CBRNE - Lung-Damaging Agents, Toxic Smokes - NOx, HC, RP, FS, FM, SGF2, Teflon Treatment & Management

  • Author: Lanny F Littlejohn, MD; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: May 14, 2010
 

Prehospital Care

  • Prehospital care of inhalational injuries is directed toward securing the airway as needed, administering oxygen, and obtaining intravenous (IV) access. Cardiac monitoring also is important for any patient with respiratory distress. Beta-agonists such as albuterol may be given as a nebulized treatment to those who demonstrate signs of bronchoconstriction.
  • Although the care is mostly supportive, prompt delivery to the emergency department should be a priority for prehospital care providers.
  • As always, the prehospital care providers must do all in their power to remove the patient from ongoing exposure without becoming casualties themselves.
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Emergency Department Care

Treatment of inhalation injuries caused from toxic smokes is based on clinical presentation and involves primarily supportive care directed at the cardiopulmonary system.

  • Begin treatment by removing the patient from the source of exposure and providing appropriate detoxification.
  • Provide intravenous access, cardiac monitoring, and supplemental oxygen in the setting of hypoxia.
  • Begin bronchodilators in a patient with bronchoconstriction.
  • Subcutaneous epinephrine has been used in zinc oxide (HC) exposures.
  • Steroids remain controversial but have been suggested as having some value in oxides of nitrogen (NOx), zinc oxide (HC), red phosphorus (RP), sulfur trioxide (FS), titanium tetrachloride (FM), and polytetrafluoroethylene (PTFE) exposures. In a case series by Huang et al, 25% of patients presented after HC exposure with acute lung injury requiring ventilatory support. All of these patients survived with glucocorticoids, antibiotics and lung-protective ventilatory management. However, there was no control group, so a causal link could not be made between survival and steroid treatment.[9]
  • HC exposures may require British anti-Lewisite (BAL) administration and the chelating agent calcium ethylenediaminetetraacetic acid (CaEDTA).
  • If the patient was exposed to particulate RP and burns are present, a topical bicarbonate solution to neutralize phosphoric acids may be used. Mechanical removal and debridement of contaminated wounds helps diminish toxicity to elemental phosphorus.
  • FS and FM exposures require washing of irritated skin with water and then a sodium bicarbonate solution. Any eye involvement should prompt generous irrigation and examination with fluorescein. Obtain ophthalmology follow-up care. Mydriasis with atropine sulfate has been suggested as potentially helpful.
  • Some animal studies suggest that in the setting of PTFE exposure, increasing concentrations of pulmonary oxygen free radical scavengers containing thiol groups may be valuable. N -acetyl cysteine has been found effective.
  • In mass casualty scenarios, the use of fiberoptic bronchoscopy may be beneficial to rapidly triage patients to intensive care, ward, or observation status. Mobilization of otolaryngology and/or anesthesia resources may be necessary to accomplish this in a timely fashion.
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Contributor Information and Disclosures
Author

Lanny F Littlejohn, MD  Staff Emergency Physician and Medical Director for Tactical Combat Casualty Care, Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia

Lanny F Littlejohn, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Special Operations Medical Association, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

William Byrne Cogar, DO, FACEP  Medical Director, Emergency Management and Preparedness; Assistant Chair, Department of Emergency Medicine, Naval Medical Center, Portsmouth, VA

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.

References

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  2. Conner MW, Flood WH, Rogers AE, Amdur MO. Lung injury in guinea pigs caused by multiple exposures to ultrafine zinc oxide: changes in pulmonary lavage fluid. J Toxicol Environ Health. 1988;25(1):57-69. [Medline].

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