Medical Management Guidelines for Acute Chemical Exposure


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Medical Management Guidelines for Acute Chemical Exposures

U.S. Department of Human Services, Public Health Service, Agency for Toxic Substance and Disease Registry

Publication date: 08/01/1992

Preface

Introduction

Description Chemical Name (Chemical Formula)
Health Effects
Prehospital Management
Prehospital Management
Emergency Department Management
Emergency Department Management

Protocol for the Unidentified Chemical Contaminant
Unidentified Chemical Prehospital Management
Unidentified Chemical Emergency Department Management

Appendix I AAPCC - Certified Regional Poison Control Centers

Appendix II Association of Occupational and Environmental Clinics

Appendix III Consultation Resources
State/Federal/National Resources
State Health Departments

For Additional Information

POINT OF CONTACT FOR THIS DOCUMENT:

Figures
Organization Of A Hazmat Incident Area
Detail Of Decontamination Zone

Preface

The Agency for Toxic Substances and Disease Registry (ATSDR) is an agency of the federal Public Health Service and part of the U.S. Department of Health and Human Services. ATSDR was created by the U.S. Congress through the Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA). The Agency's responsibilities were markedly increased through the Superfund Amendments and Reauthorization Act of 1986 (SARA). The mission of ATSDR is to prevent or mitigate adverse human health effects and diminished quality of life resulting from exposure to hazardous substances in the environment. Through its legislative authority, ATSDR is mandated to develop informational materials and educational programs that aid healthcare professionals in evaluating symptoms, making diagnoses, providing treatment, and conducting surveillance of human exposure to hazardous substances. Programs formulated in the Division of Health Education are directed primarily toward health professionals and provide guidance on evaluating and treating persons potentially exposed to hazardous substances in the environment. ATSDR also provides emergency response consultation on uncontrolled hazardous chemicals release incidents.

The Medical Management Guidelines for Acute Chemical Exposures (Guidelines) have been developed to aid emergency department physicians and other emergency healthcare professionals who manage acute exposures resulting from chemical incidents. The guidelines in this document are intended to aid healthcare professionals involved in emergency response to effectively decontaminate patients, protect themselves and others from contamination, communicate with other involved personnel, efficiently transport patients to a medical facility, and provide competent medical evaluation and treatment to exposed persons.

The objectives of the Guidelines are to provide the following:

Information on physical and chemical properties and on health effects of chemicals that may be encountered in acute environmental or occupational exposures;
Accurate, concise management information and treatment for patients acutely exposed to environmental toxicants;
Guidelines for effective decontamination of acutely exposed patients, while protecting others from secondary contamination;
Guidelines for patient disposition and follow-up;
Guidelines for reporting that encourage emergency department physicians to consider the patient as a sentinel case of environmentally or occupationally caused disease; and
Information for persons potentially exposed during a hazardous chemical release incident.

Introduction

The Guidelines contains 27 chemical-specific medical management protocols for the treatment of exposed patients. The chemicals were selected using the following criteria: (1) prevalence at hazardous waste sites, (2) ability to cause serious adverse health effects, and (3) frequency of reported deaths, injuries, or transportation accidents. Final selection was made by a peer review committee composed of experts in emergency medicine, toxicology, and occupational and environmental medicine representing academia, industry, and government.

Each chemical protocol is divided into five major sections, which are color-coded for easy identification:

(1) Description (synonyms, appearance, routes of exposure, potential for secondary contamination, physical properties table, sources and uses); (2) Health Effects (organ systems affected by acute exposure, potential sequelae, effects of chronic exposure);

(3) Prehospital Management organized by Hot Zone, Decontamination Zone, and Support Zone (personal protection, decontamination, support, triage, transportation);

(4) Emergency Department Management organized by Decontamination Area and Critical Care Area (specific medical procedures to treat the exposed patient, patient disposition); and

(5) Patient Information Sheet (the exposure and its potential effects, follow-up instructions).

In addition to information on specific chemicals, the Guidelines contains prehospital and hospital management approaches to incidents involving an unidentified hazardous substance. Appendices provide information resources for the emergency department physician seeking consultation in treating a chemically exposed patient, and a glossary supplements the information in the protocols.

To keep the individual protocols brief, we first present annotation and background information for each of the first four sections (descriptive, health effects, prehospital management, and emergency department management) in the same format as that of the individual protocols. You are urged to read the complete introduction before using the protocols in an emergency situation.

The patient information sheet with follow-up instructions is intended to be given to exposed or potentially exposed persons. It contains a description of the chemical, information on immediate and future potential health effects, treatment of acute poisoning, biologic tests to assess exposure, information resources, and follow-up medical instructions. The follow-up instructions alert patients to delayed symptoms that could warrant further medical evaluation. Other patient instructions specific to the exposure are provided by a check-off list that the clinician completes.

Description Chemical Name (Chemical Formula)

CAS Number; UN Number; Synonyms (other names) for the chemical:

Summary of important characteristics such as odor and flammability.
Potential routes of exposure: inhalation, dermal absorption, ingestion.
Potential for secondary contamination.

Description --

This section summarizes the color, odor, and physical state (solid, liquid, or gas) of the chemical at room temperature. Methods of shipment or storage and the physical hazards associated with the chemical also are described.

Warning properties: The odor threshold is the lowest air concentration at which the chemical can be detected by smell. For those chemicals with an odor threshold lower than the toxic air concentration, odor may be a sufficient warning of dangerous exposure conditions. However, if a chemical has no detectable color or odor at toxic concentrations, or it has an odor that is unreliably detected because of olfactory adaptation, or does not cause irritation, it is considered to have inadequate warning properties.

Routes of Exposure --

The most likely route or routes of exposure to the chemical are described-- inhalation, direct contact with the skin or eyes, or ingestion. With each route of exposure, the likelihood of injury depends on the toxicity of the chemical involved, the concentration of the material, and the duration of contact.

Inhalation -

Inhalation is the most common route of exposure to gases and vapors. Liquids and solids also may be inhaled when they are in the form of finely divided mists, aerosols, or dusts. Highly water-soluble gases and vapors and larger mist or dust particles (greater than 10 microns in diameter) generally are deposited in the upper airways. Less soluble gases and vapors and smaller particles can be inhaled more deeply into the respiratory tract. Inhaled substances can be absorbed into systemic circulation, causing toxicity to various organ systems.

Skin/Eye Contact -

Skin and eye contact can occur with solids, liquids, or gases. Corrosive agents can cause direct damage to tissues by various mechanisms including low or high pH, chemical reaction with surface tissue, or removal of normal skin fats (defatting) or of moisture (desiccant effect). Chemicals also can be absorbed systemically through the skin. This is more likely to occur when the normal skin barrier is disrupted (e.g., with a chemical burn or a traumatic injury) or if the chemical is highly fat-soluble (e.g., organophosphate and organochlorine pesticides).

Ingestion -

Ingestion is not a common route of accidental exposure in adults, although it is the most common route in suicide attempts. Ingestion of a corrosive agent can cause severe burns to the mouth, throat, esophagus, and stomach. Chemicals also may be aspirated into the lungs (e.g., liquid hydrocarbons), causing a direct chemical pneumonia. Ingested chemicals are absorbed systemically but also may react with stomach acid, creating products toxic to the healthcare provider, as well as to the patient (e.g., hydrogen cyanide is formed from ingested cyanide salts).

Potential for Secondary Contamination --

Primary contamination occurs by direct exposure in the Hot Zone. Secondary contamination is the transfer of contaminating material from the victim to personnel or equipment in or beyond the Hot Zone. The potential for secondary contamination has implications for decontamination and triage of victims and for the protection of rescue and healthcare personnel.

A substance is likely to pose a risk of secondary contamination if it is both seriously toxic and it is likely to contaminate the clothing, skin, or hair in sufficient quantities to threaten personnel outside the Hot Zone. Every effort must be made to decontaminate victims before they are transferred to the Support Zone or to a medical care facility. Substances that present a serious risk of secondary contamination include the following:

highly toxic liquids and solids or finely divided solids (e.g., organophosphate pesticides)
radioactive liquids and dusts
certain biologic agents (e.g., harmful viruses or bacteria)

Examples of substances with little or no risk of secondary contamination include the following:

gases (e.g., carbon monoxide, arsine)
vapors (unless they condense to a liquid state on clothing or skin)
substances with no serious toxicity or skin absorption (e.g., propylene glycol, motor oil)

Sources/Uses --

This section describes the most common uses of the chemical and how it is manufactured if it is synthetic.

Properties --

A table of properties lists the common physical properties and exposure standards or guidelines that may assist in making emergency decisions.

Standards and Guidelines -

The OSHA permissible exposure limit (PEL) is the time-weighted average (TWA) air concentration of the chemical that must not be exceeded during any 8-hour work shift of a 40-hour workweek. The PEL has little relevance to acute, short-term exposures since an exposure to an air concentration 10 or even 100 times greater than the PEL may be safe for some chemicals but dangerous for others. However, if the measured air concentration at an incident is less than the PEL, the atmosphere is safe for short-term exposure, provided other toxicants are not present. The OSHA ceiling concentration must not be exceeded any time during the workday; if instantaneous monitoring is not feasible, the ceiling must be assessed as a 15-minute TWA exposure. The OSHA short-term exposure limit (STEL) is a 15- minute TWA exposure (unless otherwise noted) that should not be exceeded at any time.

The NIOSH immediately dangerous to life or health (IDLH) level represents the maximum concentration from which, in the event of respirator failure, one could escape within 30 minutes without a respirator and without experiencing any escape-impairing (e.g., severe eye irritation) or irreversible health effects.

The AIHA Emergency Response Planning Guideline (ERPG) values are included in the table whenever they are available. ERPGs are intended to provide estimates of concentration ranges at which adverse effects can be anticipated.

ERPG-I is the maximum airborne concentration below which nearly all persons exposed for up to 1 hour will not experience other than mild transient adverse health effects or will not detect a clearly defined objectionable odor.

ERPG-2 is the maximum airborne concentration below which nearly all persons exposed for up to 1 hour will not experience or develop irreversible or other serious health effects or symptoms that could impair their ability to take protective action. ERPG-2 values are included in these protocols because these values are used by the U.S. Department of Transportation (DOT) to compute the Initial Isolation and Protective Action Distance Tables for chemical incidents (as found in the DOT Emergency Response Guidebook). ERPG-3 is the maximum airborne concentration below which nearly all persons can be exposed for up to 1 hour without experiencing or developing life-threatening health effects.

Physical Properties -

Vapor pressure determines the extent to which a liquid or solid material will produce a vapor (gas). The higher the vapor pressure, the greater the amount of chemical existing in the vapor phase. A vapor pressure over 760 mm Hg, or a boiling point at or below room temperature, indicates that the chemical exists mostly as a gas under normal conditions.

Vapor density compares the weight of the vapor to that of air. A vapor density greater than 1 means that the vapor or gas is heavier than air and will collect in low-lying areas where it may create an oxygen-deficient atmosphere by displacing oxygen-containing air.

Water solubility may suggest the effectiveness of water in decontamination. A material that is poorly water soluble is not likely to be removed effectively from the skin and hair with a plain water wash and may require the use of soaps or other agents for removal.

Flammability and explosivity are important properties in most emergency situations. The temperature and concentration range at which a chemical is flammable and the ability of a vapor or gas to travel to an ignition source and flash back may impact rescue activities. It should be noted that most chemical-resistant protective clothing is neither heat nor flame resistant and may melt if a fire occurs.

Health Effects

Summary of the major acute adverse health effects produced by the chemical. (Effects of acute exposure, by organ system, are explained further in the text. Potential sequelae and effects of chronic exposure also are noted.)

Acute Exposure --

An acute exposure is defined as an exposure to a chemical for a duration of 14 days or less. Although the duration of exposure during an unscheduled chemical release may be brief, the chemical concentration may be high. The onset of health effects resulting from an acute exposure can be immediate or delayed.

Estimating the risk of adverse effects from an exposure is known as health risk assessment. Health risk depends on the intrinsic toxic potential of the chemical, its concentration, the duration of exposure, and the health status of the person exposed. Even very toxic chemicals may not pose a risk of illness if the duration is brief or the concentration of the substance is low. Exposures to high concentration of even mildly toxic substances, however, can be dangerous.

The toxic potential of a chemical can be gauged by measuring the dose that will kill half of a group of test animals and comparing that dose to similar values for other chemicals. When the dose is administered to test animals by ingestion or injection, it is referred to as the lethal dose (LD(50)). The LC(50) refers to the lethal air concentration that is fatal to 50% of the test animals when it is inhaled. The lower the LD(50) or LC(50), the more potent the chemical. Although widely used to describe relative toxicity of chemicals, these numbers have limited clinical relevance. The values apply only to animal species, not humans. Also, they provide no information about doses that might not kill but could cause serious injury to the lungs, kidneys, or other organs.

The lowest concentration of a chemical in air that has been reported to cause death in humans or animals is referred to as LC(Lo). The dose of chemical at which there are no statistically or biologically significant increases in frequency or severity of adverse effects between the exposed population and appropriate controls is the No-Observed-Adverse-Effect Level or NOAEL.

CNS -

The brain is affected by many drugs and chemicals. Depressants (e.g., chloroform, hydrocarbon solvents) cause a generalized decrease in brain activity that may result in headache, dizziness, confusion, lethargy, stupor, or coma. Some early effects of depressants may appear to be stimulatory, producing euphoria and giddiness (similar to beverage alcohol). Severe depression of the brain stem can cause respiratory arrest and cardiovascular collapse.

Central nervous system stimulants (e.g., DDT, other chlorinated hydrocarbon insecticides, organophosphates) can cause agitation, anxiety, delirium, and seizures. Excessive muscular activity associated with seizures can result in hyperthermia.

Respiratory -

Inhalation of a chemical irritant (e.g., ammonia, chlorine) usually causes rapid onset of burning and irritation of the nose, throat, and upper respiratory tract. Painful coughing, wheezing, and stridor may develop. If the exposure is massive, death may rapidly ensue due to upper airway obstruction, massive alveolar destruction, or asphyxiation. Chest radiography may show pulmonary edema when damaged lung cells allow fluid to leak into the alveoli (referred to as noncardiogenic pulmonary edema because it is not caused by left ventricular failure).

The onset and location of respiratory symptoms are related partially to the water solubility of the inhaled chemical. Highly water-soluble gases, such as ammonia, cause rapid onset of symptoms as they dissolve in the moist mucous membranes of the upper airway. However, less soluble gases, such as phosgene, can be breathed deeply into the lower airways and typically cause few or no early symptoms; delayed noncardiogenic pulmonary edema may then occur 12 to 36 hours later.

Injury to the respiratory tract also can occur when the unconscious or convulsing patient vomits and then, because of depressed airway protective reflexes, aspirates gastric contents into the lungs. Pulmonary aspiration of an ingested hydrocarbon can cause a particularly severe pneumonitis due to the irritating action of these chemicals on lung tissue, as well as their propensity to spread over a wide surface area. Pulmonary aspiration sometimes can be prevented by inserting a cuffed endotracheal tube into the airway in patients with depressed mental status or by placing the patient in a head down, left side position and using suction immediately if vomiting occurs.

Cardiovascular -

Adverse cardiovascular conditions (e.g., hypotension, dysrhythmias) often are caused or aggravated by hypoxia resulting from respiratory depression or pulmonary aspiration of gastric contents. In addition, many chemicals may have direct depressant effects on cardiac function or may stimulate the heart, resulting in dysrhythmias. Hypotension also may have a component of volume depletion, resulting from excessive vomiting, diarrhea, or chemical burns.

Certain solvents (e.g., chlorinated hydrocarbons, freons, aromatic hydrocarbons) can cause cardiac dysrhythmias by lowering the myocardial threshold to the dysrhythmogenic effects of catecholamines. For several hours after the exposure, the victim may be susceptible to ventricular dysrhythmias (e.g., premature ventricular contractions, ventricular tachycardia, ventricular fibrillation) caused by endogenous epinephrine or by administered sympathomimetic drugs such as bronchodilators or dopamine.

Renal -

The kidneys can be injured directly by many chemicals. In addition, any poisoning causing massive muscle destruction can lead to kidney injury from excessive myoglobin in the kidney tubules. Arsine-induced hemolysis results in kidney damage from excessive hemoglobin in the kidney tubules.

When kidney damage is suspected, a urinalysis should be performed for proteinuria or to look for abnormal microscopic casts or cells. If a urine dipstick test is positive for hemoglobin but no red blood cells are seen on microscopic examination, excessive serum hemoglobin or myoglobin is suggested.

Serum tests for renal function (e.g., BUN, creatinine) may not become abnormal until several hours to days after chemical exposure.

Dermal -

The skin provides a relatively impermeable protective barrier against excessive fluid losses from the body or inward movement of microorganisms, allergens, and chemicals. Many chemicals disrupt the integrity of the skin by killing cells or removing fats from the skin. The barrier effect also may be lost by thermal burns or traumatic injuries. Disruption of the normal protective barrier can allow easier entry of chemicals into the systemic circulation. In addition, systemic illness can occur even without skin damage because many fat-soluble chemicals (e.g., some organophosphate insecticides) can penetrate intact skin.

The extent and severity of many chemical burns is evident almost immediately (e.g., mineral acids). However, some chemicals cause progressive penetrating injury (alkaline corrosives, hydrofluoric acid), the extent of which may not be apparent for many hours. Dilute hydrofluoric acid solutions (< 20%) cause little pain or swelling during the first several hours after exposure, but damage is occurring nonetheless.

Ocular -

Most serious eye injuries result from direct contact by corrosive liquids or solids. Vapors and gases also may injure the eye if the exposure is highly concentrated or prolonged. Ocular exposure creates the risk of blindness or other visual impairment and demands immediate evaluation and treatment.

Most patients with an eye injury involving the conjunctival or corneal surface experience pain and irritation, excessive lacrimation, and possibly crusting and swelling of the eyelid. Corneal damage almost always causes intense pain and the sensation of a foreign body in the eye.

Although a corneal burn or abrasion may not be visible with the naked eye, it can be seen easily with the aid of fluorescein staining, a UV light source, and a magnifier or slit lamp. The disrupted corneal surface allows accumulation of the fluorescein, which fluoresces under UV light.

Conjunctival irritation and superficial corneal injuries generally improve quickly with symptomatic care such as use of topical antibiotics, analgesics, or mydriatics. If serious injury is suspected (i.e., if there is extensive corneal fluorescein accumulation, cloudy or bloody material in the anterior chamber, or obvious perforation of the globe), an ophthalmologist must be consulted immediately.

Gastrointestinal -

Nausea, vomiting, abdominal pain, and diarrhea are common symptoms after chemical exposure and may be due to direct gastrointestinal irritation or to systemic effects of the poison. Ingestion of some poisons also can cause severe corrosive injury to the mouth, throat, esophagus, and stomach, with bleeding, perforation, or scarring and stricture formation as potential sequelae.

An important consequence of many chemical exposures is acute injury to the liver, which is typically not detected until 2 to 3 days after exposure. Laboratory tests then show elevated hepatic aminotransferase levels (e.g., AST, ALT) and abnormal liver function (e.g., elevated bilirubin, prothrombin time), although many chemical exposures cause only subclinical derangements in these laboratory tests. If present, toxic hepatitis can progress to liver failure, hepatic encephalopathy, and death.

Potential Sequelae -

Known or suspected sequelae, including the prognosis for recovery after an acute exposure, are described in this section.

Chronic Exposure --

Chronic exposure, which refers to repeated exposures over a period of time, often produces health effects that differ in type or degree from effects of acute, short-term exposure. Most information about chronic toxicity comes from epidemiologic studies and case reports resulting from workplace exposures. In some hazardous materials (hazmat) incidences, it may be difficult to classify an exposure as strictly acute or chronic. Health effects typically resulting from occupational exposures are presented in this section.

Two main concerns of patients who have experienced an acute chemical exposure are the risk of cancer and the risk of reproductive or developmental effects. Little or no data are available for most chemicals on carcinogenic or reproductive effects due to acute exposure. However, to provide some guidance to the clinician who must address these patient concerns, we have included the known carcinogenic and reproductive effects due to chronic exposure. The carcinogenic potential of a chemical is included if, at the time of publication, it was described by the International Association for Research on Cancer (IARC), the National Toxicology Program (NTP), or the U.S. Environmental Protection Agency (EPA).

Information about reproductive and developmental effects caused by exposure to specific chemicals was sought from three data files that are included in Tomes Plus, a proprietary database of Micromedex, Inc., Denver, CO: Reprotext, edited by Betty J. Dabney, PhD; the Teratogen Information System (TERIS), developed by the University of Washington; and Shepard's Catalog of Teratogenic Agents, written by Thomas H. Shepard, MD. In addition, the list of 30 chemicals reported by the U.S. General Accounting Office (GAO) as having widely acknowledged reproductive or developmental affects was used as a resource (U.S. General Accounting Office. Reproductive and developmental toxicants, October, 1991. Report no. GAO/PEMD92-3).

The topic of reproductive hazards is controversial and emotionally charged. The potential risk to the fetus creates the possibility that an exposed pregnant woman may consider an abortion. Most obstetricians and pediatricians are not adequately prepared to help the patient make this decision. Expert assistance may be available from regional poison control centers, regional reproductive risk/teratogen information centers, or the Motherisk Program in Toronto, Canada (see Appendices I and III).

Prehospital Management

In the Prehospital Management section we describe the activities that typically occur in the three concentric circular areas surrounding a hazardous materials incident (Figure 1) and (Figure 2), particularly those activities that relate to Emergency Medical Services (EMS) personnel. The information provided is based on the consensus of a panel of experts and is an attempt to offer an accurate and practical approach to management of hazardous materials emergencies. The user of the protocols should be aware, however, that there are large "data gaps" in the scientific literature, especially about clinical signs and symptoms of poisoning and about medical treatment.

Goals of the EMS Hazmat Responder -

Protect yourself. Approach the scene cautiously, arriving upwind. Maintain a safe distance and inspect the scene from a nearby elevated area such as a hill, respect the established exclusion zones, and resist the temptation to rush in to attempt a rescue. Report to the Incident Commander. Maintain a "buddy system," if feasible.
Attempt to identify the chemical product. Become familiar with the DOT placard system, MSDS or shipping papers, and the NFPA hazard labeling system. After identifying the chemical, contact the regional poison control center (see Appendix I) for information about health effects, medical treatment, and decontamination guidelines.
Determine the potential for secondary contamination. Know whether the substance is likely to create a risk to yourself or others in the Support Zone, ambulance, or hospital if decontamination is not completed at the scene.
Be certain that adequate decontamination measures have been performed.
Provide basic and advanced life support (ALS) as required and transport victims to an appropriate medical facility as soon as possible.

Prehospital Management

Summary of the health effects expected from an acute exposure.
Description of patient care (supportive care, antidotes).

Potential for Secondary Contamination--

The route and extent of exposure are important in determining the potential for secondary contamination. Victims who were exposed only to gas or vapors are not likely to carry significant amounts of the chemical beyond the Hot Zone, and so are not likely to pose a risk to personnel outside the Hot Zone. However, victims whose skin or clothing is grossly contaminated with solid or liquid chemical (including condensed vapor) may contaminate personnel by direct contact or by off-gassing vapor. Victims who have ingested a toxic chemical may expose others through vomitus.

Hot Zone --

The Hot Zone includes the area immediately around the chemical spill and the surrounding region that may be in serious danger from physical hazards, such as fire or explosion, or chemical exposure. Generally, only firefighters who are members of a specialized hazmat team will enter the Hot Zone. Although some of these persons may be trained as paramedics, most have only basic EMT training. Rescuers with more advanced medical training will generally be waiting in the Support Zone or the Decontamination Zone.

Rescuer Protection -

When the identity of the chemical is not known, rescuers in the Hot Zone must wear the maximum level of personal protective equipment. A four-stage classification of chemical protective gear has been developed by EPA.

Level A is the highest level of chemical protection. It includes a positive-pressure self-contained breathing apparatus (SCBA) and a fully encapsulating chemical-resistant suit.

Level B includes SCBA, but lesser protection against skin exposure since the suit need not be fully encapsulating.

Level C includes an air-purifying respirator and nonencapsulating chemical- resistant suit, gloves, and boots.

Level D consists of common work clothes that do not provide any specific respiratory or skin protection.

Only rescuers with prior training and fitting should use specialized personal protective gear. The choice of specific brands (e.g., Tyvek, Saranex) or chemical-resistant materials (e.g., butyl rubber) is beyond the scope of this document and is generally the responsibility of an expert on the hazmat team. The expert will also determine whether risks of fire or explosion exist and what additional protective equipment may be required for these possibilities. The EPA classification does not address the use of common fire-fighting ensemble (SCBA with standard "bunker" gear), although this gear may be adequate for many chemical incidents.

ABCs -

This section describes basic airway, breathing, and circulatory support (ABCs). Little patient care can be performed when wearing Level A or Level B protective gear. Rescuers often can perform only simple maneuvers such as ensure a patent airway, apply a cervical collar, brush off gross contaminants, and apply direct pressure to contain arterial bleeding.

Victim Removal -

Victims should be removed from the Hot Zone to the Decontamination or Support Zone, as appropriate, in the safest and quickest way possible. If victims can walk, they can be led out of the Hot Zone to the Decontamination Zone. If they are unable to walk, they can be removed on a backboard, litter, or gurney. If no practical means of transport is available, the victim may be carried or dragged out.

Decontamination Zone --

The Decontamination Zone, which is the corridor between the Hot Zone and the Support Zone, may be set up in any convenient location that is safely beyond the Hot Zone. If possible, this zone should be established outdoors (preferably upwind and uphill from the Hot Zone ) where natural ventilation allows dispersion of off-gassing vapors. Victims exposed to only gas or vapors and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone.

Rescuer Protection -

Personnel in the Decontamination Zone are required to wear protective gear; only personnel with prior fitting and training should be permitted to don respiratory protective gear. Generally, the level of gear is the same as that worn in the Hot Zone or no less protective than one level below this. However, if the risk of inhaling off-gassing vapors is low (i.e., the chemical is not highly volatile or the decontamination area is set up outside with good natural ventilation) it may be acceptable to use an even lower level of protection (e.g., an air-purifying respirator [Level C] instead of Level A).

ABCs -

To provide airway, breathing, and circulatory support for patients in the Decontamination Zone, it may be possible to insert an artificial airway, administer supplemental oxygen or nebulized bronchodilators, and assist ventilation. Direct pressure should be applied to control heavy bleeding.

Rescuers wearing respirators and heavy gloves may find it difficult to insert an intravenous line or perform endotracheal intubation. Electronic equipment such as cardiac monitors generally should not be taken into this area because the equipment may be difficult to decontaminate. Even victims with serious trauma or medical complications (e.g., seizures) may have to wait for advanced medical care until decontamination is completed, depending on the concentration of the chemical and its potential for secondary contamination.

Basic Decontamination -

Consider bagging the victim's jewelry and other valuables separately from clothing for easier retrieval later.

Note: Many chemicals can react violently with water, creating an explosion or liberating toxic gases. When cautions about water reactivity are given, they usually apply to adding water to a large amount of chemical (e.g., using water to fight a fire associated with a spill) and not to flushing victims in the Decontamination Zone whose clothing has been removed and who have very little material left on or around their body. There is little risk of creating a serious reaction hazard by adding large amounts of water to the small amount of residual chemical left on the body. In fact, the naturally occurring moisture on the skin is already reacting with the residual chemical, and hastening removal from the skin is most often preferable to leaving the chemical on the victim.

Skin/Eyes: The length of time for flushing the skin or eyes with water may vary with the chemical and the circumstances of exposure. Concentrated or strongly alkaline materials may require 10 to 15 minutes; chemicals that cause only mild skin or eye irritation can be flushed for a shorter time.

Removal of oily or insoluble materials from the skin and hair requires washing with soap or shampoo. Any liquid hand or dish washing soap will be satisfactory. Use only soft bristled brushes; abrasive brushing may enhance skin injury and penetration.

Decontaminating solutions such as bleach or vinegar should not be used for washing skin and hair. These solutions may be appropriate for equipment, but they are not appropriate for patients.

Ingestion: Inducing vomiting is not generally recommended. Attempting to empty the stomach after a chemical ingestion is relatively ineffective and can be dangerous. Vomiting may increase the damage to the esophagus and stomach if corrosive or very irritating chemicals have been ingested; vomiting also increases the risk of pulmonary aspiration.

Activated charcoal adsorbs many poisons and is relatively easy to administer. Give a slurry of 50 to 60 grams to the patient who is awake and has a gag reflex. However, if a corrosive chemical has been ingested, charcoal may obscure the view when endoscopy is later performed at the hospital to determine the extent of injury.

The patient should be moved to the Support Zone as soon as basic decontamination is completed.

Support Zone --

Because the Support Zone is set up away from the dangers of physical hazards or chemical exposure, contamination is not a serious problem in this area. Generally, personnel in the Support Zone do not require special protective clothing as long as victims have been decontaminated properly. One important exception is exposure to a potent organophosphate pesticide or similar chemical-the Support Zone team should wear disposable aprons or gowns and latex gloves.

ABCs -

In the Support Zone, basic medical care can be administered readily. This care is initially centered on airway, breathing, and circulatory support to the patient.

Advanced Treatment -

More sophisticated medical management also can begin in the Support Zone. Prehospital personnel should contact the regional poison control center (see Appendix I) or the hospital base station for expert advice.

Bronchodilators such as metaproterenol (Alupent or Metaprel) or albuterol (Proventil or Ventolin ) can be administered by metered-dose inhaler, or preferably, by hand-held nebulizer. However, these medications can increase heart rate and may provoke cardiac dysrhythmias in victims exposed to certain chlorinated or aromatic hydrocarbons. When bronchodilators are needed in these cases, the lowest effective dose should be given and cardiac rhythm should be monitored.

Evaluate the patient for possible opioid overdose or hypoglycemia and administer naloxone (or Narcan) and dextrose according to standard ALS protocols. Consider the possibility that coma or seizures may be the result of a head injury rather than due to chemical poisoning.

Administer specific antidotes if they are indicated and within the prehospital scope of practice.

Additional Decontamination -

Exposure to a concentrated or strongly alkaline material may require continued irrigation of eyes and skin during transport and in the hospital. In cases of ingestion, administer a slurry of activated charcoal to the patient if it was not administered earlier and if the patient is alert and has a gag reflex. Additional decontamination recommendations do not imply that the victim poses a risk of secondary contamination.

Transport to Medical Facility -

If decontamination of the patient with skin or eye exposure has been carried out effectively, there is no danger of secondary contamination to ambulance personnel or equipment. However, ingested poisons may create a special hazard in the small, enclosed area of an ambulance. Some chemicals are converted to poisonous gases by the action of stomach acids (e.g., cyanide salts create hydrogen cyanide gas, sodium azide can produce hydrazoic acid gas), and toxic vomitus can contaminate personnel and equipment by direct contact or by off-gassing volatile chemicals. Zipping the patient into a "body bag" to prevent secondary contamination, which is recommended by some texts, provides no protection against toxic vomitus.

If ingestion may have occurred and toxic vomitus is a possible risk, the following should be included in the ambulance equipment:

Plastic trash bags (10 to 20, clear, 3- to 4-mil thick) and plastic sheeting for the floor
Large basin or bucket that can be lined with a trash bag to collect and isolate toxic vomitus
Disposable towels to soak up toxic vomitus

Multi-Casualty Triage --

When exposures to hazardous materials involve several or perhaps hundreds of victims, decisions must be made as to whom to transport and when. Triage attempts to identify victims with the most serious injuries who can benefit most from rapid treatment and transport. It is a complex process based on the chemical's routes of 21 exposure, potential for secondary contamination, acute health effects, warning properties, and potential for delayed onset of toxicity. The Multi-casualty Triage section in each chemical protocol makes some general recommendations for transport based on the chemical; however, you should call the regional poison control center (see Appendix I) for advice about a specific situation.

Emergency Department Management

The management and treatment provided in these protocols is based on the consensus of a panel of experts and is an attempt to offer an accurate and practical approach to patients involved in hazardous materials emergency incidents. The reader should be aware, however, that there are large "data gaps" in the scientific literature, especially in regards to clinical signs and symptoms of poisoning and medical treatment.

Goals of the Hospital Provider in Hazmat Incidents:

To determine the potential for secondary contamination. If there is risk of secondary contamination, to assure that appropriate decontamination measures are carried out at the scene prior to transport.
To quickly move victims without prior decontamination (e.g., "walk-ins") to a predesignated Decontamination Area.
To obtain toxicity information from a reliable resource such as the protocols that follow or a regional poison control center (Appendix I).
To provide emergency supportive care (basic and advanced).
To perform adequate and appropriate laboratory testing.
To determine the need for prolonged observation, hospital admission, and follow-up.

Emergency Department Management

Summary of important health effects expected from an acute exposure.
Description of required patient care (supportive care, antidotes).

Potential for Secondary Contamination -

The risk of secondary contamination may have been reduced or eliminated if the victim has undergone thorough decontamination before arrival at the ED. (See Prehospital Management). The route and extent of exposure are important in determining the potential for secondary contamination. Victims who were exposed to only gas or vapors but have no gross deposition of the material on their clothing or skin are not likely to carry significant amounts of chemical beyond the Hot Zone and are not likely to pose a risk of secondary contamination to other personnel. However, victims whose skin or clothing is soaked with liquid chemical or victims who have condensation of chemical vapor on their clothes or skin may contaminate response personnel by direct contact or by off-gassing vapor. If the victim has ingested a chemical, toxic vomitus may pose a danger to hospital personnel through direct contact or off gassing vapor.

Although basic decontamination should be carried out at the scene before transport, there are circumstances in which this does not occur. For example, a contaminated victim might be brought directly to the emergency department by a coworker. Therefore, it is necessary to plan for the unexpected contaminated victim.

Indoor decontamination facilities:

Indoor facilities create a potentially serious risk of inhalation exposure for hospital personnel, especially if the material is volatile. Typical protocols require shutting off the ventilation system to protect the remainder of the hospital from cross-contamination. However, lack of ventilation may compound the risk to emergency department personnel. Very few hospitals have the financial resources to properly fit or train staff to use self-contained breathing apparatus or air-purifying respirators.

Outdoor Decontamination Facilities:

It is safer and more practical to perform basic decontamination outside in a well-ventilated area adjacent to the ambulance entrance. Suggested equipment and supplies for an outdoor hospital Decontamination Area include the following:

An old gurney with plastic tub or runoff collector. (Several companies make disposable or reusable decontamination tables or foldable rubber tubs that can be placed on top of a gurney.)
A warm water source with a hose and soft stream shower handle
Disposable chemical-resistant jumpsuits (e.g., Tyvek or Saranex)
Several pairs of chemical-resistant gloves (e.g., butyl rubber) in different sizes and rubber aprons
Mild soap and shampoo
Gentle bristled brushes
Splash-protective goggles or other protective eye wear
Inflatable wading pool to catch contaminated water runoff from ambulatory patients
Large supply of plastic garbage bags
Extra oxygen tanks and oxygen delivery supplies
Extra disposable towels and gauze

ABCs -

Priorities of emergency care in the Decontamination Area may change depending on the type and extent of contamination. For example, a victim heavily contaminated with a highly toxic organophosphate insecticide poses a great risk of secondary contamination to health care personnel; touching the patient must be delayed until staff are appropriately gloved and gowned. Similarly, a person soaked with a flammable material cannot be treated with DC countershock until decontamination has been carried out because of the fire and explosion hazard.

