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INTRODUCTION

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There are over 50,000 hazardous chemicals used in various industrial processes throughout the United States. Exposures are inevitable and the emergency physician must be prepared to appropriately care for these patients. Material Safety Data Sheets, regional poison control centers and medical toxicologists are valuable resources for information on specific hazards, optimal management, and patient disposition. Children and pregnant women are patient populations who require special attention, the former due to differences in respiratory, dermatologic, and gastrointestinal physiology and the latter requiring a focus on maternal care in order to optimize fetal well-being.

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RESPIRATORY TOXINS

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Clinical Features

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Phosgene, chlorine, nitrogen dioxide, and ammonia are significant respiratory toxins seen in industrial exposures, and are further described in Table 115-1. Hydrocarbons, cyanide, and carbon monoxide are also inhalational toxins that can have systemic effects.

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Table Graphic Jump Location
Table 115-1

Toxic Industrial Exposures That Cause Respiratory Symptoms

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Diagnosis and Differential

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Examine the upper airway for evidence of singed nasal hair, soot in the oropharynx, facial or oropharyngeal burns, stridor, hoarseness, dysphagia, cough, carbonaceous sputum, tachypnea, retractions, accessory muscle use, wheezing, or cyanosis. Diagnostic workup includes arterial blood gas analysis with carboxyhemoglobin, methemoglobin, serum lactate concentration, chest radiography, electrocardiogram, and cardiac monitoring.

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Emergency Department Care and Disposition

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  1. Give supplemental oxygen for hypoxemia and inhaled bronchodilators for bronchospasm. A low threshold for endotracheal intubation is appropriate in cases of upper airway injury.

  2. Irrigation of the eyes and skin if necessary.

  3. Prophylactic antibiotics and steroids are NOT routinely indicated following toxic gas inhalation, except in cases of nitrogen dioxide exposure, but can be considered in patients with toxin-induced bronchospasm or underlying reactive airway disease.

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PHOSGENE

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Clinical Features

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Phosgene, once used in chemical warfare, is a precursor in the production of plastics, pharmaceuticals, dyes, polyurethane, and pesticides. It is also produced when chlorinated fluorocarbons are heated, a potential danger for those who work in the refrigeration or air-conditioning industries. Initial symptoms ...

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