Phosgene Toxicity Medication

  • Author: Daniel Noltkamper, MD, FACEP; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 19, 2011
 

Medication Summary

Management of phosgene toxicity is supportive. Oxygen, corticosteroids (inhaled, systemic), leukotriene inhibitors, IV fluids, and prophylactic antibiotics are recommended. The recommended steroid dose is much higher than the dose conventionally used in asthma. Prophylactic antibiotics and antifungals may be required because of the risk of superinfection. Pressor agents may be required to treat hypotension, bradycardia, and renal failure.

Next

Corticosteroids

Class Summary

Reduce inflammatory response. Whether early administration of corticosteroids can prevent development of noncardiogenic pulmonary edema is unknown. The decision to administer corticosteroids must be made on clinical grounds.

Treatments lasting more than 1 week may require a taper to prevent abrupt steroid withdrawal.

Beclomethasone (Beclovent, Vanceril)

 

Inhibits bronchoconstriction mechanisms, producing direct smooth muscle relaxation; may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness.

View full drug information

Methylprednisolone (Solu-Medrol)

 

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

View full drug information

Betamethasone (Celestone, Soluspan)

 

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Previous
Next

Vasopressors

Class Summary

Used to treat hypotension, bradycardia, or renal failure.

View full drug information

Dopamine (Intropin)

 

Stimulates adrenergic and dopaminergic receptors. Hemodynamic effect is dependent on the dose. Lower doses predominantly stimulate dopaminergic receptors that, in turn, produce renal and mesenteric vasodilation. Use low dose to protect renal function; use high dose to combat severe hypotension unresponsive to fluid administration.

Previous
Next

Leukotriene antagonists

Class Summary

Reduce the inflammatory response elicited by the leukotriene cascade. Leukotriene antagonists are approved by the Food and Drug Administration (FDA) only for chronic asthma management.

View full drug information

Zafirlukast (Accolate)

 

No human studies have evaluated the efficacy and safety of zafirlukast in patients exposed to phosgene. Nevertheless, given the known effects of leukotriene stimulation by phosgene, the results from animal studies, and the drug's safety profile, should be considered first line.

In the presence of food, bioavailability of oral zafirlukast is decreased by 40%. Administer on an empty stomach.

Previous
Proceed to Follow-up
 
 
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  Medical Director, Emegency Preparedness and Management, 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.

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, 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.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and 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.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

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.

References

  1. Snyder RW, Mishel HS, Christensen GC 3d. Pulmonary toxicity following exposure to methylene chloride and its combustion product, phosgene. Chest. Mar 1992;101(3):860-1. [Medline].

  2. Nelson LS. Simple asphyxiants and pulmonary irritants. In: Goldfrank L, ed. Goldfrank's Toxicologic Emergencies. 6th ed. New York: McGraw-Hill; 1998:1530.

  3. Selden A, Sundell L. Chlorinated solvents, welding and pulmonary edema. Chest. Jan 1991;99(1):263. [Medline].

  4. Sjogren B, Plato N, Alexandersson R, et al. Pulmonary reactions caused by welding-induced decomposed trichloroethylene. Chest. Jan 1991;99(1):237-8. [Medline].

  5. Balmes J. Phosgene. In: Olson KR, ed. Poisoning and Drug Overdose. 2nd ed. Appleton & Lange; 1994:256.

  6. Parrish JS, Bradshaw DA. Toxic inhalational injury: gas, vapor and vesicant exposure. Respir Care Clin N Am. Mar 2004;10(1):43-58. [Medline].

  7. Sidell FR, Takafuji ET, Franz DR. Toxic inhalation injury. In: Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare. Walter Reed Army Medical Center; 1997:257-60.

  8. Borak J, Diller WF. Phosgene exposure: mechanisms of injury and treatment strategies. J Occup Environ Med. Feb 2001;43(2):110-9. [Medline].

  9. Schelble DT. Phosgene and phosphine. In: Haddad LM, Shannon MW, Winchester J, eds. Clinical Management of Poisoning and Drug Overdose. 3rd ed. Philadelphia: WB Saunders; 1998:960-3.

  10. Bardana EJ Jr. 8. Occupational asthma and allergies. J Allergy Clin Immunol. Feb 2003;111(2 Suppl):S530-9. [Medline].

  11. Ng TP, Tsin TW, O'Kelly FJ. An outbreak of illness after occupational exposure to ozone and acid chlorides. Br J Ind Med. Oct 1985;42(10):686-90. [Medline].