Basic Decontamination -

Consider bagging the patient's jewelry and other valuables separately for easier retrieval later.

Note: Many chemicals can react violently with water, creating an explosion or liberating toxic gases. When cautions about water reactivity are given, they generally apply to adding water to a large amount of chemical (e.g., fighting a fire associated with a chemical spill) and so not apply to flushing victims in the Decontamination Area whose contaminated clothing has been removed and who have very little of the material left on or around their body. There is little risk of creating a serious reaction hazard by adding large amounts of water to the small amount of residual chemical left on the body. In fact, the naturally occurring moisture on the skin is already reacting with the residual chemical; hastening removal from the skin is most often preferable to leaving the chemical on the patient.

The length of time for flushing the skin or eyes may vary with the chemical and the circumstances of exposure. Concentrated or strongly alkaline materials may require 10 to 15 minutes; vapor exposure with only mild skin or eye irritation may require flushing for a shorter time.

Removal of oily or insoluble materials from the skin and hair requires washing with soap or shampoo. Any liquid hand or dish washing soap is satisfactory. Use only soft bristled brushes; abrasive brushes may enhance skin penetration and injury.

If the chemical is an acid or alkali, frequently check the pH of the conjunctival sac and continue irrigating the eye until the pH is 7 to 7.5.

Critical Care Area -

If appropriate decontamination efforts have been completed before entry to the Critical Care Area, there should be no need for special equipment or precautions such as covering floors and walls with plastic or shutting off the ventilation system. However, if the patient has ingested a chemical, prepare to isolate toxic vomitus quickly (see Ingestion Exposure below).

ED staff in the Critical Care Area should not need specialized protective gear. Water-resistant gowns or, aprons, latex gloves, and eye splash protection are prudent only if there is risk of residual skin contamination from a potent chemical, such as a potent organophosphate pesticide, or from radioactive dust.

ABCs -

Perform frequent monitoring of the airway and vital signs. Many chemicals can cause progressive airway injury or systemic illness with respiratory compromise several minutes to hours after the original exposure. Watch for signs of laryngeal edema and respiratory system compromise such as progressive hoarseness, stridor, hypoventilation, or cyanosis.

Consider the possibility of exposure to multiple chemicals or of multiple system injuries. For example, smoke inhalation can cause immediate dramatic airway injury due to heat and irritant chemicals, as well as coma from inhaled systemic asphyxiants such as carbon monoxide and cyanide.

Evaluate for possible opioid overdose or hypoglycemia and administer naloxone (or Narcan) and dextrose according to usual protocols. Treat seizures with usual anticonvulsants (e.g., diazepam, phenytoin, phenobarbital). Consider the possibility that coma or seizures may be from a head injury or from alcohol or other drug intoxication, rather than from chemical poisoning.

Treat hypotension with rapid infusions of normal saline of 250 mL up to 2 liters in adults. Use dopamine or other inotropic drugs for persistent hypotension. Persistent hypotension may be caused by hypothermia or hyperthermia, both of which can be complications of chemical exposures. Hypothermia should be considered if the victim was stripped and decontaminated with cold water or in a cold ambient setting. Hyperthermia can be a result of certain systemic poisons (e.g., dinitrophenol). (Depending on ambient temperature, hypothermia and hyperthermia can occur in rescuers from wearing Level A or B encapsulating chemical suits.)

Ventricular dysrhythmias after exposure to solvents, most commonly chlorinated, fluorinated, or aromatic solvents, may be caused by a reduction of the myocardial threshold for the dysrhythmogenic effects of catecholamines. These dysrhythmias may respond more favorably to beta- blockers (e.g., esmolol, propranolol) than to lidocaine and other traditional antidysrhythmic drugs. Dysrhythmias occurring after exposure to hydrogen fluoride or hydrofluoric acid may be caused by hypocalcemia and should be treated with intravenous calcium.

Inhalation Exposure -

Bronchodilators may provoke ventricular dysrhythmias in some patients with exposure to certain types of hydrocarbons.

Although pulse oximetry (to measure arterial blood gases) is a convenient way to monitor oxygenation in patients continuously, it is unreliable or falsely normal in patients with dyshemoglobinemias (e.g., methemoglobinemia or carboxyhemoglobinemia) because it measures only O(2) dissolved in the blood and not the status of tissue oxygenation. In patients with altered hemoglobins, the 0(2) dissolved in the blood may be adequate but the 0(2) cannot be taken up by the tissues. In these situations, specific levels of hemoglobins unable to transport O(2) must be obtained using a Co-Oximeter.

Chemically induced pulmonary edema is not due to left ventricular failure as is cardiogenic pulmonary edema but due to leaky pulmonary alveoli. Patients with noncardiogenic edema do not benefit from digoxin, morphine, afterload reduction, or diuretics. Supplementary oxygen, delivered by mechanical ventilation and positive end expiratory pressure, if needed, are the standards of treatment for noncardiogenic edema.

Corticosteroids and antibiotics have been recommended commonly for treatment of chemical pneumonitis, but there is little evidence that they are of special benefit.

Hazardous agents commonly associated with delayed onset pulmonary edema (e.g., phosgene and nitrogen oxides, such as nitric oxide and nitrogen dioxide) are poorly soluble in water. Unlike soluble irritants, such as ammonia or hydrogen chloride, which act rapidly, poorly soluble irritants produce slow onset of airway irritation or respiratory distress. Thus, patients exposed to poorly soluble irritants may not develop pulmonary edema until 12 to 72 hours later.

Skin Exposure -

Chemical burns have characteristics that are different from thermal burns. The extent and depth of injury in a chemical burn often is not apparent immediately; severity is frequently underestimated. Circulating fluid loss can occur as with thermal burns. In addition, absorption of a corrosive chemical may cause acute or delayed systemic toxicity.

Patients with exposure to a highly corrosive, penetrating, oily or persistent chemical may require additional decontamination to prevent further injury and systemic absorption. Common sites of residual contamination include the armpits, groin, buttocks, hair, ears, nostrils, and under the fingernails and toenails. Usually, these patients do not pose a risk of secondary contamination if they have undergone the basic decontamination, but if the material is highly contaminating (e.g., organophosphate pesticides, radioactive dust), caregivers should wear gowns and gloves to protect themselves.

Use plain liquid soap or shampoo for cleansing the skin. For a few chemicals, special solutions are recommended for skin decontamination (see specific protocols).

Eye Exposure -

Be sure that contact lenses have been removed, that there is no visible residual material in the conjunctival sac, and that the Ph of the tears is normal.

Ingestion Exposure -

Ingested chemicals and the reaction products resulting from their contact with stomach acid may be hazardous to ED personnel through direct contact with vomitus or by inhalation of toxic liberated gases. For example, ingested cyanide is convened to highly toxic hydrogen cyanide gas in the stomach. Staff must take measures, therefore, to isolate toxic vomitus or gastric washings. This can be done by attaching the lavage tube to isolated wall suction or another closed container.

The use of gastric lavage for ingested corrosive materials is controversial. Opponents argue that the lavage tube may further injure the chemically damaged esophagus or stomach. However, endoscopists point out that blind gastric tube placement and stomach emptying is routinely done prior to endoscopy in any case, and that it is better to remove the corrosive liquid from the stomach as early as possible. Dilution with a glass of water is an alternative, but it is not as effective as lavage.

Activated charcoal is capable of adsorbing most poisons and should be given as early as possible. Even poisons that have relatively poor adsorption to charcoal (e.g., cyanide, alcohols) are still bound to a limited extent, and charcoal may be lifesaving in patients exposed to these substances. Note that charcoal may obscure the endoscopist's view and may have to be washed out before endoscopy.

Antidotes and Other Treatments -

There are very few established antidotes for poisoning. Contact the regional poison control center (Appendix I) for advice if the specific chemical agent is known.

Laboratory Tests -

Laboratory results may be normal immediately after the exposure. Abnormal findings are often delayed for several hours or even days, depending on the specific chemical exposure. For example, chest radiography may not show signs of pulmonary edema until 12 to 24 hours after phosgene exposure. Signs of liver injury may not appear until 2 to 3 days after exposure to hepatotoxic agents.

Note that pulse oximetry and routine tests for serial blood gases may provide falsely normal, unreliable, or misleading results in patients with abnormal hemoglobin states (e.g.,methemoglobinemia, carboxyhemoglobinemia).

A regional poison control center (Appendix I) can assist with the selection and interpretation of routine and specialized toxicologic laboratory tests. Blood or urine tests for a specific chemical are Disposition and Follow-up Delayed Effects Patient Release Follow-up Reporting rarely available on an emergency basis; frequently the turn-around time is several hours to days. However, these tests may aid in confirming or documenting an exposure.

Disposition and Follow-up --
Delayed Effects -

The usual duration of observation in an emergency department is 6 to 8 hours. If the chemical agent is unidentified or is known to produce delayed onset illness, the asymptomatic patient who has a suspected serious exposure should be admitted.

Patient Release -

The individual protocols include a detailed Patient Information Sheet with a list of symptoms for patients to watch for after discharge.

Follow-up -

Appendix III contains the phone numbers and addresses of member clinics of the Association of Occupational and Environmental Clinics (AOEC). These clinics employ specialists in diagnosing and treating occupational and environmental chemical exposure. They may provide consultation and patient follow-up.

Reporting --

Some state or local governments may require the physician to file a report after treating a patient for a specific chemical exposure or a worker for an occupational exposure. Appendix III contains the phone numbers of the state health departments. The patient may wish to call the regional office OSHA office to report a suspected violation of safe work practices. Appendix III also contains the number of the several NIOSH offices that may be of assistance.

To determine procedures for clean-up of hospital facilities and equipment, contact the local or state health department or EPA's Environmental Response Team, Edison, New Jersey ([201] 321-6660).

Do not release clothing or personal items to the patient before a determination is made regarding the hazard of residual contamination. Most items may be reused after washing (e.g.,cloth clothing contaminated with hydrofluoric acid). However, some chemically contaminated articles cannot be rendered safe for reuse (e.g.,leather goods such as shoes that are contaminated with certain pesticides). Some contaminated articles will require disposal by incineration or at a hazardous waste site. Consult a hazmat specialist attached to the local fire department or the ATSDR Division of Health Assessment and Consultation or advice on the disposition of contaminated personal effects.

Protocol for the Unidentified Chemical Contaminant

Because thousands of chemicals are manufactured, used, and transported in the United States, the number of accidents involving chemical exposures is increasing. Although most of these accidents occur at fixed facilities where the chemical hazards are known, emergency medical personnel are increasingly more likely to be involved in incidents in which victims have been exposed to an unknown or incorrectly identified chemical hazard. Emergency medical technicians, therefore, must learn to deal with presenting symptoms and provide basic supportive medical care for complications (respiratory, cardiovascular, and neurologic) that are most likely to cause a serious threat to life.

Unidentified Chemical Prehospital Management

Potential for Secondary Contamination. The route and extent of exposure are important in determining the potential for secondary contamination. Victims who were exposed to only gas or vapor but have no gross deposition of the material on their clothing or skin are not likely to carry significant amounts of chemical beyond the Hot Zone and are not likely to pose a risk of secondary contamination to other personnel. However, victims whose skin or clothing is soaked with liquid chemical or victims who have condensation of chemical vapor on their clothes or skin may contaminate others by direct contact or by off-gassing vapor. If the victim has ingested a chemical, toxic vomitus may pose a danger to others through direct contact or off-gassing vapor.

Hot Zone --

Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA) and chemical-resistant protective clothing and gloves (EPA Level A protection or NFPA vapor-protective gear).

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. Injured persons who are unable to walk should be removed on a backboard or gurney. If there is no means of transport, carefully carry or drag the victim out; be aware that the victim may have sustained head and neck injuries, as well as a chemical exposure.

Decontamination Zone --

Victims with exposure to only vapors and with no evidence of skin or eye contamination or irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves (EPA Level B or NFPA splash-protective) if they will be caring for victims with liquid chemical contamination. If the proper equipment is not available or if rescue personnel have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organizations. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Basic Decontamination -

If the clothing is wet with liquid chemical contamination, remove and double-bag the clothing. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Skin Contact: Flush exposed skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent chemicals, use mild soap or shampoo.

Eye Contact: Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present. Look for and remove any residual chemical material in the conjunctival sacs.

Ingestion: If the victim has ingested a liquid or solid chemical, have him or her drink a glass of plain water. Do not induce vomiting. Administer charcoal orally (50 to 60 g of activated charcoal in a water slurry).

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Be certain that victims who require basic decontamination, have undergone it (see Decontamination Zone above). Victims who have been decontaminated or those with exposure to only gas or vapor with no evidence of wet skin or clothing generally pose no serious risk of secondary contamination.

ABCs -

Advanced Treatment -
Intubate the trachea if indicated.

Treat wheezing with aerosolized bronchodilators; use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias after exposure to certain chemicals.

Treat coma and ventricular dysrhythmias according to standard ALS protocol.

Additional Decontamination -

If skin or eyes remain irritated, continue irrigation until irritation is resolved or the victim is transported.

If the victim has ingested a liquid or solid chemical, insure that decontamination has occurred.

Transport to Medical Facility -

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If the victim ingested a chemical, prepare the ambulance for possible vomiting of toxic material. Cover the floor of the ambulance with plastic or other protective material, and have ready several absorbent towels and opened plastic bags to quickly soak up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

In general, patients with brief exposure to only vapors and without acute symptoms (e.g., dizziness, respiratory distress) can be observed without immediate treatment.

Unidentified Chemical Emergency Department Management

Potential for Secondary Contamination. Victims who were exposed to only gas or vapor but have no gross deposition of the material on their clothing or skin are not likely to carry significant amounts of chemical beyond the Hot Zone and are not likely to pose a risk of secondary contamination to other personnel. However, victims whose skin or clothing are covered with liquid or solid chemical or victims who have condensation of chemical vapor on their clothes or skin may contaminate hospital personnel and the ED by direct contact or by off-gassing vapor. If the victim has ingested a chemical, toxic vomitus also may pose a danger through direct contact or off-gassing vapor.

Decontamination Area --

Patients with exposure to only gas or vapors and with no evidence of skin or eye irritation or contamination do not need decontamination. They may be transferred immediately to the Critical Care Area. Other victims will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Treat wheezing and bronchospasm with aerosolized bronchodilators if needed.

Treat coma, seizures, hypotension, and ventricular dysrhythmias in the conventional manner.

Basic Decontamination -

If the patient has not been decontaminated, perform basic decontamination immediately. Emergency department staff should don chemical-resistant jumpsuits ( e.g., Tyvek, Seranex ) or butyl rubber aprons, rubber gloves, and eye splash protection. After the patient has been decontaminated, no special protective clothing or equipment is needed for ED personnel.

If the clothing is wet with liquid contamination, remove and double-bag it. Patients who are able and cooperative may remove their own contaminated clothing and assist with basic decontamination.

Skin Contact: Flush exposed skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent materials, use mild soap or shampoo.

Eye Contact: Remove contact lenses and irrigate exposed eyes with water or saline dripped from intravenous tubing or using a Morgan lens. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids. Look for and remove any residual chemical material in the conjunctival sacs. Check conjunctival pH with test paper and continue irrigating until the pH is 7 to 7.5..

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Decontamination Area above.

ABCs -

Evaluate and support airway, breathing, and circulation. Intubate the trachea if indicated. Continuously monitor cardiac rhythm.

Assess and treat hypotension, coma, seizures, and ventricular dysrhythmias in the conventional manner.

For all patients who are unconscious, obtunded, hypotensive, or who may become so, or who have been exposed to a substance that may cause cardiac sensitization or intravascular hemolysis, an intravenous line should be placed as soon as possible. An initial bolus of normal saline or D5 normal saline should be given as appropriate for age, typically 500 mL to 1000 mL in an adult. The fluid should be titrated to maintain urine output and blood

pressure at acceptable levels for age. However, because inhalation injuries may result in the development of pulmonary edema, care must be taken not to overhydrate the patient.

Inhalation Exposure -

Administer supplemental oxygen. Treat wheezing with aerosolized bronchodilators (e.g., metaproterenol or albuterol). Obtain a chest radiograph and measure arterial blood gases.

Observe patients for at least 4 to 6 hours. If there are progressive symptoms or if the chemical agent is suspected of causing delayed pulmonary edema, admit the patient for treatment or further observation.

Skin Exposure -

Ensure that adequate decontamination has been performed. Admit patients with serious chemical burns to a burn center or refer to a qualified burn specialist.

Eye Exposure-

Ensure that adequate eye irrigation has been completed. Test visual acuity and examine the eyes using a magnifying device or a slit lamp and fluorescein staining to evaluate corneal injury. Small corneal defects may be treated with topical ophthalmic antibiotic ointment or drops of a mydriatic agent, an eye patch, and oral analgesic medication. Have the patient return within 24 hours for evaluation. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion Exposure -

Do not induce emesis. Perform gastric lavage using a small flexible tube to remove and dilute the material in the stomach, then administer 50 to 100 g activated charcoal via the gastric tube. If a corrosive material was ingested, consider endoscopy to evaluate the extent of gastrointestinal tract injury.

Antidotes and Other Treatments -

There are very few established antidotes or specific treatments for chemical poisonings. Contact the regional poison control center for advice if the specific chemical agent is known.

Laboratory Tests -

Depending on the chemical exposure and the patient's symptoms and signs of toxicity, useful routine tests include CBC, glucose, electrolytes, renal function tests, liver enzymes, urinalysis, and ECG. Chest radiographs and measurements of arterial blood gases are recommended for severe inhalation exposure. Occasionally, a specific blood or urine toxicologic test may be indicated.

Disposition and Follow-up --

Hospitalization should be considered for all patients with a suspected serious exposure and those with persistent or progressive symptoms.

Delayed Effects -

If there is a possibility of delayed onset of serious effects, the patient should be observed for an extended period or admitted. Consult the specific protocols for possible delayed effects.

Patient Release -

Asymptomatic patients with minimal exposure, a normal initial examination, and no signs of toxicity after a period of observation may be discharged with instructions to seek medical care promptly if symptoms develop. These symptoms are listed in the patient follow-up instructions on the Patient Information Sheet that accompanies each chemical protocol.

For all acute inhalation injuries, and all ingestion injuries where there is a possibility of chemical pneumonitis, patients should be advised to refrain from smoking for up to 72 hours after exposure.

Follow-up -

Provide follow-up instructions to return to the emergency department or a private physician as needed for additional testing or to reevaluate initial findings.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Health Hazard Evaluation Division of NIOSH. Consult the appendices for agencies that may be of assistance.

Chemical Protocols

Ammonia NH(3)

CAS: 7664-41-7: UN 2672 (between 12% and 44% solution); 2073 (>44% solution); 1005 (anhydrous gas or > 50% solution)

Synonyms include ammonia gas, anhydrous ammonia, liquid ammonia, aqueous ammonia, ammonia solution and ammonium hydroxide.

Victims exposed to only ammonia gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid ammonium hydroxide can secondarily contaminate response personnel by direct contact or through off-gassing ammonia vapor.
Ammonia is a gas that dissolves readily in moisture to form an alkaline, corrosive solution. It can result in fatalities if inhaled.
Ammonia's pungent odor and irritating properties usually provide adequate warning of its presence; however, olfactory fatigue may occur.

Description --

At room temperature, anhydrous ammonia is a colorless, highly irritating gas with a pungent, suffocating odor. It is lighter than air and flammable at high concentrations and temperatures. It is easily compressed and forms a clear, colorless liquid under pressure. Ammonia dissolves readily in water to form ammonium hydroxide--an alkaline, corrosive solution. The concentration of aqueous ammonia solutions for household use is typically 5% to 10%, but solutions for commercial use may be 25% to 30% or more.

Routes of Exposure --

Inhalation -

Exposure to ammonia may be fatal if it is inhaled. Ammonia's odor threshold is sufficiently low to provide adequate warning of its presence; however, olfactory fatigue or adaptation can occur, making its presence less detectable.

Skin/Eye Contact -

Even fairly low airborne concentrations of ammonia produce rapid eye and nose irritation. Contact with concentrated ammonia solutions, such as some industrial cleaners, can cause serious corrosive injury. Contact with liquefied ammonia may cause frostbite.

Ingestion -

Ingestion of ammonia solution occurs occasionally.

Sources/Uses --

Ammonia is manufactured by reacting hydrogen with nitrogen. It is among the five most abundantly produced chemicals in the world. About 80% is used in fertilizers; it also is used as a refrigerant gas, and in the manufacture of plastics, explosives, pesticides, detergents, and other chemicals. Small amounts of ammonia occur naturally from decomposition of organic matter.

Properties of Ammonia --

Appearance: Clear, colorless gas at room conditions; easily liquefied; readily dissolves in water to form caustic solutions.

Warning properties: Sharp, pungent odor at = 5 ppm; eye and throat irritation at = 20 to 50 ppm

OSHA STEL (Short Term Exposure Limit) = 35 ppm

NIOSH IDLH (Immediately dangerous to life or health ) = 500 ppm

Molecular weight = 17.0

Boiling point (760 mm Hg) = -28 degrees (F), -33.4 degrees (C)

Vapor pressure 67.1 degrees (F) = > 6000 mm Hg

Vapor density = 0.59 (air = 1)

Water soluble (34 g/100 mL)

May burn, but does not ignite readily

Health Effects

Ammonia vapor is highly irritating to the eyes and upper respiratory tract. Upper airway obstruction, bronchospasm, and noncardiogenic pulmonary edema may occur.
If skin contact is prolonged (more than a few minutes), ammonia causes severe burning pain and corrosive injury.

Acute Exposure --

Ammonia gas dissolves in moisture to produce an alkaline solution. Exposure to ammonia gas or an aqueous solution of ammonia can result in corrosive injury to the eyes, skin, or gastrointestinal tract.

Respiratory -

Even fairly low concentrations of ammonia produce rapid onset of eye, nose, and throat irritation; coughing; and bronchospasm. More severe clinical signs include immediate laryngospasm and laryngeal edema resulting in upper airway obstruction. Pulmonary edema can occur.

Dermal -

Dilute aqueous solutions (less than 5%) rarely cause serious burns but are moderately irritating. Exposure to concentrated vapor or solution can cause stinging pain, erythema, and vesiculation, especially on moist skin areas. Skin contact with compressed, liquid ammonia causes frostbite injury; severe burns with deep ulcerations may result.

Ocular -

Even low concentrations of ammonia produce rapid onset of eye irritation. Contact with high gas concentrations or with concentrated ammonium hydroxide may cause conjunctival edema and corneal erosion.

Gastrointestinal -

Swallowing ammonium hydroxide causes immediate burning in the mouth and throat. Concentrated solutions cause severe pain in the mouth, chest, and abdomen with swallowing difficulty, drooling, and vomiting. Perforation of the esophagus or stomach may occur.

Potential Sequelae -

Survivors of severe inhalation injury often suffer residual chronic lung disease. In cases of eye contact, ulceration and perforation of the cornea can occur after weeks or months, and blindness may ensue. Cataracts and glaucoma have been reported in persons acutely exposed.

Chronic Exposure --

Repeated exposure to ammonia may cause chronic irritation of the respiratory tract. Chronic bronchitis and airway hyperactivity have been noted in several case reports. Chronic irritation of the conjunctiva also has been reported.

Ammonia is not considered to be carcinogenic. At doses that do not cause maternal toxicity, ammonia is not likely to have adverse reproductive and developmental effects. If maternal pulmonary function becomes severely compromised because of irritation or corrosion, there is a possibility of nonspecific effects on the unborn.

Prehospital Management

Ammonia muses rapid onset of a burning sensation in the eyes, nose, and throat, accompanied by lacrimation, rhinorrhea, and coughing. Upper airway swelling may lead to airway obstruction.
Ammonia gas or solution can cause serious corrosive burns on contact.
There is no specific antidote for ammonia poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination. Victims exposed to only ammonia gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid ammonium hydroxide can secondarily contaminate response personnel by direct contact or through off-gassing ammonia vapor.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with anhydrous ammonia gas or concentrated ammonium hydroxide is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. If a victim is unable to walk, remove him or her on a backboard or gurney. If there is no means of transport, carefully drag the victim out.

Decontamination Zone --

Victims with exposure to only ammonia gas and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with ammonia-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway in the patient. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen

if available. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Basic Decontamination -

Rapid skin decontamination qs critical. Remove and double-bag contaminated clothing while flushing exposed areas. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Flush liquid-exposed skin and hair with plain water for at least 5 minutes.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of ammonia ingestion, do not induce emesis. If the patient is conscious and able to swallow, administer 1 to 2 glasses of plain water to dilute stomach contents.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Be certain that patients have undergone basic decontamination (see Decontamination Zone above). Patients who have undergone proper decontamination or have been exposed to only vapor pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Watch for signs of laryngeal edema and airway compromise such as progressive hoarseness, stridor, or cyanosis. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device as needed. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment -

Intubate the trachea if necessary (severe respiratory distress or coma). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so.

Treat hypotension and seizures in the conventional manner. Treat bronchospasm with aerosolized bronchodilators.

Additional Decontamination -

If skin or eyes remain irritated, continue flushing with plain water or saline until pain is relieved or definitive medical treatment is obtained. Remove contact lenses if present.

In case of ammonia ingestion, do not induce emesis. If the patient is alert and able to swallow, administer 1 or 2 glasses of water to dilute stomach contents. Charcoal is ineffective.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested ammonium hydroxide, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

The following persons exposed to ammonia should be evaluated at a medical facility: those with persistent upper respiratory irritation or other acute symptoms of severe inhalation exposure, persons with eye or skin burns that cover a large surface area, and persons who have ingested ammonia. Persons who have been exposed to only ammonia gas and are currently asymptomatic are not likely to develop complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with follow-up instructions. (See Ammonia Patient Information Sheet.)

Emergency Department Management

Inhaling ammonia causes rapid onset of a burning sensation in the eyes, nose, and throat, accompanied by lacrimation, rhinorrhea, and coughing. Upper airway swelling may lead to airway obstruction.
Ammonia gas or solution can cause serious corrosive burns on contact.
There is no antidote for ammonia poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination. Hospital personnel in an enclosed area can be secondarily contaminated by vapor off-gassing from heavily soaked clothing. Patients do not pose a contamination risk after contaminated clothing is removed and the skin and hair is washed.

Decontamination Area --

Patients exposed to only ammonia gas and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require rapid decontamination as described in Basic Decontamination below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of laryngeal edema and airway compromise. Monitor cardiac rhythm.

Treat seizures in the conventional manner. Manage hypotension and shock with IV fluids; pressor agents may be required.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapor do not require decontamination unless they have skin or eye irritation.

Since contacting clothing or skin wet with ammonium hydroxide may cause burns, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek*, Saranex*) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with ammonia solution, quickly remove and double-bag the contaminated clothing and all personal belongings while cleansing the skin. A water wash using copious water (preferably under a shower) should be instituted without delay.

Remove contact lenses and irrigate exposed eyes with water for at least 15 to 30 minutes. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids.

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Basic Decontamination above.

ABCs -

Evaluate and support airway, breathing, and circulation as above. Continuously monitor cardiac rhythm.

Assess and treat hypotension, seizures, and ventricular dyshythmias in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, and drug intoxication).

Inhalation Exposure -

Observe patients carefully for 6 to 12 hours for signs of upper airway obstruction. Administer supplemental oxygen by mask to patients with respiratory complaints. Patients who have received severe exposure may develop noncardiogenic pulmonary edema.

Skin Exposure -

If ammonia solution or ammonia gas was in contact with the skin, chemical burns may result.

Eye Exposure -

If eye irritation or injury is evident, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. Small corneal defects may be treated with topical ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion -

Give water or milk by mouth to dilute stomach contents. Do not induce emesis because the patient is at risk of abrupt seizures or coma. Do not administer activated charcoal. Gastric lavage with a small nasogastric tube is recommended to remove caustic material from the stomach and to prepare for endoscopic examination.

Antidotes and Other Treatments -

There is no specific antidote for ammonia poisoning. Although administration of corticosteroids is favored by many toxicologists in an attempt to limit esophageal scarring, this treatment is unproven and may be harmful in patents with perforation or serious infection. Hemodialysis is ineffective.

Laboratory Tests -

Chest radiography and ABGs are recommended for severe inhalation exposure or if pulmonary aspiration is suspected. There are no blood levels specific for ammonia exposure that indicate degree of ammonia toxicity.

Disposition and Follow-up --

Consider hospitalization for patients with evidence of respiratory distress or significant skin burns or who have ingested ammonia solution.

Delayed Effects -

Pulmonary injury may continue to evolve over 18 to 24 hours. Inhalation patients who are initially symptomatic should be observed carefully and reexamined periodically. Patients who develop pulmonary edema should be admitted to an intensive care Unit.

Patient Release -

Patients who are currently asymptomatic are not likely to develop complications. They may be released and advised to rest and to seek medical care promptly if symptoms develop. (For a list of symptoms, see the reverse side of Ammonia Patient Information Sheet.)

Follow-up -

Patients whose eyes have contacted ammonia but who have no signs of irritation after treatment may be released. Patients with eye injury should be reevaluated in 24 hours by an ophthalmologist.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other people may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH.

Ammonia Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to ammonia gas or ammonium hydroxide solution.

What is ammonia?

Ammonia is a colorless, highly irritating gas with a sharp, suffocating odor. It easily dissolves in water to form a caustic solution called ammonium hydroxide. Ammonia is among the five most abundantly produced chemicals in the world. About 80% of the ammonia produced is used in fertilizers. It is also used as a refrigerant and in the manufacture of plastics, explosives, pesticides, and other chemicals. It is found in many household and industrial-strength cleaning solutions.

What immediate health effects may result from ammonia exposure? Most exposures to ammonia are by breathing the gas. Even with very short or low-level exposures, most people will notice the pungent odor and experience burning of the eyes, nose, and throat. With higher doses, coughing or choking may occur. Severe exposure can cause death from throat swelling or from chemical burns to the lungs. Skin contact with ammonia containing liquids may cause burns. Contact with rapidly escaping ammonia gas from a leaking pressurized cylinder can cause frostbite injury. Eye exposure to concentrated gas or liquid can cause serious corneal burns or blindness. Drinking a concentrated ammonia solution can cause burns to the mouth, throat, and stomach.

What is the treatment for ammonia poisoning?

There is no antidote for ammonia poisoning, but its effects can be treated and most people do recover fully. Persons who have experienced serious signs and symptoms (such as severe or persistent coughing, tearing eyes or running nose) may require close medical observation for several hours.

Are any future health effects likely to occur?

After a single, short exposure with rapid recovery, no delayed or long-term effects are likely to occur. After a severe exposure, symptoms may progress over 18 hours. Following is a list of some signs and symptoms to watch for. If any of them occur, seek medical care.

What tests can be done if a person has been exposed to ammonia? There are no specific blood and urine tests that can indicate recent exposure to ammonia. Generally, the severity of burns is the best indicator of the seriousness of the exposure. Blood tests and a chest X ray may be done to evaluate possible lung injury, but testing is not needed in every case.

If ammonia contacts the eyes, the doctor may put an orange dye in the eyes and examine them with a magnifying lamp.

Where can more information about ammonia be found?

More information about ammonia may be obtained from your regional poison control center,, your state, county, or local health department; or your doctor. If the exposure happened at work, talking with your employer and coworkers may help prevent future exposures.

Ammonia Follow-up Instructions -

Please follow the instructions indicated below by the doctor.

( ) Call your doctor or the Emergency Department if you develop any of the
following signs or symptoms within the next 24 hours:

  * cough
  * difficulty breathing or shortness of breath
  * wheezing or high-pitched voice
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn
  * belly pain, vomiting, diarrhea

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr.____________ in the practice of
_________. When you call for your appointment, please tell the
receptionist/nurse that you were treated in the Emergency Department at
_________ Hospital by ________ and were advised to be seen again in ___ days.

( ) Return to the Emergency Department/___________Clinic on_______ (date)
at_____AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for 1 to 2 days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for ___ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________
_______________________________________________________________________ 

( )
Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient___________________________ Date______________________

Signature of physician_________________________ Date______________________

Arsine AsHJ(3)

CAS 7784.2-1; UN 2188,

Synonyms include arsenic hydride, arsenic trihydride, arseniuretted hydrogen, arsenous hydride, and hydrogen arsenide.

Arsine presents little risk of secondary contamination to personnel outside the Hot Zone.
Arsine is a flammable and highly toxic gas with a garlic-like or fishy odor that does not provide adequate warning of dangerous levels.
Inhalation is the major route of arsine exposure. It has no toxic effects on the skin or eyes, and it is not absorbed through the skin.

Description --

Industrial arsine is a colorless, flammable and highly toxic gas. It has a garlic-like or fishy odor at concentrations of O.5 ppm and above. Because it is nonirritating, persons exposed to dangerous levels may experience no immediate symptoms.

Routes of Exposure --

Inhalation -

Inhalation is the major route of exposure. The odor threshold of arsine is 1O-fold greater than the OSHA permissible exposure limit. Odor is not an adequate indicator of arsine's presence and does not provide reliable warning of dangerous concentrations. Serious exposure can occur even if the garlic-like odor is not smelled. Arsine is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Arsine has no toxic effects on the skin or eyes, and it is not absorbed through the skin.

Ingestion -

Ingestion of arsine itself is unlikely since it is a gas at room temperature. However, metal arsenides are solids that can react with the gastric mileux and release arsine gas in the stomach.

Sources/Uses --

Arsine gas is formed when arsenic-containing materials react with water or acids. Accidental exposures have occurred during refining of ores (e.g., lead, copper, zinc, iron, and antimony ores) that are contaminated with arsenic. Arsine is used as a dopant in the semiconductor industry and in the manufacture of crystals for fiberoptics and computer chips. It has minor uses in galvanizing, soldering, etching, and lead plating.

Properties of Arsine --

Appearance: Colorless, nonirritating gas at room temperature

Warning properties: Inadequate; garlic-like or fishy odor at 0.5 ppm

OSHA PEL (Permissible Exposure Limit) =0.05 ppm (averaged over an 8-hour workshift)

OSHA Ceiling Limit = 0.002 ppm (15-minute sample)

NIOSH IDLH (Immediately Dangerous to life or Health) = 6 ppm

Molecular weight = 78.0

Boiling point (760 mm Hg) = --80.4 degrees F (-55 degrees C)

Vapor pressure (67.1 degrees F) = >760 mm Hg

Vapor density = 2.7 (air = 1)

Water soluble (20% at 67 degrees F)

Extremely flammable; may be ignited by heat, sparks, or flames. Vapors may travel to a source of ignition and flash back.

Health Effects

Arsine is a highly toxic gas. Its primary toxic effect after inhalation is massive intravascular hemolysis resulting in acute renal failure.
Signs and symptoms of acute arsine poisoning are usually delayed for 2 to 24 hours, depending on exposure intensity.

Acute Exposure --

After absorption by the lungs, arsine enters red blood cells and inhibits red cell catalase, which leads to accumulation of hydrogen peroxide. Hydrogen peroxide, in turn, destroys red cell membranes and causes massive intravascular hemolysis. Arsine produces no adverse effects on the skin or eyes, and contact with these organs does not result in systemic toxicity. Gastrointestinal effects from ingestion of arsine are unlikely, but ingestion of metallic arsenides can lead to arsine intoxication.

