Emergency Medicine Book


Chemical Toxin

Aka: Chemical Toxin, Chemical Burn, Chemical Weapon, Toxic Chemical Syndrome, Chemical Warfare Agents, Chemical Hazard Release, Chemical Terrorism, Hazardous Material, Hazardous Substance, Hazmat, NFPA 704
  1. See Also
    1. Biological Neurotoxin
    2. Biological Weapon
    3. Occupational Illness
    4. Toxin Induced Vital Sign Changes
    5. Toxin Induced Skin Changes
    6. Toxin Induced Neurologic Changes
    7. Toxin Induced Odors
    8. Chemical Eye Injury
    9. Irritant Contact Dermatitis
  2. Background: History
    1. Sparta in Peloponnesian War 423 BC
      1. Smoke from coals and sulfur pitch directed into fort
    2. Greeks: 7th Century AD directed Greek Fire
      1. Rosin, Sulfur, Pitch, Naphtha, Lime, Saltpeter
    3. Venice: 15-16th Centuries
      1. Loaded hollow mortar shells with poisons
    4. World War I: German use in Belgium
      1. Chlorine gas (1915)
      2. Sulfur Mustard (1917)
    5. Pre-World War II
      1. Great Britain
        1. Chemicals against Russians
        2. Mustards against Afghans at Khyber Pass, Spain
      2. Spain
        1. Mustard against Riff tribes in Morocco
      3. Soviet Union
        1. Lung Irritants against Kurdistan tribesman
      4. Italy
        1. Tear Gas, mustard against Abyssinia
    6. World War II
      1. Nazi Germany synthesized OrganophosphateNerve Agents
        1. Tabun (GA)
        2. Sarin (GB)
    7. Post-World War II
      1. 1963-1967 Egypt in Yemen War used mustard bombs
    8. Vietnam
      1. U.S. used defoliants and riot-control agents
    9. Afghanistan in 1970's and 1980's
      1. Soviet Union used Chemical Agents
    10. Iran-Iraq War and Operation Desert Shield and Storm
      1. Iraq used Sulfur Mustard, Tabun, Sarin, Cyanide
    11. Stockpiles of Chemical Agents
      1. Russia and former Soviet Union
      2. France
      3. Libya
      4. United States (Sarin, Mustard)
    12. Chemical Precursors used in Manufacturing
      1. Phosgene
    13. Terrorism
      1. Sarin use in Matsumoto, Tokyo 1994-5
  3. Background: Hazardous Material Labeling (NFPA 704 Labeling System)
    1. Hazardous Materials in the United States are labeled with a 4 quadrant diamond (NFPA 704)
    2. Fire Hazard or Flammability (RED top quadrant)
      1. Flash Point 4: <73 degrees F
      2. Flash Point 3: <100 degrees F
      3. Flash Point 2: 100 to 200 degrees F
      4. Flash Point 1: >200 degrees F
      5. Flash Point 0: Does not burn
    3. Health Hazard (BLUE left quadrant)
      1. Hazard 4: Deadly
      2. Hazard 3: Extreme Danger
      3. Hazard 2: Hazardous
      4. Hazard 1: Slightly Hazardous
      5. Hazard 0: Normal Material
    4. Reactivity or Instability (YELLOW right quadrant)
      1. Reactivity 4: May detonate
      2. Reactivity 3: Shock and heat may detonate
      3. Reactivity 2: Violent chemical change
      4. Reactivity 1: Unstable if heated
      5. Reactivity 0: Stable
    5. Specific Hazard (WHITE bottom quadrant)
      1. Ox: Oxidizer
      2. ACID: Acid
      3. ALK: Alkali
      4. COR: Corrosive
      5. W: Use NO water
      6. Radioactive Symbol
    6. Resources
      1. https://www.nfpa.org/Assets/files/AboutTheCodes/704/704_FAQs.pdf
