Phosgene Exposure Clinical Presentation

  • Author: Joy C Crandall, DO; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Mar 22, 2012
 

History

Time to onset of symptoms after phosgene exposure is a critical historical detail.

  • Head, ears, eyes, nose, and throat (HEENT) (immediate if high concentrations of phosgene; typically lasts 3-30 min)
    • Lacrimation
    • Conjunctival irritation/burning
    • Burning sensation in mouth/throat
    • Throat swelling/changes in phonation - May reflect laryngeal edema due to irritant effects of phosgene hydrolysis (hydrochloric acid formation) at vocal cords
  • Respiratory (usually 4-24 h postexposure)
    • Cough - Initially dry, then increasing frothy white/yellow sputum
    • Chest tightness, chest pain, or substernal burning
    • Dyspnea - Present at rest but much worse on exertion
    • If patient is a smoker, metallic or unpleasant taste to cigarettes
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Physical

  • HEENT
    • Pharyngeal erythema
    • Conjunctivitis
    • Altered phonation
  • Respiratory
    • Crackles on auscultation - Herald the onset of pulmonary edema
    • Cyanosis - Late finding
    • Thin, frothy white/yellow secretions
    • Wheezing
    • Tachypnea
    • Stridor
    • Accessory muscle use for respiratory effort
  • Cardiac
    • Tachycardia
    • Hypotension - Late finding secondary to inflammation-mediated fluid diversion out of vascular system and into lung interstitium
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Causes

Phosgene exposure may result from a weapon of mass destruction release by extremist groups, traditional military conflict involving chemical munitions, industrial sabotage, industrial accident, fire exposure, or small-scale accidental exposure involving the heating of chlorinated hydrocarbons.[4] Any weapon of mass destruction release will likely produce large numbers of casualties presenting simultaneously with similar symptoms, but a large industrial accident could result in similar patient arrival patterns.

Phosgene toxicity may occur in 3 phases. The first is an immediate irritant reaction likely caused by the hydrolysis of phosgene to hydrochloric acid on mucous membranes, which results in conjunctivitis, lacrimation, and oropharyngeal burning sensations. This symptom complex occurs only in the presence of high concentration (>3-4 ppm) exposures but does not have any prognostic value for the timing and severity of later respiratory symptoms. The most important finding to identify during this stage is a laryngeal irritant reaction causing laryngospasm, which may lead to sudden death. The irritant symptoms last only a few minutes and then resolve as long as further exposure to phosgene ceases.

One of the hallmarks of phosgene toxicity is an unpredictable asymptomatic latent phase before the development of noncardiogenic pulmonary edema. Typically, the latent phase lasts 3-24 hours, but it may be as short as 30 minutes or as long as 48 hours after phosgene exposure. The duration of the latent phase is an extremely important prognostic factor for the severity of the ensuing pulmonary edema. Patients with a latent phase of less than 4 hours have a poor prognosis. Increased physical activity may shorten the duration of the latent phase and worsen the overall clinical course. Unfortunately, there are no reliable historical or physical examination findings during the latent phase to predict its duration.

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Contributor Information and Disclosures
Author

Joy C Crandall, DO  Brigade Surgeon, Department of Emergency Medicine, United States Army, 214th Fires Brigade, Fort Sill, Oklahoma

Joy C Crandall, DO is a member of the following medical societies: American College of Emergency Physicians and American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kermit D Huebner, MD, FACEP  Research Director, Carl R Darnall Army Medical Center

Kermit D Huebner, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, Association of Military Surgeons of the US, Society for Academic Emergency Medicine, and Society of USAF Flight Surgeons

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; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Elizabeth A Gray, MD, John W Love, MD, and Jeffery L Arnold, MD, to the development and writing of this article.

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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 Image courtesy of Fred P. Harchelroad, MD, and Ferdinando L. Mirarchi, DO.
 
 
 
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