Respiratory -

Delayed pulmonary edema has been described after massive exposure. Respiratory effects may be secondary to hemolysis hypoxia.

Hematologic -

Acute intravascular hemolysis develops within hours and continues for up to 96 hours. Haptoglobin levels decline rapidly. Plasma free hemoglobin rises, with greater than 2 g/dL reported. Anemia develops; the peripheral smear shows anisocytosis, poikilocytosis, red-cell fragments, basophilic stippling, and ghost cells. The bone marrow usually shows no abnormalities. Coomb's and Ham's tests are negative, and RBC fragility is normal.

Renal -

Renal failure due to acute tubular necrosis is a significant sequela of arsine exposure. Hemoglobinuria is thought to be the major insult, but a direct toxic effect of arsine or deposition of the arsine- hemoglobin- haptoglobin complex may also play a role. Urinalysis shows large amounts of methemoglobin, protein, and hemoglobin without intact RBCs. Urine may be colored (brown, red, orange, etc.) Oliguria or anuria may develop within 24 to 48 hours.

Gastrointestinal -

Nausea, vomiting, and crampy abdominal pain are among the first signs of arsine poisoning. Onset varies from a few minutes to 24 hours after exposure.

Dermal -

The skin bronzing noted with arsine toxicity is not true jaundice due to the presence of bilirubin but is induced by hemolysis.

Neurologic -

Acute encephalopathy can develop several days after severe exposure. Signs include restlessness, memory loss, disorientation, agitation, and psychosis. Some victims suffer peripheral neuropathy beginning 1 to 2 weeks after exposure.

Musculoskeletal -

Skeletal muscle injury has been reported in some patients. Findings include severe myalgia, myoglobinuria, and elevated serum CPK and aldolase levels.

Chronic Exposure --

Chronic exposure to arsine can result in gastrointestinal distress and anemia. Repeated exposure may cause damage to lungs, kidneys, liver, nervous system, heart, and blood and blood-forming organs.

Arsine has been associated with skin and lung cancers. IARC states that sufficient evidence exists to conclude that arsine is a human carcinogen.

Arsine should be treated as a potential teratogenic agent. Although the reproductive effects of acute or chronic exposure to arsine are unknown, some related inorganic arsenicals produce a broad spectrum of adverse developmental effects in animals.

Prehospital Management

Even if arsine's odor is not detected by persons at the scene, victims could have received a serious exposure. All exposure victims should be evaluated at a medical facility.
Signs of hemolysis and pulmonary edema may be delayed 2 to 24 hours.
There is no specific antidote for arsine poisoning. Treatment is supportive.

Potential for Secondary Contamination. Although small amounts of arsine gas can be trapped in the victim's clothing or hair after an overwhelming exposure, these quantifies are not likely to create a hazard for response personnel outside the Hot Zone.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing is not required.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

Victims with exposure to only arsine gas do not need decontamination. They may be transferred immediately to the Support Zone.

Support Zone --

Support Zone personnel require no specialized protective gear if the patient has been exposed to only arsine.

ABCs -

Establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment --

Intubate the trachea if indicated (respiratory distress or apnea). If massive exposure is suspected or if the patient is hypotensive, infuse intravenous saline or lactated Ringer's solution (adult dose: 500 to 1000 mL).

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

Multiple Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

It is difficult to determine at the scene which patients have had the most serious exposure and are likely to develop severe hemolysis; therefore, all patients with potential exposure should be evaluated at a medical facility.

Patients whose history indicates massive exposure and those who have smelled a garlic- or fish-like odor should be transported first.

Emergency Department Management

Arsine poisoning causes acute intravascular hemolysis, which may lead to renal failure. Arsine gas does not produce arsenic intoxication.
Even if arsine's odor was not detected by persons at the scene, victims could have had a serious exposure. All exposure victims should be evaluated and observed.
There is no specific antidote for arsine poisoning. Treatment is supportive.

Potential for Secondary Contamination. Although small amounts of arsine gas can be trapped in the victim's clothing or hair after an overwhelming exposure, these quantities are not likely to create a hazard for hospital personnel.

Critical Care Area --

Patients with exposure to only arsine gas do not need decontamination.

ABCs -

Evaluate and support airway, breathing, and circulation. Monitor cardiac rhythm.

Observe inhalation patients for up to 24 hours. Follow-up as clinically indicated.

Treatment for Hemolysis -

If hemolysis develops, initiate urinary alkalinization. Add 50 to 100 mEq of sodium bicarbonate to one liter of 5% dextrose in 0.25 normal saline and administer intravenously at a rate that maintains urine output at 2 to 3 mL/kg/hr. Maintain alkaline urine (i.e., pH>7.5) until urine is hemoglobin free. Closely monitor serum electrolytes, calcium, BUN, and creatinine.

Antidotes and Other Treatments -

Although BAL (dimercaprol) and other chelating agents are useful in arsenic poisoning, they are not effective antidotes for arsine poisoning. Consider hemodialysis if renal failure is severe. (Although hemodialysis will assist the patient with renal failure, it will not effectively remove the arsine-hemoglobin or arsine-haptoglobin complexes deposited in the renal tubules.)

Blood transfusions may be necessary if hemolysis causes severe anemia.

Laboratory Tests -

If significant exposure is a possibility and transfusion may be necessary, immediately obtain blood type and screen (cross match, if needed). Laboratory tests to determine hemolysis include CBC with peripheral smear, urinalysis with hemoglobin quantitation, and plasma free hemoglobin and haptoglobin analyses. Other useful tests include renal function tests (BUN, creatinine), Serum electrolytes, and unconjugated bilirubin levels.

Disposition and Follow-up --

Decisions to admit or discharge a patient should be based on exposure history, physical examination, and test results.

Delayed Effects -

All patients with suspected arsine exposure should be carefully observed for 24 hours, including hourly urine monitoring to assure absence of hemolysis. Onset of hemolysis may be delayed up to 24 hours, and acute renal failure may not become evident for as long as 72 hours after exposure.

Patient Release -

Patients with no signs of hemolysis may be discharged after 24 hours of observation with instructions to return to the ED if symptoms of toxicity develop (see the reverse side of Arsine--Patient Information Sheet). Released patients should be instructed to rest and to drink plenty of fluids.

Follow-up -

All patients should receive repeat laboratory tests in 12 to 24 hours.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH. See Appendix XX for a list of these and other agencies that may be of assistance.

Arsine Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to arsine gas.

What is arsine?

Arsine is a colorless gas that does not burn the eyes, nose, or throat like some other dangerous gases. It has a garlic-like or fishy smell, but only at relatively high concentrations. A person can be exposed to a high concentration of arsine and not be able to smell it.

Certain ores or metals may contain traces of arsenic. If water or acid contacts these ores or metals, they may release small amounts of arsine gas. Arsine is widely used in manufacturing of fiberoptic equipment and computer microchips. It is sometimes used in galvanizing, soldering, etching, and lead plating.

What immediate health effects may result from arsine exposure? Besides the odor, there may be no other immediate sign that a person is breathing arsine. Its main effect is to destroy red blood cells, causing anemia (destruction of red blood cells) and kidney damage (from red blood cell debris). Within hours after a serious exposure, the victim may develop dark red or brown urine, back pain or belly pain, weakness, or shortness of breath. The skin or eyes may become yellow or bronze in color. Although arsine is related to arsenic, it does not produce the usual signs of arsenic poisoning.

What is the treatment for arsine poisoning?

There is no antidote for arsine poisoning, but its effects can be treated. The doctor may give the exposed patient fluids through a vein to protect the kidneys from damage. For severe poisoning, blood transfusions and cleansing of the blood (hemodialysis) may be needed.

Are any future health effects likely to occur?

After a serious exposure, symptoms usually begin within 2 to 24 hours. People who have no signs of poisoning during this time probably have not breathed a large amount of arsine and may be sent home with instructions for follow-up medical care (see the reverse side of this page). Most people do not have long term effects from a single, small exposure to arsine. In rare cases, permanent kidney damage or nerve damage has developed after a severe exposure.

Repeated exposure to arsine may cause skin and lung cancer.

What tests can be done if a person has been exposed to arsine? The are no specific tests for arsine exposure. However, blood, urine and other tests may show if there has been any serious injury to the lungs, blood cells, kidneys, or nerves.

Where can more information about arsine be obtained?

More information about arsine may be obtained from your regional poison control center; your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Arsine Follow-up Instructions --

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * unusual fatigue or weakness
  * shortness of breath
  * abnormal urine color (red, brown, etc.)
  * belly pain or tenderness

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. __________ in the practice of ________
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at __________________ Hospital
by __________ and were advised to be seen again in ___ days.

( ) Return to the Emergency Department/__________ Clinic on (date) ________
at AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for__ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) You may continue taking the following medication(s) that your doctor(s)

prescribed for you: ___________________________________________________
_______________________________________________________________________ ( )

Other instructions: ___________________________________________________
_______________________________________________________________________

Signature of patient ___________________________ Date _____________________

Signature of physician _________________________ Date _____________________

Benzene (C(6)H(6))

CAS: 71-43-2; UN 1114

Synonyms include benzol, coal tar naphtha, phenyl hydride, and cyclohexatriene.

Victims exposed to only benzene vapor do not pose a significant risk of secondary contamination; however, victims whose clothing or skin is contaminated with liquid benzene can cause secondary contamination by direct contact or through off-gassing vapor.
Benzene is a highly volatile, flammable, and combustible liquid. Its vapor is heavier than air and may accumulate in low-lying areas.
Benzene is absorbed rapidly after inhalation and ingestion. It is absorbed slowly through through intact skin; however, percutaneous absorption can contribute to total body burden.

Description --

At room temperature, benzene is a clear, colorless to light yellow liquid that is highly flammable and combustible. Because it is volatile, it can spread to a source of ignition and flash back. Benzene has a sweet aromatic odor. It is only slightly soluble in water but readily miscible with most organic solvents. Benzene is less dense than water and will float on the surface of water.

Routes of Exposure --

Inhalation -

Most exposures to benzene occur by inhalation. Its odor generally provides adequate wanting of acutely dangerous concentrations. Benzene vapor is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Benzene vapor is only mildly irritating to mucous membranes; however, liquid benzene splashed in the eyes can result in corneal injury. Repeated or prolonged skin contact with liquid benzene can defat the skin, causing it to crack and peel. Percutaneous absorption is slow through intact skin; however, benzene absorbed through the skin can contribute to body burden and systemic toxicity.

Ingestion -

Acute toxic effects can result from ingestion of benzene.

Sources/Uses --

Benzene is the 16th most abundantly produced chemical in the United States. It is obtained from crude petroleum. Benzene is used mainly as raw material for synthesizing chemicals such as styrene, phenol, and cyclohexane and for manufacturing dyes, detergents, explosives, rubber, plastics, and pharmaceuticals. It also is found as a contaminant in some industrial solvents and as a constituent in motor fuels, unleaded gasoline in particular.

Properties of Benzene --

Appearance: Clear, colorless to light yellow liquid

Warning properties: Sweet solvent odor at 1.5 to 5 ppm. Adequate warning for acute exposure; inadequate for chronic exposure.

OSHA PEL (Permissible Exposure Limit) = 1 ppm (averaged over an 8-hour workshift)

OSHA STEL (Short Term Exposure Limit) = 5 ppm (15-minute sample)

NIOSH IDLH (immediately Dangerous to Life or Health) = 3000 ppm

Molecular weight = 78.1

Boiling point (760 mm Hg) = 176 degrees F (80.1 degrees C)

Freezing point = 41.9 degrees F (5.5 degrees C)

Vapor pressure (67 degrees F) = 75 mm Hg

Vapor density = 2.8 (air = 1)

Slightly water soluble (0.07% at 61 degrees F)

Flammable at temperatures > 12 degrees F (-11 degrees C)

Flammable range is 1.3% to 7.9% (concentration in air)

Health Effects

Benzene is irritating to the skin, eyes, and respiratory tract.
Benzene may cause central nervous system depression and cardiac dysrhythmias in persons acutely exposed.

Acute Exposure --

CNS -

Generally, symptoms of CNS toxicity are apparent immediately after inhalation and 30 to 60 minutes after ingestion. Mild effects include headache, euphoria, dizziness, confusion, nausea, ataxia, and impaired visual accommodation. More severe effects include blurred vision, tremors, respiratory depression, delirium, unconsciousness, and death. Coma may be prolonged, although most victims regain consciousness rapidly after they are removed from exposure.

Respiratory -

Acute exposure to benzene vapor may irritate the mucous membranes of the respiratory tract. With massive exposure,noncardiogenic pulmonary edema and respiratory arrest may ensue. Pulmonary aspiration of ingested liquid benzene may cause chemical pneumonitis.

Cardiovascular -

Massive doses of benzene can cause cardiac abnormalities. Benzene may increase susceptibility of myocardial cells to the dysrhythmogenic effects of catecholamines.

Renal -

Hematuria and proteinuria can occur after massive inhalation. These effects usually are reversible if exposure is terminated.

Dermal -

Benzene can cause significant skin irritation and defatting dermatitis, particularly after prolonged or repeated contact with the liquid. Erythema and bullae may occur.

Ocular -

High concentrations of benzene vapor can cause eye irritation, but inflammation is generally slight. When splashed in the eyes, benzene may cause burning pain, corneal injury, and sloughing of corneal epithelium.

Gastrointestinal -

If swallowed, liquid benzene can irritate the stomach lining causing nausea, vomiting, and diarrhea. The estimated lethal oral dose is 100 mL, although as little as 15 mL has caused death.

Potential Sequelae -

During recovery, victims may continue to experience ataxia, depressed level of consciousness, dilated and poorly responsive pupils, and decreased or absent deep tendon reflexes. Anxiety, fatigue, and insomnia may last several days. Retrobulbar neuritis and optic neuritis have occurred after systemic benzene poisoning.

Chronic Exposure --

Repeated exposure to high levels of benzene can result in persistent CNS effects. Chronic benzene exposure in the workplace has been associated with hematologic disorders (thrombocytopenia, aplastic anemia, myelocytic and monocytic leukemia). IARC states that sufficient evidence exists to conclude that benzene is a human carcinogen, and NTP includes benzene in its list of substances known to be carcinogenic.

The human fetus appears to be less sensitive to benzene than the mother. In the absence of maternal toxicity, reproductive and developmental effects are unlikely to occur. A 1991 report (Reproductive and Developmental Toxicants) published by the U.S. General Accounting Office (GAO) lists 30 chemicals of concern because of widespread acknowledgment of their reproductive and developmental consequences; benzene is not on this list.

Prehospital Management

Benzene may cause central nervous system depression and cardiac dysrhythmias.
There is no specific antidote for benzene poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination. Victims exposed to only benzene vapor do not pose a significant risk of secondary contamination to rescuers outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid benzene can secondarily contaminate response personnel by direct contact or through off-gassing vapor.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are recommended if contact with concentrated vapors or liquid is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. If an injured person is unable to walk, remove him or her on a backboard or gurney. If there is no means of transport, carefully drag the victim out.

Decontamination Zone --

Victims with exposure to only vapors of benzene and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination.

Rescuer Protection -

Rescuers in the Decontamination Zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with liquid-soaked clothing or skin. If the proper equipment is not available, or if rescue personnel have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Supplemental oxygen can be administered if available. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Basic Decontamination -

Remove and double-bag contaminated clothing. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Flush liquid-exposed skin and hair with plain water for 2 to 3 minutes, then wash with mild soap or shampoo and rinse with copious water.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of benzene ingestion, do not induce emesis. Administer a slurry of activated charcoal (50 to 60 g) if the patient is conscious and able to swallow.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

ABCs -

Advanced Treatment -

Treat wheezing with aerosolized bronchodilators; use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias.

Treat coma and ventricular dysrhythmias according to standard ALS protocol.

Additional Decontamination -

If skin or eyes remain irritated, flush with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of benzene ingestion, do not induce emesis. Administer a slurry of activated charcoal (50 to 60 g) if it was not administered in the Decontamination Zone and if the patient is conscious and able to swallow.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested benzene, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Patients with a history or evidence of significant exposure and all persons who have ingested benzene should be transported to a medical facility and evaluated.

Victims of inhalation exposure who did not experience alteration of consciousness (e.g., confusion, syncope, coma) are not likely to have had a significant exposure. After recording their names, addresses, and telephone numbers, they may be released from the scene with follow-up instructions.

Emergency Department Management

Benzene may came central nervous system depression and cardiac dysrhythmias.
There is no antidote for benzene poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination. Hospital personnel in an enclosed area can be secondarily contaminated by vapor off-gassing from heavily soaked clothing or from the vomitus of victims who ingested benzene. Patients do not pose a contamination risk after contaminated clothing is removed and the skin is washed.

Decontamination Area --

Patients with exposure to only vapors of benzene and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Intubate the trachea if indicated (coma or apnea).

Treat wheezing with aerosolized brochodilators; use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias.

Treat coma and ventricular dysrhythmias according to standard ALS protocol.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only benzene vapor do not require decontamination unless they have skin or eye irritation.

If the patient's clothing is wet with benzene, remove and double bag the contaminated clothing and all personal belongings. Flush exposed skin with copious water for 2 to 5 minutes (preferably under a shower). Use mild soap or shampoo for oily or adherent materials.

Irrigate irritated eyes with water for 5 to 10 minutes. Remove contact lenses if present. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids.

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Decontamination Area above.

ABCs -

Evaluate and support airway, breathing, and circulation as above. Continuously monitor cardiac rhythm.

Assess and treat hypotension and seizures in the conventional manner. Sympathomimetics or catecholamines should be avoided or should be used with caution to avoid inducing ventricular fibrillation. Ventricular tachyrhythmias may respond effectively to beta-blockers. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints. Treat wheezing and bronchospasm with bronchodilators (use with caution).

Skin Exposure -

If liquid benzene was in prolonged contact with the skin, chemical burns may result. Treat chemical burns as thermal burns.

Eye Exposure -

Ingestion -

Perform gastric lavage if the patient has ingested a large dose and presents within 30 minutes of exposure, then administer activated charcoal and a cathartic. When small amounts of benzene have been ingested, activated charcoal may be administered orally without gut emptying.

Antidotes and Other Treatments -

If the patient who has ingested benzene is coughing or is dyspneic, pulmonary aspiration may have occurred. Patients who show no clinical signs of pulmonary aspiration within 6 hours are unlikely to develop aspiration chemical pneumonia.

There is no specific antidote for benzene poisoning. Hemodialysis and hemoperfusion are ineffective.

Laboratory Tests -

In cases of significant exposure, useful laboratory studies include CBC, electrolytes, BUN, creatinine, urinalysis, liver function tests, and ECG monitoring. Chest radiography and ABGs are recommended for severe inhalation exposure or if pulmonary aspiration is suspected.

Blood levels of benzene or phenol may be used to document exposure, although they are not useful clinically. OSHA's benzene standard mandates that urinary phenol testing be performed on all workers exposed to benzene in an emergency situation. Other factors may contribute to a high phenol level including ingestion of benzoate preservatives and certain medications (e.g., Pepto-Bismol, Chloraseptic) and smoking.

Periodic CBCs are also mandated by OSHA (at least monthly for 3 months) to monitor for potential bone marrow effects.

Disposition and Follow-up --

Consider hospitalization for symptomatic patients who have a history of significant inhalation exposure or aspiration chemical pneumonia and patients who have ingested significant amounts of benzene.

Delayed Effects -

Observe hospitalized patients for signs of acute tubular necrosis, encephalopathy, and dysrhythmias. In addition, patients exposed by inhalation should be observed for signs of pulmonary edema, and those who have ingested benzene should be watched for signs of aspiration pneumonia.

Patient Release -

Patients who have remained asymptomatic 6 to 12 hours after exposure may be discharged, advised to rest and to promptly seek medical care if symptoms of toxicity develop (see the reverse side of Benzene--Patient Information Sheet).

Follow-up -

Patients who have received a significant exposure (as determined by history or clinical signs and symptoms such as dysrhythmias, syncope, or confusion) should be monitored for hematopoietic effects. Patients with urinary phenol levels above 75 mg/L should receive periodic complete blood counts (at least monthly for 3 months). Patients with corneal injury should receive follow-up evaluation within 24 hours.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department. Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH.

Benzene Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to benzene liquid or vapor.

What is benzene?

When pure, benzene is a clear, colorless liquid with a sweet odor. It burns readily. Benzene is obtained from crude petroleum. Small amounts may be found in products such as paints, glues, pesticides, and gasoline.

What immediate health effects may be caused by exposure to benzene? Breathing benzene vapor in small amounts may cause headache, euphoria (a "high"), a light-headed feeling, dizziness, drowsiness, or nausea. With more serious exposure, benzene may cause sleepiness, stumbling, irregular heart beats, passing out, or even death. Benzene vapors are mildly irritating to the skin, eyes, and lungs. If liquid benzene contacts the skin or eyes, it may cause burning pain. Liquid benzene splashed in the eyes can damage the cornea of the eyes.

What is the treatment for benzene poisoning?

There is no antidote for benzene poisoning, but its effects can be treated and most exposed persons do recover fully. Persons who have experienced serious symptoms may need close medical observation for 24 hours.

Are any future health effects likely to occur?

After a single, small exposure, no delayed or long-term effects are likely to occur. After a severe exposure, symptoms may develop within a few days. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care.

Repeated exposure to benzene may cause blood disorders and cancer of blood- forming cells. Aplastic anemia and leukemia have been reported in some workers exposed to benzene.

What tests can be done if a person has been exposed to benzene? Specific tests for the presence of benzene in blood are not medically useful. Phenol, a metabolite of benzene, can be measured in urine if the benzene exposure was high. In cases of severe exposure, other tests may show if injury has occurred in the heart, kidneys, blood, or nervous system. The severity of symptoms is usually the best measure of the seriousness of the exposure.

Where can more information about benzene be found?

More information about benzene may be obtained from your regional poison control center;, the state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor;, or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Benzene Follow-up Instructions --

Please follow the instructions indicated below by the doctor.

( ) Call your doctor or the Emergency Department if you develop any of the
following signs or symptoms within the next 24 hours:

  * cough
  * shortness of breath or wheezing
  * chest pain
  * irregular heart beats
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn
  * fever
  
( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr.___________. When you call for your
appointment, please tell the receptionist/nurse that you were treated in the
Emergency Department at __________ Hospital by _____________ and were advised
to be seen again in __ days.

( ) Return to the Emergency Department/___________ Clinic on(date)_____.
at____ AM/PM for a follow-up examination.

( ) You may resume your normal activities including driving, operating
machinery, physical exercise, and work.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you: ___________________________________________________
_______________________________________________________________________ ( )

Other instructions: ___________________________________________________
_______________________________________________________________________

Signature of patient_________________________ Date ________________________

Signature of physician_______________________ Date ________________________

Ethylene Oxide ((CH(2))(2)0)

CAS: 75-21-8; UN 1040

Synonyms of ethylene oxide include dimethylene oxide, epoxy ethane, oxirane, oxacyclopropane, amprolene, and anprolene.

Victims exposed to only ethylene oxide gas do not pose a significant risk of secondary contamination; however, victims whose clothing or skin is contaminated with ethylene oxide liquid or solution can secondarily contaminate personnel by direct contact or through off-gassing vapor.
Ethylene oxide is a flammable, explosive, and highly penetrating gas; its odor does not provide sufficient warning of dangerous concentrations.
Ethylene oxide is rapidly absorbed after inhalation or skin contact.

Description --

Ethylene oxide is a colorless gas at room temperature and a colorless liquid below 51 degrees F. It is shipped as a liquefied, compressed gas. Both the gas and liquid are potential fire and explosion hazards. Ethylene oxide has an ether-like odor at air concentrations of 500 ppm and above.

Inhalation -

Most ethylene oxide exposures occur by inhalation or skin contact, both of which may cause or contribute to systemic effects. Odor is not a reliable indicator of ethylene oxide's presence and may not provide adequate warning of dangerous concentrations. The gas is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Ethylene oxide vapors are absorbed readily through the skin and eyes, which can cause or contribute to systemic effects. Contact with solutions of ethylene oxide or high vapor concentrations may cause chemical burns. Contact with liquid anhydrous ethylene oxide may result in burns and frostbite injury.

Ingestion -

Ethylene oxide is used commonly as a gas at room temperature, so ingestion is unlikely to occur.

Sources/Uses --

Ethylene oxide is produced by catalytically reacting ethylene (a hydrocarbon) and oxygen. It ranks 26th in volume among the major industrial chemicals produced in the United States. About 65% of ethylene oxide is used for synthesis of ethylene glycol, an anti-freeze product. Ethylene oxide also is used as a cold sterilizing agent for foods and medical equipment and supplies; as a fumigant and fungicide in the manufacture of medical products and foodstuffs; and as a solvent, plasticizer, and chemical intermediate.

Properties of Ethylene Oxide --

Appearance: Colorless gas with a sweet, ether-like odor

Warning properties: Inadequate; odor is detectable at about 500 ppm, and many sensitized persons experience symptoms below the odor threshold.

OSHA PEL (Permissible Exposure Limit) = 1 ppm (averaged over an 8-hour workshift)

OSHA STEL (Short Term Exposure Limit) = 5 ppm (15-minute sample)

NIOSH IDLH (Immediately Dangerous to Life or Health) = 800 ppm

Molecular weight -- 44.1

Boiling point (760 mm Hg) = 51 degrees F (10.7 degrees C)

Vapor pressure (67 degrees F) = > 760 mm Hg

Vapor density = 1.49 (air = 1)

Miscible with water

Flammable gas between 3% and 100% (concentration in air); extremely flammable liquid; may be ignited by heat, sparks, or flames. Vapors may travel to a source of ignition and flash back.

Health Effects

Ethylene oxide gas may produce immediate local irritation of the skin, eyes, and upper respiratory tract. At high doses, it may cause immediate or delayed pulmonary edema, CNS depression, and respiratory paralysis.
Ethylene oxide inhalation or skin contact may result in allergic or immune-mediated sensitization.

Acute Exposure --

Systemically, ethylene oxide is a highly reactive alkylating agent that forms adducts with cellular macromolecules, such as DNA and hemoglobin, causing cellular dysfunction and death. Because ethylene oxide is highly water soluble, it may produce immediate local irritation of skin and mucous membranes. At high concentrations, it can produce CNS depression and respiratory paralysis.

Respiratory -

Initially, ethylene oxide affects the nasopharynx. Concentrations as low as 200 ppm produce rapid onset of nose and throat irritation. Higher concentration may cause inflammation of the trachea and bronchi, bronchoconstriction, and atelectasis. Acute pulmonary edema may evolve up to 12 hours or more after exposure.

Neurologic -

Ethylene oxide is a CNS depressant. High-dose exposures can result in diverse neurologic manifestations including seizures and coma. Onset of neurologic signs and symptoms may be delayed up to 6 hours or more after exposure. Respiratory paralysis and delayed peripheral neuropathy have been reported after massive exposure.

Gastrointestinal -

Exposure to even low vapor concentrations of ethylene oxide can result in nausea and vomiting, often delayed.

Dermal -

Skin contact with concentrated vapor or aqueous solutions of ethylene oxide may cause inflammation with erythema, blistering, and crusted ulcerations. Initially, lesions are painless but later can become painful and pruritic. Skin reactions may be delayed up to 5 hours or more after exposure. Exposure to anhydrous ethylene oxide liquid may cause burns and frostbite injury.

Ocular -

Exposure to high concentrations of vapor or splashes of concentrated solutions can cause eye irritation, conjunctivitis, and corneal injury.

Cardiovascular -

Dysrhythmias may occur after a severe inhalation exposure.

Immunologic -

Inhalation and skin exposure may cause allergic and immune-mediated sensitization leading to contact dermatitis, urticaria, and anaphylactic reactions.

Potential Sequelae -

Survivors of severe inhalation injury may suffer residual chronic lung disease. Skin burns may result in scarring or hyperpigmentation. Cataracts may develop after serious eye exposure.

Chronic Exposure --

Chronic ethylene oxide exposure may cause delayed peripheral nerve damage resulting in denervation atrophy, especially in the lower extremities. Although the results are inconclusive, some data suggest that chronic ethylene oxide exposure causes impairment of cognitive function. It also may damage the liver and kidneys. Skin allergy can result from exposure and some persons can become sensitized to the chemical.

Data suggest that repeated exposure to ethylene oxide causes an increased risk of leukemia in humans. It has been shown to cause leukemia and abdominal cavity cancer in animals. IARC states that there is limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in animals. Ethylene oxide is on NTP's list of substances that may reasonably be anticipated to be carcinogens.

Shepard's Catalog of Teratogenic Agents describes one study of in which the spontaneous abortion frequency in hospital workers exposed to ethylene oxide during pregnancy was 16.7% (average for the general population); however, the frequency for appropriate hospital controls was 5.6% (below average for the general population). A 1991 Report (Reproductive and Developmental Toxicants) published by the US General Accounting Office (GAO) lists 30 chemicals of concern because of their reproductive and developmental consequences; ethylene oxide is on this list.

Prehospital Management

Ethylene oxide can produce immediate eye, skin, and respiratory irritation; CNS depression and respiratory paralysis.
There is no antidote for ethylene oxide intoxication. Treatment is supportive.

Potential for Secondary Contamination. Victims exposed to only ethylene oxide gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with ethylene oxide liquid or solution can secondarily contaminate personnel by direct contact or through off-gassing vapor.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with liquid ethylene oxide or its concentrated vapors is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal-

Decontamination Zone --

Victims with exposure to only ethylene oxide gas and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others see Basic Decontamination.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with ethylene oxide-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Basic Decontamination -

If the exposure involved liquid ethylene oxide (ambient temperature below 51 degrees F) and there is evidence of wet clothing, remove and double-bag the contaminated clothing. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Flush exposed skin and hair with plain water for 3 to 5 minutes.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of ingestion, do not induce emesis. If the patient is conscious and able to swallow, administer 1 to 2 glasses of water to dilute stomach contents. The effectiveness of activated charcoal in cases of ethylene oxide ingestion is not known.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Be certain that patients have undergone basic decontamination (see Decontamination Zone). Patients who have undergone proper decontamination or have been exposed to only vapors pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device, if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment -

Intubate the trachea if indicated (severe respiratory distress or apnea). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so.

Treat bronchospasm with aerosolized bronchodilators.

Treat coma, seizures, and ventricular dysrhythmias according to ALS protocol.

Additional Decontamination -

If skin or eyes remain irritated, continue rinsing with water or saline. Remove contact lenses if present and irrigate the eyes with saline via IV tubing for 10 to 15 minutes or until pain and irritation have resolved.

In case of ingestion, do not induce emesis. Administer 1 to 2 glasses of water to dilute stomach contents if it was not administered in the decontamination zone and if the patient is conscious and able to swallow. The effectiveness of charcoal in cases of ethylene oxide ingestion is not known.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested ethylene oxide solution, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Because effects may be delayed for up to several hours after exposure, it is prudent to refer all patients with a potential exposure to a medical facility.

Emergency Department Management

Ethylene oxide can produce immediate eye, skin, and respiratory tract irritation; CNS depression; and respiratory paralysis.
There is no specific antidote for ethylene oxide poisoning. Treatment is supportive.

Decontamination Area --

Patients with exposure to only ethylene oxide gas and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Treat bronchospasm with aerosolized bronchodilator.

Seizures, coma, hypotension, renal failure, and apnea may complicate serious exposure. Treat in the conventional manner.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapors do not require decontamination unless they have skin or eye irritation.

Since touching clothing or skin wet with ethylene oxide may cause burns, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek, Saranex*) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with ethylene oxide, quickly remove and double-bag the contaminated clothing and all personal belongings while flushing the skin. Flush exposed skin with copious water (preferably under a shower).

Remove contact lenses and irrigate exposed eyes with water for at least 5 minutes. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids.

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Basic Decontamination above.

ABCs -

Evaluate and support airway, breathing, and circulation. Continuously monitor cardiac rhythm. Treat hypotension, seizures, and ventricular arrhythmias in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of other underlying disorders (e.g., trauma, hypoglycemia, and drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints. Observe patients in respiratory distress for up to 12 hours and periodically reexamine them using chest examinations and other appropriate studies. Follow-up as clinically indicated.

Treat bronchospasm with aerosolized bronchodilators.

Skin Exposure -

If ethylene oxide was in contact with the skin, chemical burns may result.

Eye Exposure -

Ingestion -

Do not induce emesis. Offer the alert patient water or milk to dilute the ethylene oxide and minimize corrosive injury. Perform gastric lavage and consider endoscopy to evaluate esophageal or gastric injury. The effectiveness of charcoal in cases of ethylene oxide ingestion is unknown.

Antidotes and Other Medications -

There is no antidote for ethylene oxide poisoning; treatment is supportive.

Laboratory Tests -

Disposition and Follow-up --

Hospitalization should be considered for patients with evidence of systemic toxicity from any route of exposure.

Delayed Effects -

Patients with a history of significant ingestion exposure, severe respiratory distress, or extensive skin burns should be admitted to an intensive care unit.

Because neurologic and respiratory signs and symptoms may not be evident for as long as 12 hours after exposure, patients with a suspected serious exposure should be observed and reexamined periodically. Patients with bronchospasm or pulmonary edema should be admitted and watched for signs of impending respiratory failure and managed accordingly.

Patient Release -

Patients with mild exposure and those who initially are asymptomatic should be observed for 4 to 6 hours, then discharged if no symptoms occur during this period. Advise discharged patients to seek medical care promptly if symptoms develop. (For a list of symptoms, see the reverse side of Ethylene Oxide--Patient Information Sheet.)

Follow-up -

Patients requiring ophthalmic care should be reevaluated in 24 hours.

Reporting --

Ethylene Oxide-- Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to ethylene gas or solution.

What is ethylene oxide?

Ethylene oxide is a colorless liquid below 51 degrees F and a colorless gas at room temperature. It is used in the sterilization of hospital supplies, foods, and cosmetics; as a fumigant for spices, tobacco, furs, bedding, etc.; and in the manufacture of antifreeze and other chemicals. At toxic air concentrations, ethylene oxide may have a sweet, ether-like odor. However, odor is not a reliable warning of the seriousness of the exposure.

What immediate health effects may result from ethylene oxide exposure? Most exposures to ethylene oxide occur from breathing the gas. Exposure to small amounts can cause eye, nose, and throat irritation; and skin rash. More serious exposure can cause severe breathing difficulty, skin burns, weakness, twitching, convulsions, and coma.

What is the treatment for ethylene oxide poisoning?

There is no antidote for ethylene oxide poisoning, but its effects can be treated and most exposed persons do recover fully. Persons who have had a serious exposure may need close medical observation for 12 hours or more.

Are any future health effects likely to occur?

After a single, small exposure, no delayed or long-term health effects are likely to occur. After a severe exposure, symptoms may be delayed up to 12 hours. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care.

Ethylene oxide is suspected of causing cancer of the blood, and birth defects may occur in offspring of mothers who were repeatedly and excessively exposed at work.

What tests can be done if a person has been exposed to ethylene oxide? There are no specific blood and urine tests that can indicate a recent exposure to ethylene oxide. Generally, the severity of irritation symptoms is the best indicator of the seriousness of the exposure. However, blood, urine, and other tests may show if there has been any serious effect on the blood, heart, lungs, liver, or kidneys.

