CBRNE - Lung-Damaging Agents, Toxic Smokes - NOx, HC, RP, FS, FM, SGF2, Teflon Workup

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

Laboratory Studies

  • In the workup of inhalation injuries caused by toxic smokes, the primary investigation is toward the pulmonary system. Other tests should be clinically indicated based on history, physical examination, and underlying health problems.
  • Arterial blood gas determination aids in the evaluation of the degree of hypoxia and alerts the health care provider to other possible toxins such as carbon monoxide and methemoglobin.
  • Carbon dioxide levels also may be monitored, since patients with prior lung disease such as asthma and COPD may be affected more severely and are at greater risk to retain carbon dioxide.
  • Perform baseline pulmonary function tests (PFTs) once the patient is stable. This may be difficult in the emergency department, but serial peak flow readings may be helpful. Later, PFTs allow evaluation and comparison of lung function and reversibility with bronchodilators and potentially steroids. If the patient develops dyspnea on exertion, then perform PFTs with exertion if PFTs at rest cannot explain the symptoms.
  • Exposure to HC/ZnO warrants baseline LFTs on initial presentation. These should be followed over the course of hospitalization if exposure is severe enough to warrant admission.
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Imaging Studies

  • Chest radiography
    • Chest radiography can help in evaluating the presence of hyperinflation that may suggest injury of the smaller airways and air trapping. Noncardiogenic pulmonary edema also is a clue to toxic inhalation.
    • CXR changes may lag behind clinical changes by hours or days; therefore, if findings are normal, they may be of limited value.
    • Individuals with fume fever often are sent home after 4 hours observation and with a clear CXR, only to return after the initial recovery and latent phase with more severe dyspnea and florid noncardiogenic pulmonary edema.
    • CXR in a significant HC exposure may not show anything abnormal until 4-6 hours postexposure. CXR findings slowly may improve with supportive care or advance to a long-standing diffuse interstitial fibrosis.
    • In phase III of NOx exposure, a noncardiogenic pulmonary edema pattern may be seen on CXR. Pathologic findings may demonstrate classic bronchiolitis fibrosa obliterans, which may mimic miliary tuberculosis on CXR. Fibrotic changes either may clear spontaneously or proceed to severe respiratory failure.
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Other Tests

  • ECG and serial cardiac enzymes also are important in the setting of chest pain, as clinically indicated, to evaluate underlying cardiac ischemia, which may be precipitated by hypoxia or increased oxygen demand.
  • A baseline complete blood count is warranted as certain smokes, such as HC, are associated with a significant drop in hemoglobin and hematocrit beginning at 1 week postexposure.[8]
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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.

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