Chlorine Poisoning Treatment & Management

• Take precautions to minimize exposure to toxins. In areas of large concentrations or enclosed environments, providers should use self-contained breathing apparatus.
• Remove victims from the toxic environment. Begin initial decontamination at the scene if the skin or eyes are involved. Copious amounts of water may be used. Remove the patient's clothing if it has been contaminated with liquid chlorine.
• Properly sealed chemical containers or material safety data sheets (MSDS) should accompany the patient if available.

The most important aspect of treating patients exposed to chlorine gas is the provision of good supportive care. No antidotes are available. The medications listed below are adjuncts to rigorous attention to the airway patency, breathing, and circulation.

Initial assessment

Remove the patient's clothing if it has been contaminated with liquid chlorine.

Evaluate the airway, breathing, and circulation. Provide supplemental oxygen (humidified if possible) as required by nasal cannula, face mask, nonrebreather mask, noninvasive positive pressure ventilation, or intubation. Poor oxygenation or laryngospasm may necessitate intubation. Positive pressure ventilation with positive end-expiratory pressure (PEEP) set at 5-10 mm Hg may improve oxygenation in patients with noncardiogenic pulmonary edema and allow for lower fraction of inspired oxygen settings to minimize the risk of oxygen toxicity.

Decontamination

Wear appropriate protective gear during decontamination, especially if the exact toxin is not identified. Chlorine gas exposure represents a low risk for cross-contamination.

Irrigate the eyes and skin with copious amounts of water or saline if involvement is reported. Remove contact lenses (if present) prior to irrigation. If skin exposure is significant, wash with a mild soap and water.

Use a pH reagent strip capable of measuring the ranges 0-14 to assess any eye injury. Continue irrigation of the eye until the pH returns to near 7.

Evaluate the cornea with fluorescein staining under a slit lamp.

Bronchospasm

Treat initial bronchospasm with beta agonists such as albuterol. Ipratropium may be added to the treatment.

Poor responses may require terbutaline or aminophylline.

Nebulized lidocaine (4% topical solution) may provide analgesia and reduce coughing.

Sodium bicarbonate

In the past, several authors advocated nebulized sodium bicarbonate. Most recommendations are based on anecdotal experience, and little supporting clinical data are available.

The mechanism of action is believed to be the neutralization of hydrochloric acid formed in the airways. Theoretically, an exothermic reaction may occur.

Animal studies suggest nebulized sodium bicarbonate may cause chemical pneumonitis.

Corticosteroids

Inhaled and parenteral steroids have been used with many patients exposed to chlorine gas, but no strong clinical evidence supports their use except in patients with an exacerbation of underlying reactive airway disease. Some animal studies demonstrate better lung compliance and arterial oxygen tension if treated with inhaled steroids within 30 minutes of exposure.

Fluid management

Closely monitor the patient's fluid input and output because of the potential of pulmonary edema.

Fluid restriction may be required and diuretics may be used to treat impending pulmonary edema.

Antibiotics

No evidence supports the use of prophylactic antibiotics.

Base decisions for administering antibiotics on clinical data supporting infection, typically pneumonia.

The choice of agent can be based on sputum Gram stain or cultures.

• Request critical care or pulmonary consultation for most admissions.
• Toxicology or poison control center consultation is recommended.
• Obtain ophthalmologic consultation for patients with ocular involvement.