Where can more information about ethylene oxide be found? More information about ethylene oxide may be obtained from your regional poison control center;, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Ethylene Oxide Follow-up Instructions --

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * difficulty breathing or shortness of breath
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn
  * fever
  * unexplained drowsiness, fatigue, headache
  * belly pain, vomiting, diarrhea

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Formaldehyde (HCHO)

CAS: 50-00-0; UN 1198 (Formalin), 2209 (Formalin)

Synonyms of gaseous formaldehyde include formalin, formic aldehyde, methanal, methyl aldehyde, methylene oxide, oxomethane, and paraform.

Victims exposed to only formaldehyde vapor do not pose a significant risk of secondary contamination; however, victims whose clothing or skin is contaminated with formalin can cause secondary contamination by direct contact or through off-gassing vapor.
Formaldehyde is a highly toxic and flammable gas that is slightly heavier than air. It often is used in aqueous solution (formalin).
Most formaldehyde exposures occur by inhalation or skin or eye contact. It is a potent allergen that can elicit hypersensitivity reactions in susceptible individuals.

Description --

Formaldehyde is a nearly colorless gas with a pungent, irritating odor below 1 ppm. Its vapors are flammable and explosive. Because the pure gas tends to polymerize, it is used commonly in solution. Formalin is the aqueous solution of formaldehyde (37% to 50% formaldehyde), which contains up to 15% methanol as a stabilizer.

Routes of Exposure --

Inhalation -

Most formaldehyde exposures occur by inhalation or skin/eye contact. In cases of acute exposure, formaldehyde will most likely be detected by smell; however, persons who are sensitized to formaldehyde may experience headaches and minor eye and airway irritation at levels below the odor threshold. For them, odor is not a adequate indicator of formaldehyde's presence and may not provide reliable warning of dangerous concentrations. Odor adaptation does occur.

Skin/Eye Contact -

Formaldehyde vapor or formalin splashes can cause injury to the skin and eyes.

Ingestion -

Ingestion of as little as 30 mL of 37% formalin has been reported to cause death in an adult.

Sources/Uses --

Formaldehyde is produced by the oxidation of methanol. It is among the 25 most abundantly used chemicals in the world. It is used in the manufacture of plastics, resins, and urea-formaldehyde foam insulation. Formaldehyde- containing resins are found in construction materials (plywood, particle board, and fiber board) and are used in the processing of paper, carpets, crease-resistant textiles, paint, and furniture. Under certain conditions, formaldehyde may be released from building materials, carpeting, furniture, drapes, etc., thereby contributing to indoor pollution.

Formalin in varying concentrations is used as a disinfectant, antiseptic, deodorant, tissue preservative, and embalming fluid.

Properties of Formaldehyde --

Appearance: Nearly colorless gas with a pungent, irritating odor

Warning properties: Odor is detectable at less than 1 ppm, but many sensitive persons experience symptoms below the odor threshold.

OSHA PEL (Permissible Exposure Limit) = 1 ppm (averaged over an 8-hour workshift)

OSHA STEL (Short Term Exposure Limit) = 2 ppm (15-minute sample)

NIOSH IDLH Immediately Dangerous to Life or Health = 30 ppm

AIHA ERPG-2 = 10 ppm

Molecular weight = 30.0

Boiling point (760 mm Hg) = -6 degrees F

Vapor pressure (67 degrees F) = > 760 mm Hg

Vapor density = 1.07 (air = 1)

Miscible with water

Flammable gas between 7% and 73% (concentration in air); combustible liquid (formalin)

Health Effects

Formaldehyde is an eye, skin, and respiratory tract irritant. When inhaled, it can produce bronchospasm and pulmonary edema.
Metabolic acidosis may occur as a result of accumulation of the metabolite formic acid in the body.
Formaldehyde is a potent sensitizer and a suspected human carcinogen.

Acute Exposure --

In high concentrations, formaldehyde reacts with most substances within the cell, thus interfering with cellular functions. In exposed tissue, it causes precipitation of proteins, which results in coagulation necrosis. Because formaldehyde is highly water soluble, it produces immediate local irritation in mucous membranes including eyes, nose, and upper respiratory tract. Formaldehyde is metabolized to formic acid, which may accumulate in the body and cause metabolic acidosis.

Respiratory -

Even fairly low concentrations of formaldehyde can produce rapid onset of nose and throat irritation, which cause coughing, chest pain, dyspnea, and wheezing. Higher exposures can cause significant inflammation of the lower respiratory tract resulting in laryngeal spasm and edema, tracheobronchitis, bronchospasm, pneumonitis, and pulmonary edema. Pulmonary injury may evolve over 12 hours or more.

Previously sensitized individuals can develop severe bronchospasm at very low concentrations (0.3 ppm). Attacks may begin immediately or can be delayed for 3 to 4 hours; effects may worsen for up to 20 hours after exposure and can persist for several days.

Metabolic -

Accumulation of the formic acid metabolite can cause an anion gap metabolic acidosis. If formalin is ingested, the absorption of methanol stabilizer may contribute to metabolic acidosis and can result in both an anion and osmolar gap.

Immunologic -

In persons who have been previously sensitized, inhalation and skin contact may result in contact dermatitis, urticaria, anaphylactic reactions, and rarely, hemolysis.

Gastrointestinal -

Ingestion of aqueous solutions of formaldehyde may cause severe corrosive esophageal and gastric injury. Nausea, vomiting, diarrhea, abdominal pain, gastritis, ulceration, and perforation can occur. Both formaldehyde and the ethanol stabilizer are easily absorbed and can contribute to systemic toxicity.

Aspiration of stomach contents containing formalin may cause pneumonitis.

Ocular -

Exposure to low vapor concentrations can cause eye irritation that abates within minutes after exposure has ended. Exposure to high vapor concentrations or formalin splashed in the eyes can lead to corneal ulceration or opacification, corneal necrosis, perforation, and acute glaucoma. These effects may be delayed for 12 hours or more.

Dermal -

Exposure to vapor concentrations greater than 300 ppm or to formalin solutions can cause irritation and skin burns. In sensitized persons, contact dermatitis may develop at air levels less than 1 ppm.

Potential Sequelae -

Pulmonary function in survivors of severe inhalation injury usually returns to normal. Eye exposure to high concentrations of formaldehyde or formalin can cause ulceration and perforation of the cornea, eventually resulting in blindness. Esophageal strictures can occur after ingestion.

Chronic Exposure --

The major concerns of repeated formaldehyde exposure are sensitization and cancer. In sensitized persons, formaldehyde can cause asthma and contact dermatitis. In persons who are not sensitized, prolonged inhalation of formaldehyde at low levels is unlikely to result in chronic pulmonary injury.

Formaldehyde is listed by IARC and NTP as a substance that may reasonably be anticipated to be a carcinogen. Various studies suggest that long-term formaldehyde exposure is associated with increased risk in humans of nasal, mouth, throat and lung cancer, leukemia, and brain cancer.

Evidence suggests that formaldehyde does not cause adverse reproductive or developmental effects. Formaldehyde does not appear in a 1991 report published by the US General Accounting Office (GAO) which lists 30 chemicals of concern because of their reproductive and developmental consequences. TERIS states that the teratogenic risk to a child born after exposure during gestation is none to minimal. Shepard's Catalog of Teratogenic Agents indicates that there is no evidence that formaldehyde is embryotoxic in humans.

Prehospital Management

Inhalation of formaldehyde can cause airway irritation, bronchospasm, and pulmonary edema.
Formaldehyde absorption can cause severe systemic toxicity leading to metabolic acidosis and coma.
There is no specific antidote for formaldehyde poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination. Victims exposed to only formaldehyde gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with formaldehyde-containing solution (formalin) can secondarily contaminate personnel by direct contact or through off-gassing vapor.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with concentrated formaldehyde vapor or formalin is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

Decontamination Zone --

Victims with exposure to only formaldehyde vapor and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with formalin-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Basic Decontamination-

Remove and double-bag contaminated clothing. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Flush liquid-exposed skin and hair with plain water for at least 5 minutes.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of formalin ingestion, do not induce emesis. The effectiveness of activated charcoal is unknown. Administer 1 to 2 glasses of water to dilute stomach contents if the patient is conscious and able to swallow.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Be certain that patients have undergone basic decontamination (see Decontamination Zone above). Patients who have undergone proper decontamination or who have been exposed to only vapor pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Watch for signs of airway swelling and obstruction such as progressive hoarseness, stridor, or cyanosis. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment -

Treat bronchospasm with aerosolized bronchodilators.

Additional Decontamination -

In case of formalin ingestion, do not induce emesis. Administer 1 to 2 glasses of water to dilute stomach contents if it has not been administered in the decontamination zone and if the patient is conscious and able to swallow.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested formalin, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly isolate and clean up vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Patients who have ingested formalin or have obvious injury, such as severe wheezing or dyspnea, or skin or eye burns, should be transported immediately to a medical facility.

Patients with no eye, skin, or throat irritation, or with only mild or transient symptoms, probably did not have a significant exposure and probably will not develop severe complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with instructions to rest and to seek medical care if they develop respiratory difficulty. (See the follow-up instructions on the reverse side of Formaldehyde--Patient Information Sheet.)

Emergency Department Management

Inhalation of formaldehyde can cause airway irritation, bronchospasm, and pulmonary edema.
Formaldehyde absorption can cause severe systemic toxicity leading to metabolic acidosis and coma.
There is no specific antidote for formaldehyde poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination --

Hospital personnel in an enclosed area can be secondarily contaminated by vapors off-gassing from heavily soaked clothing. Patients do not pose a contamination risk after contaminated clothing is removed and the skin is washed.

Decontamination Area --

Patients with exposure to only formaldehyde vapor and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Treat bronchospasm with aerosolized bronchodilators.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapor do not require decontamination unless they have skin or eye irritation.

Since touching clothing or skin wet with formalin may cause bums, ED staff should don chemical-resistant jumpsuits (e.g.,Tyvek, Saranex) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with formalin, quickly remove and double-bag the contaminated clothing and all personal belongings while flushing the skin. Flush exposed skin with copious water (preferably under a shower).

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Basic Decontamination on the preceding page.

ABCs -

Evaluate and support may, breathing, and circulation. Watch for airway compromise. Continuously monitor cardiac rhythm.

Treat hypotension, seizures, and ventricular arrhythmias in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, and drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patents with respiratory complaints. Observe patents in respirator distress for up to 12 hours and periodically reexamine them using chest examinations and other appropriate studies. Follow-up as clinically indicated.

Skin Exposure -

If formalin or high concentrations of formaldehyde vapor were in contact with the skin, chemical bums may result Treat chemical bums as thermal bums.

Eye Exposure -

Ingestion -

Do not induce emesis. If not administered previously, administer water or milk to dilute the formalin in the stomach and minimize corrosive injury. Perform gastric lavage if large amounts of formalin have been ingested and the ingestion has occurred within 30 to 60 minutes of presentation. The effectiveness of activated charcoal in binding formaldehyde is unknown.

Consider endoscopy to evaluate the extent of corrosive injury to the gastrointestinal tract.

Antidotes and Other Treatments -

There is no antidote for formaldehyde poisoning. Hemodialysis is effective in removing formate and methanol and in correcting severe metabolic acidosis.

Metabolic acidosis also can be treated with sodium bicarbonate. Correction of acidosis should be guided by ABGs.

If methanol poisoning due to ingestion of formalin is suspected (serum methanol level of greater than 20 micrograms/dL or elevated osmolar gap), start ethanol infusion. With 10% ethanol, the loading dose is 7.5 mL/kg maintenance dose is 1 to 1.5 mL/kg/h; and maintenance dose during hemodialysis is 1.5 to 2.5 mL/kg/h.

Laboratory Tests -

Useful laboratory studies include CBC, electrolytes, BUN, creatinine, glucose, urinalysis (may see protein, casts, and red blood cells), liver function tests, osmolar gap, and ABGs (to monitor acidosis in severe toxicity). Chest radiography and ABGs may be helpful in cases of inhalation exposure. Plasma formaldehyde levels axe not useful.

Disposition and Follow-up --

Hospitalization should be considered for patients with evidence of systemic toxicity from any route of exposure.

Delayed Effects -

Patients with a history of significant ingestion exposure should be admitted to an intensive care unit for observation (for aspiration pneumonia and renal failure).

Patients with inhalation exposure who complain of chest pain, chest tightness, or cough should be observed and examined periodically for 6 to 12 hours to detect delayed onset pulmonary edema or respiratory failure.

Patient Release -

Patients who are asymptomatic should be observed for 4 to 6 hours, then discharged if no symptoms occur during this period. Advise discharged patients to seek medical care promptly if symptoms develop. (For a list of symptoms, see Formaldehyde--Patient Information Sheet.)

Follow-up -

Patients with eye injury requiring ophthalmic care should be reevaluated in 24 hours.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Formaldehyde Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to formaldehyde gas or solution (formalin).

What is formaldehyde?

Formaldehyde is a nearly colorless, highly irritating gas with a sharp odor. It dissolves easily in water and is found in formalin (a formaldehyde solution containing water), formaldehyde, and methanol (wood alcohol). Formaldehyde is used in the manufacture of plastics, urea-formaldehyde foam insulation, and resins used to make construction materials, paper, carpets, textiles, paint, and furniture.

What immediate health effects may result from formaldehyde exposure? Most people will notice the pungent odor and experience irritation of the eyes, nose, and throat when they breathe the gas, even at low levels for short periods. Longer exposure or higher doses can cause coughing or choking. Severe exposure can cause death from throat swelling or from chemical bums to the lungs. Direct skin contact with formaldehyde containing liquids, such as formalin, may cause bums. Eye exposure to concentrated gas or liquid can cause serious corneal bums. Drinking formalin can cause severe bums to the throat and stomach, and as little as 30 mL (about 2 tablespoons) of formalin can cause death.

What is the treatment for formaldehyde poisoning?

There is no antidote for formaldehyde poisoning, but its effects can be treated and most exposed persons do recover fully. Patients who have had a serious exposure (with signs and symptoms such as tearing eyes, running nose, or severe or persistent coughing) may require close medical observation for 18 hours or more.

Are any future health effects likely to occur?

After a single, small exposure, no delayed or long term effects are likely to occur. After a severe exposure, symptoms may be delayed up to 18 hours. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care. Long-term, repeated exposure to formaldehyde in the workplace may cause cancer of the nasal passages, mouth, lungs, or bone marrow.

What tests can be done if a person has been exposed to formaldehyde? There are no specific blood and urine tests that can indicate a recent exposure to formaldehyde. Generally, the severity of irritation symptoms is the best indicator of the seriousness of the exposure. Blood tests and a chest X ray may be done to evaluate possible lung injury.

Where can more information about formaldehyde be found? More information about formaldehyde may be obtained from your regional poison control center;, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor;, or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Formaldehyde Follow-up Instructions

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough
  * difficulty breathing or shortness of breath
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn
  * fever
  * unexplained drowsiness, fatigue, headache
  * belly pain, vomiting, diarrhea

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Hydrogen Fluoride (HF) and Hydrofluoric Acid

CAS: 7664-39-3; UN 1052 (anhydrous)/UN 1790 (solution) Synonyms include hydrogen fluoride, fluoric acid, hydrofluoride, hydrofluoric acid, and fluorine monohydride.

Victims exposed to HF vapors only do not pose a significant risk of secondary contamination; however, victims whose clothing or skin is contaminated with HF liquid or solution can secondarily contaminate response personnel by direct contact or through off-gassing vapors.
Hydrofluoric acid is a serious systemic poison. Its severe and sometimes delayed health effects are due to deep tissue penetration by the fluoride ion. The surface area of the burn is not predictive of effects.
Most hydrogen fluoride exposures occur by inhalation of the gas and dermal contact with hydrofluoric acid.

Description --

Hydrogen fluoride is a colorless, fuming liquid or gas with a strong, irritating odor. It is usually shipped in cylinders as a compressed gas. HF readily dissolves in water to form colorless hydrofluoric acid solutions; dilute solutions are indistinguishable from water. It is present in a variety of over-the-counter products at a concentration of 6% to 12%.

Although hydrofluoric acid is weak when compared to most other mineral acids, it can produce serious health effects when exposure occurs by any route. These effects are due to the fluoride ion's aggressive, destructive penetration of tissues.

Routes of Exposure --

Inhalation -

Inhalation hazards result not only from exposure to HF gas but also from fumes arising from concentrated HF liquid. Even fairly low airborne concentrations of HF produce rapid onset of eye, nose, and throat irritation.

Skin/Eye Contact -

Most hydrogen fluoride exposures occur by cutaneous contact with hydrofluoric acid. The fluoride ion, which penetrates tissues deeply, can cause both local cellular destruction and systemic toxicity.

Ingestion -

Ingestion of even a small amount of hydrofluoric acid is likely to produce systemic effects and may be fatal.

Properties --

Description: Colorless gas or fuming liquid; weak solutions have the appearance of water.

Warning properties: Disagreeable, pungent odor at <1 ppm; irritation of eyes and throat at 3 ppm

OSHA PEL (permissible exposure limit) = 3 ppm (averaged over an 8-hour workshift)

OSHA STEL (short term exposure limit) = 6 ppm ( 15-minute sample)

NIOSH IDLH (immediately dangerous to life or health) = 30 ppm ERPG-2 (emergency response planning guideline) = 20 ppm

Molecular weight = 20.01 daltons

Boiling point (760 mm Hg) = 67.1 degree F (20 degrees C)

Vapor pressure (34 degrees F) = 400 mm Hg

Vapor density = 0.7 (air = 1)

Miscible with water with release of heat

Nonflammable

Sources/Uses -

HF is primarily an industrial raw material. It is obtained commercially by action of sulfuric acid on the mineral fluorspar. HF is used in separating uranium isotopes, as a cracking catalyst in oil refineries, and for etching glass and enamel, removing rust, and cleaning brass and crystal. It also is used in manufacturing silicon semiconductor chips. Some consumer products that may contain HF include automotive cleaning products (for aluminum, chrome), rust inhibitors, rust removers(for ceramic tubs, sinks, fabrics), and water spot removers.

Health Effects

HF differs from most other mineral acids. In addition to its corrosive effect as an acid, the fluoride ion readily penetrates the skin, causing destruction of deep tissues. Absorption of significant amounts of HF by any route may be fatal.
Often, patients exposed to HF (<20%) initially are asymptomatic; effects can be delayed 12 to 24 hours.
Systemic effects can include hypocalcemia, hypomagnesemia, and hyperkalemia.

Acute Exposure --

Mechanism of injury. The toxic effects of HF are due primarily to the fluoride ion, which is able to penetrate tissues and bind intracellular calcium and magnesium. This results in cell destruction, local bone demineralization, and systemic hypocalcemia, hypomagnesemia, and hyperkaleremia. The effects of HF may continue for several days.

Respiratory -

Inhaled HF mist or vapor affects initially the nasopharynx and eyes. Mild clinical effects include mucous membrane irritation and inflammation, coughing, and bronchospasm. Severe clinical effects include almost immediate laryngospasm and laryngeal edema, resulting in upper airway obstruction. Pulmonary injury may evolve rapidly or may be delayed in onset for 12 to 36 hours. Noncardiogenic pulmonary edema, bronchoconstriction, and atelectasis can occur. Pulmonary effects can result even from splashes on the skin.

Dermal -

Depending on the concentration and duration of exposure, skin contact may produce pain, erythema, and deep, slow-healing burns.

Acid concentrations over 50% (including anhydrous HF) cause immediate severe, throbbing pain and a whitish discoloration of the skin, which usually proceeds to blister formation.

HF solutions from 20% to 50% may produce pain and swelling, delayed by up to 8 hours.

HF solutions of less than 20% cause almost no immediate pain on contact but may cause delayed serious injury 12 to 24 hours after contact.

Ocular -

Mild effects of HF vapor exposure include rapid onset of eye irritation. More severe effects, which may result from even minor hydrofluoric acid splashes, include sloughing of corneal surface epithelium, conjunctival edema, corneal stroma edema, and ischemic necrosis. Potentially permanent corneal opacification may develop immediately or after several days.

Gastrointestinal -

Ingestion of hydrofluoric acid may cause corrosive injury to the mouth, throat, and esophagus. Hemorrhagic gastritis occurs commonly. Nausea, vomiting, diarrhea, and abdominal pain may cur. Systemic effects are likely. Because HF is an acid, metabolic acidosis can occur from acute ingestions. Aspiration may lead to pulmonary complications.

Electrolyte disturbance -

Exposure by any route may result in systemic effects, namely, severe hypocalcemia, hypomagnesemia, and hyperkalemia. Hypotension, cardiac dysrhythmias, tetany, seizures, and death may ensue.

Potential Sequelae -

Survivors of severe inhalation injury may suffer residual chronic lung disease. Healing of skin bums caused by concentrated HF may be prolonged, and extensive scarring loss may result. Fingertip injuries are troublesome with persistent pain, bone loss, and nail bed injury. After eye exposure, prolonged or permanent visual defects, blindness, or total eye destruction may occur. After ingestion, damage to the esophagus and stomach may progress for several weeks. Persistent esophageal strictures may result.

Chronic Exposure --

Repeated ingestion of more than 6 mg of fluoride per day may result in mottling of the teeth in developing children, accumulation of fluoride in the bone (fluorosis), and osteosclerosis in adults and children. Long-term HF exposure has been reported to damage the kidneys and liver.

Carcinogenicity -

The question of whether fluoride can cause cancer is controversial. The findings of a recent NTP study in experimental animals is inconclusive.

Reproductive and Developmental Effects -

Fluoride at low doses is thought to be essential for normal fetal development in humans. There have been rare cases of mottling of deciduous teeth in infants born to mothers who had a high daily intake of fluoride during pregnancy. Skeletal abnormalities due to exposure during prenatal development are considered unlikely. Reproductive effects due to HF are unknown.

Prehospital Management

Victims exposed to only HF gas or vapor do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with HF liquid, solution, or condensed vapors can secondarily contaminate response personnel by direct contact or through off-gassing vapors.
Hydrogen fluoride is a corrosive chemical that can cause immediate or delayed onset of deep penetrating injury. Absorption of fluoride ion can cause hypocalcemia hypomagnesemia, and hyperkalemia, which can result in cardiac arrest.
Rapid decontamination is critical. Calcium-containing gels, solutions, and medications are used to neutralize the effects of hydrogen fluoride.

Hot Zone --

Note. Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with liquid HF, its concentrated vapors, or hydrofluoric acid is possible.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. If victims are unable to walk, remove them on a backboard or gurney. If there is no other means of transport, carefully carry or drag the victim to safety.

Decontamination Zone -

Note. Victims with exposure to only hydrogen fluoride gas or vapor and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone.

Rescuer Protection -

Rescuers in the Decontamination Zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with hydrofluoric acid soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Supplemental oxygen may be administered if available. Establish intravenous access in all seriously symptomatic patients and attach a cardiac monitor. Monitor ECG for prolonged Q-T or QRS interval.

Decontamination -

Rapid decontamination is critical. Remove and double-bag contaminated clothing while flushing exposed skin with water. Patients who are able and cooperative may assist with their own decontamination.

Flush exposed skin and hair with plain water for at least 5 minutes. If available, cover exposed skin with one of the following preparations: (a) calcium-containing slurry or gel (2.5 g calcium gluconate in 100 cc of water-soluble lubricant such as K-Y Jelly) or

(b) aqueous quaternary ammonium salt (Zephiran, 1.3 g in 1 liter of water). (Caution: do not use on face or in eyes.) or
(c) magnesium-containing solution (Maalox, epsom salts).

Flush exposed or irritated eyes with plain water or saline for at least 5 minutes. Remove contact lenses if present.

In case of hydrofluoric acid ingestion, do not induce emesis. Do not administer activated charcoal. If the patient is alert and able to swallow, administer 1 to 2 glasses of water, milk, or a magnesium-containing (Maalox, milk of magnesia) or calcium-containing (Tums) antacid to dilute stomach contents.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Note. Be certain that patients have undergone basic decontamination ( see Decontamination Zone). Patients who have undergone proper decontamination or have been exposed to only gas or vapor pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Establish intravenous access in all seriously symptomatic patients and attach a cardiac monitor. Monitor ECG for prolonged Q-T or QRS interval.

Treat bronchospasm with aerosolized bronchodilators.

Treat coma, seizures, and ventricular dysrhythmias according to ALS protocol.

Advanced Treatment -

Intubate the trachea if indicated (severe respiratory distress, apnea, or throat swelling due to ingestion of HF). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so.

Hypocalcemia (manifested by tetany and dysrhythmias) is probable after ingestion of even small amounts of HF. With medical consultation, treat hypocalcemia with intravenous injections of a 10% solution of calcium gluconate.

If available, administer to inhalation victims 2.5% calcium gluconate (2.5 g of calcium gluconate in 100 mL of water) with oxygen by nebulizer.

Additional Decontamination -

Continue flushing exposed skin for 15 minutes. If either of the treatments recommended in (a) or (b) below is available, water flushing may be reduced to 5 minutes and the treatment should be started immediately. DO NOT USE CALCIUM CHLORIDE for treating skin burns. It will cause extreme pain and may further injure tissues.

(a) Vigorously massage calcium gluconate gel (2.5 g in 100 cc water-soluble lubricant such as K-Y Jelly) into the burned areas. Initially, rubber or latex gloves should be worn by the health care provider to prevent secondary contamination. Continue this procedure until pain is relieved or more definitive care is rendered.

If immersion is not practical, soak towels with the Zephiran solution and use them as compresses for the burned area. Change compresses every 2 to 4 minutes. Exercise caution when using these solutions near the eyes since they are irritating to sensitive tissues. Continue Zephiran treatment until pain is relieved or more definitive care is rendered.

If the eyes are still irritated, flush with water or saline for 3 to 5 minutes. Remove contact lenses if present and continue irrigating the eyes with saline via IV tubing for 10 to 15 minutes or until pain and irritation have resolved. In case of hydrofluoric acid ingestion, do not induce emesis. If the patient is alert and able to swallow, administer 1 to 2 glass of water or milk to dilute stomach contents. Do not administer activated charcoal.

Report to the base station and receiving medical facility condition of the patient, treatment given, and estimated time of arrival at the medical facility. If a patient has ingested hydrofluoric acid, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Immediately transport to a medical facility those patients who have inhaled HF and have upper respiratory irritation or other acute symptoms.

Transport to a Medical Facility -

All persons with serious exposure (i.e., eye exposure, fingertip exposure, or skin exposure greater than the total surface area of the palm) or any evidence of bums (e.g., erythema, pain, or blisters) should be transported to a hospital as soon as possible. Continue skin/eye irrigation or treatment during transport.

Multi-casualty Triage --

Inhalation Exposure -

Patients who have had skin or eye contact with HF should be brought to the attention of a physician as soon as possible since they may have delayed pain and systemic complications.

Skin/Eye Contact -

In cases of ingestion, patients should be transported to a hospital without delay. Watch patients carefully since systemic effects are likely to occur.

Ingestion -

Person s who have had minor or brief exposure to only HF gas or vapor and are initially asymptomatic are not likely to develop complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with follow-up instructions.

Emergency Department Management

Victims exposed to only HF gas or vapor do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with HF liquid or solution can secondarily contaminate personnel by direct contact or through off-gassing vapor.
Hydrogen fluoride is a corrosive chemical that can cause deep penetrating injury. Absorption of fluoride ion can result in hypocalcemia and cardiac arrest. Hypocalcemia should be considered a risk in all instances of inhalation or ingestion and whenever skin burns exceed 25 in(2) (an area about the size of the palm).
Because of HF's rapid skin penetration and the serious toxicity of the fluoride ion, rapid decontamination is critical. Calcium-containing gels, solutions, and medications can be used to neutralize the fluoride ion. The intense pain of HF burns should not be suppressed with local anesthetics since the degree of pain is an indicator of treatment efficacy.

Decontamination Area --

Note. Patients exposed to only hydrogen fluoride gas or vapor and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below. Since contacting HF-soaked clothing or skin can cause burns, ED personnel should don chemical resistant jumpsuits (e.g., of Tyvek, Saranex) or butyl rubber aprons, multiple layers of latex gloves, and eye protection.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Basic Decontamination -

Rapid skin decontamination is critical. If the patient's clothing is soaked, remove and double-bag the clothing while flushing the skin with copious water (preferably under a shower).

Remove contact lenses and irrigate exposed eyes with water for at least 15 minutes or until the pH of the conjunctival fluid is above 7. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids.

Critical Care Area --

Note. Be certain that decontamination has been carried out. See Decontamination Area.

ABCs -

Evaluate and support ABCs. Watch for signs of airway compromise. Monitor heart, renal, and liver functions. Hypocalcemia may cause prolonged Q-T interval and cardiac rhythm abnormalities. Calcium gluconate (2.5 grams of calcium gluconate in 100 mL of water) may be administered with oxygen by nebulizer to victims with severe respiratory distress.

Inhalation Exposure -

Pulmonary edema or edema of the upper airway may occur. Observe the patient for at least 24 hours and monitor with repeated chest examinations, blood gases, and other appropriate tests. Follow up as clinically indicated.

Skin Contact -

If blisters have formed, they should be opened and drained and necrotic tissue debrided prior to treatment; early debridement may facilitate healing.

Two topical treatments that are generally recommended are discussed in (a) and (b) below.

(a) Continuously massage calcium gluconate gel (2.5 grams in 100 mL water soluble lubricant such as K-Y Jelly) into the burned area until the pain is relieved. If used as definitive treatment, the gel should be applied 4 to 6 times daily for 3 to 4 days. Initially, rubber gloves should be worn to protect the health care providers' fingers from secondary contamination. If some relief of pain is not obtained within 30 to 60 minutes, consider Zephiran soaks or calcium gluconate injections.

(b) Some investigators recommend immersing the burned area in an iced (use ice cubes, not shaved ice) solution of a quaternary ammonium salt such as Zephiran (1.3 grams of Zephiran per liter of water). Intermittent immersion for at least 2 hours is recommended. If pain recurs after treatment is stopped, immersion should be continued for another 2 hours. Total treatment of 4 to 6 hours is usually required. If immersion is impractical, compresses soaked with the Zephiran solution and changed every 2 to 4 minutes can be used.

Care must be taken that victims do not suffer frostbite from prolonged immersion. Because quaternary ammonium solutions are very irritating to sensitive tissues, they should not be used on the face, particularly around the eyes or on other sensitive areas.

Severe Burns -

Large burns or deeply penetrating bums (from delayed treatment or exposure to HF concentrations greater than 50%) may require injections of sterile aqueous calcium gluconate into and around the burned area. Authorities in industry currently recommend injections of 5 % calcium gluconate solution using a small gauge needle (#30). Do not inject more than 0.5 mL per cm(2) of affected skin surface. No local infiltration of anesthetic should be used, but in the case of severe bums, regional or general anesthesia may be considered.

DO NOT USE CALCIUM CHLORIDE for treating skin burns. It will cause extreme pain and may further injure tissues.

Hand Exposures -

Subungal (under the nail) bums often do not respond to immersion treatment, The treatments for hand burns require expert assistance; obtain consultation with a poison center, medical toxicologist, or hand surgeon.

Calcium gluconate in very small doses can be injected into the fingers. In some cases, burr holes must be drilled in the nail or the nail must be split or removed (using regional anesthesia) to permit adequate contact with the sequestering agent. Care must be used since multiple injections into the fingers can lead to pressure necrosis. Patients who have received multiple injections of calcium gluconate in skin that has compromised integrity may have an increased risk of infection. Consider the use of antibiotic creams such as Silvadene or Garamycin in these cases.

An alternative to intradermal injection is infusion of calcium gluconate or calcium chloride (10 mL of 10% solution in 40 mL of normal saline) into the radial artery over 4 hours. (A recent study in which this alternative was used for HF burns can be found in Siegel DC, Heard JM. Intra-arterial calcium infusion for hydrofluoric acid burn. Aviation, Space, and Environmental Medicine, 1992;March:206-211.)

Eye Contact -

Do not use oils, salves, or ointments for injured eyes. Do not use Zephiran or the gel form of calcium gluconate in eyes as described for skin.

Irrigate exposed eyes with a 1% aqueous solution of calcium gluconate (50 mL Of 10% solution in 450 mL of sterile saline) using a nasal prong or Morgan Therapeutic Lens. Up to 500 mL over 1 to 2 hours may be used. If calcium gluconate is not available, use normal saline for irrigation.

A topical anesthetic can minimize the tendency for eyelid closure and facilitate insertion of an irrigation lens. One or two drops of proparacaine or tetracaine will usually provide rapid-onset ocular anesthesia for 20 minutes to an hour. If exposure was minor, perform visual acuity testing and examine the eyes for corneal damage using fluorescein and a slit lamp. In cases of significant exposure, an ophthalmologist should be consulted immediately. Do not give emetics and do not administer activated charcoal.

Ingestion -

If it has not been administered previously and if the patient is conscious and alert, immediately give 1 to 3 glasses of water to dilute the acid. Orally administer a one-time dose of several ounces of Mylanta, Maalox, or milk of magnesia; the magnesium in these products may act to chemically bind the fluoride in the stomach. Consider gastric lavage using a small lumen tube. Consider endoscopic examination to evaluate the extent of damage. Extreme throat swelling may cause airway obstruction, which may require endotracheal intubation or cricothyroidotomy.

Systemic Toxicity -

Serum calcium, potassium, and magnesium levels must be monitored. Treat hypocalcemia using calcium gluconate infusions. Infusions can be repeated until serum calcium, ECG changes or symptoms improve. Treat hypomagnesemia with 1 to 2 grams of magnesium.

Disposition and Follow-up -

Patients who fall to respond to treatment with diminished pain and those with respiratory distress, ingestion exposure, finger-tip or eye bums, or significant skin burns should be admitted to an intensive care unit and carefully watched for 24 hours. (Significant skin burns are those covering an area greater than the palm of a hand, or causing skin changes, or producing pain within 1 hour of exposure.) ECG monitoring may aid in determining treatment need and effectiveness.

Patient Release -

Eye contact victims with no signs of irritation after treatment do not require hospitalization.

Patients in the ED with bums covering less than an area equivalent to the palm of the hand and with normal serum calcium level s, who have responded to treatment, can be discharged for outpatient follow-up after remaining stable for at least 6 hours. They should be advised to seek medical care promptly if pain recurs (see the reverse side of Hydrogen Fluoride--Patient Information Sheet).

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, contact the employer or OSHA for assistance in evaluating workplace conditions. An appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from NIOSH. See Appendix Ill for a list of these and other agencies that may be of assistance.

Hydrogen Fluoride and Hydrofluoric Acid Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to hydrogen fluoride gas or hydrofluoric acid solution or vapor.

What is hydrogen fluoride?

Hydrogen fluoride (HF) is a colorless, highly irritating gas with a pungent odor. It easily dissolves in water to form hydrofluoric acid. In addition to some industrial products, over-the- counter products that contain HF include rust removers, water spot removers, and chrome cleaners.

What immediate health effects may result from exposure to hydrogen fluoride?

Most poisoning occurs when hydrogen fluoride gets on the skin or in the eyes. Concentrated HF solutions can cause severe deep and disfiguring burns and absorption of the chemical into the body can cause the heart to beat irregularly and death. Although exposure to concentrated HF solutions (greater than 60%) causes immediate burning, exposure to more dilute solutions (less than 20%) may cause few or no symptoms at first but may be followed by severe pain later. Drinking hydrofluoric acid can cause severe bums to the throat and stomach, and even death.