  4. Types: Chemical Agents and Syndromes
    1. Pulmonary Intoxicants (Phosgene, Chlorine)
      1. Inflammation at alveoli causing Pulmonary Edema
    2. Cyanide ("Blood Agents")
      1. Systemic, rapid diffuse tissue effects
    3. Vesicants or Blister Agents (Sulfur Mustard, Lewisite)
      1. Local inflammation: Blisters, eye and airway effects
    4. Nerve Agents (Tabun, Sarin, Soman, VX)
      1. Inhibits enzyme acetylcholinesterase
    5. Incapacitating Agents (BZ)
      1. Impairs performance usually via CNS effects
    6. Riot Control Agents (Mace, Pepper Spray)
      1. Local irritants causing Lacrimation, cough
    7. Miscellaneous Agents
      1. See Occupational Illness
      2. Ammonia
      3. Chemical acid burns (e.g. Hydrochloric acid, hydrofluric acid, Hydrocarbon solvents)
        1. See Chemical Eye Injury
        2. Hydrofluoric Acid requires specific management (Calcium Gluconate)
        3. Decontaminate other acid burns with copious water (e.g. shower for 20-30 minutes)
      4. Solvent Exposures (e.g. paint thinners, methylene chloride, toluene)
      5. Organophosphate Poisoning
  5. Differential Diagnosis
    1. See Biological Weapon (Bioterrorism)
    2. See Biological Neurotoxin
    3. Consider Panic Symptoms from those of agents
  6. Findings
    1. Hazardous exposure risk assessment
      1. Occupancy and location (e.g. labs, farms, factories)
      2. Container shape
      3. Markings and colors
        1. Diamond shaped transport labels (with risk numbers 0-minimal to 4-high)
        2. Health risks (blue, left quadrant)
        3. Flammability (red, top quadrant)
        4. Reactivity (yellow, right quadrant)
        5. Other (white, lower quadrant)
      4. Placards and labels
      5. Shipping papers
      6. Odors
    2. Recognition of chemical attack
      1. Chemical attack is typically immediately evident by signs of affected victims
      2. Unlike Bioterrorism, no Incubation Period (effects are immediate)
      3. Large number of initial victims
  7. Management
    1. See Contaminated Casualty Management
    2. See Decontamination
    3. See Decontamination in Children
    4. Children are more susceptible to chemical attacks
      1. Increased Minute Ventilation (greater inhalation of agents)
      2. Lower height (closer to ground level where gases may settle)
      3. Thin, more permeable skin (greater toxin absorption and injury)
      4. Often dependent on adults to escape exposure
      5. Antidote dosing is not well established in children
    5. Children also are more susceptible to exposure to household chemicals (cleaners, cosmetics)
      1. Acidic and alkaline substances may cause Chemical Burns of skin, eyes or the Gastrointestinal Tract if ingested
  8. Resources
    1. US Army Medical Research Institute of Chemical Defense
      1. http://WWW.CW-MED.ORG
  9. References
    1. Campana, Patel and Martin (2016) Crit Dec Emerg Med 30(2): 14-9
    2. Seeyave (2015) Crit Dec Emerg Med 29(5): 13-21
    3. Medical Response to Chemical Warfare and Terrorism
      1. US Army Medical Research Institute Chemical Defense
      2. Video-Teleconference: 4/20/00 to 4/22/99
      3. Video-Teleconference: 12/5/00 to 12/7/00
      4. Text: 3rd Edition, December 1998

