//fpnotebook.com/
Pulmonary Intoxicant
Aka: Pulmonary Intoxicant, Green Cross Agent, Phosgene, Chlorine, Irritant Gas Syndrome, Lung Irritant Chemical Warfare Agent
- See Also
- Chemical Weapon
- Background
- History
- Phosgene synthesized in 1812 by John Davy
- First used as Chemical Weapon 1917 by Germany
- Transported as liquid on rail lines
- Current
- Chlorine used as precursor for chemical manufacturing and as disinfectant
- Risk Factors: Worse course with respiratory comorbid conditions
- Asthma or reactive airway disease
- COPD
- Tobacco Smoking
- Pathophysiology: Toxicity
- Chlorine LCt50: 6000 mg-min/m3
- Phosgene LCt50: 3200 mg-min/m3
- Preparations
- Chlorine (CL)
- Appearance
- Green-yellow gas
- Low lying gas (twice the density of air)
- Liquid when in pressurized canister, but becomes gas at room Temperature out of container
- Odor
- Pungent, swimming pool odor
- Household bleach
- Common use as disinfectant in the U.S.
- Drinking Water Disinfection
- Swimming pool chlorination
- Industrial waste cleaning solution
- Household cleaning solutions (e.g. Bleach)
- Phosgene (CG)
- Vesicant (Blister Agent) when in liquid form
- More lethal than Chlorine
- Appearance
- Forms white cloud on explosion or dispersion
- Settles into colorless low lying gas
- Odor
- Sweet, newly mown hay
- Freshly cut grass
- Corn
- Diphosgene (DP)
- Chloropicrin (PS)
- Perfluoroisobutylene (PFIB)
- Teflon combustion (e.g. aircraft insulated wiring)
- HC smoke (smoke containing zinc)
- Smoke grenades: white obscurant smoke
- Oxides of nitrogen (burning munitions)
- Labs: Detection
- See specific agents as above for characteristics
- Detector kits sensitivity for Phosgene
- MINICAMS (50 ppbv)
- Monitox Plus (0.25 TWA)
- Draeger tubes (0.02-0.6 ppm)
- ICAD (25 mg/m3)
- M18A2 (12.0 mg/m3)
- M90 (>50 ppm)
- M93A1 Fox (115 mg/m3)
- Findings: Symptoms and Signs
- Nasopharynx irritation (mild exposure)
- Eye irritation and tearing
- Nose irritation, Rhinorrhea, sneezing
- Throat irritation
- Lung and airway (more severe exposure)
- Cough
- Dyspnea
- Hypoxia
- Hoarseness, Stridor or choking Sensation (laryngeal edema, tracheitis)
- Wheezing (bronchospasm)
- Chest tightness
- Copious watery airway secretions
- Delayed Pulmonary Edema (at least 2-4 hours from time of exposure)
- Differential Diagnosis
- Riot Control Agents
- Nerve Agents
- Vesicant Agents
- Labs
- No specific Lab testing
- Hematocrit increased
- Arterial Blood Gas (ABG)
- Low PaO2
- Low PaCO2
- Peak Expiratory Flow decreased
- Prognosis: Indicators of severe exposure
- Signs or symptom onset in first 4 hours after exposure
- Imaging
- Chest XRay
- Hyperinflation
- Delayed Pulmonary Edema
- No cardiomegaly
- Pneumomediastinum has been reported
- CT Chest
- Ventilation Perfusion Scan (V/Q Scan)
- High Test Sensitivity but not specific
- Management: General
- Terminate exposure immediately
- Degree of injury is directly proportional to the exposure duration
- Decontamination
- Vapor exposure
- Fresh air
- Liquid exposure
- Copious water irrigation
- Hypochlorite 0.5%
- M291
- ABC Management
- Pulmonary Management
- Oxygen
- Treat Bronchospasm
- Beta-adrenergic Bronchodilators (Nebulized Albuterol)
- Consider Solu-Medrol (e.g. 125 mg every 6 hours) in severe cases
- Consider nebulized Sodium Bicarbonate
- May improve symptoms and improve pulmonary function (studied in Chlorine gas exposure)
- Observe for signs respiratory distress
- Evaluate for Pulmonary Edema
- Positive Pressure Ventilation
- Keep pressures as low as possible to avoid Barotrauma
- Consider Non-Invasive Positive Pressure Ventilation (e.g. BIPAP)
- Mechanical Ventilation if indicated in severe cases
- Intravenous Fluid hydration with crystalloid
- Rest and Observation
- Management: Triage of Patients presenting within 12 hours
- Immediate
- Pulmonary Edema with ICU available
- Delayed
- Dyspnea without other signs
- Re-triage hourly
- Minimal
- Asymptomatic with exposure
- Re-triage every 2 hours
- Expectant
- Pulmonary Edema, Cyanosis, or Hypotension
- Ominous if onset within 6 hours of exposure
- Management: Triage of Patients presenting over 12 hours
- Immediate
- Pulmonary Edema if ICU within hours
- Delayed
- Re-triage every 2 hours
- Discharge if recovering and 24 hours observation
- Minimal
- Asymptomatic
- Expectant
- Persistent Hypotension despite ICU
- Prevention
- Activated Charcoal in chemical protective mask
- Absorbs Phosgene and offers complete protection
- Complications
- Acute Pulmonary Edema
- Pulmonary fibrosis
- References
- Ashoo (2018) EM:Rap 18(2): 4-5
- Seeyave (2015) Crit Dec Emerg Med 29(5): 13-21
- Medical Response to Chemical Warfare and Terrorism
- US Army Medical Research Institute Chemical Defense
- Video-Teleconference: 4/20/00 to 4/22/99
- Video-Teleconference: 12/5/00 to 12/7/00
- Text: 3rd Edition, December 1998