Injury also can occur from breathing HF gas or the vapor from concentrated HF solutions. With small doses, few or no symptoms may occur at first. With larger doses, however, most people will notice a sharp odor and their skin, eyes, nose, and throat will bum. Breathing high concentrations of HF vapor can cause rapid death from throat swelling or from chemical burns to the lungs.

What is the treatment for hydrogen fluoride poisoning? Patients who have experienced serious symptoms (such as severe or persistent coughing or skin or eye burns) may need to be hospitalized for several hours. Calcium- or magnesium-containing medicines may be used to treat the skin, and doctors may even inject calcium-containing medicines into burned areas or into the blood to neutralize the fluoride that causes the injury.

Are any future health effects likely to occur?

After a single, small exposure, no delayed or long-term effects are likely to occur. After a severe exposure, you may not notice any symptoms for up to 36 hours. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care. Scarring may occur from skin contact with HF.

What tests can be done ira person has been exposed to HF? The doctor may order blood tests, urine tests, chest X ray, and a heart monitoring test to see if damage has been done to the heart, lungs, or other organs. Testing is not needed in every case. If HF contacts the eyes, the doctor may put an orange dye into them and examine them with a magnifying lamp. If hydrofluoric acid is swallowed, the doctor may administer a solution containing calcium or magnesium.

Where can more information about hydrogen fluoride be found? More information about hydrogen fluoride or hydrofluoric acid may be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help in locating these telephone numbers.

Hydrogen Fluoride and Hydrofluoric Acid Follow-up Instructions --

Follow only the instructions checked below. Please bring this page with you
to your next appointment.

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 3 days:

  * difficulty breathing or shortness of breath
  * chest pain
  * wheezing
  * hoarseness, high-pitch voice, or difficulty speaking
  * fever
  * any skin changes or discharge where skin is burned
  * belly pain, vomiting, diarrhea

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 72 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Hydrogen Peroxide (H(2)O(2))

CAS:7722-84-1; UN 2984(8-20%); 2014 (20-52%); 2015 (>52%) Synonyms of hydrogen peroxide include dihydrogen dioxide, hydrogen dioxide, hydroperoxide, and peroxide.

Victims exposed to only hydrogen peroxide gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with concentrated hydrogen peroxide solution can secondarily contaminate personnel by direct contact or through off-gassing vapor.
Hydrogen peroxide is a powerful oxidizing agent. When it contacts organic material, spontaneous combustion can occur.
Hydrogen peroxide is used commonly in aqueous solutions, which poses an inhalation and contact danger.

Description -

Pure hydrogen peroxide is a crystalline solid below 12 degrees F and a colorless liquid with a bitter taste above 12 degrees F. It is almost always used as an aqueous solution, which is available in dilute form (3% to 10%) for household use and in concentrated form (>30%) for industrial use. Hydrogen peroxide is unstable, decomposing readily to oxygen and water with release of heat. Commercial products contain a stabilizer (usually acetanilide) to slow the rate of spontaneous decomposition.

Hydrogen peroxide is nonflammable, but it is a powerful oxidizing agent that can cause spontaneous combustion of any organic material it contacts.

Routes of Exposure --

Inhalation -

Inhalation of vapors, mists, or aerosols from concentrated solutions of hydrogen peroxide can cause significant morbidity. Because it is nearly odorless and nonirritating except at high concentrations, persons may not be aware of its presence. Odor is not a reliable indicator of hydrogen peroxide's presence and may not provide adequate warning of dangerous concentrations. Hydrogen peroxide vapors are heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Hydrogen peroxide is poorly absorbed through intact skin. When used for household disinfectant purposes (3% to 5%), it is mildly irritating to the skin and mucous membranes. At concentrations of 10%, which is found in some hair-bleaching solutions, is strongly irritating. Solutions >20% are potentially corrosive.

Ingestion -

If ingested, dilutions of hydrogen peroxide up to 9% are generally nontoxic; however, even a 3% solution is mildly irritating to mucosal tissue and may cause vomiting and diarrhea. Ingestion of industrial strength solutions has been associated with fatalities.

Sources/Uses -

In industry, hydrogen peroxide is used as a bleach for textiles and paper, as a component of rocket fuels, and as a reagent for producing foam rubber and organic chemicals. In the home, dilute hydrogen peroxide solutions are used as disinfectants, deodorants, and as hair bleaching agents.

Properties of Hydrogen Peroxide --

Appearance: Colorless liquid at room temperature; used commonly in aqueous solution

Warning properties: Odor is inadequate as index of exposure; irritating at high concentrations

OSHA PEL (Permissible Exposure Limit) = 1 ppm (averaged over an 8-hour workshift)

NIOSH IDLH (Immediately Dangerous to Life or Health) = 75 ppm Molecular weight = 34.0

Boiling point (760 mm Hg) = 286 degrees F (141 degrees C)

Freezing point = 12 degrees F (-11.l degrees C)

Vapor pressure (86 degrees F) = 5 mm Hg

Vapor density = 1.2 (air = 1 )

Very water soluble

Nonflammable, but a powerful oxidizer;, may ignite any organic matter it contacts

Health Effects

Inhaled hydrogen peroxide can cause upper respiratory tract and mucous membrane irritation. Pulmonary edema also can occur.
Ingestion of concentrated hydrogen peroxide solutions may cause corrosive burns of the oropharyngeal, esophageal, and gastric linings. Rapid production of oxygen in the stomach can cause gastric distention. Gastric perforation may occur, although this is rare.

Acute Exposure --

Respiratory -

Depending on concentration, vapors, mists, or aerosols can ca use upper airway irritation, rhinitis, hoarseness, shortness of breath, and burning chest tightness. High-dose exposure can result in severe mucosal congestion of the trachea and bronchi and delayed onset pulmonary edema.

Neurologic -

Severe high-dose inhalation results in systemic poisoning with prominent CNS effects including headache, dizziness, tremors, numbness, hyperreflexia, loss of consciousness, and seizures.

Dermal -

Prolonged exposure to concentrated vapor or to dilute solutions can cause irritation and temporary bleaching of skin and hair. Contact with concentrated solutions can cause severe bums with blistering.

Ocular -

Exposure to concentrated vapor, mist, or aerosol can cause stinging pain and lacrimation. Splash contact with solutions that are 5% or greater can cause corneal injury, sometimes with delayed effects.

Gastrointestinal -

Ingestion of household solutions usually causes mild mucosal irritation and vomiting. Gastric distention due to liberation of oxygen in the stomach may occur, but hollow viscus rupture is uncommon when dilute solutions are ingested. Ingestion of concentrated solutions, however, can be more devastating. Extreme irritation, inflammation, and burns of the alimentary tract can occur and hollow viscus distention and rupture is a significant danger. Hydrogen peroxide enemas have caused colonic rupture, intestinal gangrene with gas embolization, and fulminant acute ulcerating colitis.

Potential Sequelae -

Survivors of severe inhalation injury may sustain

permanent lung damage. Severe eye exposures may result in corneal ulceration and blindness.

Chronic Exposure --

Because hydrogen peroxide is rapidly decomposed by catalase in the body, it is unlikely to cause systemic or chronic toxicity. However, repeated exposures to hydrogen peroxide vapor may cause chronic irritation of the respiratory tract and atelectasis. Repeated contact with vapor or solution may result in bleaching of skin and hair.

Hydrogen peroxide is unlikely to cross the placenta to cause a direct risk to the unborn. However, if maternal respiration were severely compromised as a result of-hydrogen peroxide exposure, there could possibly be an indirect effect on the ferns.

Prehospital Management

Hydrogen peroxide vapor causes upper respiratory and mucous membrane irritation. Swallowing a concentrated solution can cause vomiting and corrosive burns, gastric distention, and even rupture.
There is no specific antidote for hydrogen peroxide poisoning. Treatment requires supportive measures.

Potential for Secondary Contamination --

Victims exposed to only hydrogen peroxide vapor do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with concentrated hydrogen peroxide solution can secondarily contaminate personnel by direct contact or through off-gassing vapor.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with hydrogen peroxide solution or concentrated vapor is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone Ira victim is unable to walk, remove him or her on a backboard or gurney. If there is no means of transport, carefully drag the victim out.

Decontamination Zone --

Victims with exposure to only vapors of hydrogen peroxide or to dilute solutions (3% to 5% [household strength]) and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with concentrated liquid soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if traumas suspected. Supplemental oxygen can be administered if available. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Basic Decontamination -

Rapid skin decontamination is critical. Remove and double-bag contaminated clothing. Patients who axe able and cooperative may remove their own clothing and assist with basic decontamination.

Flush liquid-exposed skin and hair with plain water for at least 5 minutes.

Flush exposed or irritated eyes with plain water or saline for at least 5 minutes. Remove contact lenses if present.

In case of hydrogen peroxide ingestion, do not induce emesis. Administer a glass of plain water or milk to dilute stomach contents if the patient is conscious and able to swallow. The effectiveness of activated charcoal to absorb hydrogen peroxide is unknown.

Patient Transfer -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

ABCs -

Advanced Treatment -

Intubate the trachea if indicated (severe respiratory compromise or apnea). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so. Treat wheezing and bronchospasm with aerosolized bronchodilators.

Additional Decontamination -

If skin or eyes remain irritated, flush with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of hydrogen peroxide ingestion, do not induce emesis. Administer a glass of water or milk to dilute stomach contents flit was not given in the Decontamination Zone and ff the patient is conscious and able to swallow. The effectiveness of activated charcoal to absorb hydrogen peroxide is unknown.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested hydrogen peroxide, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Patients with obvious injury, such as severe wheezing or dyspnea or skin or eye bums, should be transported immediately to a medical facility. Patients who have ingested hydrogen peroxide solutions (except minor ingestions of household strength solutions of 3% to 5%) should also be transported for medical evaluation.

Persons with no eye, skin, or throat irritation or with mild or transient symptoms are unlikely to develop severe complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with advise to rest and to seek medical care if symptoms of toxicity develop.

Emergency Department Management

Concentrated hydrogen peroxide vapors can cause upper respiratory and mucous membrane irritation. Swallowing concentrated solution can cause vomiting and corrosive burns, gastric distension and even rupture.
There is no specific antidote for hydrogen peroxide poisoning. Treatment requires supportive measures.

Potential for Secondary Contamination --

Decontamination Area --

Patients with exposure to only vapors of hydrogen peroxide and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Monitor cardiac rhythm.

Treat CNS compromise and seizures in the conventional manner.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapors do not require decontamination unless they have skin or eye irritation.

Since contacting clothing or skin wet with concentrated hydrogen peroxide may cause bums, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek*, Saranex*) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with hydrogen peroxide, quickly remove and double-bag the contaminated clothing and all personal belongings. Flush the exposed skin with copious water (preferably under a shower).

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Basic Decontamination.

ABCs -

Evaluate and support airway, breathing, and circulation. Continuously monitor cardiac rhythm. Treat hypotension and seizures in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, and drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints.

Skin Exposure -

If concentrated hydrogen peroxide solution was in contact with the skin, chemical bums may result. Treat chemical bums as thermal bums.

Eye Exposure -

If hydrogen peroxide was splashed in the eyes, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp

and fluorescein staining. Small corneal defects may be treated with topical

ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion -

Do not induce emesis because of the risk of corrosive injury. The effectiveness of activated charcoal and cathartics is unknown. Offer the alert patient 1 to 2 glasses of water or milk to dilute stomach contents if it has not been given previously and if the patient is conscious and able to swallow.

Antidotes and Other Treatments -

Large ingestions may produce gastritis from hydrogen peroxide decomposition,

which releases large volumes of oxygen and causes gastric distention. Gently place a small nasogastric tube to relieve distention or to lavage an obtunded patient. Most ingestions of dilute hydrogen peroxide are benign, and mild irritation is self limited. There is no proven antidote for hydrogen peroxide poisoning. Enhanced elimination methods are neither necessary nor effective.

Laboratory Tests -

Useful laboratory tests include CBC, electrolytes, and glucose. Chest radiography and ABGs may be helpful in patients suffering from inhalation exposure.

Disposition and Follow-up --

Consider hospitalization for symptomatic patients who have a history of significant inhalation exposure and patients who having ingested a concentrated solution.

Delayed Effects -

Patients with complaints of chest pain, chest tightness, or cough should be observed for 24 to 72 hours and reexamined periodically to detect delayed onset pulmonary edema or respiratory failure.

Patient Release -

Asymptomatic patients should be observed for 4 to 6 hours and discharged if no symptoms occur during this period. Advise discharged patients to seek medical care promptly if symptoms develop.

Follow-up -

Patients who require ophthalmic care should have their eyes evaluated within 24 hours.

Reporting --

If a work-related incident has occurred, you may be legally required to file

a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH. See Appendix XX for a list of these and other agencies that may be of assistance.

Hydrogen Peroxide Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to hydrogen peroxide liquid or vapor.

What is hydrogen peroxide?

Hydrogen peroxide is a strong oxidizing agent used widely in industry to bleach cloth and paper and to manufacture other chemicals. It also is an ingredient of some rocket fuels. Hydrogen peroxide is most often used as a liquid dissolved in water. It is found in dilute form (3% to 10%) in the home and in concentrated form (30% or greater) in industry. In the home, 3% solutions of hydrogen peroxide are used as disinfectants for cuts and scrapes, and slightly more concentrated

solutions (10%)' are used in hair bleaches. Dilute solutions have almost no odor but stronger solutions have a sharp odor similar to that of ozone.

What immediate health effects may result from hydrogen peroxide exposure? Most serious exposures to hydrogen peroxide are from concentrated solutions (10% or greater) and may occur after breathing the vapors, contacting the skin, or by accidental swallowing. Depending on the concentration, hydrogen peroxide vapor can cause eye and throat irritation, coughing, and breathing difficulty. Direct contact with concentrated vapors or solutions can cause serious eye or skin bums and bleaching of the haft. Since an odor is present only at high concentrations, the presence or absence of odor is not a good measure of exposure. Drinking a concentrated hydrogen peroxide solution can cause vomiting and severe burns of the throat and stomach.

What is the treatment for hydrogen peroxide poisoning? There is no proven antidote for hydrogen peroxide poisoning, but its effects can be treated and most persons do recover fully. Persons who have experienced serious symptoms may need close medical observation for up to 72 hours. Are any future health effects likely to occur? After a single, small exposure with quick recovery, delayed or long-term effects are unlikely to occur. After a severe exposure, symptoms may be delayed up to 72 hours. The instructions on the reverse side of this page list some signs and symptoms to watch for--if any of them occur, seek medical care.

What tests can be done if a person has been exposed?

There are no specific blood and urine tests that can indicate exposure to hydrogen peroxide. However, blood tests and a chest X ray may be used to evaluate lung injury. Generally, the severity of irritation symptoms are the best measure of the seriousness of the exposure.

Where can more information about hydrogen peroxide be obtained? More information about hydrogen peroxide may be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor, or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Hydrogen Peroxide Follow-up Instructions

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough
  * difficulty breathing or shortness of breath
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn
  * fever
  * unexplained drowsiness, fatigue, headache
  * belly pain, vomiting, diarrhea
  
( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Hydrogen Sulfide (H(2)(S))

CAS: 7783-06-4; UN 1053

Synonyms of hydrogen sulfide include dihydrogen sulfide, sulfur hydride, sulfuretted hydrogen, "sewer gas," and "stink damp."

Hydrogen sulfide is a highly flammable and explosive gas produced naturally by decaying organic matter and by certain industrial processes.
Hydrogen sulfide has a characteristic rotten-egg odor; however, olfactory nerve paralysis may occur, which makes odor an unreliable warning property.

Description --

Hydrogen sulfide is a colorless, flammable, highly toxic gas. It is shipped as a liquefied, compressed gas. It has a characteristic rotten egg odor that is detectable at concentrations as low as 0.0 2 ppm.

Routes of Exposure --

Inhalation -

Inhalation is the major route of hydrogen sulfide exposure. The gas is absorbed rapidly by the lungs. Although its strong odor is readily identified, olfactory nerve paralysis occurs at persistent low concentrations and at high concentrations. For this reason, odor is not a reliable indicator of hydrogen sulfide's presence and may not provide adequate warning of dangerous concentrations. Hydrogen sulfide is slightly heavier than air and may accumulate in enclosed, poorly ventilated, and low-lying areas.

Skin/Eye Contact -

Prolonged exposure to hydrogen sulfide, even at relatively low levels, may result in painful dermatitis and burning eyes. Direct contact with the liquefied gas can cause burns and frostbite. Absorption through intact skin is minimal.

Ingestion -

Since hydrogen sulfide is a gas at room temperature, ingestion is unlikely to occur.

Sources/Uses -

Hydrogen sulfide is produced naturally by decaying organic matter and is released from sewage sludge, liquid manure, sulfur hot springs, and natural gas. It is a byproduct of many industrial processes including petroleum refining, tanning, mining, wood pulp processing, rayon manufacturing, sugar beet processing, and hot asphalt paving. Hydrogen sulfide is used to produce elemental sulfur, sulfuric acid, and heavy water for nuclear reactors.

Properties of Hydrogen Sulfide -

Appearance: Colorless gas with odor of rotten eggs

Warning properties: Undependable; characteristic rotten-egg odor detectable at about 0.02 ppm, but olfactory nerve paralysis occurs in 2 to 15 minutes at 100 to 150 ppm

OSHA PEL (Permissible Exposure Limit) = 10 ppm (averaged over an 8-hour workshift)

OSHA STEL (Short Term Exposure Limit ) = 15 ppm (15-minute sample)

NIOSH IDLH (Immediately Dangerous to Life or Health) = 300 ppm

AIHA ERPG-2 = 30 ppm

Molecular weight = 34.1

Boiling point (760 mm Hg) = -77 F (-60.6 (7)

Vapor pressure (67 F) = > 760 mm Hg

Vapor density = 1.2 (air = 1 )

Slightly water soluble (0.4% at 20 C)

Highly flammable and explosive between 4% and 44% (concentration in air); may travel to a source of ignition and flash back

Health Effects

Hydrogen sulfide can be rapidly fatal. It can paralyze the respiratory control center in the brain and inhibit cellular respiration.
Hydrogen sulfide is a mucous membrane and respiratory tract irritant; pulmonary edema, which may be immediate or delayed, can occur alter exposure to high concentrations.

Acute Exposure --

Acute Exposure Hydrogen sulfide's mechanism of toxicity is similar to that of cyanide inhibition of the cytochrome oxidase system resulting in cellular asphyxia. Metabolic acidosis can occur secondary to anaerobic metabolism. Hydrogen sulfide is also a mucous membrane and respiratory tract irritant.

Nervous system -

Upon exposure to hydrogen sulfide, the central nervous system suffers the most immediate and significant insult. At high concentrations, only a few breaths can lead to loss of consciousness, respiratory paralysis, seizures, and death. CNS stimulation may precede significant depression. Stimulation manifests as excitation, tachypnea, and headache; depression manifests as staggering gait, dizziness, and unconsciousness, possibly progressing to respiratory paralysis and death. In addition, olfactory nerve paralysis occurs at 100 to 150 ppm.

Respiratory -

Inhaled hydrogen sulfide affects initially the nasopharynx. Low concentrations (< 50 ppm) can produce rapid irritation of the nose, throat, and lower respiratory tract. Pulmonary manifestations include cough, dyspnea, and hemoptysis. Higher concentrations can provoke bronchitis and pulmonary edema, which may be immediate or delayed for 24 hours or more. Hypoxia may result in cyanosis.

Cardiovascular -

High-dose exposures may cause myocardial depression, dysrhythmias, and conduction abnormalities.

Renal -

Transient renal effects include hematuria, cylindruria, and proteinuria. Renal failure as a direct toxic effect of hydrogen sulfide has not been described, although it can occur secondary to cardiovascular compromise.

Gastrointestinal -

Symptoms may include nausea and vomiting.

Ocular-

Irritation may cause keratoconjunctivitis and corneal opacity. Symptoms include blurting of vision, photophobia, and blepharospasm.

Dermal -

Potential Sequelae Prolonged or massive exposure may cause burning, itching , erythema, and painful dermatitis.

Potential Sequelae -

Bronchopneumonia can be a late development. Survivors of severe exposure may suffer psychic disturbances and permanent damage to the brain and heart.

Chronic Exposure --

Hydrogen sulfide does not accumulate in the body. Nevertheless, repeated or prolonged exposure has been reported-to cause hypotension, headache, nausea, loss of appetite, weight loss, impaired gait, conjunctivitis, and chronic cough. Neurologic symptoms including psychological disorders have been associated with chronic exposure.

No studies on the possible carcinogenic activity of hydrogen sulfide were found.

Reports in which human reproductive and developmental effects were noted involved mixed exposures. Hydrogen sulfide is not listed in TERIS or in Shepard's Catalog of Teratogenic Agents. It also is not included in a 199 1 report published by the U.S. General Accounting Office, which lists 30 chemicals of concern because of their reproductive and developmental consequences. In the absence of maternal toxicity, reproductive and developmental consequences appear unlikely to occur.

Prehospital Management

Hydrogen sulfide is a highly toxic gas that can produce respiratory irritation, rapid CNS and respiratory depression.
There are no proven antidotes for hydrogen sulfide poisoning. Treatment requires aggressive supportive measures.

Potential for Secondary Contamination --

Victims exposed to only hydrogen sulfide gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves is not required for brief entry for victim rescue. If prolonged exposure in the Hot Zone is anticipated, chemical-protective clothing is recommended to prevent dermatitis.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

Decontamination Zone --

Victims with exposure to only hydrogen sulfide gas and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination.

Rescuer Protection -

Rescuers in the decontamination zone require no specialized protective gear since patients exposed to hydrogen sulfide gas pose no serous risk of causing secondary contamination.

ABCs -

Basic Decontamination -

Remove and double-bag contaminated clothing. Patients who axe able and cooperative may remove their own clothing and assist with basic decontamination.

Flush exposed skin and hair with plain water for 2 to 3 minutes. Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

Patient Transfer -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

ABCs -

Advanced Treatment -

Additional Decontamination -

If skin or eyes remain irritated, flush with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

All patients with potentially significant exposure should be evaluated at a medical facility.

Currently asymptomatic patients with a history transient eye, nose, or throat irritation or dizziness or nausea may be released from the scene after recording their names, addresses, and telephone numbers. They should be encouraged to rest and to seek medical care if symptoms of toxicity develop.

Emergency Department Management

Hydrogen sulfide is a highly toxic gas that can produce respiratory irritation, rapid CNS and respiratory depression.
There are no proven antidotes for hydrogen sulfide poisoning. Treatment requires aggressive supportive measures.

Potential for Secondary Contamination --

Hospital personnel away from the scene are at little risk of secondary contamination from patients exposed to only hydrogen sulfide gas; however, personnel can be secondarily contaminated by contacting or breathing vapors from clothing heavily soaked with hydrogen sulfide-containing solution.

Decontamination Area --

Patients with exposure to only hydrogen sulfide gas and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Monitor cardiac rhythm.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Remove and double-bag the contaminated clothing and all personal belongings. Flush the exposed skin with copious water (preferably under a shower).

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Decontamination area.

ABCs -

Evaluate and support airway, breathing, and circulation. Continuously monitor cardiac rhythm.

Assess and treat hypotension and seizures in the conventional manner. Patients with significant and persistent CNS depression should be evaluated

for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, and drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints and observe them for 24 hours using repeated chest examinations and other appropriate tests. Follow-up as clinically indicated.

Skin Exposure -

If concentrated hydrogen peroxide solution was in contact with the skin, chemical bums may result. Treat chemical bums as thermal bums.

Eye Exposure -

Antidotes and Other Treatments -

Theoretically, administration of nitrites to produce methemoglobinemia may promote conversion of systemic sulfide ion to sulfhemoglobin, which is far less toxic. However, there is only anecdotal evidence that nitrite therapy is effective and victims of hydrogen sulfide poisoning have survived without sequelae after supportive care alone. Furthermore, the usefulness of nitrite therapy given late in the course of management (beyond the first few minutes after exposure) is questionable. For adults, the reported dose is 10 to 15 mL of an IV solution of 3% sodium nitrite infused over at least 5 minutes. For children, the reported dose is O. 15 to 0.2 mL/kg, not to exceed 10 mL, infused over at least 5 minutes.

Hyperbaric oxygen therapy is controversial and based on anecdotal evidence. It may be efficacious in patients in whom other treatments were unsuccessful.

Laboratory Tests -

Useful laboratory studies include CBC, electrolytes, glucose, renal function tests, and liver function tests. Arterial blood gases and chest radiography may be helpful in cases of inhalation exposure.

Disposition and Follow-up --

Delayed Effects -

Patients who suffer unconsciousness or hypotension should be observed closely for complications including post hypoxic encephalopathy. Because pulmonary edema may be delayed, seriously exposed patients with inhalation exposure should be monitored for 24 hours. If pulmonary edema is suspected, admit patients to an intensive care unit.

Patient Release -

Asymptomatic patients with no evidence of pulmonary edema or CNS or respiratory compromise and with no signs of eye irritation, may be discharged after 4 to 6 hours of observation. These patients should be instructed to return to the ED if symptoms of toxicity develop.

Follow-up -

Patients exposed to hydrogen sulfide should be monitored for possible damage to the heart and brain, including evaluation for neurologic deficits.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Hydrogen Sulfide Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to hydrogen sulfide.

What is hydrogen sulfide?

Hydrogen sulfide is a highly toxic, colorless gas with a rotten-egg odor. It is produced naturally by decaying organic matter and is released from sewage sludge, liquid manure, sulfur hot springs, and natural gas. It is used in several industries and is a by-product of many industrial processes such as oil refining, mining, and rayon manufacturing.

What immediate health effects may result from hydrogen sulfide exposure? Hydrogen sulfide has a strong rotten-egg odor even at low concentrations. However, with continued exposure and at high levels, the poison may deaden a person's sense of smell, making the individual unaware that he or she continues to be exposed to hydrogen sulfide. If the rotten egg odor is no longer noticeable, it may not necessarily mean that exposure has stopped. After a serious exposure, symptoms usually begin immediately. At low levels, hydrogen sulfide causes irritation of the eyes, nose, and throat. Moderate levels can cause headache, dizziness, nausea, and vomiting, as well as cough and breathing difficulty. Higher levels can cause shock, convulsions, coma, and death.

What is the treatment for hydrogen sulfide poisoning?

The main treatment is to remove the victim from exposure and give fresh air and oxygen, and to take the person to an emergency medical facility for evaluation. There is no proven specific antidote for hydrogen sulfide poisoning.

Are any future health effects likely to occur?

After a single, small exposure with quick recovery, no delayed or long term effects are likely to occur. After a serious exposure that causes coma or convulsions, damage may have been done to the brain and heart.

What tests can be done if a person has been exposed to hydrogen sulfide? Specific tests for the presence of hydrogen sulfide in blood and urine are not medically useful. If a severe exposure has occurred, blood, urine, and other tests may show if damage has been done to the brain, nerves, heart, kidneys, or liver. If hydrogen sulfide was inhaled, blood tests and a chest X ray may be necessary to determine if the lungs have been injured. Testing is not needed in every case. Generally, the severity of symptoms is the best measure of the seriousness of the exposure.

Where can more information about hydrogen sulfide be found? More information about hydrogen sulfide may be obtained from your regional poison control center; your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Hydrogen Sulfide Follow-up Instructions

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough, wheezing, difficulty breathing or shortness of breath
  * chest pain
  * increased redness, pain, or pus-like discharge in the area of a skin
  * headache
  * memory loss or personality changes
  * belly pain, vomiting, diarrhea

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Methyl Bromide (CH(3)Br)

CAS: 74-83-9; UN 1062

Synonyms include bromomethane, monobromomethane, and iscobrome.

Victims exposed to methyl bromide gas only do not pose a significant risk of secondary contamination. However, victims whose clothing or skin is contaminated with liquid methyl bromide (temperatures less than 38.5 degrees F) can secondarily contaminate personnel by direct contact or through off-gassing vapor.
A gas at room temperature, methyl bromide readily penetrates skin, cloth, and other protective materials such as rubber and leather.
Because methyl bromide is odorless and nonirritating, a lacrimator is often added as a warning agent.

Description --

Methyl bromide is a colorless gas at room temperature and a colorless liquid below 38.5 degrees F (3.6 degrees C). It is usually shipped as a liquefied, compressed gas. It is odorless and nonirritating at low concentrations and has a musty or fruity odor at high concentrations. Because of its poor physiologic warning properties, up to 2% chloropicrin, a lachrimator, often is added as a warning agent.

Routes of Exposure --

Inhalation -

Most exposures occur by inhalation and by absorption through the skin. Odor is not an adequate indicator of the presence of pure methyl bromide and does not provide reliable warning of dangerous concentrations. Because pure methyl bromide lacks adequate warning properties, significant exposure can occur before the onset of symptoms.

Methyl bromide is 3 times heavier than air and can accumulate in poorly ventilated or low-lying areas. Under adverse conditions, it can remain in the air for days after application as a fumigant. Fatalities have occurred after clean-up operations and after premature reentry into fumigated buildings, as well as during the application process.

Skin/Eye Contact -

Methyl bromide gas easily penetrates cloth and protective clothing (e.g., cloth, rubber, and leather). Prolonged retention in clothing and rubber boots may lead to chemical dermatitis and severe burns. Skin absorption may contribute to systemic toxicity.

Ingestion -

Ingestion of methyl bromide is unlikely since it is a gas at room temperature.

Properties --

Description: Colorless gas at room temperature; colorless liquid below 38.5 degrees F

Warning properties: Inadequate; musty or fruity odor at greater than 1000 ppm; eye and throat irritation at greater than 500 ppm OSHA PEL (permissible exposure limit) = 5 ppm (averaged over an 8-hour workshift) [Skin]

NIOSH IDLH (immediately dangerous to life or health) = 2000 ppm Molecular weight = 95.0 daltons

Boiling point (760 mm Hg) = 38.5 degrees F (3.6 degrees C)

Freezing point = -137 degrees F (-94 degrees C)

Vapor pressure at 67 degrees F (20 degrees C) = 1420 mm Hg

Gas density = 3.3 (air = 1)

Water-soluble (2% at 67 degrees F)

Flammable but only in the presence of a high energy ignition source

Flammable range is 10% to 16% (concentration in air)

Sources/Uses --

Methyl bromide is produced by adding sulfuric acid to a mixture of sodium bromide and methyl alcohol. It is used primarily as a space, structural, and commodity pesticidal fumigant. It also is used as a methylating agent, low-boiling solvent, and oil extractant in chemical syntheses. Less toxic chemicals have replaced it as a refrigerant and fire extinguisher constituent.

Health Effects

Methyl bromide is a neurotoxic gas that can cause convulsions and coma.
Exposure to high concentrations of pure methyl bromide may cause irritation of the eyes and nose, pneumonitis, and pulmonary edema. Lachrimators that are added to methyl bromide to provide warning of its presence also can cause these symptoms, even at low concentrations.
Skin contact with high vapor concentrations or with liquid methyl bromide can result in systemic toxicity and may cause stinging pain and vesiculation.

Acute Exposure --

Mechanism of Injury. Methyl bromide methylates the sulfhydryl groups of complex enzymes, causing cellular disruption and reduced glutathione levels. Cellular disruption, primarily in the central nervous system (CNS), results in progressive dysfunction. In sublethal poisoning, a latency period of 2 to 48 hours can occur between exposure and onset of symptoms.

Neurologic -

The most serious effects of acute inhalation exposure involve the CNS. Depending on the concentration and duration of exposure, initial neurologic effects may be delayed in onset for 2 or more hours after exposure and may include headache, nausea, vomiting, dizziness, vertigo, malaise, and visual disturbances. Examination may reveal nystagmus, dilated pupils, slurred speech, intention tremor, ataxia, impaired cutaneous sensation (light touch), cerebellar abnormalities, motor deficits, and decreased reflexes.

Neuropsychiatric abnormalities often occur after acute exposure, although onset may be delayed for days to weeks. In some cases, mental disturbances may predominate with only mild neurologic signs and no seizures; in others, severe status epilepticus may occur.

Respiratory -

Respiratory symptoms are the most likely nonneurologic effects of acute methyl bromide inhalation. Throat irritation, chest pain, and shortness of breath are common. Severe exposures may cause bronchitis, pneumonitis, and noncardiogenic pulmonary edema, which may be delayed up to 24 hours after exposure. Death may result from pulmonary or cardiovascular failure.

Cardiovascular -

Acute inhalation of high concentrations can cause ventricular fibrillation.

Renal -

Proteinuria, hematuria, oliguria, anuria, and uremia due to acute tubular necrosis have been described. Complete recovery is usual.

Hepatic -

Occasionally, jaundice and elevated serum liver enzymes occur after acute exposure.

Ocular -

High concentrations of methyl bromide vapor may cause corneal irritation and bums.

Dermal -

Methyl bromide is an intense vesicant. Contact with either liquid or high vapor concentrations may cause stinging pain, erythema, and blistering characteristic of second-degree bums.

Potential Sequelae -

Peripheral neuropathy, speech difficulty, and neuropsychiatric sequelae (such as ataxia, nystagmus, tremors, myoclonus, seizures, dementia, and psychosis) may develop weeks after exposure and may result in persisting neurologic disorders.

Chronic Exposure --

Repeated exposures have been associated with peripheral neuropathies, especially sensory neuropathy, ataxia, behavioral changes, and mild hepatic and renal dysfunction. Visual impairment secondary to optic atrophy has been reported in one chronically exposed fumigator.

Reproductive and Developmental Effects -

Methyl bromide is not considered to be a reproductive or developmental toxin. No human data are available and one animal study (in rats and rabbits) did not find teratogenicity at levels below those causing maternal death.

Carcinogenicity -

IARC states that the evidence for carcinogenicity of methyl bromide in humans is inadequate, and the evidence in animals is limited.

Prehospital Management

Victims exposed to only methyl bromide gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid methyl bromide (i.e., ambient temperature less than 38.5 degrees F) can secondarily contaminate response personnel by direct contact or through off gassing vapor.
Methyl bromide is a neurotoxic gas that can cause acute convulsions and coma.
Exposures to high concentrations of methyl bromide can cause eye, skin, and respiratory tract irritation, as well as chemical pneumonia. Dermal absorption can contribute to systemic toxicity.
There is no specific antidote for methyl bromide poisoning. Treatment is supportive.

Hot Zone --

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA) and fully encapsulated protective clothing. No skin surface should be exposed.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

Decontamination Zone --

Note. Remove clothing, including footwear, from all victims since methyl bromide gas can persist in cloth, leather, and rubber. After clothing has been removed, patients exposed only to gas and with no skin or eye irritation

may be transferred immediately to the Support Zone.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and fully encapsulated protective clothing if they will be caring for victims with liquid-soaked (i.e., ambient temperature less than 38.5 degrees F) clothing or skin. If the victim is not contaminated with liquid and

the decontamination area is outdoors and has good natural ventilation, a lesser level of protection may, suffice, and rescuers should wear loose-fitting clothing. Use of conventional chemical-protective clothing and gloves may result in burns caused by methyl bromide vapor trapped against the skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Supplemental oxygen may be administered if available.