  12. Weiss SJ, Lesser SH. Hazards associated with metalworking by artists. South Med J. Jul 1997;90(7):665-71. [Medline].

  13. Parkhouse DA, Brown RF, Jugg BJ, Harban FM, Platt J, Kenward CE. Protective ventilation strategies in the management of phosgene-induced acute lung injury. Mil Med. Mar 2007;172(3):295-300. [Medline].

  14. Phosgene Medical Experts Group. Phosgene: Information on Options for First Aid and Medical Treatment. American Chemistry Council: Phosgene Panel. Available at http://www.americanchemistry.com/s_acc/bin.asp?CID=1175&DID=4396&DOC=FILE.PDF. Accessed 3/3/2008.

  15. British War Office. Medical Manual of Chemical Warfare. London: 1941:31-38.

  16. Sciuto AM, Stotts RR. Posttreatment with eicosatetraynoic acid decreases lung edema in guinea pigs exposed to phosgene: the role of leukotrienes. Exp Lung Res. May-Jun 1998;24(3):273-92. [Medline].

  17. Sciuto AM, Strickland PT, Kennedy TP, Gurtner GH. Postexposure treatment with aminophylline protects against phosgene- induced acute lung injury. Exp Lung Res. Jul-Aug 1997;23(4):317-32. [Medline].

  18. Sciuto AM, Stotts RR, Hurt HH. Efficacy of ibuprofen and pentoxifylline in the treatment of phosgene- induced acute lung injury. J Appl Toxicol. Sep-Oct 1996;16(5):381-4. [Medline].

  19. Sciuto AM. Assessment of early acute lung injury in rodents exposed to phosgene. Arch Toxicol. Apr 1998;72(5):283-8. [Medline].

  20. Kennedy TP, Michael JR, Hoidal JR, et al. Dibutyryl cAMP, aminophylline, and beta-adrenergic agonists protect against pulmonary edema caused by phosgene. J Appl Physiol. Dec 1989;67(6):2542-52. [Medline].

  21. Sciuto AM, Strickland PT, Kennedy TP, et al. Intratracheal administration of DBcAMP attenuates edema formation in phosgene-induced acute lung injury. J Appl Physiol. Jan 1996;80(1):149-57. [Medline].

  22. Sciuto AM, Strickland PT, Kennedy TP, Gurtner GH. Protective effects of N-acetylcysteine treatment after phosgene exposure in rabbits. Am J Respir Crit Care Med. Mar 1995;151(3 Pt 1):768-72. [Medline].

  23. Ellenhorn MJ. Chemical warfare. In: Ellenhorn's Medical Toxicology. 2nd ed. Lippincott Williams & Wilkins; 1997:1301-2.

  24. Dombi A, Fekete ZA, Kiricsi I. In Situ Photocatalytic Reactor with FT-IR Analysis for Heterogeneous Catalytic Studies. Applied Catalysis. 2000;193:L5-L8.

  25. Grainge C, Rice P. Management of phosgene-induced acute lung injury. Clin Toxicol (Phila). Jul 2010;48(6):497-508. [Medline].

  26. Noort D, Hulst AG, Fidder A, et al. In vitro adduct formation of phosgene with albumin and hemoglobin in human blood. Chem Res Toxicol. Aug 2000;13(8):719-26. [Medline].

  27. Warden CR. Respiratory agents: irritant gases, riot control agents, incapacitants, and caustics. Crit Care Clin. Oct 2005;21(4):719-37, vi. [Medline].

 
Previous
Next
 
British machine-gunners in anti-phosgene masks, Somme, 1915. (Photograph courtesy of the Imperial War Museum, London)
Phosgene structure.
The chest radiograph of a 42-year-old woman chemical worker 2 hours postexposure to phosgene. Dyspnea progressed rapidly over the second hour; PO2 was 40 mm Hg breathing room air. This radiograph shows bilateral perihilar, fluffy, and diffuse interstitial infiltrates. The patient died 6 hours postexposure. (Used with permission from Medical Aspects of Chemical and Biological Warfare, Textbook of Military Medicine, 1997, p 258)
A lung section of the patient whose chest radiograph is presented above. This patient died 6 hours following exposure to phosgene; the biopsy section was taken during postmortem examination. The section shows nonhemorrhagic pulmonary edema with few scattered inflammatory cells. Hematoxylin and eosin stain; original magnification X 100. (Used with permission from Medical Aspects of Chemical and Biological Warfare, Textbook of Military Medicine, 1997, p 258)
An anteroposterior (AP) portable chest radiograph of a male patient, who developed phosgene-induced adult respiratory distress syndrome. Notice the bilateral infiltrates and ground-glass appearance. (Image courtesy of Fred P. Harchelroad, MD, and Ferdinando L. Mirarchi, DO)
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.