Medical Management Guidelines for Acute Chemical Exposures

U.S. Department of Human Services, Public Health Service, Agency for Toxic Substance and Disease Registry

Publication date: 08/01/1992

Table of Contents

Preface

Introduction

Description Chemical Name (Chemical Formula)
Health Effects
Prehospital Management
Prehospital Management
Emergency Department Management
Emergency Department Management

Protocol for the Unidentified Chemical Contaminant
Unidentified Chemical Prehospital Management
Unidentified Chemical Emergency Department Management

Chemical Protocols
Ammonia NH(3)
Health Effects
Prehospital Management
Emergency Department Management
Ammonia Patient Information Sheet
Ammonia Follow-up Instructions -
Arsine AsHJ(3)
Health Effects
Prehospital Management
Emergency Department Management
Arsine Patient Information Sheet
Arsine Follow-up Instructions --
Benzene (C(6)H(6))
Health Effects
Prehospital Management
Emergency Department Management
Benzene Patient Information Sheet
Benzene Follow-up Instructions --
Ethylene Oxide ((CH(2))(2)0)
Health Effects
Prehospital Management
Emergency Department Management
Ethylene Oxide-- Patient Information Sheet
Ethylene Oxide Follow-up Instructions --
Formaldehyde (HCHO)
Health Effects
Prehospital Management
Emergency Department Management
Formaldehyde Patient Information Sheet
Formaldehyde Follow-up Instructions
Hydrogen Fluoride (HF) and Hydrofluoric Acid
Health Effects
Prehospital Management
Emergency Department Management
Hydrogen Fluoride and Hydrofluoric Acid Patient Information Sheet
Hydrogen Fluoride and Hydrofluoric Acid Follow-up Instructions --
Hydrogen Peroxide (H(2)O(2))
Health Effects
Prehospital Management
Emergency Department Management
Hydrogen Peroxide Patient Information Sheet
Hydrogen Peroxide Follow-up Instructions
Hydrogen Sulfide (H(2)(S))
Health Effects
Prehospital Management
Emergency Department Management
Hydrogen Sulfide Patient Information Sheet
Hydrogen Sulfide Follow-up Instructions
Methyl Bromide (CH(3)Br)
Health Effects
Prehospital Management
Emergency Department Management
Methyl Bromide Patient Information Sheet
Phenol (C(6)H(5)-OH)
Health Effects
Prehospital Management
Emergency Department Management
Phenol Patient Information Sheet
Phosgene (COC1(2))
Health Effects
Prehospital Management
Emergency Department Management
Phosgene Patient Information Sheet
Phosgene Follow-up Instructions --
Phosphine Phosphine (PH(3)) CAS 7803-51-2; UN 2199
Health Effects
Prehospital Management
Emergency Department Management
Phosphine and Phosphides Patient Information Sheet
Phosphine and Phosphides Follow-up Instructions -
Toluene (C(6)H(5)-CH(3)) CAS: 108-88-3; UN 1294
Health Effects
Prehospital Management
Emergency Department Management -
Toluene Patient Information Sheet
Toluene Follow-up Instructions --
Xylene (CH(3)-C(6)H(4)-CH(3)) CAS:1330-20-7; UN 1307
Health Effects
Prehospital Management
Emergency Department Management
Xylene Patient Information Sheet
Xylene Follow-up Instructions --

Appendix I AAPCC - Certified Regional Poison Control Centers

Appendix II Association of Occupational and Environmental Clinics

Appendix III Consultation Resources
State/Federal/National Resources
State Health Departments

For Additional Information

POINT OF CONTACT FOR THIS DOCUMENT:

Figures
Organization Of A Hazmat Incident Area
Detail Of Decontamination Zone

Preface

The Medical Management Guidelines for Acute Chemical Exposures (Guidelines) have been developed to aid emergency department physicians and other emergency healthcare professionals who manage acute exposures resulting from chemical incidents. The guidelines in this document are intended to aid healthcare professionals involved in emergency response to effectively decontaminate patients, protect themselves and others from contamination, communicate with other involved personnel, efficiently transport patients to a medical facility, and provide competent medical evaluation and treatment to exposed persons.

The objectives of the Guidelines are to provide the following:

• Information on physical and chemical properties and on health effects of chemicals that may be encountered in acute environmental or occupational exposures;
• Accurate, concise management information and treatment for patients acutely exposed to environmental toxicants;
• Guidelines for effective decontamination of acutely exposed patients, while protecting others from secondary contamination;
• Guidelines for patient disposition and follow-up;
• Guidelines for reporting that encourage emergency department physicians to consider the patient as a sentinel case of environmentally or occupationally caused disease; and
• Information for persons potentially exposed during a hazardous chemical release incident.

Introduction

Each chemical protocol is divided into five major sections, which are color-coded for easy identification:

(1) Description (synonyms, appearance, routes of exposure, potential for secondary contamination, physical properties table, sources and uses); (2) Health Effects (organ systems affected by acute exposure, potential sequelae, effects of chronic exposure);

(3) Prehospital Management organized by Hot Zone, Decontamination Zone, and Support Zone (personal protection, decontamination, support, triage, transportation);

(4) Emergency Department Management organized by Decontamination Area and Critical Care Area (specific medical procedures to treat the exposed patient, patient disposition); and

(5) Patient Information Sheet (the exposure and its potential effects, follow-up instructions).

In addition to information on specific chemicals, the Guidelines contains prehospital and hospital management approaches to incidents involving an unidentified hazardous substance. Appendices provide information resources for the emergency department physician seeking consultation in treating a chemically exposed patient, and a glossary supplements the information in the protocols.

To keep the individual protocols brief, we first present annotation and background information for each of the first four sections (descriptive, health effects, prehospital management, and emergency department management) in the same format as that of the individual protocols. You are urged to read the complete introduction before using the protocols in an emergency situation.

The patient information sheet with follow-up instructions is intended to be given to exposed or potentially exposed persons. It contains a description of the chemical, information on immediate and future potential health effects, treatment of acute poisoning, biologic tests to assess exposure, information resources, and follow-up medical instructions. The follow-up instructions alert patients to delayed symptoms that could warrant further medical evaluation. Other patient instructions specific to the exposure are provided by a check-off list that the clinician completes.

