. The anemia
and hypoalbuminemia seen in our case were not ob-
served in the Danish report, and likely preceded the
ingestion. The pneumonitis found in the child likely
resulted from aspiration rather than inhalation injury,
judging from the low vapor pressure of the product.
Reatment of butyrolactone intoxication should em-
pha size maintenance of the airway, continuous cardiac
mo litoring, and supportive care. Decontamination
measures are controversial. Emesis is probably not in-
dicated due to the potential for rapid central nervous
system (CNS) depression ( 10). Information regarding
the use of activated charcoal for this product is not
avzilable. Steroids, which were administered in this
REFERENCES
1. Anas N, Namasonthia V, Ginsburg C. Criteria for hospitalizing
children who have ingested products containing hydrocarbons.
JAMA. 1981;246:840-3.
2. Beamon R, Siegel C, Landers G. Hydrocarbon ingestion in chil-
dren: a six year retrospective study. JACEP. 1976;5:771-5.
3. Geehr E. Management of hydrocarbon ingestions. Top Emerg
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4. McGuigan M. The management of petroleum distillate hydro-
carbon ingestions. Clin Toxic01 Rev. 1978; l(3):] -2.
5. Dabbous I, Bergman A, Robertson W. The ineffectiveness of
mechanically induced vomiting. J Pediatr. 1965; 66:952.
437
case by the attending pediatrician, have not been shown
to improve outcome in hydrocarbon-induced aspiration
pneumonia.
These cases reveal the potential for life-threatening
illness following oral exposure to butyrolactone, and
thus the need for vigilance on the part of emergency
physicians. Available material safety data sheets un-
derestimate the potential for toxicity. Finally, we be-
lieve that child-resistant packaging should be required
for products such as these that may find household use.
The Consumer Product Safety Commission has been
contacted concerning this product.
Acknowledgments-The authors are in debt to Rivka Horo-
witz, MD, PhD, at the Rocky Mountain Poison and Drug Cen-
ter for her assistance in obtaining technical information from
the manufacturer; and to Karen Villalba, MD, and Klaus
Damkjaer Nielsen, MD, for assistance with language transla-
tion.
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