Phosgene Exposure Workup

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

Laboratory Studies

  • No combinations of laboratory or radiographic studies have been shown to discriminate reliably, which asymptomatic (latent phase) patients exposed to phosgene will develop life-threatening pulmonary edema.
  • Pulse oximetry measurements remain normal during the latent phase, but it is useful for following progression over several hours of observation. Increase triage priority and level of intervention if oxygen saturation begins to decline, as hypoxemia heralds onset of pulmonary edema.
  • Arterial blood gas measurements are normal during the latent phase but are useful for following progression of manifest illness after the onset of pulmonary edema. Also, arterial blood gas measurements may be useful for making adjustments in respiratory care therapy (ventilator settings). Acidosis typically occurs, initially as a respiratory acidosis, but later becomes a mixed acidosis due to anaerobic metabolism in the wake of profound tissue hypoxia.
  • CBC may reflect hemoconcentration due to third spacing of fluid into lungs once pulmonary edema has occurred, but this test is of little value prognostically.
  • A 2009 study noted that levels of secreted phospholipase A2 (sPLA-IIA) found on bronchial alveolar lavage increased markedly after phosgene exposure, peaking at 6 hours, and correlated well with severity of lung injury in the study population. While not specific for phosgene exposure, measurement of sPLA-IIA in bronchial lavage is a potential future measurement for the progression of lung injury from phosgene exposure.[5]
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Imaging Studies

  • Chest radiograph
    • In patients without preexisting cardiac disease, the heart silhouette should be normal.
    • Chest radiograph may help exclude other possibilities in the differential diagnosis (pneumothorax, pneumonia, hemothorax, pleural effusion).
    • Early changes after phosgene exposure include hyperinflation and hilar enlargement.
    • Later changes are typical for noncardiogenic pulmonary edema: fluffy "batwing" perihilar interstitial infiltrates.
    • Radiographic findings may evolve rapidly over the first few hours after phosgene exposure and clear over several days as clinical improvement occurs.
    • Using a low-energy exposure technique (50-80 kV) may facilitate early identification of evolving pulmonary edema (as early as halfway through the latent period).
    • A chest radiograph of a patient who developed phosgene-induced adult respiratory distress syndrome is shown below.Anteroposterior portable chest radiograph in a malAnteroposterior 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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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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