Description Chemical Name (Chemical Formula)

• Summary of important characteristics such as odor and flammability.
• Potential routes of exposure: inhalation, dermal absorption, ingestion.
• Potential for secondary contamination.

This section summarizes the color, odor, and physical state (solid, liquid, or gas) of the chemical at room temperature. Methods of shipment or storage and the physical hazards associated with the chemical also are described.

Warning properties: The odor threshold is the lowest air concentration at which the chemical can be detected by smell. For those chemicals with an odor threshold lower than the toxic air concentration, odor may be a sufficient warning of dangerous exposure conditions. However, if a chemical has no detectable color or odor at toxic concentrations, or it has an odor that is unreliably detected because of olfactory adaptation, or does not cause irritation, it is considered to have inadequate warning properties.

Routes of Exposure --

The most likely route or routes of exposure to the chemical are described-- inhalation, direct contact with the skin or eyes, or ingestion. With each route of exposure, the likelihood of injury depends on the toxicity of the chemical involved, the concentration of the material, and the duration of contact.

Inhalation -

Inhalation is the most common route of exposure to gases and vapors. Liquids and solids also may be inhaled when they are in the form of finely divided mists, aerosols, or dusts. Highly water-soluble gases and vapors and larger mist or dust particles (greater than 10 microns in diameter) generally are deposited in the upper airways. Less soluble gases and vapors and smaller particles can be inhaled more deeply into the respiratory tract. Inhaled substances can be absorbed into systemic circulation, causing toxicity to various organ systems.

Skin/Eye Contact -

Skin and eye contact can occur with solids, liquids, or gases. Corrosive agents can cause direct damage to tissues by various mechanisms including low or high pH, chemical reaction with surface tissue, or removal of normal skin fats (defatting) or of moisture (desiccant effect). Chemicals also can be absorbed systemically through the skin. This is more likely to occur when the normal skin barrier is disrupted (e.g., with a chemical burn or a traumatic injury) or if the chemical is highly fat-soluble (e.g., organophosphate and organochlorine pesticides).

Ingestion -

Ingestion is not a common route of accidental exposure in adults, although it is the most common route in suicide attempts. Ingestion of a corrosive agent can cause severe burns to the mouth, throat, esophagus, and stomach. Chemicals also may be aspirated into the lungs (e.g., liquid hydrocarbons), causing a direct chemical pneumonia. Ingested chemicals are absorbed systemically but also may react with stomach acid, creating products toxic to the healthcare provider, as well as to the patient (e.g., hydrogen cyanide is formed from ingested cyanide salts).

Potential for Secondary Contamination --

Primary contamination occurs by direct exposure in the Hot Zone. Secondary contamination is the transfer of contaminating material from the victim to personnel or equipment in or beyond the Hot Zone. The potential for secondary contamination has implications for decontamination and triage of victims and for the protection of rescue and healthcare personnel.

A substance is likely to pose a risk of secondary contamination if it is both seriously toxic and it is likely to contaminate the clothing, skin, or hair in sufficient quantities to threaten personnel outside the Hot Zone. Every effort must be made to decontaminate victims before they are transferred to the Support Zone or to a medical care facility. Substances that present a serious risk of secondary contamination include the following:

• highly toxic liquids and solids or finely divided solids (e.g., organophosphate pesticides)
• radioactive liquids and dusts
• certain biologic agents (e.g., harmful viruses or bacteria)

• gases (e.g., carbon monoxide, arsine)
• vapors (unless they condense to a liquid state on clothing or skin)
• substances with no serious toxicity or skin absorption (e.g., propylene glycol, motor oil)

This section describes the most common uses of the chemical and how it is manufactured if it is synthetic.

Properties --

A table of properties lists the common physical properties and exposure standards or guidelines that may assist in making emergency decisions.

Standards and Guidelines -

The OSHA permissible exposure limit (PEL) is the time-weighted average (TWA) air concentration of the chemical that must not be exceeded during any 8-hour work shift of a 40-hour workweek. The PEL has little relevance to acute, short-term exposures since an exposure to an air concentration 10 or even 100 times greater than the PEL may be safe for some chemicals but dangerous for others. However, if the measured air concentration at an incident is less than the PEL, the atmosphere is safe for short-term exposure, provided other toxicants are not present. The OSHA ceiling concentration must not be exceeded any time during the workday; if instantaneous monitoring is not feasible, the ceiling must be assessed as a 15-minute TWA exposure. The OSHA short-term exposure limit (STEL) is a 15- minute TWA exposure (unless otherwise noted) that should not be exceeded at any time.

The NIOSH immediately dangerous to life or health (IDLH) level represents the maximum concentration from which, in the event of respirator failure, one could escape within 30 minutes without a respirator and without experiencing any escape-impairing (e.g., severe eye irritation) or irreversible health effects.

The AIHA Emergency Response Planning Guideline (ERPG) values are included in the table whenever they are available. ERPGs are intended to provide estimates of concentration ranges at which adverse effects can be anticipated.

ERPG-I is the maximum airborne concentration below which nearly all persons exposed for up to 1 hour will not experience other than mild transient adverse health effects or will not detect a clearly defined objectionable odor.

ERPG-2 is the maximum airborne concentration below which nearly all persons exposed for up to 1 hour will not experience or develop irreversible or other serious health effects or symptoms that could impair their ability to take protective action. ERPG-2 values are included in these protocols because these values are used by the U.S. Department of Transportation (DOT) to compute the Initial Isolation and Protective Action Distance Tables for chemical incidents (as found in the DOT Emergency Response Guidebook). ERPG-3 is the maximum airborne concentration below which nearly all persons can be exposed for up to 1 hour without experiencing or developing life-threatening health effects.

Physical Properties -

Vapor pressure determines the extent to which a liquid or solid material will produce a vapor (gas). The higher the vapor pressure, the greater the amount of chemical existing in the vapor phase. A vapor pressure over 760 mm Hg, or a boiling point at or below room temperature, indicates that the chemical exists mostly as a gas under normal conditions.

