eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Lung-Damaging Agents, Chlorine: Follow-up

Author: Daniel Noltkamper, MD, FACEP, EMS Medical Director, Department of Emergency Medicine, Naval Hospital of Camp Lejeune
Coauthor(s): Gerald F O'Malley, DO, Clinical Associate Professor of Emergency Medicine, Thomas Jefferson University Hospital; Director of Research, Director, Division of Toxicology, Department of Emergency Medicine, Albert Einstein Medical Center
Contributor Information and Disclosures

Updated: Jul 3, 2008

Follow-up

Further Inpatient Care

  • Pulmonary edema may present in a delayed fashion after chlorine gas exposure.
    • Patients who present asymptomatic and remain asymptomatic 6 hours after exposure may be discharged with appropriate instructions and in the presence of reliable family members.
    • Admit patients who present with symptoms that continue for 6 hours after exposure for an observation period of at least 24 hours. If asymptomatic at 24 hours, patients may be discharged with appropriate follow-up care.
    • Consider patients exposed to large concentrations in an enclosed environment, those with underlying cardiopulmonary disorders, and children for admission and observation, even if initially asymptomatic.

Further Outpatient Care

  • Discharge medications are not applicable since only asymptomatic patients should be discharged from the ED.
  • Cases of chronic reactive airway disease after acute exposures to chlorine gas are described in the literature. Consider referring patients for pulmonary function testing.

Transfer

  • Consider transfer to a higher level of care when patients cannot be treated locally. The major concern is the treatment of noncardiogenic pulmonary edema that may require positive pressure ventilation.

Deterrence/Prevention

  • Proper labeling and avoiding mixing chemicals facilitate prevention. Household cleaning products should not be mixed. Using proper precautions when handling swimming pool chemicals reduces risks. Adequate ventilation is necessary when handling any potentially noxious chemical.
  • On a larger scale, chemical warfare treaties between countries and the safe transportation and handling of industrial chlorine compounds facilitate deterrence.
  • Training prehospital and hospital providers in the management of chemical casualties can improve the treatment provided to exposed personnel while minimizing personal risks. Hospitals can establish mass casualty plans and perform drills to ensure that preparations are adequate in the event of a large-scale industrial accident.

Complications

  • Short-term effects
    • Bacterial superinfection resulting in bronchitis or pneumonia may present 3-5 days after chlorine gas exposure. Search for infection if the patient fails to recover from chlorine gas toxicity in 3-4 days.
    • Pleural effusions associated with pulmonary edema are possible.
  • Long-term effects: Long-term complications from exposure are rare, but some reports of chronic reactive airway disease following exposure exist. Other authors attribute these consequences to bacterial superinfection or smoking.

Prognosis

  • Most individuals exposed to chlorine gas recover without significant sequelae. Even exposure to high-concentration chlorine gas is unlikely to result in significant, prolonged pulmonary disease.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Discharging a patient prior to resolution of symptoms that may indicate impending pulmonary edema
  • Failure to ascertain a possibility of chlorine gas exposure through occupational history or mixed household chemicals
  • Failure to consider bacterial superinfection in patients who are not responding to several days of appropriate therapy
  • Failure to monitor patients in a setting in which respiratory support is immediately available, or failure to transfer patients to a facility with appropriate respiratory support capability

Special Concerns

  • Superheated chlorine gas from an industrial fire or chemical warehouse explosion may carry the danger of direct thermal injury to the mucous membranes of the eyes, mouth, and respiratory tract in addition to the chemical effects.
 


More on CBRNE - Lung-Damaging Agents, Chlorine

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Differential Diagnoses & Workup: CBRNE - Lung-Damaging Agents, Chlorine
Treatment & Medication: CBRNE - Lung-Damaging Agents, Chlorine
Follow-up: CBRNE - Lung-Damaging Agents, Chlorine
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References
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References

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Further Reading

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Keywords

chemical warfare agent, mucous membrane irritant, respiratory tract irritant, noncardiogenic pulmonary edema, ICD-9-CM 983-9 corrosive aromatics, International Classification of Diseases, Ninth Revision, Clinical Modification 983-9 corrosive aromatics, lung-damaging agents, lung damaging agents chlorine, chlorine, chlorine gas, chlorine liquid, chlorine toxicity

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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)

Gerald F O'Malley, DO, Clinical Associate Professor of Emergency Medicine, Thomas Jefferson University Hospital; Director of Research, Director, Division of Toxicology, Department of Emergency Medicine, Albert Einstein Medical Center
Gerald F O'Malley, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, American College of Osteopathic Emergency Physicians, American Osteopathic Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mark Keim, MD, Senior Science Advisor, Office of the Director, National Center for Environmental Health, Centers for Disease Control and Prevention
Mark Keim, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

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

Robert G Darling, MD, FACEP, 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, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

 
 
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