eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Phosgene: Follow-up

Author: Daniel Noltkamper, MD, FACEP, EMS Medical Director, Department of Emergency Medicine, Naval Hospital of Camp Lejeune
Coauthor(s): Stephen W Burgher, MD, FACEP, Assistant Medical Director, Department of Emergency Medicine, Baylor University Medical Center
Contributor Information and Disclosures

Updated: Jul 10, 2008

Follow-up

Further Inpatient Care

  • Admit patient to an intensive care setting for continued monitoring and supportive care. Improvement typically occurs within 48-72 hours.

Further Outpatient Care

  • In a case of suspected exposure to phosgene, monitor the patient for a minimum of 8-12 hours because of the potential for delayed-onset pulmonary edema. (The patient must remain asymptomatic and have no chest x-ray changes or hypoxemia after observation to be released from the ED or inpatient ward.)
  • Instruct patients discharged from the hospital after recovery from pulmonary edema to avoid exertion and any pulmonary toxins that may precipitate a recurrence. Also, instruct patients to avoid circumstances similar to their exposure and to warn others of the same dangers.

Transfer

  • Provide supplemental oxygen and/or bilevel positive airway pressure (BiPAP) and immediately transfer patients to an appropriate facility if they present to clinics or hospitals without endotracheal intubation capability, ventilator capability, or ICU monitoring.

Deterrence/Prevention

  • A standard field protective mask or gas particulate filter provides adequate protection.
  • Personnel working with chlorinated hydrocarbon compounds should ensure adequate ventilation and avoid exposing the compounds and the vapors to heat or UV sources.

Complications

  • Recurrence of pulmonary edema because of exertion, re-exposure, or exposure to other pulmonary toxins
  • Pneumonia
  • Development of reactive airway dysfunction syndrome with bronchospasm and chronic airway inflammation

Prognosis

  • The prognosis of acute phosgene exposure is good with early intervention. Few significant long-term sequelae occur after recovery.
  • Studies involving combat personnel and workers involved in the uranium enrichment process have shown increased morbidity and mortality with high level exposure because of the development of pneumonitis, chronic bronchitis, emphysema, and impaired pulmonary function.
  • The degree of the patient's cyanosis provides a rough estimate of survivability. Historically, patients with a mouse grey cyanosis have a worse prognosis than those with a plum blue cyanosis (quantitative assessment of hypoxemia was not routinely available at the time of these historical observations). To estimate the time until respiratory failure, double the length of time from exposure to the development of crackles.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the asymptomatic period and delayed onset of symptoms associated with phosgene toxicity and discharging the patient from the ED without an adequate period of observation
  • Failure to ascertain a history consistent with phosgene exposure
  • Failure to recognize phosgene as a combustion product of certain chemicals, especially chlorinated compounds (eg, methylene chloride, trichloroethylene)
  • Failure to associate phosgene with the manufacturing process of common chemicals (eg, methyl isocyanate)
  • Failure to consider phosgene toxicity in patients who present dyspnea or chest discomfort and who have occupations (eg, welding, refinishing) with increased risk of exposure
  • Administering diuretics to a volume-depleted patient, causing further circulatory collapse
  • Failure to consider secondary pneumonia in patients not responding after 2-3 days of aggressive therapy
  • Failure to recognize early signs of significant respiratory distress and document either a pO2 or oxygen saturation via pulse oximetry
  • Failure to monitor the patient in a setting where respiratory support is immediately available or failure to transfer the patient to a facility with appropriate respiratory support capability
  • Failure to consider carbon monoxide poisoning from exposure to methylene chloride
  • Failure to evaluate and treat possible angina or myocardial infarction

Special Concerns

  • The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government.
 


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References
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Further Reading

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Keywords

phosgene toxicity, phosgene exposure, phosgene poisoning, COCl2, carbonic dichloride, carbon oxychloride, carbonyl dichloride, chloroformyl chloride, d-stoff, green cross, CG, pulmonary irritant

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Contributor Information and Disclosures

Author

Daniel Noltkamper, MD, FACEP, EMS Medical Director, Department of Emergency Medicine, Naval Hospital of Camp Lejeune
Daniel Noltkamper, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen W Burgher, MD, FACEP, Assistant Medical Director, Department of Emergency Medicine, Baylor University Medical Center
Stephen W Burgher, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Medical Editor

Miguel C Fernández, MD, FAAEM, FACEP, FACMT, FACCT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio
Miguel C Fernández, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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