Vapor density compares the weight of the vapor to that of air. A vapor density greater than 1 means that the vapor or gas is heavier than air and will collect in low-lying areas where it may create an oxygen-deficient atmosphere by displacing oxygen-containing air.

Water solubility may suggest the effectiveness of water in decontamination. A material that is poorly water soluble is not likely to be removed effectively from the skin and hair with a plain water wash and may require the use of soaps or other agents for removal.

Flammability and explosivity are important properties in most emergency situations. The temperature and concentration range at which a chemical is flammable and the ability of a vapor or gas to travel to an ignition source and flash back may impact rescue activities. It should be noted that most chemical-resistant protective clothing is neither heat nor flame resistant and may melt if a fire occurs.

Health Effects

Acute Exposure --

An acute exposure is defined as an exposure to a chemical for a duration of 14 days or less. Although the duration of exposure during an unscheduled chemical release may be brief, the chemical concentration may be high. The onset of health effects resulting from an acute exposure can be immediate or delayed.

Estimating the risk of adverse effects from an exposure is known as health risk assessment. Health risk depends on the intrinsic toxic potential of the chemical, its concentration, the duration of exposure, and the health status of the person exposed. Even very toxic chemicals may not pose a risk of illness if the duration is brief or the concentration of the substance is low. Exposures to high concentration of even mildly toxic substances, however, can be dangerous.

The toxic potential of a chemical can be gauged by measuring the dose that will kill half of a group of test animals and comparing that dose to similar values for other chemicals. When the dose is administered to test animals by ingestion or injection, it is referred to as the lethal dose (LD(50)). The LC(50) refers to the lethal air concentration that is fatal to 50% of the test animals when it is inhaled. The lower the LD(50) or LC(50), the more potent the chemical. Although widely used to describe relative toxicity of chemicals, these numbers have limited clinical relevance. The values apply only to animal species, not humans. Also, they provide no information about doses that might not kill but could cause serious injury to the lungs, kidneys, or other organs.

The lowest concentration of a chemical in air that has been reported to cause death in humans or animals is referred to as LC(Lo). The dose of chemical at which there are no statistically or biologically significant increases in frequency or severity of adverse effects between the exposed population and appropriate controls is the No-Observed-Adverse-Effect Level or NOAEL.

CNS -

The brain is affected by many drugs and chemicals. Depressants (e.g., chloroform, hydrocarbon solvents) cause a generalized decrease in brain activity that may result in headache, dizziness, confusion, lethargy, stupor, or coma. Some early effects of depressants may appear to be stimulatory, producing euphoria and giddiness (similar to beverage alcohol). Severe depression of the brain stem can cause respiratory arrest and cardiovascular collapse.

Central nervous system stimulants (e.g., DDT, other chlorinated hydrocarbon insecticides, organophosphates) can cause agitation, anxiety, delirium, and seizures. Excessive muscular activity associated with seizures can result in hyperthermia.

Respiratory -

Inhalation of a chemical irritant (e.g., ammonia, chlorine) usually causes rapid onset of burning and irritation of the nose, throat, and upper respiratory tract. Painful coughing, wheezing, and stridor may develop. If the exposure is massive, death may rapidly ensue due to upper airway obstruction, massive alveolar destruction, or asphyxiation. Chest radiography may show pulmonary edema when damaged lung cells allow fluid to leak into the alveoli (referred to as noncardiogenic pulmonary edema because it is not caused by left ventricular failure).

The onset and location of respiratory symptoms are related partially to the water solubility of the inhaled chemical. Highly water-soluble gases, such as ammonia, cause rapid onset of symptoms as they dissolve in the moist mucous membranes of the upper airway. However, less soluble gases, such as phosgene, can be breathed deeply into the lower airways and typically cause few or no early symptoms; delayed noncardiogenic pulmonary edema may then occur 12 to 36 hours later.

Injury to the respiratory tract also can occur when the unconscious or convulsing patient vomits and then, because of depressed airway protective reflexes, aspirates gastric contents into the lungs. Pulmonary aspiration of an ingested hydrocarbon can cause a particularly severe pneumonitis due to the irritating action of these chemicals on lung tissue, as well as their propensity to spread over a wide surface area. Pulmonary aspiration sometimes can be prevented by inserting a cuffed endotracheal tube into the airway in patients with depressed mental status or by placing the patient in a head down, left side position and using suction immediately if vomiting occurs.

Cardiovascular -

Adverse cardiovascular conditions (e.g., hypotension, dysrhythmias) often are caused or aggravated by hypoxia resulting from respiratory depression or pulmonary aspiration of gastric contents. In addition, many chemicals may have direct depressant effects on cardiac function or may stimulate the heart, resulting in dysrhythmias. Hypotension also may have a component of volume depletion, resulting from excessive vomiting, diarrhea, or chemical burns.

Certain solvents (e.g., chlorinated hydrocarbons, freons, aromatic hydrocarbons) can cause cardiac dysrhythmias by lowering the myocardial threshold to the dysrhythmogenic effects of catecholamines. For several hours after the exposure, the victim may be susceptible to ventricular dysrhythmias (e.g., premature ventricular contractions, ventricular tachycardia, ventricular fibrillation) caused by endogenous epinephrine or by administered sympathomimetic drugs such as bronchodilators or dopamine.

Renal -

The kidneys can be injured directly by many chemicals. In addition, any poisoning causing massive muscle destruction can lead to kidney injury from excessive myoglobin in the kidney tubules. Arsine-induced hemolysis results in kidney damage from excessive hemoglobin in the kidney tubules.

When kidney damage is suspected, a urinalysis should be performed for proteinuria or to look for abnormal microscopic casts or cells. If a urine dipstick test is positive for hemoglobin but no red blood cells are seen on microscopic examination, excessive serum hemoglobin or myoglobin is suggested.

Serum tests for renal function (e.g., BUN, creatinine) may not become abnormal until several hours to days after chemical exposure.

