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Content Update: March 2023

The February 3, 2023 crash site of the Norfolk Southern Railway in East Palestine, Ohio, USA, released a number of toxic chemicals. Review of exposure effects from vinyl chloride, butyl acrylate, ethylene glycol, isobutylene, and ethylnexyl acrylate are provided at the end of this chapter, in the section entitled ‘Vinyl Chloride and additional toxic chemicals from railway derailment’.


A hazardous chemical is defined by the U.S. Occupational Safety and Health Administration as any chemical that has been scientifically shown to be a health hazard (causes acute or chronic health effects) or a physical hazard (e.g., combustible liquid, explosive, flammable). The Occupational Safety and Health Administration estimates that there are 575,000 chemicals in the workplace, with 53,000 being potentially hazardous.1 Considering that unplanned exposures and contamination can occur at any time during manufacturing, transport, storage, usage, or disposal of these chemicals, inevitably, emergency physicians can expect to occasionally be responsible for the management and care of a hazardous materials patient (see Chapter 5, “Disaster Preparedness”).2

When managing a patient exposed to an industrial chemical, it is helpful to refer to the Material Safety Data Sheet and adhere to the recommendations regarding decontamination. Although the Material Safety Data Sheet will also include “first aid” recommendations (Table 204-1), the provider should also consult with a medical toxicologist or a regional poison control center to discuss case-specific hazards, optimal treatments, and dispositions. Although many exposures produce immediate effects, some agents may result in delayed onset of symptoms that require at least 24 hours of observation (Table 204-2).

TABLE 204-1Agents Absorbed Through Intact Skin That May Result in Systemic Toxicity*
TABLE 204-2Toxins With Delayed Onset of Symptoms or Requiring Prolonged Monitoring

Children are more sensitive to chemical exposures; higher minute volumes, smaller airway diameters, and lesser ability to clear secretions make them more susceptible to inhaled toxins, and thinner, more permeable skin with a larger body surface-to-mass ratio increases the potential for dermal absorption.3-5 A pregnant woman should be treated as any other adult patient.6


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