Basic Decontamination -

Remove all contaminated clothing including footwear. Methyl bromide can persist in cloth, leather, and rubber, and these materials may contribute to severe chemical bums as a result of prolonged skin contact with the gas. Patients who are able and cooperative may assist with theft own decontamination.

Flush exposed skin and hair with copious water for 2 to 3 minutes.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone -

Note. Be certain that patients have undergone basic decontamination (see Decontamination Zone). Patients who have undergone proper decontamination or who have been exposed to only vapor pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Advanced Treatment -

Intubate the trachea if indicated (as in cases of respiratory compromise). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so. Treat bronchospasm with aerosolized bronchodilators.

Additional Decontamination -

If skin or eyes remain irritated, flush with plain water or saline for 15 minutes. Remove contact lenses if present.

Transport to Medical Facility -

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

Multi-Casualty Triage --

Note. If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims. Because systemic symptoms may be delayed for several hours after exposure, it is prudent to refer all exposed patients to a medical facility. Symptomatic patients should receive priority in transport.

Emergency Department Management

In cases of methyl bromide exposure, hospital personnel away from the scene are at little risk of secondary contamination from patients exposed to vapors or to liquid at ambient temperatures greater than 38.5 degrees F.
Methyl bromide is a neurotoxic gas that can cause acute convulsions and coma.
Exposures to high concentrations of methyl bromide can cause eye, skin, and respiratory tract irritation, as well as chemical pneumonia. Dermal absorption can contribute to systemic toxicity.
There is no specific antidote for methyl bromide poisoning. Treatment consists of supportive measures.

Decontamination Area --

Remove all clothing, including footwear, since methyl bromide penetrates many materials and may remain trapped in them. Patients exposed to only methyl bromide gas and with no skin or eye irritation may be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs - Evaluate and support airway, breathing, and circulation. Watch for signs of laryngeal edema and airway compromise. Monitor cardiac rhythm.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Remove all clothing since methyl bromide can penetrate and persist in cloth, leather, or rubber. Prolonged skin contact with contaminated clothing may cause severe chemical bums. (NOTE: If clothing is to be reused, it must undergo thorough decontamination.)

Wash exposed skin with soap and copious water (preferably under a shower). Irrigate exposed eyes with water or normal saline for 2 to 5 minutes. Remove contact lenses and continue irrigation for an additional 15 minutes irritation is still present. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids. Critical Care Area Note. Be certain that appropriate decontamination has been carried out. See Basic Decontamination above.

ABCs -

Evaluate and support airway, breathing, and circulation as above. Treat hypotension and seizures in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (such as trauma, hypoglycemia, or drug intoxication).

Inhalation Exposure -

Skin Exposure -

If the skin was in contact with concentrated methyl bromide vapor or liquid, chemical burns may result. Bums may be delayed in onset. Treat chemical bums as thermal bums.

Eye Exposure -

If eye irritation or injury is evident, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. S mall corneal defects may be treated with topical ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury.

Antidotes and Other Treatments -

There is no proven antidote for methyl bromide poisoning, although dimercaprol (BAL) or acetylcysteine (MucoMyst) have been suggested based on the postulated mechanism of methyl bromide's action. However, no adequate studies have tested the efficacy of these therapies so they cannot be recommended for routine use.

Laboratory Tests -

Serum bromide levels can be used to document that the exposure did occur. However, bromide levels do not accurately predict the clinical course. Other laboratory studies include CBC, electrolytes, BUN, and creatinine. In cases of inhalation exposure, chest

Disposition and Follow-up -

Decisions to admit or discharge a patient should be based on exposure history, physical examination, and test results.

Delayed Effects -

Because pulmonary edema may be delayed, patients with severe exposure should be monitored with serial examinations before absence of toxic effects can be assured. If pulmonary edema is suspected, admit patients to an intensive care unit.

Patient Release -

Asymptomatic patients with no evidence of neuropsychiatric or pulmonary effects 24 hours after exposure may be discharged with instructions to return to the ED if symptoms of toxicity develop (see MethylBromide -- Patient Information Sheet).

Follow-up -

Patients exposed to methyl bromide should be monitored for late neuropsychiatric sequelae.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department. Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, contact the employer or OSHA for assistance in evaluating workplace conditions. An appropriate public agency can be notified ira public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from NIOSH. See Appendix III for a list of these and other agencies that may be of assistance.

Methyl Bromide Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to methyl bromide liquid or vapor.

What is methyl bromide?

Methyl bromide is a colorless gas or liquid that is odorless at low concentrations. At very high concentrations, it has a sweet, fruity odor. Tear gas is often mixed with methyl bromide so that a person exposed to it will be warned of its presence. Methyl bromide is used to kill insects in the soil and to rid soils and buildings of termites. Typically, the field or home is covered ("tented") by a large tarpaulin and the methyl bromide is pumped in. Methyl bromide also is used in industry to make other chemicals.

What immediate health effects may be caused by exposure to methyl bromide? Breathing methyl bromide can' cause injury to the brain and nerves, lungs, and throat. High doses also can injure the kidneys and liver. Contact with the skin and eyes can lead to irritation and bums.

What is the treatment for methyl bromide poisoning?

There is no antidote for methyl bromide poisoning, but its effects can be treated. Persons who have experienced serious symptoms may need to be hospitalized for 24 hours.

Are any future health effects likely to occur?

After a single, small exposure with prompt recovery, no delayed or long-term effects are likely to occur. After a serious exposure that causes coma or convulsions, permanent brain or nerve damage may result.

What tests can be done if a person has been exposed to methyl bromide? Generally, specific tests for the presence of methyl bromide in blood and urine won't help the doctor diagnose your symptoms. If a severe exposure has occurred, blood, urine, and other tests may show if damage has been done to the brain, nerves, kidneys, or liver. Testing is not needed in every

case. Generally, the severity of symptoms is the best measure of the seriousness of the exposure.

Where can more information about methyl bromide be found? More information about methyl bromide may be obtained from your regional poison control center; your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help in locating these telephone numbers.

Methyl Bromide Follow-up

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough, wheezing
  * difficulty breathing or shortness of breath, chest pain
  * difficulty walking
  * confusion or passing out
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Phenol (C(6)H(5)-OH)

CAS: 108-95-2; UN 1671 (solid), 2312(molten), 2821 (solution) Synonyms include carbolic acid, hydroxybenzene, monohydroxyl benzene, benzenol, monophenol, phenyl hydroxide, phenyl alcohol, phenic acid, phenylic acid, and phenylic alcohol.

Victims exposed to phenol vapor only do not pose a significant risk of secondary contamination. However, victims whose clothing or skin is contaminated with liquid phenol can secondarily contaminate personnel by direct contact or through off-gassing vapor.
Phenol is a flammable, combustible, and highly corrosive chemical that can cause serious burns and systemic poisoning by all exposure routes.
Introduced originally as an antiseptic, phenol is still used in small amounts in disinfectants, insecticides, and many over-the-counter products that have antiseptic qualities.

Description -

At room temperature, phenol is a translucent, colorless, crystalline mass, white powder, or thick, syrupy liquid. The crystals are hygroscopic and turn pink to red in air. When pure, phenol has a sweet, tar-like odor that is readily detected at low concentrations (0.05 ppm in air). It is soluble in alcohol, glycerol, petrolatum and, to a lesser extent, water.

Routes of Exposure --

Inhalation -

Phenol is absorbed rapidly by all routes. Because of phenol's low volatility, inhalation hazard is limited. The odor threshold of phenol is sufficiently low to provide adequate warning of dangerous concentrations.

Skin/Eye Contact -

Acute toxic effects most often occur by skin contact. Even dilute solutions (1% to 2%) may cause severe bums if contact is prolonged. Systemic toxicity can result from skin or eye exposures. Phenol vapor and liquid penetrate the skin with an absorption efficiency approximately equal to the absorption efficiency by inhalation. In one case, death occurred within 30 minutes of skin contact.

Ingestion -

Accidental and intentional ingestions of phenol have been reported. As little as 50 to 500 mg has been fatal in infants. Deaths in adults have resulted after ingestions of 1 to 32 g.

Properties -

Description: Colorless to pink crystalline mass or white powder, syrupy liquid

Warning properties: adequate; sweet, acrid odor at > 0.05 ppm

OSHA PEL (Permissible Exposure Limit) = 5 ppm (averaged over an 8-hour workshift) [Skin]

NIOSH IDLH (Immediately Dangerous to Life and Health) = 250 ppm

AIHA ERPG-2 (emergency response program guideline)= 50 ppm

Molecular weight = 94.1 daltons

Melting point = 104.9 degrees F (43 degrees C)

Boiling point (760 mm Hg) = 359 degrees F (182 degrees C)

Vapor pressure at 67.1 degrees F (20 degrees C) = 0.36 mm Hg

Gas density = 3.24 (air = 1)

Water solubility = 9% at 77 degrees F (25 degrees C); hygroscopic

Flammable range = 1.7% to 8.6% (concentration in air); combustible solid

Sources/Uses -

Phenol is obtained by fractional distillation of coal tar and by organic synthesis. By far, its largest single use is in manufacture of phenolic resins and plastics. Other uses include manufacture of explosives, fertilizers, paints, rubber, textiles, adhesives, drugs, paper, soap, wood preservatives, and photographic developers. When mixed with slaked lime and other reagents, phenol is an effective disinfectant for toilets, stables, cesspools, floors, drains, etc.

Phenol was once an important antiseptic and is still used as a preservative in injectables. It also is used as an antipruritic, a cauterizing agent, a topical anesthetic, and as a chemical skin peeler (chemexfoliant). It can be found in low concentrations in many over-the-counter products including preparations for treatment of localized skin disorders (Castellani's paint, PRID salve, CamphoPhenique lotion), in topical preparations (Sting-Eze), and in throat sprays and lozenges (Chloraseptic, Ambesol, Cepastat, Cheracol).

Health Effects

Exposure to phenol by any route can produce systemic poisoning. Initially, central nervous system (CNS) stimulation may result, followed rapidly by CNS depression. Coma and seizures can occur within minutes of exposure or may be delayed up to 18 hours.
Phenol is corrosive and causes chemical burns at the contact site.

Acute Exposure -

Mechanism of Injury. As a corrosive substance, phenol denatures proteins and generally acts as a protoplasmic poison. Systemic poisoning can occur after inhalation, skin contact, eye contact, or ingestion. Typically, transient central nervous system (CNS) excitation occurs, then profound CNS depression ensues rapidly. Metabolic acidosis and acute renal failure may complicate the condition.

Neurologic -

Initial signs and symptoms may include nausea, diaphoresis, headache, dizziness, and tinnitus. Seizures, coma, respiratory depression, and death may ensue quickly. Coma and seizures usually occur within minutes to a few hours after exposure or after a delay of up to 18 hours. Phenol also may cause demyelination and axonal damage of peripheral nerves.

Cardiovascular -

Phenol exposure causes initial blood pressure elevation, then progressively severe hypotension and shock.

Cardiac dysrhythmias occasionally have been described in poisoned patients, most often in persons undergoing chemexfoliation (chemical skin-peeling). Atrial and ventricular dysrhythmias have been noted.

Respiratory -

Mild exposure may cause upper respiratory irritation. With more serious exposure, laryngeal edema, inflammation and ulceration of the trachea, and pulmonary edema can occur.

Gastrointestinal -

Vomiting and diarrhea are common effects of phenol toxicity by any route. In cases of ingestion, diffuse corrosive mucosal injury can involve the entire intestinal tract, sometimes causing significant ulceration and bleeding. Ingestion may lead to death from respiratory failure.

Renal -

Renal failure has been reported in acute poisoning. Urinalysis may reveal a green to brown discoloration of the urine, albuminuria, and casts.

Hematologic -

Acute hemolysis has been associated with severe phenol toxicity. Methemoglobinemia has been reported in infants.

Ocular -

Contact with concentrated phenol solutions can cause severe ocular damage including corneal opacification, if it is, and palpebral bums.

Dermal -

When phenol is applied directly to skin, a white pellicle of precipitated protein forms. This soon tums red and eventually sloughs, leaving the surface stained slightly brown. If phenol is left on the skin, it will penetrate rapidly and lead to necrosis and gangrene. If more than 60 square inches is affected, there is risk of imminent death. Phenol appears to have local anesthetic properties and may cause extensive damage before pain is felt.

Potential Sequelae -

Chronic neuropathy has been reported as a result of acute exposure. Chronic skin and eye effects may result from chemical bums.

Phenol ingestion may lead to esophageal strictures.

Chronic Exposure --

Repeated phenol exposure in the workplace has caused renal damage including nephritis, edema of the convoluted tubules, cloudy swelling of the tubular cells, and degenerative changes in glomeruli. Liver damage and pigment changes of the skin have been noted in some workers. Chronic exposure also has been correlated with an increased risk of ischemic heart disease in workers.

Carcinogenicity -

Insufficient evidence exists to classify phenol as a carcinogen in humans or animals.

Reproductive and Developmental Effects -

Phenol has been reported to be embryotoxic or fetotoxic, but not teratogenic. In humans, no clear association between phenol exposure and risk for birth defects is found; in experimental animals, phenol has generally not caused developmental effects except at doses that also caused maternal toxicity.

Prehospital Management

Victims exposed to phenol vapor only do not pose a significant risk of secondary contamination. However, victims whose clothing or skin is contaminated with liquid phenol can secondarily contaminate personnel by direct contact or through off-gassing vapor 'from heavily soaked clothing or from vomitus of victims who have ingested phenol.
Phenol may cause convulsions, sudden collapse, and coma. Because of its corrosivity, contact causes severe chemical burns.
Rapid decontamination may affect greatly the odds of survival.
There is no specific antidote for phenol poisoning. Treatment is supportive.

Hot Zone -

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with liquid phenol or its concentrated vapors is possible.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

Decontamination Zone --

Note. Victims with exposure to only vapors of phenol and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with phenol-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Supplemental oxygen may be administered if available.

Basic Decontamination -

Rapid skin decontamination is critical. Remove and double-bag contaminated clothing. Patients who are able and cooperative may assist with their own decontamination. Flu sh exposed skin and hair with plain water for 2 to 3 minutes, then wash with mild soap or shampoo and rinse with copious water. If immediately available, use polyviny pyrrolidone (PVP), polyethylene glycol (PEG 300 or PEG 400),glycerol, or vegetable oil to assist removal of phenol from exposed skin. Isopropyl alcohol may be used for small bums, but caution should be used since isopropyl alcohol toxicity may occur.

Note: Some investigators suggest that a water paste of polyvinyl pyrrolidone (PVP) is superior to PEG for skin decontamination and detoxification because PVP has the ability to form a complex with phenol.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of phenol ingestion, do not induce emesis. If the patient is alert and able to swallow, administer a glass of plain water, then administer a slurry of activated charcoal (adult dose: 50 to 100 g).

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone -

Note. Be certain that patients have undergone basic decontamination (see Decontamination Zone above). Patients who have undergone proper decontamination or who have been exposed to only vapors pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such Cases

ABCs -

Advanced Treatment -

Treat hypotension and seizures according to ALS protocol.

Additional Decontamination -

If skin or eyes remain irritated, flush with plain water or saline for 3 to 5 minutes.

Remove contact lenses if present. For patients with significant skin exposure, it may be necessary to repeat the soap or shampoo wash, or to continue using PVP, PEG or other solvents as described in Decontamination Zone.

In case of phenol ingestion, do not induce emesis. If the patient is alert and able to swallow, administer a glass of plain water. If it has not been done earlier, administer a slurry of activated charcoal (adult dose: 50 to 100 g).

Transport to Medical Facility -

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested phenol, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage -

Note. If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Persons with severe inhalation exposure, or skin bums over a large body surface area, or persons who have ingested phenol, or have experienced serious symptoms such as syncope or convulsions, need to be evaluated at a medical facility. (The severity of exposure can be estimated by the concentration of phenol and the amount and duration of contact.)

Persons who have had exposure to phenol vapor only and are asymptomatic are not likely to develop complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with follow-up instructions.

Emergency Department Management

Hospital personnel in an enclosed area can be secondarily contaminated by vapor offgassing from heavily soaked clothing or from the vomitus of victims who have ingested phenol. Patients do not pose a contamination risk after contaminated clothing is removed and the skin is washed.
Phenol may cause convulsions, sudden collapse, and coma. Because of its corrosive nature, contact can cause severe chemical burns.
There is no specific antidote for phenol poisoning. Treatment consists of supportive measures.

Decontamination Area --

Note. Patients with exposure to vapors of phenol only and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of laryngeal edema and airway compromise. Monitor cardiac rhythm.

Treat seizures in the conventional manner. Manage hypotension and shock with IV fluids; pressor agents may be required.

Basic Decontamination -

Rapid skin decontamination is critical. If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapor do not require decontamination unless they have skin or eye irritation.

Since contacting clothing or skin wet with phenol may cause bums, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek, Saranex) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has

been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with phenol, quickly remove and double-bag the contaminated clothing and all personal belongings while cleansing the skin. Thoroughly wash the skin with soap or mild detergent and copious water. If immediately available, use a water paste of polyvinyl pyrrolidone (PVP), polyethylene glycol (PEG 300 or PEG 400), glycerol, or vegetable oil to assist removal of phenol from exposed skin.

Some investigators suggest that PVP is superior to PEG for skin decontamination and detoxification because PVP has the ability to form a complex with phenol. If PVP, PEG, glycerol, or olive oil are not available immediately, a water wash using copious water (preferably under a shower) should be continued.

Critical Care Area -

Note. Be certain that appropriate decontamination has been carried out. See Basic Decontamination.

ABCs -

Evaluate and support airway, breathing, and circulation. Continuously monitor cardiac rhythm.

Treat hypotension, seizures, and ventricular arrhythmias in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (such as trauma, hypoglycemia, or drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints. Patients in respiratory distress or with abnormal pulmonary examination may require chest radiography and ABGs.

Skin Exposure -

If the skin contacted liquid phenol, chemical burns may result. Treat chemical burns as thermal burns.

Eye Exposure -

If eye irritation or injury is evident, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. Small corneal defects may be treated with ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion Exposure -

Do not induce emesis because the patient is at risk of abrupt seizures and coma. If the patient has ingested a large dose of phenol, perform gastric lavage with a small bore tube, then administer activated charcoal and a cathartic. When small amounts of phenol have been ingested, gastric emptying

may not be necessary if activated charcoal can be given promptly.

Consider endoscopy to evaluate the extent of corrosive injury to the gastrointestinal tract.

Antidotes and Other Treatments -

There is no specific antidote for phenol poisoning. Although charcoal hemoperfusion can remove free phenol from the blood and exchange transfusion has been suggested for phenol poisoning, the clinical value of these procedures is unproven.

Laboratory Tests -

Depending on the initial evaluation, useful tests might include CBC, glucose, electrolytes, renal function tests (BUN, creatinine, urinalysis), and ECG monitoring. Chest radiography and ABGs also are recommended for severe inhalation exposure or if pulmonary aspiration is suspected. Urinary phenol levels above 80 mg/L suggest overexposure.

Disposition and Follow-up --

Hospitalization should be considered for patients with evidence of systemic toxicity from any route of exposure.

Delayed Effects -

Because pulmonary edema or CNS effects may be delayed, patients with suspected serious exposure should be observed and reexamined periodically for 18 to 24 hours.

Patient Release -

Patients with mild exposure who are initially asymptomatic should be observed for 4 to 6 hours, then discharged if no symptoms occur during this period. Advise discharged patients to rest and to seek medical care promptly if symptoms develop. (For a list of symptoms, see the reverse side of Phenol Patient Information Sheet.)

Follow-up -

Patients with skin or eye burns who have been released should be reevaluated in 24 hours.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department. Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, contact the employer or OSHA for assistance in evaluating workplace conditions. An appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from NIOSH. See Appendix III for a list of these and other agencies that may be of assistance.

Phenol Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to phenol liquid or vapor.

What is phenol?

Phenol may be found as a translucent, clear or light-pink crystalline mass; a white powder;, or a clear liquid. It has a sweet, sharp odor. Phenol is used in many commercially available products including plastics, resins, fertilizers, paints, photographic developers, and some medicines.

What immediate health effects may result from exposure to phenol? Poisoning can occur when phenol gets on the skin or in the eyes, when it is inhaled, and when it is swallowed. Skin and eyes can be mildly or severely burned, depending on how much and how long the phenol was contacted. Breathing phenol vapors can bum the lining of the nose, throat, and lungs,just like it bums the skin. Severe injury to the lungs can cause them to fill with fluid, making breathing difficult. Swallowing phenol bums the lining of the digestive tract and can result in internal bleeding. Phenol is absorbed easily into the body through the skin, lungs, and stomach. The brain is very sensitive to phenol. Phenol can cause seizures and coma and may interfere with the brain's control of normal heart beat and regular breathing patterns. It can cause dangerous rhythm changes in the heart.

What is the treatment for phenol poisoning?

There is no antidote for phenol poisoning, but its effects can be treated and most exposed persons do get well. Persons who have had a serious exposure may need to be hospitalized for 24 hours.

Are any future health effects likely to occur?

After a single, small exposure, no delayed or long-term effects are likely to occur. After a severe exposure, you may not notice any symptoms for up to 24 hours. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care.

What tests can be done if a person has been exposed to phenol? Depending on the severity of symptoms, the doctor may order blood tests, urine tests, chest X ray, and a heart monitoring test. These tests may show if damage has been done to the heart, kidneys, lungs, or nervous system. Abnormally high amounts of phenol may be found in the urine if exposure was severe. Testing is not needed in every case. If phenol got in your eyes, the doctor may have put an orange dye in your eyes and examined them with a magnifying lamp. If you swallowed phenol, you may have been given a solution containing charcoal, which will soak up phenol in your stomach.

Where can more information about phenol be found?

More information about phenol may be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact your employer, the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help in locating these telephone numbers.

Phenol Follow-up --

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * coughing or wheezing
  * difficulty breathing or shortness of breath, chest pain
  * irregular heartbeats, pounding, or fluttering in your chest
  * increased pain, swelling, redness or discharge where skin is burned
  * unexplained drowsiness
  * fever or headache
  * fatigue or flu-like symptoms

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for 1 to 2 days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 72 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Phosgene (COC1(2))

CAS: 75-44-5; UN 1076

Synonyms of phosgene include carbonic acid dichloride, carbonic dichloride, carbon oxychloride, carbonyl chloride, and chloroformyl chloride.

Victims exposed to phosgene gas only do not pose a significant risk of secondary contamination. However, victims whose clothing or skin is contaminated with liquid phosgene (ambient temperature below 47 degrees F) can secondarily contaminate response personnel through direct contact or off-gassing vapor.
Phosgene is a nonflammable gas at room temperature. It slowly hydrolyzes to hydrochloric acid, which irritates and damages cells.
Phosgene is a combustion product of many volatile organochlorine compounds found in household substances, which poses a hazard to fire victims and firefighters.

Description -

Phosgene is a colorless, fuming liquid below 47 degrees F (8.2 degrees C) and a colorless, nonflammable gas above 47 degrees F. It is shipped as a liquified, compressed gas. At low concentrations, its odor is similar to that of green corn or new-mown hay; at high concentrations, its odor can be sharp and suffocating. Phosgene is hydrolyzed slowly by moisture to form hydrochloric acid and carbon dioxide.

Routes of Exposure --

Inhalation -

Inhalation is the major route of phosgene toxicity. Phosgene's odor provides

sufficient warning of dangerous concentrations, but its irritating quality can be mild and delayed, which may allow persons to be exposed for a prolonged interval. Phosgene is heavier than air and may cause asphyxiation in poorly ventilated, lying, or enclosed spaces.

Skin/Eye Contact -

When phosgene gas contacts moist or wet skin, it can cause irritation and erythema. High airborne concentrations also can cause corneal inflammation and opacification. Direct contact with liquid phosgene causes skin and eye burns.

Ingestion -

Ingestion of phosgene is unlikely since it is a gas at room temperature.

Properties -

Description: Colorless gas with musty odor at room temperature; a fuming liquid below 47'17

Warning properties: Adequate for brief emergency releases; slightly irritating in high concentration; Odor threshold 0.4 to 1.5 ppm

OSHA PEL (permissible exposure limit) = O. 1 ppm (averaged over a 10-hour workshift)

NIOSH IDLH (immediately dangerous to life or health) = 2 ppm ACGIH ERPG-2 (emergency response planning guideline) = 0.2 ppm

Molecular weight = 98.9 daltons

Boiling point (760 mm Hg) = 47 degrees F (8 degrees C)

Vapor pressure (67.1 degrees F) = 1215 mm Hg

Gas density = 3.4 (Air = 1)

Slightly water-soluble

Nonflammable

Sources/Uses --

Phosgene is produced commercially by chlorinating carbon monoxide. It is a combustion or decomposition byproduct of most volatile chlorinated compounds; therefore, household substances such as solvents, paint removers, and dry cleaning fluids can produce phosgene when exposed to heat or fire. Phosgene may also be produced during the welding of metal parts that have been cleaned with chlorinated hydrocarbons.

Phosgene is used as an intermediate in the manufacture of many chemicals including isocyanates, polyurethane, polycarbonates, dyes, pesticides, and pharmaceuticals.

Health Effects

Phosgene is a severe pulmonary irritant that usually provokes minimal irritation immediately after exposure but causes severe delayed damage.
Phosgene poisoning results in respiratory and cardiovascular failure; manifestations include hypovolemia, hemoconcentration, hypertension, and pulmonary edema.

Acute Exposure --

Mechanism of Injury. Because phosgene is poorly water soluble and hydrolysis tends to be slow, victims inhaling low concentrations of the gas experience no symptoms or only mild irritation of the upper airway. Lack of irritation allows victims to inhale the gas deeper into the lungs and for a prolonged period. Direct cytotoxicity leads to an increase in capillary permeability resulting in large shifts of body fluid with a resultant decrease in plasma volume. When phosgene hydrolyzes, it forms hydrochloric acid which causes epithelial damage and cellular necrosis in the bronchi and small bronchioles.

Respiratory -

Inhaling low concentrations of phosgene may cause no signs or symptoms initially, or symptoms may be due to only mild irritation of the airways, including dryness and burning of the throat and cough. Even these symptoms may cease when the patient is removed from exposure. However, after an asymptomatic interval of 30 minutes to a few hours, chest pain, bronchospasm, hypoventilation, and bradycardia can develop. A latency period of up to 24 hours may occur before profound damage manifests as dyspnea, hypoxemia, and severe transudative (noncarcliogenic) pulmonary edema. Hemolysis in pulmonary circulation can cause capillary plugging that leads to corpulmonale and death.

Cardiovascular -

Cardiovascular collapse may occur if the patient is severely hypoxemic from pulmonary edema.

Dermal -

If the skin is wet or moist, contact with phosgene vapor can cause irritation and erythema. Contact with liquid phosgene under pressure can result in frostbite injury.

Ocular -

High vapor concentrations can cause lacrimation and conjunctival hyperemia. Contact with liquid phosgene may result in corneal opacification and delayed perforation.

Potential Sequelae -

If the patient survives the initial 48 hours after exposure, recovery is typical. Sensitivity to irritants may persist, causing bronchospasm and chronic bronchitis. Pulmonary tissue destruction and scarring may lead to bronchiectasis and increased susceptibility to infection.

Chronic Exposure --

A group of workers who were exposed to high levels of phosgene daily showed an increase in mortality and morbidity (pneumonitis, chronic bronchitis, emphysema, and impaired pulmonary function studies). Chronic exposures to low levels of phosgene have not been described.

Carcinogenicity -

No evidence exists that phosgene is carcinogenic.

Reproductive and Developmental Effects

There is no evidence that phosgene causes reproductive or developmental hazards.

Prehospital Management

Victims exposed to phosgene gas only do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid phosgene (ambient temperature below 47 degrees F) can secondarily contaminate response personnel through direct contact or off-gassing vapor.
Phosgene is a severe pulmonary irritant. Because of its slow hydrolysis in the alveoli to hydrochloric acid, serious pulmonary effects may be delayed up to 24 hours.
There is no antidote for phosgene intoxication. Treatment consists of supportive measures.

Hot Zone --

Note. Rescuers should be trained' and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with liquid phosgene or its concentrated vapor is possible.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. If victims are unable to walk, remove them on a backboard or gurney. If there is no other means of removal, carefully carry or drag the victim to safety.

Decontamination Zone --

Note. Victims with exposure to only phosgene gas and with no evidence of skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with phosgene-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Supplemental oxygen may be administered if available.

Basic Decontamination -

If the exposure involved liquid phosgene (ambient temperature below 47 degrees F) and there is evidence of contaminated clothing, remove and double-bag the clothing. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Flush exposed skin and hair with plain water for 3 to 5 minutes.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone--

Note. Be certain that patients have undergone basic decontamination (see Decontamination Zone). Patients who have undergone proper decontamination or have been exposed to phosgene gas only pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Watch for signs of airway swelling and obstruction such as progressive hoarseness, stridor, or cyanosis. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment -

Intubate the trachea if indicated (as in cases of respiratory compromise). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothroidotomy if equipped and trained to do so.

Additional Decontamination -

Treat bronchospasm with aerosolized bronchodilators.

Treat coma, seizures, or dysrhythmias with usual measures.

Transport to Medical Facility -

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

Multi-Casualty Triage --

Note. If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims. Phosgene has relatively little odor or irritating effects at moderately toxic air concentrations; it is possible for serious health effects to occur without warning or symptoms of exposure. Because serious complications may be delayed for up to several hours after exposure, it is prudent to refer all patients with a suspected phosgene exposure to a medical facility.

Emergency Department Management

Victims exposed to phosgene gas only do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid phosgene (ambient temperature below 47 degrees F) can secondarily contaminate response personnel through direct contact or through off-gassing vapor.
Phosgene is a severe pulmonary irritant. Because of its slow hydrolysis in the alveoli, serious pulmonary effects may be delayed up to 24 hours.
There is no antidote for phosgene intoxication. Treatment consists of supportive measures.

Decontamination Area --

Note. Patients with exposure to phosgene gas only and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm. Treat bronchospasm with aerosolized bronchodilators. Seizures, coma, hypotension, renal failure, and apnea may complicate serious exposure. Treat in the conventional manner.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only phosgene gas do not require decontamination unless they have skin or eye irritation.

Since contact with clothing or skin wet with phosgene liquid may cause bums, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek , Saranex) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with phosgene, quickly remove and double-bag the contaminated clothing and all personal belongings while flushing the skin. Wash the exposed skin with soap or mild detergent and copious water (preferably under a shower).

Critical Care Area --

Note. Be certain that appropriate decontamination has been carried out. See Basic Decontamination on previous page.

ABCs -

Evaluate and support airway, breathing, and circulation. Continuously monitor cardiac rhythm.

Treat hypotension, seizures, and ventricular arrhythmias in the conventional manner.

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints. Observe patients in respiratory distress for up to 24 hours and periodically reexamine them using chest examinations and other appropriate studies. Follow-up as clinically indicated. Consider bronchodilators, which have been helpful in many cases.

Prophylactic antibiotics are recommended because autopsy studies invariably have found evidence of pneumonia and bronchitis in phosgene victims. Pneumonia can complicate severe pulmonary edema and was responsible for deaths that occurred more than 48 hours after onset of pulmonary edema.

Steroids are suggested for intense inflammation, especially inflammation of the respiratory epithelium. If the patient experienced severe exposure, consider initiating IV steroid therapy while the patient is still asymptomatic. Diuretics are contraindicated. Pulmonary edema due to phosgene inhalation is not hypervolemic in origin; patients tend to be hypovolemic and hypotensive. Dopamine may be required for treatment of hypotension, bradycardia, or renal failure. Initiate fluid resuscitation as needed.

Skin Exposure -

If the skin contacted phosgene, chemical bums may result. Treat chemical bums as thermal bums.

Eye Exposure

If eye irritation or injury is evident, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. Small corneal defects may be treated with ophthalmic antibiotic ointment or drops and analgesic medication.

Immediately consult an ophthalmologist for patients with severe corneal injury.

Antidotes and Other Treatments -

There is no antidote or other treatment specific for phosgene poisoning.

Laboratory Tests -

Depending on the initial evaluation, useful tests might include CBC, glucose, electrolytes, renal function tests (urinalysis, BUN, creatinine), liver function tests, and ECG monitoring. Chest radiography and ABGs also are recommended for severe inhalation exposure. Evidence of pulmonary edema, hilar enlargement, and ill-defined central patch infiltrates on chest radiography are late findings that may occur 6 to 8 hours after exposure.

Disposition and Follow-up --

Note. Hospitalization should be considered for all patients with suspected phosgene exposure.

Patients with respiratory compromise should be admitted to an intensive care unit.

Delayed Effects -

Because pulmonary edema may not occur for up to 24 hours after exposure, patients with known exposure should be observed and reexamined periodically before absence of toxic effects can be assured. Patients with bronchospasm or pulmonary edema should be watched carefully for signs of impending respiratory failure and should be managed accordingly. Survival for 48 hours predicts recovery.

Patient Release -

Asymptomatic patients with normal initial examinations and no signs of toxicity after observation for 24 hours may be discharged with instructions to seek medical care promptly if symptoms develop. (For a list of symptoms,

see the reverse side of Phosgene---Patient Information Sheet. )

Follow-up -

Patients with eye injury should be reevaluated in 24 hours.

Reporting --

Note. If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, contact the employer or OSHA for assistance in evaluating workplace conditions. An appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from NIOSH. See Appendix III for a list of these and other agencies that may be of assistance.

Phosgene Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to phosgene.

What is phosgene?

At room temperature, phosgene is a colorless gas that has a suffocating odor at high concentrations. At low concentrations, it smells like green corn or newly mowed hay. Phosgene is used in the manufacture of many chemicals. It is' also produced when chlorine-containing chemicals bum or break down.

What is the treatment for phosgene poisoning?

There is no remedy specifically for phosgene poisoning, but persons exposed to phosgene have been treated and have gotten well. Persons who have experienced serious symptoms may need to be hospitalized.

What immediate health effects may result from exposure to phosgene? Most exposures to phosgene occur from breathing the gas. Exposure to small amounts usually causes eye, nose, and throat irritation. However, the irritating effects can be so mild at first that the person does not leave the area of exposure. Extended exposure can cause severe breathing difficulty, which can lead to chemical pneumonia and death. Severe breathing problems may not develop for as long as 24 hours after the exposure.

Are any future health effects likely to occur?

After a single, small exposure, future effects are unlikely to occur. The reverse side of this page lists some signs to watch for. If any of the signs occur, seek medical care. Some persons who have had a serious exposure have developed permanent breathing difficulty and have a greater tendency to develop lung infections.

What tests can be done if a person has been exposed to phosgene? There are no specific blood or urine tests for phosgene. However, blood and urine tests and chest X rays may show if any serious effects on the lungs or other organs have occurred. Testing is not needed in every case.

Where can more information about phosgene be found?

More information about phosgene may be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help in locating these telephone numbers.

Phosgene Follow-up Instructions --

Follow only the instructions checked below. Pease take this page with you to
your next appointment.

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough
  * wheezing
  * difficulty breathing or shortness of breath
  * chest pain

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Phosphine Phosphine (PH(3)) CAS 7803-51-2; UN 2199

Also:Aluminum Phosphide (CAS 20859-73-8,' UN 1397) and Zinc Phosphide (CAS 1314-84-7; UN 1714) Synonyms of phosphine include hydrogen phosphide, phosphorus hydride, phosphorous trihydride, and phosphorated hydrogen.