Dermal -

The skin provides a relatively impermeable protective barrier against excessive fluid losses from the body or inward movement of microorganisms, allergens, and chemicals. Many chemicals disrupt the integrity of the skin by killing cells or removing fats from the skin. The barrier effect also may be lost by thermal burns or traumatic injuries. Disruption of the normal protective barrier can allow easier entry of chemicals into the systemic circulation. In addition, systemic illness can occur even without skin damage because many fat-soluble chemicals (e.g., some organophosphate insecticides) can penetrate intact skin.

The extent and severity of many chemical burns is evident almost immediately (e.g., mineral acids). However, some chemicals cause progressive penetrating injury (alkaline corrosives, hydrofluoric acid), the extent of which may not be apparent for many hours. Dilute hydrofluoric acid solutions (< 20%) cause little pain or swelling during the first several hours after exposure, but damage is occurring nonetheless.

Ocular -

Most serious eye injuries result from direct contact by corrosive liquids or solids. Vapors and gases also may injure the eye if the exposure is highly concentrated or prolonged. Ocular exposure creates the risk of blindness or other visual impairment and demands immediate evaluation and treatment.

Most patients with an eye injury involving the conjunctival or corneal surface experience pain and irritation, excessive lacrimation, and possibly crusting and swelling of the eyelid. Corneal damage almost always causes intense pain and the sensation of a foreign body in the eye.

Although a corneal burn or abrasion may not be visible with the naked eye, it can be seen easily with the aid of fluorescein staining, a UV light source, and a magnifier or slit lamp. The disrupted corneal surface allows accumulation of the fluorescein, which fluoresces under UV light.

Conjunctival irritation and superficial corneal injuries generally improve quickly with symptomatic care such as use of topical antibiotics, analgesics, or mydriatics. If serious injury is suspected (i.e., if there is extensive corneal fluorescein accumulation, cloudy or bloody material in the anterior chamber, or obvious perforation of the globe), an ophthalmologist must be consulted immediately.

Gastrointestinal -

Nausea, vomiting, abdominal pain, and diarrhea are common symptoms after chemical exposure and may be due to direct gastrointestinal irritation or to systemic effects of the poison. Ingestion of some poisons also can cause severe corrosive injury to the mouth, throat, esophagus, and stomach, with bleeding, perforation, or scarring and stricture formation as potential sequelae.

An important consequence of many chemical exposures is acute injury to the liver, which is typically not detected until 2 to 3 days after exposure. Laboratory tests then show elevated hepatic aminotransferase levels (e.g., AST, ALT) and abnormal liver function (e.g., elevated bilirubin, prothrombin time), although many chemical exposures cause only subclinical derangements in these laboratory tests. If present, toxic hepatitis can progress to liver failure, hepatic encephalopathy, and death.

Potential Sequelae -

Known or suspected sequelae, including the prognosis for recovery after an acute exposure, are described in this section.

Chronic Exposure --

Chronic exposure, which refers to repeated exposures over a period of time, often produces health effects that differ in type or degree from effects of acute, short-term exposure. Most information about chronic toxicity comes from epidemiologic studies and case reports resulting from workplace exposures. In some hazardous materials (hazmat) incidences, it may be difficult to classify an exposure as strictly acute or chronic. Health effects typically resulting from occupational exposures are presented in this section.

Two main concerns of patients who have experienced an acute chemical exposure are the risk of cancer and the risk of reproductive or developmental effects. Little or no data are available for most chemicals on carcinogenic or reproductive effects due to acute exposure. However, to provide some guidance to the clinician who must address these patient concerns, we have included the known carcinogenic and reproductive effects due to chronic exposure. The carcinogenic potential of a chemical is included if, at the time of publication, it was described by the International Association for Research on Cancer (IARC), the National Toxicology Program (NTP), or the U.S. Environmental Protection Agency (EPA).

Information about reproductive and developmental effects caused by exposure to specific chemicals was sought from three data files that are included in Tomes Plus, a proprietary database of Micromedex, Inc., Denver, CO: Reprotext, edited by Betty J. Dabney, PhD; the Teratogen Information System (TERIS), developed by the University of Washington; and Shepard's Catalog of Teratogenic Agents, written by Thomas H. Shepard, MD. In addition, the list of 30 chemicals reported by the U.S. General Accounting Office (GAO) as having widely acknowledged reproductive or developmental affects was used as a resource (U.S. General Accounting Office. Reproductive and developmental toxicants, October, 1991. Report no. GAO/PEMD92-3).

The topic of reproductive hazards is controversial and emotionally charged. The potential risk to the fetus creates the possibility that an exposed pregnant woman may consider an abortion. Most obstetricians and pediatricians are not adequately prepared to help the patient make this decision. Expert assistance may be available from regional poison control centers, regional reproductive risk/teratogen information centers, or the Motherisk Program in Toronto, Canada (see Appendices I and III).

Prehospital Management

Goals of the EMS Hazmat Responder -

• Protect yourself. Approach the scene cautiously, arriving upwind. Maintain a safe distance and inspect the scene from a nearby elevated area such as a hill, respect the established exclusion zones, and resist the temptation to rush in to attempt a rescue. Report to the Incident Commander. Maintain a "buddy system," if feasible.
• Attempt to identify the chemical product. Become familiar with the DOT placard system, MSDS or shipping papers, and the NFPA hazard labeling system. After identifying the chemical, contact the regional poison control center (see Appendix I) for information about health effects, medical treatment, and decontamination guidelines.
• Determine the potential for secondary contamination. Know whether the substance is likely to create a risk to yourself or others in the Support Zone, ambulance, or hospital if decontamination is not completed at the scene.
• Be certain that adequate decontamination measures have been performed.
• Provide basic and advanced life support (ALS) as required and transport victims to an appropriate medical facility as soon as possible.

Prehospital Management

• Summary of the health effects expected from an acute exposure.
• Description of patient care (supportive care, antidotes).

The route and extent of exposure are important in determining the potential for secondary contamination. Victims who were exposed only to gas or vapors are not likely to carry significant amounts of the chemical beyond the Hot Zone, and so are not likely to pose a risk to personnel outside the Hot Zone. However, victims whose skin or clothing is grossly contaminated with solid or liquid chemical (including condensed vapor) may contaminate personnel by direct contact or by off-gassing vapor. Victims who have ingested a toxic chemical may expose others through vomitus.

