Prehospital Care

Scene responders need to ensure their own safety when possible to prevent becoming victims themselves. Remove patients from the scene and move them to fresh air or administer oxygen if necessary. Terminate exposure by removing patients' clothing. Begin skin decontamination with soap and water. Pulmonary edema may be precipitated by exertion. Enforce strict bedrest if possible.

Emergency Department Care

Management is supportive and no antidote exists. Begin or continue care as discussed in Prehospital Care above. Minimize exertion on the part of the patient so as to lessen the risk of delayed pulmonary edema.

Administer standard resuscitation measures. Patients can present with airway obstruction, although that is rare. Acute pulmonary edema is common, and patients may require positive end-expiratory pressure if they are clinically in respiratory distress or frank failure. Avoid use of diuretics. Patients also can present with hypotension; perform standard resuscitation with crystalloid fluids as first-line agents and vasopressors as second-line agents.

Give bronchodilators to patients with bronchospasm. Systemic steroids likely are not beneficial routinely for diphosgene exposure, except in patients with bronchospasm not controlled by bronchodilators. Some literature suggests using inhalational steroids for phosgene poisoning, which may lessen the severity of pulmonary edema. Similar regimens possibly may be used for diphosgene inhalation. However, treatment should be initiated within a short time of exposure (15 min). One regimen uses dexamethasone and another uses betamethasone or beclomethasone in doses higher than that prescribed for asthma therapy.

Eyes should be copiously irrigated with standard solutions and then assessed for visual acuity and corneal damage.

Contact with liquid diphosgene may produce chemical burns. After thorough decontamination, these may be treated with standard burn therapy.

Antibiotics are unnecessary, prophylactically or therapeutically, unless a secondary infection is present.

Admit patients who require resuscitation or oxygen supplementation. For at least 12 hours, observe patients with likely diphosgene exposure who have minor symptoms or are asymptomatic, since delayed pulmonary edema is the classic feature of diphosgene exposure. However, one reference suggests that a minimum of 6 hours of observation is sufficient for a phosgene exposure.^[1]

Counsel all patients with significant exposure to avoid strenuous activities for 72 hours and to return if significant respiratory symptoms develop.