Prehospital Care
The Agency for Toxic Substances and Disease Registry has published recommendations for prehospital care of arsenic exposure. The recommendations vary by zone: hot zone, decontamination zone, and support zone. [13]
Hot zone
Rescuers must be appropriately trained and attired before entering the hot zone. If training or equipment availability is questionable, assistance should be obtained from local or regional HAZMAT team or other equipped response organization. Positive pressure, self-contained breathing apparatus (SCBA) is highly recommended. Chemical protective clothing is usually not required since arsine gas is not directly absorbed through the skin. The exception is exposure to compressed liquid gas, which may cause frostbite injury to the skin or eyes. Maintain victims' airway, breathing, and circulation (ABCs) and transport them out of the hot zone.
Decontamination zone
Victims who have exposure only to arsine gas do not need decontamination. They may be transferred immediately to the support zone. In cases of contact with liquid (compressed gas), gently wash frosted skin with water; gently remove clothing from affected area. Dry with clean towels and keep victim warm and quiet.
Support zone
Support zone personnel require no protective gear if the victim has been exposed only to arsine gas. Support personnel should always continue to manage ABCs, which includes supplementary oxygen and venous access. The patient should be intubated if the airway is not patent or protected. Hypotension should be addressed with infusion of normal saline or lactated Ringer solution. If available, the victim's electrolytes status, mainly potassium, and oxygenation status with arterial blood gas (ABG) measurement should be obtained. The victim is transported to a medical facility as soon as possible.
Emergency Department Care
The main goal of the emergency medicine physician is to support vascular, renal, hematologic, and cardiorespiratory function. Management includes the following:
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Airway: Ensure the airway is patent and protected.
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Breathing: Administer supplementary oxygen or intubation as necessary. Consider using bronchodilators in patients with bronchospasm or racemic epinephrine aerosol in children with wheezing.
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Circulation: Treat hypotension with normal saline (NS) or lactated Ringer solution. Consider dopamine for hypotension or oliguria. Norepinephrine should be considered in cases of resistant shock.
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Disability: Assess the patient's neurologic status.
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Exposure: In patients exposed to liquid compressed arsine gas, frostbite injuries may be irrigated with lukewarm water according to standard treatment. A thorough eye examination should be performed along with an ophthalmologist consultation if needed in patients with eye injuries.
Several case reports have demonstrated the efficacy and benefits of exchange transfusion, to include both red blood cell exchange (RBC-E) and plasma exchange (PE). [14, 15, 16, 17, 18] RBC-E and PE may have a synergistic effect with better outcome than RBC-E alone. Exchange transfusion is the treatment of choice for patients with severe hemolysis. This treatment is believed to support the oxygen-carrying capacity of the blood, remove free hemoglobin, and remove arsine and arsenic dihydride residues.
Initiate diuresis to avoid heme-pigment nephropathy. Both intravenous mannitol and urinary alkalinization have anecdotal value.
All patients who have suspected arsine exposure should be carefully observed for 24 hours. Monitor kidney function; initiate hemodialysis as necessary for acute kidney injury. Monitor hemoglobin levels; perform transfusions to maintain oxygen-carrying capacity of the blood.
Monitor the patient for signs of chronic arsenic toxicity. Chronic arsenic toxicity from arsine exposure is treated no differently than exposure from other sources. Although chelating agents (eg, 2,3-dimercaptopropanol, British antilewisite [BAL]) have not been shown to be of benefit in acute arsine toxicity, [19] chelating agents (eg, BAL) may be used to treat chronic arsenic toxicity. [20] See Arsenic Toxicity for more information.
Consultations
Consultations are as follows:
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Contact the blood bank and hematologist regarding exchange transfusion.
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Consult a nephrologist for hemodialysis in patients with acute kidney injury.
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Follow local emergency management plan and protocols if intentional release of arsine is suspected.
Prevention
Train workers in high-risk industries to avoid toxic arsine exposures. Screen workers in the same environment as those persons already exposed to acute arsine poison.