Chemical Burns (C0006435)

Definition (NCI) A burn caused by exposure to chemical substances.
Concepts Injury or Poisoning (T037)
MSH D002057
SnomedCT 426284001, 402261004, 26696002
English Burns, Chemical, Burn, Chemical, chemical burn, Caustic Burn, CHEM BURNS, CHEMICAL BURN, BURNS CHEM, Chemical burn (disorder), burn from chemicals (diagnosis), burn from chemicals, chemical burn(s), Chemical Burns, Burns, Chemical [Disease/Finding], burns chemicals, chemical burns, burn chemical, burns chemical, burning chemicals, Chemical burns, BURN, CAUSTIC/CHEMICAL, CHEMICAL/CAUSTIC BURN, CAUSTIC/CHEMICAL BURNS, Chemical burn, Chemical burn (morphologic abnormality), Chemical burn, NOS, Chemical Burn
French BRULURE CHIMIQUE, Brûlure chimique, Brûlures chimiques
Swedish Kemiska brännskador
Czech popálení chemické, Chemické popálení
Spanish quemadura química (trastorno), quemadura química, Quemadura por sustancia química, quemadura por agente químico, quemadura por agente químico (trastorno), quemadura por sustancias químicas (anomalía morfológica), quemadura por sustancias químicas, Quemaduras Químicas
Finnish Syöpymävammat
Portuguese QUEIMADURA QUIMICA, Queimadura química, Queimaduras Químicas
Dutch chemische brandwond, Brandwond, chemische, Brandwonden, chemische, Chemische brandwond, Chemische brandwonden
Italian Ustione chimica, Ustioni da sostanze chimiche
German Verbrennung durch Chemikalien, Verätzungen
Japanese カガクネッショウ, 化学的火傷, 熱傷-化学的, 化学熱傷, 化学的熱傷, 火傷-化学的, 熱傷-化学
Polish Oparzenia chemiczne
Hungarian Kémiai égés
Norwegian Brannskade, kjemisk, Kjemiske brannsår, Kjemiske brannskader, Kjemiske forbrenninger
Derived from the NIH UMLS (Unified Medical Language System)

Chemical Warfare Agents (C0007991)

Definition (MSH) Chemicals that are used to cause the disturbance, disease, or death of humans during war.
Concepts Hazardous or Poisonous Substance (T131)
MSH D002619
SnomedCT 105888008
English Agents, Chemical Warfare, Chemical Warfare Agents, Warfare Agents, Chemical, CHEM WARFARE AGENTS, AGENTS CHEM WARFARE, WARFARE AGENTS CHEM, Agent, Chemical Warfare, Warfare Agent, Chemical, Chemical Warfare Agent, chemical warfare agents, agents chemical warfare, Chemical warfare agent (substance), Chemical warfare agent
French Armes chimiques, Agents de guerre chimique, AGC (Agents de Guerre Chimique)
Swedish Kemiska stridsmedel
Czech bojové otravné látky, chemické bojové látky
Finnish Kemialliset aseet
German Kampfstoffe, chemische, Chemische Kampfstoffe
Italian Armi chimiche, Agenti per la guerra chimica
Japanese 化学戦用物質, 化学兵器
Polish Środki bojowe chemiczne
Portuguese Substâncias para a Guerra Química, Agentes para Guerra Química, Armas Químicas
Spanish Sustancias para la Guerra Química, Armas Químicas, Agentes para la Guerra Química, Sustancias Químicas Bélicas, Agentes de Guerra Química, Agentes para Guerra Química, Sustancias Bélicas, agente químico bélico (sustancia), agente químico bélico, agente químico para armas de guerra
Norwegian Kjemiske stridsmidler
Derived from the NIH UMLS (Unified Medical Language System)

Hazardous Substances (C0018626)

Definition (MSH) Elements, compounds, mixtures, or solutions that are considered severely harmful to human health and the environment. They include substances that are toxic, corrosive, flammable, or explosive.
Definition (CSP) substances which, upon release into the atmosphere, water, or soil, or which, in direct contact with the skin, eyes, or mucous membranes, or as a food additive, cause health risks to humans or animals through absorption, inhalation, or ingestion.
Concepts Hazardous or Poisonous Substance (T131)
MSH D015386
English Hazardous Materials, Hazardous Substances, Materials, Hazardous, Substances, Hazardous, hazardous material, hazardous substance, hazardous materials, hazardous substances, Hazardous substances
French Matériaux dangereux, Substances dangereuses, Matières dangereuses, Produits dangereux
Swedish Hälso- och miljöfarliga ämnen
Czech nebezpečné látky, rizikové látky
Finnish Vaaralliset aineet
Japanese 有害化学薬品, 有害化学物質, 危険物, 有害物, 有害物質, 環境有害物質
Italian Materiali pericolosi, Sostanze pericolose
Polish Substancje zagrażające, Materiały zagrażające, Substancje toksyczne dla środowiska, Środki chemiczne zagrażające
Norwegian Farlige stoffer, Helseskadelige stoffer
Spanish Contaminantes Tóxicos, Materiales Peligrosos, Sustancias Peligrosas
Portuguese Poluentes Tóxicos, Materiais Perigosos, Substâncias Perigosas
German Gefahrstoffe, Gefährliche Materialien, Gefährliche Stoffe, Gefährliche Substanzen, Stoffe, gefährliche, Substanzen, gefährliche
Derived from the NIH UMLS (Unified Medical Language System)

