Emergency Medicine Book

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Pulmonary IntoxicantAka: Green Cross Agent, Phosgene, Chlorine

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  1. History
    1. Phosgene synthesized in 1812 by John Davy
    2. First used as Chemical Weapon 1917 by Germany
    3. Transported as liquid on rail lines
    4. Used as precursor for chemical manufacture
  2. Toxicity
    1. Chlorine LCt50: 6000 mg-min/m3
    2. Phosgene LCT50: 3200 mg-min/m3
  3. Agents
    1. Phosgene (CG)
      1. Vesicant (Blister Agent) when in liquid form
    2. Diphosgene (DP)
    3. Chloropicrin (PS)
    4. Chlorine (CL)
    5. Perfluoroisobutylene (PFIB)
      1. Teflon combustion (e.g. aircraft insulated wiring)
    6. HC smoke (smoke containing zinc)
      1. Smoke grenades: white obscurant smoke
    7. Oxides of nitrogen (burning munitions)
  4. Detection
    1. Observation
      1. Forms white cloud on explosion or dispersion
      2. Settles into colorless low lying gas
    2. Odor: Phosgene
      1. Sweet, newly mown hay
      2. Freshly cut grass
      3. Corn
    3. Detector kits sensitivity for Phosgene
      1. MINICAMS (50 ppbv)
      2. Monitox Plus (0.25 TWA)
      3. Draeger tubes (0.02-0.6 ppm)
      4. ICAD (25 mg/m3)
      5. M18A2 (12.0 mg/m3)
      6. M90 (>50 ppm)
      7. M93A1 Fox (115 mg/m3)
  5. History of comorbid conditions
    1. Asthma or reactive airway disease
    2. Tobacco smoking
  6. Symptoms and Signs
    1. Eye irritation
    2. Airway irritation
      1. Cough
      2. Sneezing
      3. Hoarseness
      4. Copious watery airway secretions
    3. Dyspnea
    4. Chest tightness
    5. Delayed pulmonary edema
  7. Differential Diagnosis
    1. Riot control agents
    2. Nerve agents
    3. Vesicant Agents
  8. Labs
    1. No specific Lab testing
    2. Hematocrit increased
    3. Arterial Blood Gas (ABG)
      1. Low PaO2
      2. Low PaCO2
    4. Peak expiratory flow decreased
  9. Prognosis: Indicators of severe exposure
    1. Signs or symptom onset in first 4 hours after exposure
  10. Radiology
    1. Chest XRay
      1. Hyperinflation
      2. Delayed pulmonary edema
      3. No cardiomegaly
    2. Ventilation Perfusion Scan (V/Q Scan)
      1. Sensitive but not specific
  11. Management
    1. Terminate exposure
    2. Decontamination
      1. Vapor exposure
        1. Fresh air
      2. Liquid exposure
        1. Copious water irrigation
        2. Hypochlorite 0.5%
        3. M291
    3. ABC Management
    4. Pulmonary Management
      1. Oxygen with positive pressure
      2. Treat Bronchospasm
        1. Beta-adrenergic Bronchodilators or Theophylline
        2. Solu-Medrol 125 mg q6h
      3. Observe for signs respiratory distress
    5. Intravenous fluid hydration with crystalloid
    6. Rest and Observation
  12. Triage: Patients presenting within 12 hours
    1. Immediate
      1. Pulmonary edema with ICU available
    2. Delayed
      1. Dyspnea without other signs
      2. Re-triage hourly
    3. Minimal
      1. Asymptomatic with exposure
      2. Re-triage every 2 hours
    4. Expectant
      1. Pulmonary edema, cyanosis, or Hypotension
      2. Ominous if onset within 6 hours of exposure
  13. Triage: Patients presenting over 12 hours
    1. Immediate
      1. Pulmonary edema if ICU within hours
    2. Delayed
      1. Re-triage every 2 hours
      2. Discharge if recovering and 24 hours observation
    3. Minimal
      1. Asymptomatic
    4. Expectant
      1. Persistent hypotension despite ICU
  14. Prevention
    1. Activated Charcoal in chemical protective mask
      1. Absorbs phosgene and offers complete protection
  15. Complications
    1. Pulmonary fibrosis
  16. References
    1. 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

Chlorine (C0008209)

Definition (MSH)A greenish-yellow, diatomic gas that is a member of the halogen family of elements. It has the atomic symbol Cl, atomic number 17, and atomic weight 70.906. It is a powerful irritant that can cause fatal pulmonary edema. Chlorine is used in manufacturing, as a reagent in synthetic chemistry, for water purification, and in the production of chlorinated lime, which is used in fabric bleaching.
Definition (NCI)A chemical used to disinfect water and as a bleach.
Definition (CSP)greenish-yellow, diatomic halogen gas element; atomic symbol Cl, atomic number 17, and atomic weight 70.906; a powerful irritant that can cause fatal pulmonary edema.
Definition (NCI)An element with atomic symbol Cl, atomic number 17, and atomic weight 35.05.
ConceptsHazardous or Poisonous Substance (T131) , Element, Ion, or Isotope (T196)
MSHD002713
EnglishChlorine, Chlorine gas, Cl, Cl - Chlorine, Cl element
Spanishcloro, gas de cloro
Parent ConceptsHalogens (C0018544), Gases (C0017110), Elements (C0013879), Chlorine AND/OR chlorine compound (C0302996)
SourcesAOD, CSP, LCH, LNC, MSH, MTH, NCI, SCTSPA, SNOMEDCT, VANDF
Derived from the NIH UMLS (Unified Medical Language System)


Phosgene (C0031591)

Definition (MSH)A highly toxic gas that has been used as a chemical warfare agent. It is an insidious poison as it is not irritating immediately, even when fatal concentrations are inhaled. (From The Merck Index, 11th ed, p7304)
ConceptsOrganic Chemical (T109) , Hazardous or Poisonous Substance (T131)
MSHD010705
EnglishCarbonic dichloride, Carbonyl chloride, Phosgene
Spanishcloruro de carbonilo, dicloruro carbonico, fosgeno
Parent ConceptsKetones (C0022634), Lung irritant chemical warfare agent (C0301227), Chlorine AND/OR chlorine compound (C0302996), Gases (C0017110)
SourcesLNC, MSH, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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