Phosgene Toxicity Workup

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

Laboratory Studies

ABG demonstrates the degree of hypoxemia. A partial pressure of oxygen (pO2) as low as 23 mm Hg on 8 L/min of oxygen by face mask has been reported. Typical presenting pO2 levels are 50-60 mm Hg while breathing room air. The carboxyhemoglobin level is important for cases involving exposure to methylene chloride or when carbon monoxide exposure is suspected. Methemoglobinemia may suggest other causes.

CBC may be obtained as a baseline level or if pneumonia is high on the differential diagnosis list. An elevated WBC count is not specific because it may result from hypoxemic stress or an infectious process. CBC may reveal hemoconcentration late in the disease process.

Electrolytes may be obtained as baseline studies because of the anticipated large fluid shifts that occur.

Cardiac enzymes (eg, creatine kinase-MB [CK-MB], troponin T, troponin I) may be obtained if cardiogenic pulmonary edema is high on the differential.

Continue pulse oximetry and cardiac monitoring in patients suspected of phosgene toxicity.

Investigation on a blood test that measures exposure to phosgene is being pursued. Most likely, this test will be used in laboratory settings.

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Imaging Studies

Chest x-ray

Initial findings may be normal; however, as the disease progresses, the chest x-ray (CXR) may demonstrate bilateral, diffuse interstitial infiltrates, as in the images below.

The chest radiograph of a 42-year-old woman chemicThe 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) An anteroposterior (AP) portable chest radiograph 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)

Heart and pulmonary vessel sizes are usually normal unless the patient has baseline cardiomegaly.

CXR findings may precede the clinical presentation.

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Procedures

  • Perform endotracheal (ET) intubation and mechanical ventilation based on the degree of respiratory failure and overall clinical picture. Lower tidal volumes and increased PEEP may result in improved oxygenation and reduced mortality.
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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  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

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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)
 
 
 
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