Hot Zone --

The Hot Zone includes the area immediately around the chemical spill and the surrounding region that may be in serious danger from physical hazards, such as fire or explosion, or chemical exposure. Generally, only firefighters who are members of a specialized hazmat team will enter the Hot Zone. Although some of these persons may be trained as paramedics, most have only basic EMT training. Rescuers with more advanced medical training will generally be waiting in the Support Zone or the Decontamination Zone.

Rescuer Protection -

When the identity of the chemical is not known, rescuers in the Hot Zone must wear the maximum level of personal protective equipment. A four-stage classification of chemical protective gear has been developed by EPA.

Level A is the highest level of chemical protection. It includes a positive-pressure self-contained breathing apparatus (SCBA) and a fully encapsulating chemical-resistant suit.

Level B includes SCBA, but lesser protection against skin exposure since the suit need not be fully encapsulating.

Level C includes an air-purifying respirator and nonencapsulating chemical- resistant suit, gloves, and boots.

Level D consists of common work clothes that do not provide any specific respiratory or skin protection.

Only rescuers with prior training and fitting should use specialized personal protective gear. The choice of specific brands (e.g., Tyvek, Saranex) or chemical-resistant materials (e.g., butyl rubber) is beyond the scope of this document and is generally the responsibility of an expert on the hazmat team. The expert will also determine whether risks of fire or explosion exist and what additional protective equipment may be required for these possibilities. The EPA classification does not address the use of common fire-fighting ensemble (SCBA with standard "bunker" gear), although this gear may be adequate for many chemical incidents.

ABCs -

This section describes basic airway, breathing, and circulatory support (ABCs). Little patient care can be performed when wearing Level A or Level B protective gear. Rescuers often can perform only simple maneuvers such as ensure a patent airway, apply a cervical collar, brush off gross contaminants, and apply direct pressure to contain arterial bleeding.

Victim Removal -

Victims should be removed from the Hot Zone to the Decontamination or Support Zone, as appropriate, in the safest and quickest way possible. If victims can walk, they can be led out of the Hot Zone to the Decontamination Zone. If they are unable to walk, they can be removed on a backboard, litter, or gurney. If no practical means of transport is available, the victim may be carried or dragged out.

Decontamination Zone --

The Decontamination Zone, which is the corridor between the Hot Zone and the Support Zone, may be set up in any convenient location that is safely beyond the Hot Zone. If possible, this zone should be established outdoors (preferably upwind and uphill from the Hot Zone ) where natural ventilation allows dispersion of off-gassing vapors. Victims exposed to only gas or vapors and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone.

Rescuer Protection -

Personnel in the Decontamination Zone are required to wear protective gear; only personnel with prior fitting and training should be permitted to don respiratory protective gear. Generally, the level of gear is the same as that worn in the Hot Zone or no less protective than one level below this. However, if the risk of inhaling off-gassing vapors is low (i.e., the chemical is not highly volatile or the decontamination area is set up outside with good natural ventilation) it may be acceptable to use an even lower level of protection (e.g., an air-purifying respirator [Level C] instead of Level A).

ABCs -

To provide airway, breathing, and circulatory support for patients in the Decontamination Zone, it may be possible to insert an artificial airway, administer supplemental oxygen or nebulized bronchodilators, and assist ventilation. Direct pressure should be applied to control heavy bleeding.

Rescuers wearing respirators and heavy gloves may find it difficult to insert an intravenous line or perform endotracheal intubation. Electronic equipment such as cardiac monitors generally should not be taken into this area because the equipment may be difficult to decontaminate. Even victims with serious trauma or medical complications (e.g., seizures) may have to wait for advanced medical care until decontamination is completed, depending on the concentration of the chemical and its potential for secondary contamination.

Basic Decontamination -

Consider bagging the victim's jewelry and other valuables separately from clothing for easier retrieval later.

Note: Many chemicals can react violently with water, creating an explosion or liberating toxic gases. When cautions about water reactivity are given, they usually apply to adding water to a large amount of chemical (e.g., using water to fight a fire associated with a spill) and not to flushing victims in the Decontamination Zone whose clothing has been removed and who have very little material left on or around their body. There is little risk of creating a serious reaction hazard by adding large amounts of water to the small amount of residual chemical left on the body. In fact, the naturally occurring moisture on the skin is already reacting with the residual chemical, and hastening removal from the skin is most often preferable to leaving the chemical on the victim.

Skin/Eyes: The length of time for flushing the skin or eyes with water may vary with the chemical and the circumstances of exposure. Concentrated or strongly alkaline materials may require 10 to 15 minutes; chemicals that cause only mild skin or eye irritation can be flushed for a shorter time.

Removal of oily or insoluble materials from the skin and hair requires washing with soap or shampoo. Any liquid hand or dish washing soap will be satisfactory. Use only soft bristled brushes; abrasive brushing may enhance skin injury and penetration.

Decontaminating solutions such as bleach or vinegar should not be used for washing skin and hair. These solutions may be appropriate for equipment, but they are not appropriate for patients.

Ingestion: Inducing vomiting is not generally recommended. Attempting to empty the stomach after a chemical ingestion is relatively ineffective and can be dangerous. Vomiting may increase the damage to the esophagus and stomach if corrosive or very irritating chemicals have been ingested; vomiting also increases the risk of pulmonary aspiration.

Activated charcoal adsorbs many poisons and is relatively easy to administer. Give a slurry of 50 to 60 grams to the patient who is awake and has a gag reflex. However, if a corrosive chemical has been ingested, charcoal may obscure the view when endoscopy is later performed at the hospital to determine the extent of injury.

The patient should be moved to the Support Zone as soon as basic decontamination is completed.

Support Zone --

Because the Support Zone is set up away from the dangers of physical hazards or chemical exposure, contamination is not a serious problem in this area. Generally, personnel in the Support Zone do not require special protective clothing as long as victims have been decontaminated properly. One important exception is exposure to a potent organophosphate pesticide or similar chemical-the Support Zone team should wear disposable aprons or gowns and latex gloves.