Victims exposed to phosphine gas only do not pose a significant risk of secondary contamination; however, victims exposed to solid phosphides may present such a risk. Metallic phosphides on clothes, skin, or hair, or in vomitus can react with water or moisture to generate phosphine gas.
Phosphine is a respiratory irritant and can cause CNS depression and cardiovascular failure.
Most phosphine exposures occur by inhalation of the gas or ingestion of metallic phosphides.

Description --

Industrial phosphine is a colorless, flammable, and toxic gas with an odor of garlic or decaying fish. It can ignite spontaneously on contact with air. The gas is shipped as a liquefied, compressed gas.

Aluminum phosphide (Celphos, Phostoxin, Quick Phos) and zinc phosphide (ZNP-Field Rat Powder) are solids that are used as a grain fumigant and rodenticide, respectively. Zinc phosphide is often mixed with bait foods such as cornmeal; if not placed judiciously, it can be a danger to pets and children. When phosphides are ingested or exposed to moisture, they release phosphine. Phosphine gas also may be released when acid contacts metal shavings.

Routes of Exposure --

Inhalation -

Inhalation is the major route of phosphine toxicity. Odor is not an adequate indicator of phosphine's presence and may not provide reliable warning of dangerous concentrations. In cases of acute exposure, however, the odor of phosphine will probably be detected. Phosphine is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Phosphine produces no adverse effects on the skin or eyes, and contact does not result in systemic toxicity. Contact with liquified or compressed phosphine may result in frostbite injury.

Ingestion -

Ingestion of phosphine is unlikely, but ingestion of metallic phosphides can produce phosphine intoxication when the solid phosphide contacts the acidic gastric milieu.

Properties --

Description: Colorless gas; odor of garlic or decaying fish

Warning properties: Inadequate; nonirritating and garlic-like or fishy odor at 1 to 3 ppm

OSHA PEL (permissible exposure limit) = 0.3 degrees ppm (averaged over an 8-hour workshift)

OSHA STEL (short term exposure limit) = 1 ppm (.15-minute sample)

NIOSH IDLH (immediately dangerous to life or health) = 200 ppm

Molecular weight = 34.0

Melting Point = -209 degrees F (-134 degrees C)

Boiling point (760 mm Hg) = -126 degrees F (- 87.7 degrees C)

Vapor pressure (67.1 degrees F) = >760 mm Hg

Gas density = 1.17 (air = 1)

Slightly water-soluble

Extremely flammable and explosive; may ignite spontaneously on contact with air.

Sources/Uses --

Phosphine is produced by reacting water or acid with metallic phosphides. It may be produced during the generation of acetylene gas. Phosphine is used in the semiconductor industry to introduce phosphorus into silicon crystals as an intentional impurity. It also is used as a fumigant and a polymerization initiator.

Health Effects

Phosphine is cytotoxic and causes profound changes in multiple organs with high oxygen demand--brain, kidneys, heart, and liver.
Signs and symptoms of phosphine poisoning typically represent various stages of cardiovascular collapse.

Acute Exposure --

Mechanism of Injury. Phosphine interferes with enzymes and protein synthesis, primarily in the myocardial mitochondria and pulmonary cells. In the myocardium, these changes produce cation permeability disturbances, which give rise to transmembrane potentials that ultimately result in peripheral vascular collapse and cardiac arrest.

The majority of deaths are cardiovascular in origin and occur within the first 12 to 24 hours after exposure. If the patient survives the initial 24 hours, the ECG returns to normal, indicating that myocardial damage is reversible. Phosphine's direct cytotoxicity to pulmonary cells can result in pulmonary edema and pneumonitis. The liver and kidneys also are affected.

Neurologic -

Phosphine is a CNS depressant. Initial effects may include headache, restlessness, vertigo, paresthesias, ataxia, intention tremor, diplopia, and stupor. Severe exposure can cause seizures and coma.

Respiratory -

Toxicity that occurs after inhalation is characterized by chest tightness, cough, and dyspnea. Severe exposure can cause pulmonary edema, which may have a delayed onset of 72 hours or more after exposure. Pulmonary symptoms also can result from ingestion of metallic phosphides (e.g., aluminum or zinc phosphide).

Cardiovascular -

Cardiovascular manifestations include toxic myocarditis, which may result in valve damage, myocardial ischemia, congestive heart failure, dysrhythmias, or cardiac arrest. Phosphine's effect on the small peripheral vessels causes a profound decrease in systemic vascular resistance. These vascular changes may lead to marked hypotension that may be poorly responsive to pressor agents.

Gastrointestinal -

Gastrointestinal symptoms are usually the first to manifest after an exposure. Symptoms may include nausea, vomiting, abdominal pain, and diarrhea.

Hepatic -

Typically, hepatic injury does not manifest until 48 to 72 hours after exposure. Findings include jaundice, hepatomegaly, and elevated serum transaminases. Hyperbilirubinemia was reported in adult patients with acute aluminum phosphide poisoning.

Renal -

Microhematuria, proteinuria, and acute renal failure can occur.

Potential Sequelae

Although most survivors of acute phosphine exposure show no permanent disabilities, ischemic damage to the brain and heart have been reported in at least one case. Subacute poisoning re suiting from exposure of a few days was reported to cause reactive airways dysfunction syndrome (RADS) 18 months later.

Chronic Exposure --

Cardiac, hepatic, and renal dysfunction may occur from chronic exposure to phosphine. Carcinogenicity No studies have been done to determine if phosphine is carcinogenic.

Reproductive and Developmental Effects -

In the absence of maternal toxicity, phosphine is unlikely to be a developmental hazard.

Prehospital Management

Victims exposed to phosphine gas only do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, patients exposed to solid phosphides, which react with moisture to produce phosphine, can pose such a risk if phosphides are on clothes, skin, or in hair.
Phosphine is a multisystem toxicant that can cause pulmonary irritation, CNS depression, and cardiovascular collapse.
There is no antidote for phosphine poisoning; treatment consists of supportive measures.

Hot Zone -

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are not required.

ABCs -

Quickly ensure a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Brush powder from the skin, hair, and clothes of victims before leaving the Hot Zone.

Victim Removal -

Decontamination Zone --

Note. Victims with exposure to only phosphine gas do not need decontamination. They may be transferred immediately to the Support Zone. Victims exposed to metallic phosphides will require decontamination; see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the Decontamination Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are not required. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

ABCs -

Decontamination -

Brush all visible particles from clothes, skin, and, hair. Remove and double-bag contaminated clothing while flushing exposed skin with water. Patients who are able and cooperative may assist with their own decontamination.

Thoroughly flush exposed skin and hair with plain water for at least 5 minutes.

If phosphides have been ingested, administer activated charcoal. Phosphides will release phosphine in the stomach; therefore, watch for signs similar to those produced by phosphine inhalation.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Note. Be certain that patients exposed to metallic phosphides have undergone basic decontamination (see Decontamination Zone). Patients who have been exposed to gas only or who have undergone proper decontamination pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Advanced Treatment -

Treat bronchospasm with aerosolized bronchodilators. Treat coma, seizures, and ventricular dysrhythmias according to ALS protocol.

If massive exposure is suspected or if the patient is hypotensive, infuse intravenous saline or lactated Ringer's solution (adult dose: 500 to 1000 mL).

If phosphides have been ingested, administer activated charcoal. Phosphides will release phosphine in the stomach; therefore, watch for signs similar to those produced by phosphine inhalation.

Transport to a Medical Facility -

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested a metallic phosphide, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

Note. If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Inhalation Exposure -

Because it is difficult to determine at the scene which patients have had the most serious inhalation exposure and because some systemic symptoms may be delayed for up to 72 hours after exposure, it is prudent to refer all patients with a potentially significant exposure to a medical facility. Those who by history have had a massive exposure and those who experienced a garlic or fish-like odor should be evaluated first.

Ingestion Exposure -

All patients who have ingested phosphides should be transported to a medical facility without delay.

Emergency Department Management

Victims exposed to only phosphine gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, solid phosphides, which react with moisture to produce phosphine, may present a secondary contamination risk if they are present on clothes, skin, or in hair.
Phosphine is a multisystem toxicant that causes acute pulmonary irritation, CNS depression, and cardiovascular collapse. Fatal outcomes after the initial 24 hours are usually due to hepatic or renal failure.
There is no antidote for phosphine poisoning. Treatment consists of supportive measures.

Decontamination Area -

Note. Patients exposed to only phosphine do not need decontamination. They may be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Basic Decontamination -

Brush powder from the skin, hair, and clothes of victims who have been exposed to solid phosphides. Remove and double-bag the patient's clothing while flushing the skin and hair with copious water (preferably under a shower).

Critical Care Area --

Note. Be certain that patients exposed to solid phosphides have been decontaminated as described above. Decontamination is unnecessary for patients exposed only to phosphine gas.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Hypotension may develop and may be poorly responsive to pressor agents.

Treat seizures and coma in the conventional manner. Patients with significant and persistent signs of CNS depression should be evaluated for the presence of intercurrent disorders (such as trauma, hypoglycemia, or drug intoxication).

Inhalation Exposure -

Symptomatic patients should receive supplemental oxygen for dyspnea and should be observed for at least 72 hours with repeated chest examinations and other appropriate studies. Follow-up as clinically indicated.

Ingestion Exposure -

Remove phosphides from the stomach as soon as possible since most phosphides release phosphine gas on contact with water or acids. Administer activated charcoal. A mineral oil cathartic ( 1 CO mL) is recommended rather than a saline cathartic.Watch for signs and symptoms similar to those produced by inhalation exposure, treat accordingly.

Antidotes and Other Treatments -

There is no antidote for phosphine toxicity. Hemodialysis was used successfully for one patient with massive renal failure from phosphine exposure. The effectiveness of exchange transfusions is questionable. The value of steroids has not been proven in phosphine-exposed patients who develop acute pulmonary symptoms.

Laboratory Tests -

Establish baseline for pulmonary function (ABGs, chest radiography), renal function (BUN, creatinine, urinalysis) and liver function (AST, ALT, bilirubin); monitor as required. Serial myocardial enzyme levels also may be helpful.

Phosphine is metabolized to phosphite and hypophosphite, which are excreted in the urine. Although analysis for these metabolites i s not clinically useful in an emergency setting, urine samples can be collected and frozen for future analysis, particularly if questions on the nature or extent of exposure are likely.

Disposition and Follow-up --

Note. Decisions to admit or discharge a patient should be based on exposure history, physical examination, and test results.

Delayed Effects -

Because onset of pulmonary edema and liver damage may be delayed for 72 hours or more after exposure, all patients with a history of significant exposure should be admitted and observed carefully. In cases of severe exposure, survival for 4 days usually predicts full recovery.

Patient Release -

Asymptomatic patients with normal initial examinations, minimal exposure, and no signs of toxicity after observation for 4 to 6 hours may be discharged with instructions to return to the ED if symptoms of toxicity develop (see the reverse side of Patient Information Sheet--Phosphine).

Follow-up -

Patients exposed to phosphine should be monitored for late neurologic sequelae and pulmonary dysfunction.

Reporting --

If a work-related incident has occurred, you may be legally required to file

a report; contact your state or local health department. Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, contact the employer or OSHA for assistance in evaluating workplace conditions. An appropriate public agency can be notified ira public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from NIOSH. See Appendix III for a list of these and other agencies that may be of assistance.

Phosphine and Phosphides Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to phosphine or phosphides.

What is phosphine? What are phosphides?

Phosphine is a toxic gas that has no color and smells like garlic or fish. A serious exposure to phosphine could occur, however, even if a person does not smell it. Phosphine is used widely in the semiconductor industry.

Certain pesticides containing zinc phosphide or aluminum phosphide can release phosphine when they come in contact with water or acid. The phosphine formed in the stomach when these solid phosphides are swallowed can result in phosphine poisoning.

What is the treatment for phosphine poisoning?

There is no antidote (remedy) for phosphine poisoning, but its effects can be treated, and most exposed persons get well. Persons who have experienced serious symptoms may need to be hospitalized for 72 hours or more.

What immediate health effects may be caused by exposure to phosphine? Exposure to even small amounts of phosphine can cause headache, dizziness, nausea, vomiting, diarrhea, drowsiness, cough, and chest tightness. More serious exposure can cause shock, convulsions, coma, abnormal heart rhythms, and liver and kidney damage.

Are any future health effects likely to occur?

After a single, small exposure, no delayed or long-term effects are likely to occur. After a severe exposure, symptoms usually begin immediately but might not appear for up to 72 hours or more. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care.

Some severely exposed persons have experienced long-term brain, heart, and lung injury.

What tests can be done if a person has been exposed to phosphine? There are no specific blood or urine tests for phosphine itself. However, metabolites of phosphine can be measured in urine. Blood, urine, and other tests also may show if there has been any serious effect on the brain, lungs, heart, liver, or kidneys. Testing is not needed in every case.

Where can more information about phosphine be found?

More information about phosphine and phosphides may be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help in locating these telephone numbers.

Phosphine and Phosphides Follow-up Instructions -

Follow only the instructions checked below. Pease take this page with you to
your next appointment.

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough
  * difficulty breathing or shortness of breath
  * wheezing
  * chest pain
  * fever
  * fatigue or flu-like symptoms

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited bais. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Toluene (C(6)H(5)-CH(3)) CAS: 108-88-3; UN 1294

Synonyms include methyl benzene, methyl benzol, phenylmethane, and toluol.

Victims exposed to only toluene vapor do not pose a significant risk of secondary contamination; however, victims whose clothing or skin is contaminated with liquid toluene can cause secondary contamination by direct contact or through off-gassing vapor.
Toluene is a volatile, flammable, and combustible liquid. Its vapor is heavier than air and may accumulate in low-lying areas.
Toluene is absorbed rapidly after inhalation and ingestion. It is absorbed slowly through intact skin; however, percutaneous absorption can contribute to total body burden.

Description --

Toluene is a clear, colorless, volatile liquid with a sweet, aromatic odor. It is flammable at temperatures greater than 40 degrees F (4.4 degrees C); therefore, it is a significant fire hazard at room temperature. Toluene mixes readily with many organic solvents but is poorly soluble in water. It is less dense than water and will float on the surface of water.

Routes of Exposure --

Inhalation -

Most exposures to toluene occur by inhalation. It's odor generally provides adequate warning of acutely dangerous concentrations. Its vapor is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Toluene is sometimes intentionally abused to induce a "sniffer's high." The process of recreational inhaling toluene is referred to as "bagging" or "hurting."

Skin/Eye Contact -

Toluene vapor is only mildly irritating to mucous membranes; however, liquid toluene splashed in the eyes can result in corneal injury. Repeated or prolonged skin contact with liquid toluene can defat the skin, causing it to crack and peel. Percutaneous absorption is slow through intact skin; however, toluene absorbed through the skin can contribute to total body burden.

Ingestion -

Acute toxic effects can result from ingestion of toluene.

Sources/Uses --

Toluene is among the 25 most abundantly produced chemicals in the United States. It is obtained primarily from crude petroleum. Toluene is an excellent solvent for paints, lacquers, thinners, and adhesives. It is used extensively in the rubber, chemical, paint, dye, printing, and pharmaceutical industries.

Properties of Toluene -

Appearance: Clear, colorless liquid

Warning properties: Adequate; sweet, aromatic odor at - 1 ppm

OSHA PEL (Permissible Exposure Limit) = 100 ppm (averaged over an 8-hour workshift)

OSHA STEL (Short Term Exposure Limit) = 150 ppm (15-minute sample)

NIOSH IDLH (Immediately Dangerous to Life or Health) = 2000 ppm

Molecular weight = 92.1

Boiling point (760 mm Hg) = 231 degrees F (110.6 degrees C)

Freezing point = -139 degrees F (-95 degrees C)

Vapor pressure (67 degrees F) = 22 mm Hg

Vapor density = 3.3 (air = 1)

Slightly water soluble (0.05% at 65 degrees F)

Flash point = 40 degrees F (4.4 degrees C); vapors may travel to a source of

ignition and flash back.

Flammable range is 1.2% to 7.1% (concentration in air)

Health Effects

In large amounts, toluene depresses the central nervous system and may increase susceptibility of the myocardium to the dysrhythmogenic effects of catecholamines.
In addition to acute effects, chronic toluene abusers may experience myopathy, hypokalemia, renal tubular acidosis, and neuropathy.

Acute Exposure --

CNS -

Generally, symptoms of CNS toxicity are apparent immediately after inhalation and 30 to 60 minutes after ingestion. Mild CNS effects include headache, euphoria, dizziness, confusion, nausea, impaired judgment, ataxia, and impaired visual accommodation. More severe effects include loss of consciousness, coma, and death. Coma may be prolonged, although most victims re gain consciousness rapidly after they are removed from exposure.

Respiratory -

Acute exposure to toluene vapor can irritate the mucous membranes of the respiratory tract. With massive exposure, noncardiogenic pulmonary edema and respiratory arrest may ensue. Pulmonary aspiration of ingested liquid toluene may cause chemical pneumonitis.

Cardiovascular -

Massive doses of toluene can cause cardiac abnormalities. Toluene may increase susceptibility of myocardial cells to the dysrhythmogenic effects of catecholamines. Dysrhythmias leading to cardiac arrest have been described in solvent abusers, often immediately preceded by intense physical activity.

Renal -

Hematuria and proteinuria can occur after massive inhalation. These effects usually are reversible if exposure is terminated.

Metabolic Disturbance -

After high-level exposure, toluene may cause metabolic acidosis. In solvent abusers, electrolyte and acid-base disturbances can cause renal tubular acidosis, hypokalemia, and hypophosphatemia. Ethanol or aspirin may prolong the half-life of toluene in the body.

Dermal -

Toluene can cause significant skin irritation and defatting dermatitis after prolonged or repeated contact with the liquid. Erythema and bullae may occur.

Ocular -

Eye irritation from toluene vapor begins at concentrations of about 300 ppm. Inflammation is generally slight. When splashed in the eyes, toluene may cause burning pain, corneal injury, and sloughing of corneal epithelium.

Gastrointestinal -

If swallowed, liquid toluene can irritate the stomach lining, causing nausea, vomiting, and diarrhea.

Potential Sequelae -

During recovery, victims may continue to experience ataxia, depressed level of consciousness, dilated and poorly responsive pupils, and decreased or absent deep tendon reflexes. Anxiety, fatigue, and insomnia may last several days. Long-term sequelae due to acute toluene exposure have not been reported.

Chronic Exposure --

Chronic toluene exposures at less than 200 ppm have been associated with headache, lassitude, and nausea. Workers repeatedly exposed at 200 to 500 ppm have reported loss of coordination, memory loss, and loss of appetite. Some workers have developed reversible toxic optic neuropathy after chronic exposure in the workplace.

Chronic exposure due to solvent abuse can result in permanent neuropsychiatric manifestations. Myopathy, cardiovascular effects, renal tubular damage, and sudden death have occurred in chronic glue sniffers. Metabolic acidosis can result from renal tubular disorders.

Toluene is not classified by IARC or NTP as carcinogenic. It has not been confirmed as a human reproductive hazard. Shepard's Catalog of Teratogenic Agents reports five cases of children whose mother's regularly used toluene "recreational." These children were born with microcephaly, CNS dysfunction, and minor craniofacial and limb anomalies. Several of the mothers had also abused alcohol during pregnancy.

Prehospital Management

Toluene may cause central nervous system (CNS) depression and cardiac dysrhythmias.
There is no specific antidote for toluene poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination --

Victims exposed to only toluene vapor do not pose a significant risk of secondary contamination to rescuers outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid toluene can secondarily contaminate response personnel by direct contact or through off-gassing vapor.

Hot Zone --

Rescuers should be trained and appropriately attired before entering the HotZone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are recommended if contact with concentrated vapor or liquid is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

Decontamination Zone --

Victims with exposure to only vapors of toluene and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with liquid-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Basic Decontamination -

Remove and double-bag contaminated clothing. Victims who are able and cooperative may remove their own clothing and assist with basic decontamination. Flush liquid-exposed skin and haft with plain water for 2 to 3 minutes, then wash with mild soap or shampoo and rinse with copious water. Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present. In case of toluene ingestion, do not induce emesis. Administer a slurry of activated charcoal (50 to 60 g) if the patient is conscious and able to swallow.

Transfer to the Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone. Support Zone Be certain that patients have undergone basic decontamination (see Decontamination). Patients who have undergone proper decontamination or have been exposed to only vaporpose no serious risk of secondary contamination to rescuers. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Advanced Treatment -

Intubate the trachea if indicated (coma or apnea).

Treat wheezing with aerosolized bronchodilators; use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias.

Treat dysrhythmias and coma according to standard ALS protocol.

Additional Decontamination -

If eyes remain irritated, flush with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of toluene ingestion, do not induce emesis. Administer a slurry of activated charcoal (50 to 60 g) if it was not administered in the decontamination zone and if the patient is conscious and able to swallow.

Transport to a Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested toluene, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Patients with a history or evidence of significant exposure and all persons who have ingested toluene should be transported to a medical facility and evaluated.

Victims of inhalation exposure who did not experience significant alteration of consciousness (e.g., confusion, syncope, coma) are not likely to have had a significant exposure. After recording their names, addresses, and telephone numbers, they may be released from the scene with follow-up instructions.

Emergency Department Management -

Toluene may cause central nervous system depression and cardiac dysrhythmias.
There is no antidote for toluene poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination --

Hospital personnel in an enclosed area can be secondarily contaminated by vapor off-gassing from heavily soaked clothing or from the vomitus of victims who ingested toluene. Patients do not pose a contamination risk after contaminated clothing is removed and the skin is washed.

Decontamination Area -

Patients with exposure to only vapors of toluene and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only toluene vapor do not require decontamination unless they have skin or eye irritation.

If the patient's clothing is wet with toluene, remove and double bag the contaminated clothing and all personal belongings. Flush exposed skin with copious water for 2 to 5 minutes (preferably under a shower). Use mild soap or shampoo to remove oily or adherent materials.

Critical Care Area -

Be certain that appropriate decontamination has been carried out. See Basic Decontamination.

ABCs -

Evaluate and support airway, breathing, and circulation as above. Continuously monitor cardiac rhythm.

Assess and treat hypotension, and seizures in the conventional manner. To avoid inducing ventricular fibrillation, use sympathomimetics or catecholamines with caution. Ventricular tackyrhythmias may respond effectively with beta-blockers. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g.,trauma, hypoglycemia, drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints. Treat wheezing with bronchodilators (use with caution).

Skin Exposure -

If liquid toluene was in prolonged contact with the skin, chemical burns may result. Treat chemical burns as thermal burns.

Eye Exposure -

Ingestion -

Perform gastric lavage if the patient has ingested a large dose and presents within 30 minutes of exposure, then administer activated charcoal and a cathartic. When small amounts of toluene have been ingested, activated charcoal may be administered orally without gut emptying.

If the patient who has ingested toluene is coughing or is dyspneic, pulmonary aspiration may have occurred. Patients who show no clinical signs of pulmonary aspiration within 6 hours are unlikely to develop aspiration chemical pneumonia.

Antidotes and Other Treatments -

There is no antidote for toluene poisoning. Hemodialysis and hemoperfusion are ineffective.

Laboratory Tests -

Useful laboratory studies include electrolytes, BUN, creatinine, urinalysis, liver function tests, and ECG monitoring. Chest radiography and ABGs are also recommended for severe inhalation exposure or if pulmonary aspiration is suspected.

Blood levels of toluene may be used to document exposure, although they are not useful clinically. Toluene is metabolized to hippuric acid, which is excreted in urine with a biologic half life of about 3 hours. Results of urinary hippuric acid tests do not correlate well with systemic effects and are not available on an emergency basis; however, they can help to confirm the diagnosis or etiology. In interpreting results, diet must be taken into consideration since hippuric acid is a normal constituent of urine, originating mainly from food containing preservatives such as benzoic acid or benzoates.

Disposition and Follow-up -

Consider hospitalization for symptomatic patients who have a history of significant inhalation exposure or aspiration chemical pneumonia and patients who have ingested significant amounts of toluene.

Delayed Effects -

Observe hospitalized patients for signs of acute tubular necrosis, encephalopathy, and dysrhythmias. In addition, victims who have inhaled significant amounts of toluene should be observed for signs of pulmonary edema, and those who have ingested toluene should be watched for signs of aspiration pneumonia.

Patient Release -

Patients who have remained asymptomatic 6 to 12 hours after exposure may be discharged, advised to rest and to promptly seek medical care if symptoms of toxicity develop (see Toluene--Patient Information Sheet).

Follow-up -

Patients with corneal injury should return for a follow-up evaluation within 24 hours. Long-term sequelae due to a single acute exposure to toluene have not been reported.

Reporting -

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Toluene Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to toluene liquid or vapor.

What is toluene?

Toluene is a clear, colorless liquid with a sweet odor. It is obtained from crude petroleum and is highly flammable. Toluene is used widely in a variety of industries and is a common solvent for products such as paints, thinners, and glues.

What immediate health effects may be caused by exposure to toluene? Breathing toluene vapors in small amounts may cause mild euphoria (a "high"), headache, dizziness, drowsiness, or nausea. With more serious exposure, toluene may cause sleepiness, stumbling, irregular heart beats, fainting, or even death. Toluene vapors are mildly irritating to the skin, eyes, and lungs. If liquid toluene contacts the skin or eyes, it may cause burning pain. Liquid toluene splashed in the eyes also can damage the cornea of the eyes.

What is the treatment for toluene poisoning?

There is no antidote for toluene poisoning, but its effects can be treated and most exposed persons do recover fully. Persons who have experienced serious symptoms may need close medical observation for 24 hours.

Are any future health effects likely to occur?

After a single, small exposure, delayed or long-term effects are likely to occur. After a serious exposure to toluene, symptoms may develop within a few days. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care. Repeated sniffing of toluene to get "high" can cause permanent damage to the brain, heart, muscles, and kidneys.

What tests can be done if a person has been exposed to toluene? Specific tests for the presence of toluene in blood and urine are not medically useful. Hippuric acid, a metabolite of toluene, may be measured in urine if the toluene exposure was high. In cases of severe exposure, other tests may show if injury has occurred in the brain, heart, muscles, and kidneys. The severity of symptoms is usually the best measure of the seriousness of the exposure.

Where can more information about toluene be found?

More information about toluene may be obtained from your regional poison control center; the state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Toluene Follow-up Instructions --

Please follow the instructions indicated below by the doctor.

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough
  * shortness of breath or wheezing
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
  * fever

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for 1 to 2 days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Xylene (CH(3)-C(6)H(4)-CH(3)) CAS:1330-20-7; UN 1307

Synonyms include dimethylbenzene, methyl toluene, xylol, and mixed xylenes.

Victims exposed to only xylene vapor do not pose a significant risk of secondary contamination; however, victims whose clothing or skin is contaminated with liquid xylene can cause secondary contamination by direct contact or through off-gas.sing vapor.
Xylene is a volatile, flammable, and combustible liquid. Its vapor is heavier than air and may accumulate in low-lying areas.
Xylene is absorbed rapidly after inhalation and ingestion. It is absorbed slowly through intact skin; however, percutaneous absorption can contribute to total body burden.

Description --

Xylene exists as three isomers (ortho-, meta-, and para-xylene), which can be found singly or, more commonly, mixed in varying proportions. Commercial grade xylene, in which m-xylene is usually the major constituent, is a clear, colorless liquid with a sweet, aromatic odor. Xylene is flammable at room temperature; therefore it constitutes a fire hazard. Xylene is insoluble in water but mixes readily with many organic solvents. It is less dense than water and will float on the surface of water.

Routes of Exposure --

Inhalation -

Most exposures to xylene occur by inhalation. Its odor generally provides adequate warning of acutely dangerous concentrations. Xylene's odor threshold is about 1 ppm; irritation of eye and throat occur at about 200 ppm. Xylene vapor is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Xylene vapor is only mildly irritating to mucous membranes; however, liquid xylene splashed in the eyes can result in corneal injury. Repeated or prolonged skin contact with liquid xylene can defat the skin, causing it to crack and peel. Percutaneous absorption is slow through intact skin; however, xylene absorbed through the skin can contribute to systemic toxicity.

Ingestion -

Acute toxic effects can result from ingestion of xylene.

Sources/Uses --

Xylene is among the 25 most abundantly produced chemicals in the United States. It is obtained primarily from crude petroleum. It is used widely as a degreasing agent and as a thinner and solvent in paints, inks, adhesives, and many other products. It is commonly found as a solvent in pesticide products.

Properties of Xylene --

Appearance: Clear, colorless liquid

Warning properties: Adequate; sweet, aromatic odor at - 1 ppm OSHA PEL (Permissible Exposure Limit) = 100 ppm (averaged over an 8-hour workshift)

OSHA STEL (Short Term Exposure Limit) = 150 ppm (15-minute sample) NIOSH IDLH (Immediately Dangerous to Life or Health) = 1000 ppm Molecular weight = 106.2

Boiling point (760 mm Hg) = 292, 269. 281 degrees F*

Freezing point = -13 degrees , -54 degrees , 56 degrees F* Vapor pressure (67 degrees F) = 7.9, 9 mm Hg*

Vapor density = 3.8 (air = 1)

Water insoluble

Flash point = 63% 84 degrees , 81 degrees F*

Flammable range is 1.0% to 7.0% (concentration in air) * ortho-, meta-, and para-xylene respectively

Health Effects

Xylene is an eye and respiratory tract irritant at concentrations greater than 200 ppm.
In large amounts, xylene depresses the central nervous system and may increase the susceptibility of the myocardium to the dysrhythmogenic effects of catecholamines.

Acute Exposure --

CNS -

Generally, symptoms of CNS toxicity are apparent immediately after inhalation and 30 to 60 minutes after ingestion. Mild CNS effects include headache, euphoria, dizziness, confusion, nausea, ataxia, and impaired visual accommodation. More severe effects include blurred vision, tremors, rapid respiration, paralysis, unconsciousness, and death. Coma may be prolonged, although most victims regain consciousness rapidly after they are removed from exposure.

Respiratory -

Acute exposure to xylene vapor may irritate the mucous membranes of the respiratory tract. With massive exposure, noncardiogenic pulmonary edema and respiratory arrest may ensue. Pulmonary aspiration of ingested liquid xylene may cause chemical pneumonitis.

Cardiovascular -

Massive doses of xylene can cause cardiac abnormalities. Xylene may increase susceptibility of myocardial cells to the dysrhythmogenic effects of catecholamines. Dysrhythmias leading to cardiac arrest have occurred in solvent abusers, often immediately preceded by intense physical activity.

Renal -

Hematuria and proteinuria can occur after massive inhalation. These effects usually are reversible if exposure is terminated.

Metabolic disturbance -

After high-level exposure, xylene may lead to metabolic acidosis. In solvent abusers, electrolyte and acid-base disturbances can cause renal tubular acidosis, hypokalemia, and hypophosphatemia. Ethanol or aspirin may prolong the half-life of xylene in the body.

Dermal -

Xylene can cause significant skin irritation and defatting dermatitis, particularly after prolonged or repeated contact with the liquid. Erythema and bullae may occur. Ocular High concentrations of xylene vapor can cause eye irritation, but ophthalmic injury is rare. When splashed in the eyes, xylene may cause burning pain, corneal injury, and sloughing of corneal epithelium.

Gastrointestinal -

If swallowed, liquid xylene can irritate the stomach lining, causing nausea, vomiting, and diarrhea.

Potential Sequelae -

During recovery, victims may continue to experience ataxia, depressed level of consciousness, dilated and poorly responsive pupils, and decreased or absent deep tendon reflexes. Anxiety, fatigue, and insomnia may last several days. Long-term sequelae due to acute xylene exposure have not been reported.

Chronic Exposure --

Repeated exposure to xylene due to solvent abuse can result in progressive and permanent neuropsychiatric manifestations. Xylene also can affect the heart and liver and may cause anemia. Xylene is not reported to be carcinogenic by IARC or NTP. In the absence of maternal toxicity, reproductive and developmental effects of acute xylene exposure are unlikely to occur. A 1991 report (Reproductive and Developmental Toxicants) published by the United States General Accounting Office (GAO) lists 30 chemicals of concern because of their reproductive and developmental consequences; xylene is not on this list.

Prehospital Management

Xylene may cause central nervous system depression and cardiac dysrhythmias.
There is no specific antidote for xylene poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination --

Victims exposed to only xylene vapor do not pose a significant risk of secondary contamination to rescuers outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid xylene can secondary contaminate response personnel by direct contact or through off-gassing vapor.

Hot Zone --

Rescuer Protection --

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are recommended if contact with liquid or concentrated vapor is possible.

ABCs --

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal --

Decontamination Zone --

Victims with exposure to only vapors of xylene and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Support Zone. For all others, see Basic Decontamination.

Rescuer Protection --

Rescuers in the decontamination zone should wear self contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with liquid-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen if available.

Evaluate the need for an intravenous line, cardiac monitor, and other life support. Basic Decontamination Remove and double-bag contaminated clothing. Victims who are able and cooperative may remove theft own clothing and assist with basic decontamination. Flush liquid-exposed skin and hair with plain water for 2 to 3 minutes, then wash with mild soap or shampoo and rinse with copious water. Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of xylene ingestion, do not induce emesis. Administer a slurry of activated charcoal (50 to 60 g) if the patient is conscious and able to swallow. Transfer to Support Zone As soon as basic decontamination is completed, move the patient to the Support Zone. Support Zone Be certain that patients have undergone basic decontamination (see Decontamination Zone). Patients who have undergone proper decontamination or have been exposed to only vapor pose no serious risk of secondary contamination to rescuers. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Advanced Treatment -

Intubate the trachea if indicated (coma or apnea).

Treat wheezing with aerosolized bronchodilators; use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias.

Treat coma and ventricular dysrhythmias according to standard ALS protocol.

Additional Decontamination -

If skin or eyes remain irritated, flush with plain water or saline for 3 to 5 minutes. Remove contact lenses if present. In case of xylene ingestion, do not induce emesis. Administer a slurry of activated charcoal (50 to 60 g) if it was not administered in the decontamination zone and if the patient is conscious and able to swallow.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of patient, treatment given, and estimated time of arrival at the medical facility. If a patient has ingested xylene, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Patients with a history or evidence of significant exposure and all persons who have ingested xylene should be transported to a medical facility and evaluated.

Emergency Department Management

Xylene may cause central nervous system depression and cardiac dysrhythmias.

There is no antidote for xylene poisoning. Treatment consists of supportive measures.

Potential for Secondary Contamination -

Hospital personnel in an enclosed area can be secondarily contaminated by vapor off-gassing from heavily soaked clothing. Patients do not pose a contamination risk after contaminated clothing is removed and the skin is washed.

Decontamination Area --

Patients with exposure to only vapors of xylene and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm. If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only Xylene vapor do not require decontamination unless they have skin or eye irritation.

Basic Decontamination -

If the patient's clothing is wet with xylene, remove and double-bag the contaminated clothing and all personal belongings. Flush exposed skin with copious water for 2 to 5 minutes (preferably under a shower). Use mild soap or shampoo for oily or adherent materials.

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Decontamination Area.

ABCs -

Evaluate and support airway, breathing, and circulation as above. Continuously monitor cardiac rhythm.

