Hazardous chemicals are defined as agents capable of causing adverse health effects or physical danger (combustion or explosion) and are summarized in Table 115-1. Useful resources in managing patients exposed to industrial chemicals include material safety data sheets and local poison control centers. Special at risk groups include pregnant women (the medical focus should be on treating the mother first, with early obstetric consultation) and children.
Table 115-1 Common Signs and Symptoms of Exposure to Hazardous Chemicals ||Download (.pdf)
Table 115-1 Common Signs and Symptoms of Exposure to Hazardous Chemicals
- Vinyl chloride
- Nitrogen oxides
- Respiratory distress
- Pulmonary edema
- Hydrogen sulfide
- Carbon monoxide
- Cardiac arrest
- Cyanide kit for cyanides and hydrogen sulfide
- 100% oxygen or hyperbaric oxygenation for carbon monoxide
- Halogenated hydrocarbons
- Aromatic hydrocarbons
- Confusion, lethargy
- Cardiac dysrhythmias
- Respiratory distress
- Symptomatic treatment
- Avoid sympathomimetic agents
Inhaled toxins include gases, dusts, fumes, and aerosols and generally cause acute dyspnea, burning of the mucous membranes, cough, and bronchospasm. Common irritating gases include chorine, ammonia, hydrogen sulfide, and nitrogen dioxide. Some gases, particularly nitrogen dioxide, chlorine, and phosgene, can cause delayed pulmonary edema. Consider systemic toxicity from carbon monoxide and cyanide whenever there is a history of combustion. Some of the more common dangerous inhalations are described in Table 115-2.
Table 115-2 Characteristics of Selected Toxic Industrial Exposures that Cause Dyspnea ||Download (.pdf)
Table 115-2 Characteristics of Selected Toxic Industrial Exposures that Cause Dyspnea
|Agent||Source||Initial Irritation||Clinical Features||Diagnosis|
|Ammonia||Fertilizers, plastics, and explosive industry||High||Immediate mucous membrane burning; potential for pulmonary edema||Pungent odor|
|Chlorine||Paper manufacturing and water treatment||Intermediate||Early upper airway irritation followed by pulmonary edema||Green-yellow gas|
|Nitrogen dioxide||Blast weapon industry and silos||Low||Triphasic: initial dyspnea, improvement, then delayed pulmonary edema||Reddish-brown gas|
|Phosgene||Production of plastics, dyes, and pesticides||Low||Pulmonary edema||Odor of newly mown hay|
Diagnosis and Differential
ED evaluation includes chest radiography and laboratory studies (arterial blood gas, carboxyhemoglobin, methemoglobin, and lactate) in selected cases. The role of early bronchoscopy is controversial.
Emergency Department Care and Disposition
Administer 100% oxygen, usually humidified, along with bronchodilators as needed. Have a low threshold for intubation because of the potential for pulmonary edema.
Prophylactic steroids and antibiotics are generally not indicated, though steroids may be considered for patients with underlying reactive airway disease and may also reduce the risk of delayed pulmonary edema from nitrogen dioxide inhalation.
Cyanide exposure most commonly results from fires that involve synthetic materials, wool, or plastics, but may also be associated with vermicidals, precious metal reclamation, chemical laboratories, and ...