ABCs -

In the Support Zone, basic medical care can be administered readily. This care is initially centered on airway, breathing, and circulatory support to the patient.

Advanced Treatment -

More sophisticated medical management also can begin in the Support Zone. Prehospital personnel should contact the regional poison control center (see Appendix I) or the hospital base station for expert advice.

Bronchodilators such as metaproterenol (Alupent or Metaprel) or albuterol (Proventil or Ventolin ) can be administered by metered-dose inhaler, or preferably, by hand-held nebulizer. However, these medications can increase heart rate and may provoke cardiac dysrhythmias in victims exposed to certain chlorinated or aromatic hydrocarbons. When bronchodilators are needed in these cases, the lowest effective dose should be given and cardiac rhythm should be monitored.

Evaluate the patient for possible opioid overdose or hypoglycemia and administer naloxone (or Narcan) and dextrose according to standard ALS protocols. Consider the possibility that coma or seizures may be the result of a head injury rather than due to chemical poisoning.

Administer specific antidotes if they are indicated and within the prehospital scope of practice.

Additional Decontamination -

Exposure to a concentrated or strongly alkaline material may require continued irrigation of eyes and skin during transport and in the hospital. In cases of ingestion, administer a slurry of activated charcoal to the patient if it was not administered earlier and if the patient is alert and has a gag reflex. Additional decontamination recommendations do not imply that the victim poses a risk of secondary contamination.

Transport to Medical Facility -

If decontamination of the patient with skin or eye exposure has been carried out effectively, there is no danger of secondary contamination to ambulance personnel or equipment. However, ingested poisons may create a special hazard in the small, enclosed area of an ambulance. Some chemicals are converted to poisonous gases by the action of stomach acids (e.g., cyanide salts create hydrogen cyanide gas, sodium azide can produce hydrazoic acid gas), and toxic vomitus can contaminate personnel and equipment by direct contact or by off-gassing volatile chemicals. Zipping the patient into a "body bag" to prevent secondary contamination, which is recommended by some texts, provides no protection against toxic vomitus.

If ingestion may have occurred and toxic vomitus is a possible risk, the following should be included in the ambulance equipment:

• Plastic trash bags (10 to 20, clear, 3- to 4-mil thick) and plastic sheeting for the floor
• Large basin or bucket that can be lined with a trash bag to collect and isolate toxic vomitus
• Disposable towels to soak up toxic vomitus

When exposures to hazardous materials involve several or perhaps hundreds of victims, decisions must be made as to whom to transport and when. Triage attempts to identify victims with the most serious injuries who can benefit most from rapid treatment and transport. It is a complex process based on the chemical's routes of 21 exposure, potential for secondary contamination, acute health effects, warning properties, and potential for delayed onset of toxicity. The Multi-casualty Triage section in each chemical protocol makes some general recommendations for transport based on the chemical; however, you should call the regional poison control center (see Appendix I) for advice about a specific situation.

Emergency Department Management

Goals of the Hospital Provider in Hazmat Incidents:

• To determine the potential for secondary contamination. If there is risk of secondary contamination, to assure that appropriate decontamination measures are carried out at the scene prior to transport.
• To quickly move victims without prior decontamination (e.g., "walk-ins") to a predesignated Decontamination Area.
• To obtain toxicity information from a reliable resource such as the protocols that follow or a regional poison control center (Appendix I).
• To provide emergency supportive care (basic and advanced).
• To perform adequate and appropriate laboratory testing.
• To determine the need for prolonged observation, hospital admission, and follow-up.

Emergency Department Management

• Summary of important health effects expected from an acute exposure.
• Description of required patient care (supportive care, antidotes).

The risk of secondary contamination may have been reduced or eliminated if the victim has undergone thorough decontamination before arrival at the ED. (See Prehospital Management). The route and extent of exposure are important in determining the potential for secondary contamination. Victims who were exposed to only gas or vapors but have no gross deposition of the material on their clothing or skin are not likely to carry significant amounts of chemical beyond the Hot Zone and are not likely to pose a risk of secondary contamination to other personnel. However, victims whose skin or clothing is soaked with liquid chemical or victims who have condensation of chemical vapor on their clothes or skin may contaminate response personnel by direct contact or by off-gassing vapor. If the victim has ingested a chemical, toxic vomitus may pose a danger to hospital personnel through direct contact or off gassing vapor.

Although basic decontamination should be carried out at the scene before transport, there are circumstances in which this does not occur. For example, a contaminated victim might be brought directly to the emergency department by a coworker. Therefore, it is necessary to plan for the unexpected contaminated victim.

Indoor decontamination facilities:

Indoor facilities create a potentially serious risk of inhalation exposure for hospital personnel, especially if the material is volatile. Typical protocols require shutting off the ventilation system to protect the remainder of the hospital from cross-contamination. However, lack of ventilation may compound the risk to emergency department personnel. Very few hospitals have the financial resources to properly fit or train staff to use self-contained breathing apparatus or air-purifying respirators.

Outdoor Decontamination Facilities:

It is safer and more practical to perform basic decontamination outside in a well-ventilated area adjacent to the ambulance entrance. Suggested equipment and supplies for an outdoor hospital Decontamination Area include the following:

• An old gurney with plastic tub or runoff collector. (Several companies make disposable or reusable decontamination tables or foldable rubber tubs that can be placed on top of a gurney.)
• A warm water source with a hose and soft stream shower handle
• Disposable chemical-resistant jumpsuits (e.g., Tyvek or Saranex)
• Several pairs of chemical-resistant gloves (e.g., butyl rubber) in different sizes and rubber aprons
• Mild soap and shampoo
• Gentle bristled brushes
• Splash-protective goggles or other protective eye wear
• Inflatable wading pool to catch contaminated water runoff from ambulatory patients
• Large supply of plastic garbage bags
• Extra oxygen tanks and oxygen delivery supplies
• Extra disposable towels and gauze

Priorities of emergency care in the Decontamination Area may change depending on the type and extent of contamination. For example, a victim heavily contaminated with a highly toxic organophosphate insecticide poses a great risk of secondary contamination to health care personnel; touching the patient must be delayed until staff are appropriately gloved and gowned. Similarly, a person soaked with a flammable material cannot be treated with DC countershock until decontamination has been carried out because of the fire and explosion hazard.

