Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Chlorine Toxicity Medication

  • Author: Gerald F O'Malley, DO; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD  more...
 
Updated: Dec 11, 2015
 

Medication Summary

No antidote for chlorine gas is available. Instead, the goal of pharmacotherapy is to reduce morbidity and prevent complications. Beta-agonists, although not well studied in humans, have been widely used for the management of respiratory symptoms in chlorine gas exposure, and they have demonstrated efficacy in animal models. They should be considered a first-line agent in the setting of chlorine gas exposure and respiratory symptoms or signs.

Next

Beta2 Agonists

Class Summary

Beta2 agonists act on beta2 receptors to relax bronchial smooth muscle and thereby increase airway diameter. These agents have little effect on cardiac muscle contractility.

Albuterol (Proventil HFA, Ventolin HFA, ProAir HFA, VoSpire ER)

 

Albuterol is a beta2-agonist useful for treatment of bronchospasm. It is the preferred choice for initial treatment because of its rapid onset of action.

Terbutaline

 

Terbutaline is a selective beta 2-agonist that relieves bronchospasm by acting on beta 2 receptors to relax bronchial smooth muscle.

Previous
Next

Anticholinergics, Respiratory

Class Summary

Believed to work synergistically with bronchodilators.

Ipratropium (Atrovent)

 

Inhibits secretions from some respiratory mucosa; historically atropine was used in asthma, but ipratropium has fewer adverse effects.

Previous
Next

Xanthine Derivatives

Class Summary

These agents were historically used to treat asthma but lost favor because of their toxic effects and narrow therapeutic windows. They have largely been displaced by newer agents.

Theophylline (Theo 24, Elixophyllin, Theochron SR)

 

Theophylline is believed to potentiate exogenous catecholamines, stimulate endogenous catecholamine release, and relax the diaphragmatic musculature.

Previous
Next

Local Anesthetics, Amides

Class Summary

Inhaled topical anesthetics have been used to reduce cough and may reduce pain associated with chlorine inhalations.

Lidocaine (Xylocaine)

 

Lidocaine stabilizes neuronal membranes by inhibiting the ionic fluxes required for initiation and conduction of impulses. When administered by nebulizer, lidocaine acts in areas exposed to chlorine injury.

Previous
Next

Corticosteroids, Inhalants

Class Summary

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. These agents modify the body's immune response to diverse stimuli. In animal models of chlorine gas exposure, inhaled corticosteroids have been shown to improve respiratory function. Their exact mechanism of function in chlorine gas exposure is unclear.

Budesonide inhaled (Pulmicort Flexhaler)

 

Inhaled budesonide is a second-line agent for use in moderate-to-severe chlorine exposures.

Previous
 
Contributor Information and Disclosures
Author

Gerald F O'Malley, DO Clinical Associate Professor 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, Society for Academic Emergency Medicine

Disclosure: Received consulting fee from McNeil Pharmaceuticals for speaking and teaching.

Coauthor(s)

Robert Bassett, DO, FAAEM Fellow in Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center; Clinical Assistant Professor of Emergency Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Robert Bassett, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

William J Boroughf, DO Fellow in Medical Toxicology, Attending Physician, Department of Emergency Medicine, Einstein Medical Center

William J Boroughf, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Chief Editor

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Acknowledgements

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

John G Benitez, MD, MPH 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.

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.

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.

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

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.

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.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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.

Acknowledgments

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government.

References
  1. Hedges JR, Morrissey WL. Acute chlorine gas exposure. JACEP. 1979 Feb. 8(2):59-63. [Medline].

  2. Zaky A, Bradley WE, Lazrak A, Zafar I, Doran S, Ahmad A, et al. Chlorine inhalation-induced myocardial depression and failure. Physiol Rep. 2015 Jun. 3 (6):[Medline].

  3. Gilchrist HL, Matz PB. The residual effects of warfare gases: the use of chlorine gas, with report of cases. Med Bull Vet Adminis. 1933. 9:229-270.

  4. Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for Chlorine. Available at http://www.atsdr.cdc.gov/MMG/MMG.asp?id=198&tid=36. Accessed: July 30, 2013.

  5. Nelson GD. Chloramines and Bronamines. Kirk RE, Othmer DF, eds. Concise Encyclopedia of Chemical Technology. New York: John Wiley and Sons; 1985. 256.

  6. Centers for Disease Control and Prevention. Ocular and respiratory illness associated with an indoor swimming pool--Nebraska, 2006. MMWR Morb Mortal Wkly Rep. 2007 Sep 14. 56(36):929-32. [Medline].

