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

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

Author: Joy C Wethern, DO, Resident Physician PGY3, Department of Emergency Medicine, Carl R Darnall Army Medical Center, Ft Hood, Texas
Coauthor(s): Kermit D Huebner, MD, FACEP, Research Director, Carl R Darnall Army Medical Center
Contributor Information and Disclosures

Updated: May 27, 2009

Follow-up

Further Inpatient Care

  • Patients with phosgene-induced pulmonary edema should be admitted to a critical care setting. These include all phosgene-exposed persons with crackles on ausculatory examination, chest radiograph abnormalities consistent with pulmonary edema, hypoxemia, or tachypnea.
  • Patients with pulmonary edema will require ongoing supplemental oxygen therapy and likely will require positive pressure ventilation, either noninvasively through CPAP or BiPAP or invasively through endotracheal intubation and mechanical ventilation. Intubated patients are likely to require frequent suctioning due to copious secretions.
  • Patients with ongoing symptoms of dyspnea but no objective abnormalities on examination, radiograph, or vital signs should be hospitalized for observation until they declare themselves as either improving or worsening. Improving patients may be discharged, and worsening patients should be admitted to a critical care setting.

Further Outpatient Care

  • Patients may be discharged after an appropriate observation period (6-12 h if the patient has a clear chest radiograph, 24 h in a setting without chest radiography capability) if they are asymptomatic, have normal vital signs, and have a clear ausculatory examination.
  • Patients need good follow-up care instructions with precautions to return if they develop symptoms. A preprinted patient information sheet and discharge instructions are available from CDC/ATSDR.

Inpatient & Outpatient Medications

  • Discharged patients require no medications since they are asymptomatic. Previously diagnosed asthmatic patients should continue to take their inhaled steroids and inhaled bronchodilators as prescribed.
  • Inpatients should be considered for bronchodilator therapy and possibly for systemic steroids as described above. Diuretics should probably be avoided, and antibiotics should be used only in the presence of a documented infection.

Transfer

  • Patients with phosgene-induced noncardiogenic pulmonary edema require hospitalization in a critical care setting. If a local hospital cannot provide such care, then transfer must be arranged by direct physician-to-physician contact with a critical care provider at another institution. Critical care capable transport should be used (ACLS ambulance or helicopter with capability for mechanical ventilation).
  • En route deterioration should be anticipated since the pulmonary edema is often rapidly progressive. For patients who are already significantly ill, consideration should be given to pretransfer intubation, sedation, and mechanical ventilation.

Complications

  • Patients who survive the first 48 hours after phosgene exposure have a generally excellent prognosis. Clinical and radiographic improvement often occurs in 3-5 days.
  • Patients who remain significantly ill beyond 5 days should be evaluated for a concurrent disease process such as superimposed infection.
  • No data suggest carcinogenicity or reproductive/developmental hazards in association with phosgene exposure.
  • Many patients report ongoing exertional dyspnea for months or even years after phosgene exposure despite normalized chest radiographs. Some patients may develop reactive airway dysfunction syndrome (RADS), which is an irritant-induced reactive airway process. These patients may benefit from follow-up pulmonary function testing 2-3 months after phosgene exposure, possibly to include a methacholine challenge test.
  • Chronic low level exposure to phosgene (<0.1 ppm) in a cohort of almost 800 workers at a uranium enrichment facility during World War II resulted in no documented increase in all-cause mortality or respiratory causes of mortality in 35 years of follow-up when matched with unexposed control workers at the same facility.

Prognosis

  • Latent period duration of less than 4 hours suggests a severe course of illness but one that is still survivable with maximum critical care interventions.
  • Most patients exposed to phosgene recover uneventfully and have an excellent long-term prognosis.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize that phosgene is a ubiquitous industrial product and that exposures may occur at any time due to an accident, which is a more likely scenario than its use as a weapon. Failure to plan for such hazards in conjunction with local emergency planning committees/HAZMAT teams and to conduct appropriate training.
  • Failure to educate prehospital and emergency department providers about the hazards involved with liquid phosgene and provide training regarding the appropriate personal protective equipment needed to work with phosgene-exposed patients.
  • Reliance on presence of the characteristic odor of new mown hay to substantiate a suspected phosgene exposure. Some persons cannot detect the smell of this agent, and the threshold for olfactory detection is well above dangerous exposure levels.
  • Early discharge of asymptomatic patients during the latent phase after phosgene exposure. Patients who later develop severe pulmonary edema may be completely asymptomatic shortly after exposure. All patients with possible exposure should be observed for a minimum of 6 hours for development of symptoms or signs of pulmonary edema.
  • Failure to reassess patients at frequent intervals—at least every 2 hours during the first 6 hours after exposure. Hourly reassessment would be preferred.
  • Failure to anticipate rapid in-transport deterioration of the patient with phosgene-induced pulmonary edema. Strongly consider pretransport intubation and mechanical ventilation.
  • Failure to enforce rest of asymptomatic patients during the latent period. Exertion will worsen the clinical course of phosgene toxicity.
  • Failure to notify appropriate community authorities (HAZMAT, law enforcement, health department) of suspected phosgene exposure in a scenario where community health may be at risk.

Special Concerns

  • Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of Naval Medical Center San Diego, the Department of the Navy, the Department of Defense, or the United States Government.
 
Acknowledgments

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.



More on CBRNE - Lung-Damaging Agents, Phosgene

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References
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Further Reading

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Keywords

phosgene, phosgene exposure, treatment, symptoms, causes, chemical weapon, CG, COCl2, carbonyl chloride, WMD, weapons of mass destruction, chemical warfare, noncardiogenic pulmonary edema, toxic inhalation, lung-damaging agents, irritant pulmonary toxin, frostbite injuries

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Contributor Information and Disclosures

Author

Joy C Wethern, DO, Resident Physician PGY3, Department of Emergency Medicine, Carl R Darnall Army Medical Center, Ft Hood, Texas
Joy C Wethern, 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.

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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