Chlorine Poisoning Follow-up

  • Author: Daniel Noltkamper, MD, FACEP; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Apr 19, 2011
 

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.

Next

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.
Previous
Next

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.
Previous
Next

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.
Previous
Next

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.
Previous
Next

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.
Previous
Next

Patient Education

Previous
 
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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; 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. D'Alessandro A, Kuschner W, Wong H, Boushey HA, Blanc PD. Exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity. Chest. Feb 1996;109(2):331-7. [Medline].

  2. Baxter PJ. Gases. In: Hunter's Diseases of Occupations. 1994:213-235.

  3. Beckett WS. Inorganic gases. In: Textbook of Clinical Occupational and Environmental Medicine. 1994:838-843.

  4. Blanc PD, Galbo M, Hiatt P, Olson KR. Morbidity following acute irritant inhalation in a population-based study. JAMA. Aug 7 1991;266(5):664-9. [Medline].

  5. Demeter SL, Cordasco EW. Reactive airway disease after chlorine gas exposure [letter; comment]. Chest. Sep 1992;102(3):984. [Medline].

  6. Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine administered to infants and children undergoing flexible bronchoscopy. Chest. Dec 1997;112(6):1665-9. [Medline].

  7. Glindmeyer HW, Lefante JJ, Freyder LM, et al. Relationship of asthma to irritant gas exposures in pulp and paper mills. Respir Med. May 2003;97(5):541-8. [Medline].

  8. Graham DR. Noxious gases and fumes. In: Textbook of Pulmonary Disease. 1994:901-916.

  9. Horton DK, Berkowitz Z, Kaye WE. The public health consequences from acute chlorine releases, 1993-2000. J Occup Environ Med. Oct 2002;44(10):906-13. [Medline].

  10. Joy RJ. Historical aspects of medical defense against chemical warfare. In: Textbook of Military Medicine: Medical Aspects of Chemical and Biologic Warfare. 1997:87-109.

  11. Kennedy SM, Enarson DA, Janssen RG, Chang-Yeung M. Lung health consequences of reported accidental chlorine gas exposures among pulpmill workers. Am Rev Respir Dis. Jan 1991;143(1):74-9. [Medline].

  12. Moore BB, Sherman M. Chronic reactive airway disease following acute chlorine gas exposure in an asymptomatic atopic patient. Chest. Sep 1991;100(3):855-6. [Medline].

  13. Nelson LS. Simple asphyxiants and pulmonary irritants. In: Goldfrank's Toxicologic Emergencies. 1998:1529-1530.

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

  15. Rabinowitz PM, Siegel MD. Acute inhalation injury. Clin Chest Med. Dec 2002;23(4):707-15. [Medline].

  16. Schonhofer B, Voshaar T, Kohler D. Long-term lung sequelae following accidental chlorine gas exposure. Respiration. 1996;63(3):155-9. [Medline].

  17. Segal E, Lang E. Toxicity, Chlorine Gas. eMedicine Journal [serial online]. 2000. [Full Text].

  18. Smart JK. History of chemical and biologic warfare: An American perspective. In: Textbook of Military Medicine: Medical Aspects of Chemical and Biologic Warfare. 1997:9-86.

  19. Traub SJ. Respiratory agent attack (toxic inhalational injury). In: Ciottone GR. Disaster Medicine. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2006:573-575/ chap 93.

  20. Urbanetti JS. Toxic inhalational injuries. In: Textbook of Military Medicine: Medical Aspects of Chemical and Biologic Warfare. 1997:247-270.

  21. Vinsel PJ. Treatment of acute chlorine gas inhalation with nebulized sodium bicarbonate. J Emerg Med. May-Jun 1990;8(3):327-9. [Medline].

  22. Wadbrook PS. Advances in airway pharmacology. Emerging trends and evolving controversy. Emerg Med Clin North Am. Nov 2000;18(4):767-88. [Medline].

  23. White CW, Martin JG. Chlorine gas inhalation: human clinical evidence of toxicity and experience in animal models. Proc Am Thorac Soc. Jul 2010;7(4):257-63. [Medline].

 
Previous
Next
 
Chest radiograph of a 36-year-old chemical worker 2 hours postexposure to chlorine inhalant. She had severe resting dyspnea during the second hour, diffuse crackles/rhonchi on auscultation, and a partial pressure of oxygen of 32 mm Hg breathing room air. The radiograph shows diffuse pulmonary edema without significant cardiomegaly (used with permission from Medical Aspects of Chemical and Biological Warfare, Textbook of Military Medicine. 1997: 256).
A section from a lung biopsy (hematoxylin and eosin stain; original magnification X 100) from a 36-year-old chemical worker taken 6 weeks postexposure to chlorine. At that time, the patient had no clinical abnormalities and a partial pressure of oxygen of 80 mm Hg breathing room air. The section shows normal lung tissues without evidence of interstitial fibrosis and/or inflammation (used with permission from Medical Aspects of Chemical and Biological Warfare, Textbook of Military Medicine. 1997: 256).
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.
 
 
 
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.