Basic Decontamination -

Consider bagging the patient's jewelry and other valuables separately for easier retrieval later.

Note: Many chemicals can react violently with water, creating an explosion or liberating toxic gases. When cautions about water reactivity are given, they generally apply to adding water to a large amount of chemical (e.g., fighting a fire associated with a chemical spill) and so not apply to flushing victims in the Decontamination Area whose contaminated clothing has been removed and who have very little of the material left on or around their body. There is little risk of creating a serious reaction hazard by adding large amounts of water to the small amount of residual chemical left on the body. In fact, the naturally occurring moisture on the skin is already reacting with the residual chemical; hastening removal from the skin is most often preferable to leaving the chemical on the patient.

The length of time for flushing the skin or eyes may vary with the chemical and the circumstances of exposure. Concentrated or strongly alkaline materials may require 10 to 15 minutes; vapor exposure with only mild skin or eye irritation may require flushing for a shorter time.

Removal of oily or insoluble materials from the skin and hair requires washing with soap or shampoo. Any liquid hand or dish washing soap is satisfactory. Use only soft bristled brushes; abrasive brushes may enhance skin penetration and injury.

If the chemical is an acid or alkali, frequently check the pH of the conjunctival sac and continue irrigating the eye until the pH is 7 to 7.5.

Critical Care Area -

If appropriate decontamination efforts have been completed before entry to the Critical Care Area, there should be no need for special equipment or precautions such as covering floors and walls with plastic or shutting off the ventilation system. However, if the patient has ingested a chemical, prepare to isolate toxic vomitus quickly (see Ingestion Exposure below).

ED staff in the Critical Care Area should not need specialized protective gear. Water-resistant gowns or, aprons, latex gloves, and eye splash protection are prudent only if there is risk of residual skin contamination from a potent chemical, such as a potent organophosphate pesticide, or from radioactive dust.

ABCs -

Perform frequent monitoring of the airway and vital signs. Many chemicals can cause progressive airway injury or systemic illness with respiratory compromise several minutes to hours after the original exposure. Watch for signs of laryngeal edema and respiratory system compromise such as progressive hoarseness, stridor, hypoventilation, or cyanosis.

Consider the possibility of exposure to multiple chemicals or of multiple system injuries. For example, smoke inhalation can cause immediate dramatic airway injury due to heat and irritant chemicals, as well as coma from inhaled systemic asphyxiants such as carbon monoxide and cyanide.

Evaluate for possible opioid overdose or hypoglycemia and administer naloxone (or Narcan) and dextrose according to usual protocols. Treat seizures with usual anticonvulsants (e.g., diazepam, phenytoin, phenobarbital). Consider the possibility that coma or seizures may be from a head injury or from alcohol or other drug intoxication, rather than from chemical poisoning.

Treat hypotension with rapid infusions of normal saline of 250 mL up to 2 liters in adults. Use dopamine or other inotropic drugs for persistent hypotension. Persistent hypotension may be caused by hypothermia or hyperthermia, both of which can be complications of chemical exposures. Hypothermia should be considered if the victim was stripped and decontaminated with cold water or in a cold ambient setting. Hyperthermia can be a result of certain systemic poisons (e.g., dinitrophenol). (Depending on ambient temperature, hypothermia and hyperthermia can occur in rescuers from wearing Level A or B encapsulating chemical suits.)

Ventricular dysrhythmias after exposure to solvents, most commonly chlorinated, fluorinated, or aromatic solvents, may be caused by a reduction of the myocardial threshold for the dysrhythmogenic effects of catecholamines. These dysrhythmias may respond more favorably to beta- blockers (e.g., esmolol, propranolol) than to lidocaine and other traditional antidysrhythmic drugs. Dysrhythmias occurring after exposure to hydrogen fluoride or hydrofluoric acid may be caused by hypocalcemia and should be treated with intravenous calcium.

Inhalation Exposure -

Bronchodilators may provoke ventricular dysrhythmias in some patients with exposure to certain types of hydrocarbons.

Although pulse oximetry (to measure arterial blood gases) is a convenient way to monitor oxygenation in patients continuously, it is unreliable or falsely normal in patients with dyshemoglobinemias (e.g., methemoglobinemia or carboxyhemoglobinemia) because it measures only O(2) dissolved in the blood and not the status of tissue oxygenation. In patients with altered hemoglobins, the 0(2) dissolved in the blood may be adequate but the 0(2) cannot be taken up by the tissues. In these situations, specific levels of hemoglobins unable to transport O(2) must be obtained using a Co-Oximeter.

Chemically induced pulmonary edema is not due to left ventricular failure as is cardiogenic pulmonary edema but due to leaky pulmonary alveoli. Patients with noncardiogenic edema do not benefit from digoxin, morphine, afterload reduction, or diuretics. Supplementary oxygen, delivered by mechanical ventilation and positive end expiratory pressure, if needed, are the standards of treatment for noncardiogenic edema.

Corticosteroids and antibiotics have been recommended commonly for treatment of chemical pneumonitis, but there is little evidence that they are of special benefit.

Hazardous agents commonly associated with delayed onset pulmonary edema (e.g., phosgene and nitrogen oxides, such as nitric oxide and nitrogen dioxide) are poorly soluble in water. Unlike soluble irritants, such as ammonia or hydrogen chloride, which act rapidly, poorly soluble irritants produce slow onset of airway irritation or respiratory distress. Thus, patients exposed to poorly soluble irritants may not develop pulmonary edema until 12 to 72 hours later.

Skin Exposure -

Chemical burns have characteristics that are different from thermal burns. The extent and depth of injury in a chemical burn often is not apparent immediately; severity is frequently underestimated. Circulating fluid loss can occur as with thermal burns. In addition, absorption of a corrosive chemical may cause acute or delayed systemic toxicity.

