Phosgene Oxime Exposure Clinical Presentation

  • Author: Erik D Schraga, MD; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Feb 9, 2011
 

History

Important historic features of a potential toxic chemical exposure include the following:

  • Estimated time of occurrence
  • Duration and circumstances of exposure
  • Onset and time course of symptoms
  • Odor and/or color of gases or vapors
  • Protective clothing worn (if any)
  • Effects on surroundings (eg, other human or animal casualties)

CX casualties typically report unbearable pain in exposed skin and eyes; difficulty with sight or blindness after ocular exposure; and sore throat, hoarseness, dyspnea, chest pain, and cough after respiratory exposure.

Some casualties may experience a peppery or pungent odor during their initial CX vapor exposure, but this is typically lost quickly because of accommodation.

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Physical

Skin

A blanching, grayish skin lesion surrounded by an erythematous ring can be observed within 30 seconds of exposure. A wheal develops on exposed skin within 30 minutes. The original blanched area acquires a necrotic, brown pigmentation by 24 hours. An eschar forms in the pigmented area by 1 week and sloughs after approximately 3 weeks.

Eyes

Eye examination typically demonstrates conjunctivitis, lacrimation, lid edema, and blepharospasm after even minute exposures. More severe exposures can result in keratitis, iritis, corneal perforation, and blindness.

Respiratory

Irritation of the mucous membranes may be observed on examination of the oropharynx and nose. Evidence of pulmonary edema, including rales and wheezes, may be noted on auscultation. Necrotizing bronchiolitis and pulmonary venule thromboses are prominent features of severe CX exposure.[8]

Gastrointestinal

Some animal data suggest that CX may cause hemorrhagic inflammatory changes in the GI tract.

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Causes

Exposures to CX result from its deliberate use as a chemical warfare agent.[1, 4, 6] Since this chemical has no useful industrial applications, accidental exposures are extremely unlikely.

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Contributor Information and Disclosures
Author

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Coauthor(s)

Andre Pennardt, MD, FACEP, FAAEM, FAWM  Clinical Associate Professor of Emergency Medicine, Medical College of Georgia; Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Departments of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center

Andre Pennardt, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US, International Society for Mountain Medicine, National Association of EMS Physicians, Special Operations Medical Association, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred Henretig, MD  Director, Section of Clinical Toxicology, Professor, Medical Director, Delaware Valley Regional Poison Control Center, Departments of Emergency Medicine and Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Rick Kulkarni, MD 

Rick Kulkarni, 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, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References

  1. Armstrong J. Chemical warfare. RN. Apr 2002;65(4):32-9. [Medline].

  2. Dang C. Chemical warfare agents. Top Emerg Med. 2002;24(2):25-39.

  3. McManus J, Huebner K. Vesicants. Crit Care Clin. Oct 2005;21(4):707-18, vi. [Medline].

  4. Rosenbloom M, Leikin JB, Vogel SN, Chaudry ZA. Biological and chemical agents: a brief synopsis. Am J Ther. Jan-Feb 2002;9(1):5-14. [Medline].

  5. Department of the Army. Phosgene oxime. In: Field Manual 8-285: Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries. 1995:IV-17-22.

  6. Zajtchuk R, Bellamy RF, eds. Phosgene oxime. In: Textbook of Military Medicine Part I: Medical Aspects of Chemical and Biological Warfare. 1997:220-222.

  7. McAdams AJ Jr, Joffe MH. A Toxico-pathologic Study of Phosgene Oxime. 1955. Army Medical Laboratories Research Report 381.

  8. Russell D, Blain PG, Rice P. Clinical management of casualties exposed to lung damaging agents: a critical review. Emerg Med J. Jun 2006;23(6):421-4. [Medline].

  9. ATSDR. Medical management guidelines for phosgene oxime. [Full Text].

  10. USAMRICD. Phosgene oxime. In: Medical Management of Chemical Casualties Handbook. 3rd ed. 2000:96-101.

 
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Anteroposterior portable chest radiograph in a male patient who developed phosgene-induced adult respiratory distress syndrome. Notice the bilateral infiltrates and ground glass appearance.
Chemical Terrorism Agents and Syndromes. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/chemical.html.
 
 
 
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