  7. Schwartz DA. Acute inhalational injury. Occup Med. 1987 Apr-Jun. 2(2):297-318. [Medline].

  8. Jones RN, Hughes JM, Glindmeyer H, Weill H. Lung function after acute chlorine exposure. Am Rev Respir Dis. 1986 Dec. 134(6):1190-5. [Medline].

  9. Hayaishi O. Enzymatic hydroxylation. Am Rev Biochem. 1969. 38:21-44.

  10. Barrow CS, Alarie Y, Warrick JC, Stock MF. Comparison of the sensory irritation response in mice to chlorine and hydrogen chloride. Arch Environ Health. 1977 Mar-Apr. 32(2):68-76. [Medline].

  11. Henderson Y, Haggard HW. Noxious Gases and the Principles of Respiration Influencing Their Action. 2nd ed. New York: Rienhold Publishing Corp; 1943. 171-3.

  12. Das R, Blanc PD. Chlorine gas exposure and the lung: a review. Toxicol Ind Health. 1993 May-Jun. 9(3):439-55. [Medline].

  13. Adelson L, Kaufman J. Fatal chlorine poisoning: report of two cases with clinicopathologic correlation. Am J Clin Pathol. 1971 Oct. 56(4):430-42. [Medline].

  14. Rotman HH, Fliegelman MJ, Moore T, Smith RG, Anglen DM, Kowalski CJ, et al. Effects of low concentrations of chlorine on pulmonary function in humans. J Appl Physiol. 1983 Apr. 54(4):1120-4. [Medline].

  15. D'Alessandro A, Kuschner W, Wong H, Boushey HA, Blanc PD. Exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity. Chest. 1996 Feb. 109(2):331-7. [Medline].

  16. Shusterman D, Murphy MA, Balmes J. Influence of age, gender, and allergy status on nasal reactivity to inhaled chlorine. Inhal Toxicol. 2003 Oct. 15(12):1179-89. [Medline].

  17. Babu RV, Cardenas V, Sharma G. Acute respiratory distress syndrome from chlorine inhalation during a swimming pool accident: a case report and review of the literature. J Intensive Care Med. 2008 Jul-Aug. 23(4):275-80. [Medline].

  18. Martinez TT, Long C. Explosion risk from swimming pool chlorinators and review of chlorine toxicity. J Toxicol Clin Toxicol. 1995. 33(4):349-54. [Medline].

  19. Wood BR, Colombo JL, Benson BE. Chlorine inhalation toxicity from vapors generated by swimming pool chlorinator tablets. Pediatrics. 1987 Mar. 79(3):427-30. [Medline].

  20. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015 Dec. 53 (10):962-1147. [Medline].

  21. Davis DS, Dewolf GB, Ferland KA, et al. Accidental Release of Air Toxins. Park Ridge, New Jersey: NDC; 1989. 6-9.

  22. Van Sickle D, Wenck MA, Belflower A, Drociuk D, Ferdinands J, Holguin F, et al. Acute health effects after exposure to chlorine gas released after a train derailment. Am J Emerg Med. 2009 Jan. 27(1):1-7. [Medline].

  23. Jones R, Wills B, Kang C. Chlorine gas: an evolving hazardous material threat and unconventional weapon. West J Emerg Med. 2010 May. 11(2):151-6. [Medline]. [Full Text].

  24. Department of Homeland Security/Federal Bureau of Investigation. April 23, 2008. Potential Terrorist Attack Methods. Available at http://www.gwu.edu/~nsarchiv/nukevault/ebb388/docs/EBB015.pdf. Accessed: July 30, 2013.

  25. Kowitz TA, Reba RC, Parker RT, Spicer WS Jr. Effects of chlorine gas upon respiratory function. Arch Environ Health. 1967 Apr. 14(4):545-58. [Medline].

  26. Weill H, George R, Schwarz M, Ziskind M. Late evaluation of pulmonary function after acute exposure to chlorine gas. Am Rev Respir Dis. 1969 Mar. 99(3):374-9. [Medline].

  27. Kaufman J, Burkons D. Clinical, roentgenologic, and physiologic effects of acute chlorine exposure. Arch Environ Health. 1971 Jul. 23(1):29-34. [Medline].