Assess and treat hypotension and seizures in the conventional manner. Sympathomimetics or catecholamines should be avoided or should be used with caution to avoid inducing ventricular fibrillation. Ventricular tachyrhythmia may respond effectively to beta-blockers. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g.,trauma, hypoglycemia, drug intoxication).

Inhalation Exposure -

Administer supplemental oxygen by mask to patients with respiratory complaints. Treat wheezing with bronchodilators (use with caution).

Skin Exposure -

If liquid xylene was in prolonged contact with the skin, chemical burns may occur. Treat chemical burns as thermal burns. Eye Exposure If eye irritation or injury is evident, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. Small corneal defects may be treated with topical ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion -

Perform gastric lavage if the patient has ingested a large dose -and presents within 30 minutes of exposure, then administer activated charcoal and a cathartic. When small amounts of xylene have been ingested, activated charcoal may be administered orally without gut emptying.

If the patient who has ingested xylene is coughing or is dyspneic, pulmonary aspiration may have occurred. Patients who show no clinical signs of pulmonary aspiration within 6 hours are unlikely to develop aspiration chemical pneumonitis.

Antidotes and Other Treatments -

There is no antidote for xylene poisoning. Hemodialysis and hemoperfusion are ineffective.

Laboratory Tests -

In cases of significant exposure, useful laboratory studies include BUN, electrolytes, creatinine, urinalysis, liver function tests, and ECG monitoring. Chest radiography and ABGs are recommended for severe inhalation exposure or if pulmonary aspiration is suspected.

Blood levels of xylene may be used to document exposure, although they are not useful clinically. Xylene is metabolized to methylhippuric acid, which is excreted in urine. Almost total excretion occurs within 24 hours. Urinary methylhippuric acid levels do not correlate well with systemic effects and are not available on an emergency basis; however, methylhippuric acid can help confirm the diagnosis or etiology.

Disposition and Follow-up --

Consider hospitalization for symptomatic patients who have a history of significant inhalation exposure or aspiration chemicalpneumonia and patients who have ingested significant amounts of xylene.

Delayed Effects -

Observe hospitalized patients for signs of acute tubular necrosis, encephalopathy, and dysrhythmias. In addition, patients exposed by inhalation should be watched for signs of pulmonary edema, and those who have ingested xylene should be watched for signs of aspiration pneumonia.

Patient Release -

Patients who have remained asymptomatic 6 to 12 hours after exposure may be discharged, advised to rest and to promptly seek medical care if symptoms of toxicity develop.

Follow-up -

Patients with corneal injury should return for follow-up evaluation within 24 hours. Other long-term sequelae due to a single acute exposure to xylene have not been reported.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department. Other people may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH.

Xylene Patient Information Sheet

This handout provides information and follow-up instructions for persons who may have been exposed to xylene liquid or vapor.

What is xylene?

When pure, xylene is a clear, colorless liquid with a sweet odor. It burns readily. Xylene is obtained from crude petroleum and is used widely in many products such as paints, glues, and pesticides. It is found in small amounts in gasoline.

What immediate health effects may be caused by exposure to xylene? Breathing xylene vapors in small amounts may cause headache, euphoria (a "high"), a light-headed feeling, dizziness, drowsiness, or nausea. With more serious exposure, xylene may cause sleepiness, stumbling, irregular heart beats, fainting, or even death. Xylene vapors are mildly irritating to the skin, eyes, and lungs. If liquid xylene contacts the skin or eyes, it may cause burning pain. Liquid xylene splashed in the eyes can also damage the cornea of the eyes.

What is the treatment for xylene poisoning?

There is no antidote for xylene poisoning, but its effects can be treated and most exposed persons do recover fully. Persons who have experienced serious symptoms may need close medical observation for 24 hours.

Are any future health effects likely to occur?

After a single, small exposure to xylene, no delayed or long-term effects are likely to occur. After a serious exposure, symptoms may develop within a few days. The reverse side of this page lists some signs and symptoms to watch for--if any of them occur, seek medical care. Repeated sniffing of xylene to get "high" can cause permanent damage to the brain, heart, muscles, and kidneys.

What tests can be done if a person has been exposed to xylene? Specific tests for the presence of xylene in blood and urine are not medically useful. Methylhippuric acid, a metabolite of xylene, may be measured in urine if the xylene dose was high. In cases of severe exposure, other tests may show if injury has occurred in the brain, heart, muscles, or nervous system. The severity of symptoms is usually the best measure of the seriousness of the exposure.

Where can more information about xylene be found?

More information about xylene may be obtained from your regional poison control center; the state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Xylene Follow-up Instructions --

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * cough
  * shortness of breath or wheezing
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. _________ in the practice of_________.
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at__________________ Hospital by
__________ and were advised to be seen again in __ days.

( ) Return to the Emergency Department/__________Clinic on (date)__________
at____ AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for __ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________

( ) Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient _______________________ Date _________________________

Signature of physician _____________________ Date _________________________

Appendix I AAPCC - Certified Regional Poison Control Centers

Poison Control Centers were established around 1953 to help physicians deal with poisoning of adults and children in the United States. In 1983, the American Association of Poison Control Centers (AAPCC) was established as the professional organization for Poison Control Centers. The Regional Poison Control Centers can act as a valuable resource in providing information about the toxicity and health effects of hazardous exposures involved in poisonings.

ALABAMA
Birmingham
Children's Hospital of Alabama Poison Control Center
(205) 939-9201 (800) 292-6678 (In state) (205) 933-4050

ARIZONA
Samaritan Regional Poison Center
(602)253-3334
Tucson
Arizona Poison and Drug Information Center
(800) 362-0101 (In state) (602) 626-6016

COLORADO
Denver
Rocky Mountain Poison and Drug Center
(303) 629-1123

DISTRICT OF COLUMBIA
Washington
National Capitol Poison Control Center
(202) 625-3333 (202) 784-4660 (TTY)

FLORIDA
Tampa
Florida Poison Information Center
(800) 282-3171 (In state) (813) 253-4444

CALIFORNIA
Fresno
Fresno Regional Poison Control Center
(800) 346-5922 (In state) (209) 445-1222
Orange
UCI Regional Poison Center
(714) 634-5988 (800) 544-4404)Southern CA only)
Sacramento
UCDMC Regional Poison Control Center
(800) 342-9293 (Northern CA only) (916) 453-3692
San Diego
San Diego Regional Poison Control Center
(619) 543-6000 (800) 876-4766 (619 area only)
San Francisco
SF Bay Area Regional Poison Control Center
(415) 476-6600
San Jose
Santa Clara Valley Medical Center Regional Poison Center (408) 299-5112 (800) 662-9886 (CA only)

GEORGIA
Atlanta
Georgia Poison Center
(800) 282-5846 (In state) (404) 589-4400

INDIANA
Indianapolis
Indiana Poison Center
(800) 382-9097 (In state) (317) 929-2323

KENTUCKY
Louisville
Kentucky Regional Poison Center of Kosair Children's Hospital (800) 722-5725 (In state) (502) 629-7275

MARYLAND
Baltimore
Maryland Poison Center
(800) 492-2414 (In state) (410) 528-7701

MASSACHUSETTS
Boston
Massachusetts Poison Control System
(800) 682-9211 (Instate) (617) 232-2120

MICHIGAN
Detroit
Poison Control Center
(313) 745-5711
Grand Rapids
Blodgett Regional Poison Ctr
(800) 632-2727 (In state) (800) 356-3232 (TTY)

MINNESOTA
Minneapolis
Hennepin Regional Poison Ctr
(612) 347-3141 (612) 337-7474 (TDD) (612) 337-7387 (Petline)
St. Paul
Minnesota Regional Poison Ctr
(612) 221-2113

MISSOURI
St. Louis
Cardinal Glennon Children's Hospital
(800) 366-8888 (314) 772-5200

MONTANA
Denver (COLORADO)
Rocky Mountain Poison and Drug Center
(303) 629-1123

NEBRASKA
Omaha
The Poison Center
(402) 390-5555 (Omaha only)
(800) 955-9119 (In state)

NEW JERSEY
Newark
New Jersey Poison Information and Education System
(800) 962-1253 (In state)

NEW MEXICO
Albuquerque
New Mexico Poison and Drug Information Center
(800) 432-6866 (In state) (505) 843-2551

NEW YORK
East Meadow
Long Island Regional Poison Control Center
(516) 542-2323, 2324, 2325, 3813
New York
New York City Poison Center
(212) 340-4494 (212) 764-7667 (212) 689-9014 (TDD)

OHIO
Cincinnati
Regional Poison Control System and Cincinnati
Drug and Poison Information Ctr
(513) 558-5111 (800) 872-5111 (In state)
Columbus
Central Ohio Poison Center
(800) 682-7625 (614) 228-1323 (614) 228-2272 (TTY) (614) 461-2012

OREGON
Portland
Oregon Poison Center
(503) 494-8968 (800) 452-7165 (In state)

PENNSYLVANIA
Philadelphia
Poison Control Center
(215) 386-2100 or 2111
Pittsburgh
Pittsburgh Poison Center
(412) 681-6669

RHODE ISLAND
Providence
Rhode Island Poison Center
(401) 277-5727

TEXAS
Dallas
North Texas Poison Center
(800) 441-0040 (In state) (214) 590-5000

UTAH
Salt Lake City
Intermountain Regional Poison Control Center
(801) 581-2151 (800) 456-7707 (In state)

VIRGINIA
Charlottevllle
Blue Ridge Poison Center
(804) 925-5543 (800) 451-1428

Washington D.C.
National Capital Poison Center (Northern VA only)
(202) 625-3333 (202) 784-4660 (TTY)

WEST VIRGINIA
Charleston
West Virginia Poison Center
(800) 642-3625 (In state) (304) 348-4211

WYOMING
Omaha (NEBRASKA)
The Poison Center
(402) 390-5555 (Omaha) (800) 955-9119 (from Wyoming only)

Appendix II Association of Occupational and Environmental Clinics

The professionals in the AOEC act as consultants regarding treatment of persons exposed to hazardous substances.

CALIFORNIA
San Francisco
Judie Guerriero, RN. MPH Occupational Health Clinic
San Francisco General Hospital
1001 Potrero Ave.-Bld. 9 Room 1O9
San Francisco. CA 94110
(415) 206-5391 FAX (415) 206-8949 Alt. Contact,
Patricia Quinlan, MPH

Robert Harrison, MD, Dir.
Occupational & Environmental Medicine Clinic
University of California at San Francisco
400 Parnassus Ave. A585
San Francisco, CA 94143
(415) 476-1841 FAX (415)476-6426

COLORADO Denver
Kathleen Kreiss, MD

Nat'l Jewish Center of Immunology and Respiratory Medicine 1400 Jackson Street
Denver, CO 80206
(303) 398-1520 FAX (303)398-1452
AR. Contact. Cecile Rose, MD, Peggy Mroz, MSPH

CONNECTICUT New Haven
Mark Cullen, MD
Yale Occupational/Environmental Medicine Program
333 Cedar Street
New Haven, CT 06510
(203) 785-5885 FAX (203)785-7391

Farmington
Eileen Storey, MD, MPH
University of Connecticut Occupational Medicine Program
263 Framington Ave. Farmington, CT 06030
(203) 679-2366
Alt. Contact, Michael Hodgson, MD

WASHINGTON, D.C.
Laura Welch, MD
Division of Occupational and Environmental Medicine
School of Medicine, George Washington
University 2300 K Street, NW Washington, DC 20037
(202) 994-1734 FAX (202)994-0247
Alt. Contact. Rosemary Sokas, MD

GEORGIA Atlanta
Howard Frumkin, MD MPH
Environmental and Occupational Program
The Emory Clinic
1365 Clifton Road, NE Atlanta, GA 30329
(404) 727-3697 FAX (404) 727-8744

ILLINOIS Bridgeview
Geralynn Kahn, MD. MPH
MacNeal Occupational Medicine Clinic at
Bridgeview Medical Center 7217 N 84th Street
Bridgeview, IL 60455
(708) 795-3400 FAX (708)795-3341
Alt. Contact. Linda Cocchiarella, MD, MS

Chicago
Stephen Hessl, MD, MPH Occupational Medicine Clinic
Cook County Hospital
720 South Wolcott
Chicago, IL 60612
(312) 633-5310 FAX (312) 633-6442
Alt. Contact, Ann Naughton, RN

Penny Higgins. RN, BS
Managed Care Occupational Health Program
Mount Sinai Hospital Medical Center
2720 West 15th Street
Kling Bldg. Room 534
Chicago, IL 60608
(312) 650-6480 FAX (312)650-6213
Alt. Contact, Peter Orris, MD

Linda Forst, MD, MS, MPH
University of Illinois Occupational Medicine Program
840 S. Wood M/C 678, P.O. Box 6998
Chicago, IL 60612
(312) 996-2592 FAX (312) 413-0122
Aft. Contact, Stephen HessI, MD, MPH

IOWA City
David Schwartz, MD
University of Iowa, Occupational Medicine Clinic
Department of Internal Medicine, College of Medicine
T304, GH
Iowa City, IA 52242
(319) 356-8269 FAX (319) 356-8608

KENTUCKY
Lexington
Arthur Frank, MD
University of Kentucky Occupational Medicine
Program Warren Wright Medical Plaza 800 Rose
Street Lexington. KY 40536-0084
(606) 257-5166 FAX (606)258-1038 Alt- Contact,
David Fahringer, PA-C,
Terence R. Collins. MD, MPH

LOUISIANA New Orleans
Peter G. Casten, MD, MPH
Ochsner Center for Occupational Health 1514
Jefferson Highway New Orleans, LA 70121
(504) 838-3955 Fax (504)838-5721
Alt. Contact, Douglas A. Swift, MD, MPH;
Todd W. McCune, MD, MPH

MASSACHUSETTS Boston
Christine Oliver, MD, MPH, MS
Massachusetts General Hospital Occupational
Medicine Clinic 32 Fruit Street Boston, MA 02114
(617) 726-2721 or (617)726-2741
Alt. Contact, Elisha Atkins, MD;
Dean Hashimoto. MD, JD; Bruce Shackleton, EdD

Cambridge
Rose Goldman, MD. MPH
Occupational and Environmental Health
Center Cambridge HospRal 1493 Cambridge
Street Cambridge, MA 02139
(617) 498-1580 FAX (617) 498-1671 Alt.
Contact, Cathy Schwartz, RN

South Braintree
Dianne Plantamura. Coordinator
Center for Occupational and Environmental
Medicine Massachusetts Respiratory Hospital
2001 Washington Street
South Braintree. MA 02184
(617) 848-2600 FAX (617)849-3290
Alt. Contact, David Christiani, MD, MPH, Director

Worcester
Glenn Pransky. MD, MOccH Occupational
Health Service Department of Family and Community Medicine
University of Massachusetts 55 Lake Avenue
North Worcester. MA 01655
(508) 856-2734 Fax (508)856-1212
Alt. Contact, Charles Sweet, MD, MPH;
Kathleen Rest, PhD, MPA

MARYLAND Baltimore
Eric Schaub, MD, MS Johns Hopkins University
Center of Occupational and Environmental
Health 5501 Hopkins Bayview Circle Baltimore,
MD 21224
(41 O) 550-2322 FAX (41 O) 550-2090
Alt. Contact, Theresa Pluth, MSN, MPH

James Keogh, MD
Occupational Health Project/School of Medicine

Division of Genenal Internal Medicine University of Maryland 405 Redwood Street
Baltimore, MD 21202
(410)328-7464 FAX (410)328-8326

MICHIGAN Ann Arbor
David Garabrant, MD Occupational Health Program
School of Public Health, University of Michigan
1420 Washington Heights Ann
Arbor, MI 48109-2029
(313) 764-2594 FAX (313)763-8095
Alt.Contact, Alfred Franzblau, MD; Tom Robbins, MD

Detroit
Ray Demers, MD, MPH Division of Occupational Health
Wayne State/Department of Family Medicine
4201 St. Antoine, Suite 4-J
Detroit, Mi 48201
(313) 577-1420 FAX (313)577-3070
Alt. Contact, Mark Upfal, MD, MPH;
James Blessman, MD, MPH;
Maryjean Schreiber, MD, MPH;
Kendra Schwartz. MD, MPH

East Lansing
Kenneth Rosenman. MD Michigan

State University Department of Medicine B338 Clinical Center East Lansing, MI 48824-1317
(517) 353-1846 FAX (517) 336-2759

Southfield
Margaret Green, MD, MPH
Center for Occupational and Environmental
Medicine 15901 West Nine Mile Rd., Suite 410
Southfield, MI 48075
(313) 559-6663 FAX (313) 559-8254
Alt. Contact, Michael Harlont, MD, MPH

MINNESOTA St. Paul
Paula Geiger, Administrative Secretary Ramsey

Clinic Occupational and Environmental Health and Occupational Medicine Residency Training Program 640
Jackson St.
St. Paul, MN 55101-2595
(612) 221-3771 FAX (612) 221-3874
Alt. Contact,William H. Lehman, MD

NEW JERSEY Piscataway
Howard Kipen, MD. MPH
Environmental and Occupational Health Clinical Center
Environmental and Occupational Health Sciences
Institute UMDNJ-Robert Wood Johnson
Medical School P.O., Box 1179
Piscataway, NJ 08855-1179
(908) 932-0182 FAX (908)932-0127
Alt. Contact, Gall Buckler, RN, MPH, COHN

NEW YORK Latham
Anne Tencza, RN, COHN
Eastern NY Occupational Health Program 1201 Troy
Schnectady Road Latham, NY 12110
(518) 783-151 a FAX (518)783-1827
Alt. Contact, David L. Orgel. MD, MPH

New York
Stephen Mooser, MPH Mount Sinai
Irving J. Selikoff Occupational Health Clinical Center
P.O. Box 1057/1058 Gustave Levy Place New York, NY 10029
(212) 241-6173 FAX (212)996-0407
Alt. Contact, Stephen Levin, MD

Stony Brook
Wajdy Hailoo, MD
Stony Brook Occupational Medicine Center
HSC, L 3-086
SUNY
Stony Brook. NY 11794

Syracuse
Michael B. Lax, MD, MPH
Central NY Occupational Health Clinic Center
550 Harrison Center, Suite 300
Syracuse, NY 13202
(315) 464-6422 FAX (315)464-7510

NORTH CAROLINA Durham
Dennis J. Darcey, MD, MPSH
Duke University Medical Center
Division of Occupational and Environmental Medicine
Box 2914
Durham. NC 27710
(919) 2&6-3232 FAX (919)286-1021
Alt. Contact, Gary Greenberg, MD, MPH

OHIO Cincinnati
James Lockey, MD
Center for Occupational Health
University of Cincinnati College of Medicine Eden and
Bethesda Ave.
Cincinnati, OH 45267-0187
(513) 558-1234 FAX (513) 558-1010
Alt. Contact, Susan Pinney. PhD

Harriet Applegate
Greater Cincinnati Occupational Health Center Jewish
Hospital Evandale
10475 Reading Road, Suite 405
Cincinnati, OH 45241
(513) 769-0561 FAX (513)769-0766
Alt. Contact, Margaret Alterbury, MD, MPH

Cleveland
Seth Foldy, MD
Occupational/Environmental Health Clinic
Department of Family Practice Metro Health Medical
Center 2500 Metro Health Drive
Cleveland, OH 44109-1998
(216) 459-5737 FAX (216)459-3297
Alt. Contact. Kathleen Fagan, MD

OKLAHOMA City
Lynn Mitchell, MD
University Occupational Health Services Oklahoma
Memorial Hospital 800 NE 13th St., Room 5E 109

Oklahoma City, OK 73104
(405) 271-3100 FAX (405) 271-4125

PENNSYLVANIA Pittsburgh
David Tollerud, MD. MPH
Occupational and Environmental Medicine Program
University of Pittsburgh
130 DeSoto Street, Room A729
Pittsburgh, PA 15261
(412) 624-3155 FAX (412)624-3040
Alt. Contact, Betty Goodman-Klein, CRNP

Philadelphia
Eddy Bresnitz, MD Occupational Health Service
Department of Community and Preventive Medicine/MCP
3300 Henry Ave.
Philadelphia. PA 19129
(215) 842-6540 FAX (215)843-2448
Alt. Contact. Harriett Rubenstein, JD, MPH

RHODE ISLAND Pawtuckett
David G. Kern, MD, MOH
Memorial Hospital of RI Occupational Health Service
Brown University
Program in Occupational Medicine
111 Brewster St. Pawtuckett, RI 02860
(401) 729-2859 FAX (401)722-0198

WASHINGTON Seattle
Linda Rosenstock, MD Occupational Medicine Program
University of Washington Harborview Medical Center
325 9th Ave. ZA-66
Seattle, WA 98104
(206) 223-3005 FAX (206)223-8247
Alt. Contact, Scott Barnhart, MD

WEST VIRGINIA Huntington
Chris McGuffin, MS

Division of Occupational and Environmental Health Department of Family and Community Medicine Marshal
University School of Medicine
1801 6th Ave.
Huntington. WV 25755
(304) 696-7045 FAX (304)696-7036
Alt. Contact, Karen Mulloy, DO, MSCH

Appendix III Consultation Resources

American College of Occupational and Environmental Medicine 55 W. Seegers Arlington Heights, IL 60005
(708) 228-6850

Board-certified occupational physicians and members of the College of Occupational Medicine can be obtained from The American College of Occupational Medicine

American Board of Medical Toxicology
National Office
Lewis Goldfrank, MD
New York Poison Center
Bellevue Hospital
27th Street & 1 st Avenue New York, NY 10016
(212) 561-3346

Association of Occupational and Environmental Clinics
Ed Kelly,Executive Director
1030 15th Street NW, Suite 410
Washington, DC 20005
(202) 347-4976

The Association of Occupational and Environmental Clinics (AOEC) is a network of clinics affiliated with medical schools throughout the U.S. Member clinics provide professional training, community education about toxic substances, exposure and risk assessment, clinical evaluations, and consultation. A lending library of training materials is maintained for use by members. Membership is open to any person who shares the goals of the Association. Clinicians can contact the AOEC office for referrals.

Teratogen Exposure Registry and Surveillance (TERAS)

TERAS is a network of geneticists and pathologists studying human embryos and fetuses exposed to teratogens.TERAS maintains information networks for consultation and evaluations.
Frederick Bieber, Ph.D.
Department of Pathology Brigham and Women's Hospital
75 Francis St. Boston, MA 02115
(617) 732-6507

University programs In occupational health, Industrial hygiene, or toxlcology

The School of Public Health or School of Medicine at Universitys function as resources to local communities. In addition, some hospitals have occupational or environmental health clinics that accept referrals.

Mother Risk Program

The MotherRisk Program will counsel callers about the safety of an exposure to drugs, chemicals, or radiation during pregnancy or breast feeding. The team of physicians and information specialists give advice on whether medications, X-rays, or chemicals in the work environment will harm the developing fetus or breast-fed baby. Genetic counseling is available from the Hospital for Sick Children's Genetic Department.
Gideon Koren, M.D., Director
Hospital for Sick Children
555 University Avenue Toronto, Ontario M5G1 X8
(416) 813-6780

State/Federal/National Resources

Chemical Emergencies
Chemical Spills Emergency Hotline
(800) 535-0202

USEPA Hazardous Waste Hotline
(800) 535-0202

Hazardous Waste
Emergency Planning & Community Right-To-Know
Hotline (EPA)

Developing chemical contingency plans, gathering site-specific information, list of more than 400 acutely toxic chemicals
(800) 535-0202

Superfund Records of Decision

Hazardous waste, sites to be cleaned up, actions being taken (703) 920-9810

Integrated Risk Info System (IRIS)
Hazardous chemicals info, including health effects
(202) 475-6743

IRIS User Support
(513) 569-7254

Pesticides
National Pesticide Hotline
(800) 535-PEST

National Pesticide Telecommunications Network
Pesticides
(800) 858-7378

National Pesticides lnfo Retrieval System (NPIRS)

(funded by EPNUSDA, managed by Purdue University) Help number for searching NPIRS database to get fact sheets on pesticides, insecticides, fungicides, state & federally registered chemicals
(317) 494-6614

Radon
Radon Hotline
(800) SOS-RADON

EPA Office of Radon Programs (202) 475-9605

Lung Disease
Lungline/National Jewish Hospital
Information on lung disease from chemical exposure
(800) 222-5864

Lead

National Center for Environmental Health and Injury Control (CDC) Lead poisoning prevention
(404) 488-4880

Child and Maternal Health Clearinghouse
Publications on lead poisoning
(202) 625-8410

Occupational Health
NIOSH

Information and publications on health effects of occupational exposures (800) 356-4674

Medical Section/Diagnosis and Treatment
(513) 841-4386

Industrial Hygiene
(513) 841-4374

OSHA (Occupational Safety & Health Administration)

Regulations for toxic & hazardous substances in the workplace (202) 523-7111

Toxic Substances
Toxicology Info Response Center (Oak Ridge)

General toxics info, searches on chemicals (615) 567-1743 or (615) 567-1750

Agency for Toxic Substances & Disease Registry (ATSDR)

Toxicological profiles in draft (Final profiles available from Natl Technical Info System)
(404) 539-6000

Toxic Substances Control Act (TSCA) Hotline/Public Info Office (EPA)

Answers questions & gives general technical assistance on TSCA. Guidance on TSCA regulations
(202) 554-1404

Toxic Chemical Release Inventory System (EPA) Info about which chemicals are used, stored, released by companies
(800) 535-0202

Chemical Referral Center (American Chemical Society)
Nonemergency health and safety information on chemicals
Outside continental US
(202) 887-1315

Water
EPA Safe Drinking Water Hotline
(800) 426-9607

State Health Departments

Alabama Department of Public Health 434
Monroe Street Montgomery, AL 36130
205) 242-5052

Alaska Division of Public Health PO Box H-06
Juneau, AK 99811-0610
(907) 465-3090

Arizona Department of Health Services
1740 W. Adams Street Phoenix, AZ 85007
(602) 542-1024

Georgia Division of Public Health 878
Peachtree Street Atlanta, GA 30309
(404) 894-7505

Guam Public Health and Social Services
PO Box 2816 Agana, Guam 96910
(671) 734-2083

Hawaii Department of Health
1250 Punchbowl Street
PO Box 3378 Honolulu, HI 96801
(808) 548-6505

Arkansas Department of Health
4815 W. Markham Street
Little Rock, AR 72205-3867
(501) 661-2111

Idaho Division of Health Department of Health and Welfare
450 W. State Street
Boise, ID 83720
(208) 334-5945

California Department of Health Services
714 P St.
Sacramento, CA 95814
(916) 445-4171

Illinois Department of Public Health
535 W. Jefferson Street
Springfield, IL 62761
(217) 782-4977

Colorado Department of Health
4210 E. 11th Avenue
Denver, CO 80220
(303) 331-4600

Connecticut Department of Health Services
150 Washington Street
Hartford, CT 06106
(203) 566-2038

Delaware Division of Public Health Department of Health & Social Services PO Box 637 Dover, DE 19903
(302) 739-4701

District of Columbia Department of Human Services
Commission of Public Health
1660 L Street
NW Washington, DC 20036
(202) 673-7700

Florida Health Office Department of Health and Rehabilitation Services 1323 Winewood Blvd, Bldg 1
Tallahassee, FL 32399-0700
(904) 467-2705

Indiana Board of Health
PO Box 1964
1330 W. Michigan Street Indianapolis, IN 46206
(317) 633-6400

Iowa Department of Public Health
Robert Lucas State Office Bldg.
312 E.12th St
Des Moines, IA 50319
(515) 281-5605

Kansas Dept. of Health & Environment
900 SW Jackson
Topeka, KS 66612
(913) 296-1343

Kentucky Department for Health Services Cabinet for Human Resources 275 E. Main Street
Frankfort, KY 40621
(502) 564-3970

Louisiana Department of Health and Hospitals
1201 Capitol Access Road East Entrance
PO Box 629
Baton Rouge, LA 70821
(504) 342-9500

Maine Bureau of Health Department of Human Services
State House Station
11 Augusta, ME 04333
(207) 289-2736

Maryland Department of Health and Mental Hygiene
201 W. Preston Street Baltimore, MD 21201
(301) 225-6500

Massachusetts Department of Public Health 150
Tremont Street Boston, MA 02111
(617) 727-2700

Michigan Department of Public Health 3423 N. Logan
Street PO Box 30195 Lansing, MI 48909
(517) 335-8024

Minnesota Department of Health
717 Delaware Street SE
PO Box 9441 Minneapolis, MN 55440
(612) 623-5000

Mississippi Department of Health
PO Box 1700
2423 N. State Street Jackson, MS 39215
(601) 960-7634

Missouri Department of Health
PO Box 570
Jefferson City, MO 65102
(314) 751-6001

Montana Department of Health and Environmental Sciences
Cogswell Bldg
Lockey Street Helena, MT 59620
(406) 444-2544

Nebraska Department of Health
301 Centennial Mail S.
PO Box 95007 Lincoln, NE 68509
(402) 471-4047

Nevada Health Division
505 E. King Street
Carson City, NV 89710
(702) 687-4740

New Hampshire Division of Public Health Services
Health and Welfare Bldg.
Hazen Dive Concord, NH 03301
(603) 271-4501

New Jersey Department of Health
CN 360
Trenton, NJ 08625
(609) 292-7837

New Mexico Health and Environment Department
1190 St.
Francis Drive Santa Fe, NM 87503
(505) 827-2613

New York Department of Health
Tower Building
Empire State Plaza
Albany, NY 12237
(518) 474-2011

North Carolina Department of Environment, Health and Natural Resources, Division of Health Services
512 N. Salisbury St. PO Box 27687
Raleigh, NC 27611
(919) 733-4984

North Dakota Department of Health and Consolidated Labs
State Capitol Judicial Wing 600 E. Boulevard
Avenue Bismark, ND 58505-0200
(701) 224-2372

Ohio Department of Health
246 N. High Street
Columbus, OH 43266-0588
(614) 466-2253

Oklahoma Department of Health
1000 NE 10th Street PO Box 53551
Oklahoma City, OK 73152
(405) 271-4200

Oregon State Health Division
1400 SW 5th Avenue Portland, OR 97201
(503) 229-4032

Pennsylvania Department of Health
802 Health and Welfare Bldg.
Harrisburg, PA 17120
(717) 787-6436

Puerto Rico Department of Health Bldg. A,
Call Box 70184 San Juan, PR 00936
(809) 766-1616

Vermont Department of Health
PO Box 70, 60 Main Street
Burlington, VT 05402
(802) 863-7280

Virgin Islands Department of Health
St. Thomas, VI 00802
(809) 774-0117

Virginia Department of Health
1500 E. Main Street Station Room 214
Richmond, VA 23219
(804) 786-3561

Washington Department of Social and Health Services
1112 S. Quince Mail Stop ET 21
Olympia, WA 98504
(206) 753-5871

Rhode Island Department of Health
3 Capitol Hill Providence, RI 02908
(401) 277-2231

West Virginia Department of Public Health
1800 Washington Street E.
Charleston, WV 25305
(304)348-2971

South Carolina Department of Health and Environmental Control 2600 Bull Street Columbia, SC 29201
(803) 734-4880

South Dakota Department of Health
525 E. Capitol, Joe Foss Bldg.
Pierre, SD 57501-3182
605-773-3361

Wisconsin Division of Health
PO Box 309
Madison, WI 53701-0309
(608) 266-1511

Wyoming Health and Medical Services
Hathaway Bldg.,4th Floor
Cheyenne, WY 82002
(307)777-6464

Tennessee Department of Health and Environment
344 Cordell Hull Bldg.
Nashville, TN 37247-0101
(615) 741-3111

Texas Department of Health
1100 W. 49th Street Austin, TX 78756
(512) 458-7375

Utah Department of Health
288 N. 1460 W. PO Box 16700
Salt Lake City, UT 84116-0700
(801) 538-6111

For Additional Information

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Public Health Service, Agency for Toxic Substances and Disease Registry, August 1992.

Use of trade names in this document is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

Agency for Toxic Substances and Disease Registry Project Officers: Max Lum, EdD; Donna Orti, MS; and Patricia Poindexter, MPH; Edited by Terese L Ramsey, MA; Prepared by DeLima Associates, San Rafael, California, under Contract No. 205-90-0817

POINT OF CONTACT FOR THIS DOCUMENT:

To request a copy of this document or for questions concerning this document, please contact the person or office listed below. If requesting a document, please specify the complete name of the document as well as the address to which you would like it mailed. Note that if a name is listed with the address below, you may wish to contact this person via CDC WONDER/PC e-mail. DONNA L ORTI
AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY
Centers for Disease Control
1600 Clifton Rd, NE MS:(E-33)
Atlanta, GA 30333

Figure 1

Organization Of A Hazmat Incident Area

Figure 2

Detail Of Decontamination Zone

CDC Prevention Guidelines is presented as part of CDC WONDER
WONDER | Centers for Disease Control and Prevention
WONDER User Support (cwus@cdc.gov)

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Medical Management Guidelines for Acute Chemical Exposures

U.S. Department of Human Services, Public Health Service, Agency for Toxic Substance and Disease Registry

Publication date: 08/01/1992

Table of Contents

Preface

Introduction

Description Chemical Name (Chemical Formula)

Health Effects

Prehospital Management

Prehospital Management

Emergency Department Management

Emergency Department Management

Protocol for the Unidentified Chemical Contaminant

Unidentified Chemical Prehospital Management

Unidentified Chemical Emergency Department Management

Chemical Protocols

Ammonia NH(3)

Health Effects

Prehospital Management

Emergency Department Management

Ammonia Patient Information Sheet

Ammonia Follow-up Instructions -

Arsine AsHJ(3)

Health Effects

Prehospital Management

Emergency Department Management

Arsine Patient Information Sheet

Arsine Follow-up Instructions --

Benzene (C(6)H(6))

Health Effects

Prehospital Management

Emergency Department Management

Benzene Patient Information Sheet

Benzene Follow-up Instructions --

Ethylene Oxide ((CH(2))(2)0)

Health Effects

Prehospital Management

Emergency Department Management

Ethylene Oxide-- Patient Information Sheet

Ethylene Oxide Follow-up Instructions --

Formaldehyde (HCHO)

Health Effects

Prehospital Management

Emergency Department Management

Formaldehyde Patient Information Sheet

Formaldehyde Follow-up Instructions

Hydrogen Fluoride (HF) and Hydrofluoric Acid

Health Effects

Prehospital Management

Emergency Department Management

Hydrogen Fluoride and Hydrofluoric Acid Patient Information Sheet

Hydrogen Fluoride and Hydrofluoric Acid Follow-up Instructions --

Hydrogen Peroxide (H(2)O(2))

Health Effects

Prehospital Management

Emergency Department Management

Hydrogen Peroxide Patient Information Sheet

Hydrogen Peroxide Follow-up Instructions

Hydrogen Sulfide (H(2)(S))

Health Effects

Prehospital Management

Emergency Department Management

Hydrogen Sulfide Patient Information Sheet

Hydrogen Sulfide Follow-up Instructions

Methyl Bromide (CH(3)Br)

Health Effects

Prehospital Management

Emergency Department Management

Methyl Bromide Patient Information Sheet

Phenol (C(6)H(5)-OH)

Health Effects

Prehospital Management

Emergency Department Management

Phenol Patient Information Sheet

Phosgene (COC1(2))

Health Effects

Prehospital Management

Emergency Department Management

Phosgene Patient Information Sheet

Phosgene Follow-up Instructions --