Chemical Weapons (C1456640)

Concepts Hazardous or Poisonous Substance (T131) , Manufactured Object (T073)
English Chemical Weapons
Derived from the NIH UMLS (Unified Medical Language System)

Chemical Terrorism (C1565234)

Definition (MSH) The use of chemical agents in TERRORISM. This includes the malevolent use of nerve agents, blood agents, blister agents, and choking agents (NOXAE).
Concepts Activity (T052)
MSH D051337
Swedish Kemisk terrorism
Czech chemický terorismus
Finnish Kemiallinen terrorismi
French Chimioterrorisme, Terrorisme chimique
Polish Terroryzm chemiczny
Norwegian Terrorisme ved hjelp av kjemiske våpen, Kjemisk terrorisme
English Chemical terrorism, Chemical Terrorism, Terrorism, Chemical
Portuguese Terrorismo Químico
German Terrorismus mit Chemiewaffen
Italian Terrorismo chimico
Spanish Terrorismo Químico
Derived from the NIH UMLS (Unified Medical Language System)

Chemical Hazard Release (C2350599)

Definition (MSH) Uncontrolled release of a chemical from its containment that either threatens to, or does, cause exposure to a chemical hazard. Such an incident may occur accidentally or deliberately.
Concepts Human-caused Phenomenon or Process (T068) , Natural Phenomenon or Process (T070)
MSH D055884
English Chemical Hazrad Release, Chemical Hazard Release, Hazard Release, Chemical, Hazard Releases, Chemical, Incident, Chemical, Hazrad Releases, Chemical, Chemical Hazrad Releases, Hazrad Release, Chemical, Incidents, Chemical, Release, Chemical Hazard, Chemical Incident, Chemical Hazard Releases, Releases, Chemical Hazard, Release, Chemical Hazrad, Releases, Chemical Hazrad, Chemical Incidents
Spanish Liberación de Peligros Químicos, Fuga de Riesgo Químico
French Libération d'agents chimiques dangereux, Incidents chimiques, Libération de produits chimiques dangereux, Rejet de substances chimiques dangereuses, Rejet d'agents chimiques dangereux, Libération de substances chimiques dangereuses, Rejet de produits chimiques dangereux
Italian Incidenti da rischio chimico
German Chemische Gefahr, Freisetzung, Zwischenfälle, chemische
Portuguese Vazamento de Resíduos Químicos
Swedish Kemiskt miljöfarligt utsläpp
Czech nebezpečné chemické látky - únik
Polish Zagrożenie chemiczne
Japanese 化学的ハザードの放出, 化学ハザードの放出, 化学ハザードの流出, 有害化学物質放出, ケミカルハザードの放出, 化学ハザードの漏出, ハザードの放出-化学的, 化学物質ハザードの流出, ケミカルハザードの流出, 化学物質ハザードの放出
Norwegian Kjemisk miljøfarlig utslipp, Miljøfarlig kjemisk utslipp
Derived from the NIH UMLS (Unified Medical Language System)

HazMat (C3841948)

Concepts Finding (T033)
LNC LA17588-7
English HazMat
Derived from the NIH UMLS (Unified Medical Language System)

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