Toxicity, Chlorine Gas Treatment & Management

  • Author: Eli Segal, MD, CM, FRCP; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Jan 11, 2010
 

Prehospital Care

Prehospital care providers should take necessary precautions to prevent contamination. The use of a chemical cartridge respirator or self-contained breathing apparatus with full face mask should protect against the effects of chlorine gas. However, in the setting where other potential chemical exposures exist, higher levels of protection should be considered.

  • Remove the individual from the toxic environment.
  • Bring container, if applicable, so medical personnel can identify toxic agent.
  • Commence primary decontamination of the eye and skin, if necessary.
  • Real-time measurement of chlorine gas, both quantitative and qualitative, is possible through the use of mobile equipment.

Chlorine gas is denser than air and accumulates close to the ground. Therefore, during chlorine-related accidents, people should be instructed to seek higher altitudes to avoid excessive exposure.

For related information, see Medscape's Disaster Preparedness and Aftermath Resource Center.

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Emergency Department Care

  • Decontamination
    • Eye and skin exposures require copious irrigation with saline. In cases of suspected ocular injury, determine initial pH using a reagent strip. Continue irrigation with 0.9% saline until the pH returns to 7.4.
    • Topical anesthetics help limit pain and improve patient cooperation.
    • Following irrigation, perform slit lamp examination, including fluorescein staining.
    • Measure ocular pressures.
    • Treat corneal abrasions with antibiotic ointment.
  • Supplemental oxygen
    • Maintain a PaO2 of 60 mm Hg or greater.[27]
    • Long-term (>24 h) elevated fraction of inspired oxygen (FIO2) greater than 50% may result in oxygen toxicity.
  • Fluid restriction in patients with ARDS
  • Treatment of bronchospasm
    • Bronchodilators (inhaled albuterol or other beta-agonists) have been used frequently for the management of respiratory symptoms. Animal models have demonstrated improvements in blood gas parameters, airway pressure, and lung compliance with the administration of aerosolized terbutaline.
    • The role of inhaled ipratropium is not well defined.
    • Lidocaine (1% solution) added to nebulized albuterol results in both analgesic and cough-suppressant actions.
  • Intubation for laryngospasm
    • Fiberoptic aid may be required if significant edema is present.
    • Consider using the largest size endotracheal tube possible to optimize pulmonary toilet.
  • Hypoxemic respiratory failure
    • Treat with positive-pressure ventilation.
    • High positive end-expiratory pressure (PEEP) (8-10 mm Hg) and inverse ratio ventilation may be beneficial in ARDS.
    • In an animal model, prone positioning immediately following exposure to chlorine gas improved pulmonary function, whereas treatment in the supine position was associated with further compromise of pulmonary gas exchange.
  • Sodium bicarbonate
    • Use of nebulized solution of sodium bicarbonate, while recommended by some authors,[28, 29] lacks sufficient clinical evidence.
    • The mechanism of action is thought to be through the neutralizing of the hydrochloric acid formed when chlorine gas comes into contact with water. Lack of clinical trials and the theoretical possibility that an exothermic reaction may be produced when bicarbonate mixes with hydrochloric acid have led some authors to question its use.[9, 30, 31] Nonetheless, several pediatric and adult case reports did describe a clinical improvement in patients with chlorine gas induced pulmonary injury who are treated with inhaled sodium bicarbonate.
    • In a randomized, controlled trial 44 patients received either nebulized sodium bicarbonate (4 mL of 4.20% NaHCO3 solution) or saline treatment following chlorine gas exposure.[32] Treatment of all patients included corticosteroids and nebulized, short-acting β2-agonists. Compared to the placebo group, the NaHCO 3 group had significantly higher FEV1 values at 120 and 240 min.
  • Steroids
    • Parenteral steroids, while advocated by some authors to prevent short-term reactions and long-term sequelae,[33, 34] are not recommended by others[9] because of insufficient clinical trials.
    • Animal studies suggest improvements in pulmonary function and lung compliance with treatment of inhaled steroids, alone and in conjunction with aerosolized beta-agonists. Earlier administration of inhaled steroids in animal studies was associated with more beneficial effects.
  • Prophylactic antibiotics are not recommended.
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Consultations

  • Consult critical care personnel if patient exhibits severe and protracted respiratory distress.
  • Consult an ophthalmologist for patient with ocular burns.
  • Consult a medical toxicologist if one is available in the area.
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Contributor Information and Disclosures
Author

Eli Segal, MD, CM, FRCP  Assistant Professor, Department of Family Medicine, McGill University; Attending Physician, Department of Emergency Medicine, Jewish General Hospital

Eli Segal, MD, CM, FRCP, is a member of the following medical societies: American College of Emergency Physicians and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary; Assistant Professor, Department of Family Medicine, McGill University

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Peter MC DeBlieux, MD  Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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.

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM,  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM, is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

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.

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