  28. JONES AT. Noxious gases and fumes. Proc R Soc Med. 1952 Sep. 45(9):609-10. [Medline].

  29. Lawson JJ. Chlorine exposure: a challenge to the physician. Am Fam Physician. 1981 Jan. 23(1):135-8. [Medline].

  30. Shroff CP, Khade MV, Srinivasan M. Respiratory cytopathology in chlorine gas toxicity: a study in 28 subjects. Diagn Cytopathol. 1988 Mar. 4(1):28-32. [Medline].

  31. Malo JL, Cartier A, Boulet LP, L'Archeveque J, Saint-Denis F, Bherer L, et al. Bronchial hyperresponsiveness can improve while spirometry plateaus two to three years after repeated exposure to chlorine causing respiratory symptoms. Am J Respir Crit Care Med. 1994 Oct. 150(4):1142-5. [Medline].

  32. Francis HC, Prys-Picard CO, Fishwick D, Stenton C, Burge PS, Bradshaw LM, et al. Defining and investigating occupational asthma: a consensus approach. Occup Environ Med. 2007 Jun. 64(6):361-5. [Medline]. [Full Text].

  33. Brooks SM, Weiss MA, Bernstein IL. Reactive airways dysfunction syndrome (RADS). Persistent asthma syndrome after high level irritant exposures. Chest. 1985 Sep. 88(3):376-84. [Medline].

  34. Ginsberg JP, Holbrook JR, Chanda D, Bao H, Svendsen ER. Posttraumatic stress and tendency to panic in the aftermath of the chlorine gas disaster in Graniteville, South Carolina. Soc Psychiatry Psychiatr Epidemiol. 2012 Sep. 47(9):1441-8. [Medline]. [Full Text].

  35. Szerlip HM, Singer I. Hyperchloremic metabolic acidosis after chlorine inhalation. Am J Med. 1984 Sep. 77(3):581-2. [Medline].

  36. Department of Labor: Occupational Safety and Health Administration (OSHA). General description and discussion of the levels of protection and protective gear (1910.120, App B). Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9767. Accessed: July 30, 2013.

  37. Baxter PJ, Davies PC, Murray V. Medical planning for toxic releases into the community: the example of chlorine gas. Br J Ind Med. 1989 Apr. 46(4):277-85. [Medline]. [Full Text].

  38. O'Malley GF, Fasano C, Dominici P, Aguilera E. Eye irrigation is more comfortable with a lidocaine: containing irrigation solution compared with normal saline. J Trauma. 2008 May. 64(5):1360-2. [Medline].

  39. Done AK. The toxic emergency, it's a gas. Emerg Med. 1976. 305-14.

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

  41. Cevik Y, Onay M, Akmaz I, Sezigen S. Mass casualties from acute inhalation of chlorine gas. South Med J. 2009 Dec. 102(12):1209-13. [Medline].

  42. Nelson LS. Simple asphyxiants and pulmonary irritants. Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 6th ed. Stanford, Conn: Appleton & Lange; 1998. 1523-38.

  43. Aslan S, Kandis H, Akgun M, Cakir Z, Inandi T, Görgüner M. The effect of nebulized NaHCO3 treatment on "RADS" due to chlorine gas inhalation. Inhal Toxicol. 2006 Oct. 18(11):895-900. [Medline].

  44. Kramer CG. Chlorine. J Occup Med. 1967 Apr. 9(4):193-6. [Medline].

  45. Chester EH, Kaimal J, Payne CB Jr, Kohn PM. Pulmonary injury following exposure to chlorine gas. Possible beneficial effects of steroid treatment. Chest. 1977 Aug. 72(2):247-50. [Medline].

  46. Akdur O, Sozuer EM, Ikizceli I, Avsarogullari L, Ozturk F, Muhtaroglu S, et al. Experimental inhalation of chlorine gas produced with a different method; effects of N-acetyl cysteine on acute pulmonary damage. Toxicol Mech Methods. 2008 Jan. 18(9):739-43. [Medline].

  47. Fanucchi MV, Bracher A, Doran SF, Squadrito GL, Fernandez S, Postlethwait EM, et al. Post-exposure antioxidant treatment in rats decreases airway hyperplasia and hyperreactivity due to chlorine inhalation. Am J Respir Cell Mol Biol. 2012 May. 46(5):599-606. [Medline]. [Full Text].

  48. Department of Labor: Occupational Safety and Health Administration (OSHA). TABLE Z-1 Limits for Air Contaminants. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9992. Accessed: July 30, 2013.

  49. Department of Labor: Occupational Safety and Health Administration (OSHA). Occupational Safety and Health Guideline for Chlorine Dioxide. Available at http://www.cdgenvironmental.com/sites/default/files/OHSA_ClO2.pdf.

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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.