Patients with exposure to a highly corrosive, penetrating, oily or persistent chemical may require additional decontamination to prevent further injury and systemic absorption. Common sites of residual contamination include the armpits, groin, buttocks, hair, ears, nostrils, and under the fingernails and toenails. Usually, these patients do not pose a risk of secondary contamination if they have undergone the basic decontamination, but if the material is highly contaminating (e.g., organophosphate pesticides, radioactive dust), caregivers should wear gowns and gloves to protect themselves.

Use plain liquid soap or shampoo for cleansing the skin. For a few chemicals, special solutions are recommended for skin decontamination (see specific protocols).

Eye Exposure -

Be sure that contact lenses have been removed, that there is no visible residual material in the conjunctival sac, and that the Ph of the tears is normal.

Although a corneal burn or abrasion may not be visible with the naked eye, it can be seen easily with the aid of fluorescein staining, a UV light source, and a magnifier or slit lamp. The disrupted corneal surface allows accumulation of the fluorescein, which fluoresces under UV light.

Conjunctival irritation and superficial corneal injuries generally improve quickly with symptomatic care such as use of topical antibiotics, analgesics, or mydriatics. If serious injury is suspected (i.e., if there is extensive corneal fluorescein accumulation, cloudy or bloody material in the anterior chamber, or obvious perforation of the globe), an ophthalmologist must be consulted immediately.

Ingestion Exposure -

Ingested chemicals and the reaction products resulting from their contact with stomach acid may be hazardous to ED personnel through direct contact with vomitus or by inhalation of toxic liberated gases. For example, ingested cyanide is convened to highly toxic hydrogen cyanide gas in the stomach. Staff must take measures, therefore, to isolate toxic vomitus or gastric washings. This can be done by attaching the lavage tube to isolated wall suction or another closed container.

The use of gastric lavage for ingested corrosive materials is controversial. Opponents argue that the lavage tube may further injure the chemically damaged esophagus or stomach. However, endoscopists point out that blind gastric tube placement and stomach emptying is routinely done prior to endoscopy in any case, and that it is better to remove the corrosive liquid from the stomach as early as possible. Dilution with a glass of water is an alternative, but it is not as effective as lavage.

Activated charcoal is capable of adsorbing most poisons and should be given as early as possible. Even poisons that have relatively poor adsorption to charcoal (e.g., cyanide, alcohols) are still bound to a limited extent, and charcoal may be lifesaving in patients exposed to these substances. Note that charcoal may obscure the endoscopist's view and may have to be washed out before endoscopy.

Antidotes and Other Treatments -

There are very few established antidotes for poisoning. Contact the regional poison control center (Appendix I) for advice if the specific chemical agent is known.

Laboratory Tests -

Laboratory results may be normal immediately after the exposure. Abnormal findings are often delayed for several hours or even days, depending on the specific chemical exposure. For example, chest radiography may not show signs of pulmonary edema until 12 to 24 hours after phosgene exposure. Signs of liver injury may not appear until 2 to 3 days after exposure to hepatotoxic agents.

Note that pulse oximetry and routine tests for serial blood gases may provide falsely normal, unreliable, or misleading results in patients with abnormal hemoglobin states (e.g.,methemoglobinemia, carboxyhemoglobinemia).

A regional poison control center (Appendix I) can assist with the selection and interpretation of routine and specialized toxicologic laboratory tests. Blood or urine tests for a specific chemical are Disposition and Follow-up Delayed Effects Patient Release Follow-up Reporting rarely available on an emergency basis; frequently the turn-around time is several hours to days. However, these tests may aid in confirming or documenting an exposure.

Disposition and Follow-up --
Delayed Effects -

The usual duration of observation in an emergency department is 6 to 8 hours. If the chemical agent is unidentified or is known to produce delayed onset illness, the asymptomatic patient who has a suspected serious exposure should be admitted.

Patient Release -

The individual protocols include a detailed Patient Information Sheet with a list of symptoms for patients to watch for after discharge.

Follow-up -

Appendix III contains the phone numbers and addresses of member clinics of the Association of Occupational and Environmental Clinics (AOEC). These clinics employ specialists in diagnosing and treating occupational and environmental chemical exposure. They may provide consultation and patient follow-up.

Reporting --

Some state or local governments may require the physician to file a report after treating a patient for a specific chemical exposure or a worker for an occupational exposure. Appendix III contains the phone numbers of the state health departments. The patient may wish to call the regional office OSHA office to report a suspected violation of safe work practices. Appendix III also contains the number of the several NIOSH offices that may be of assistance.

To determine procedures for clean-up of hospital facilities and equipment, contact the local or state health department or EPA's Environmental Response Team, Edison, New Jersey ([201] 321-6660).

Do not release clothing or personal items to the patient before a determination is made regarding the hazard of residual contamination. Most items may be reused after washing (e.g.,cloth clothing contaminated with hydrofluoric acid). However, some chemically contaminated articles cannot be rendered safe for reuse (e.g.,leather goods such as shoes that are contaminated with certain pesticides). Some contaminated articles will require disposal by incineration or at a hazardous waste site. Consult a hazmat specialist attached to the local fire department or the ATSDR Division of Health Assessment and Consultation or advice on the disposition of contaminated personal effects.

Protocol for the Unidentified Chemical Contaminant

Unidentified Chemical Prehospital Management

Hot Zone --

Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA) and chemical-resistant protective clothing and gloves (EPA Level A protection or NFPA vapor-protective gear).

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. Injured persons who are unable to walk should be removed on a backboard or gurney. If there is no means of transport, carefully carry or drag the victim out; be aware that the victim may have sustained head and neck injuries, as well as a chemical exposure.

Decontamination Zone --

Victims with exposure to only vapors and with no evidence of skin or eye contamination or irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others, see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves (EPA Level B or NFPA splash-protective) if they will be caring for victims with liquid chemical contamination. If the proper equipment is not available or if rescue personnel have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organizations. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Basic Decontamination -

If the clothing is wet with liquid chemical contamination, remove and double-bag the clothing. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Skin Contact: Flush exposed skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent chemicals, use mild soap or shampoo.

Eye Contact: Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present. Look for and remove any residual chemical material in the conjunctival sacs.

Ingestion: If the victim has ingested a liquid or solid chemical, have him or her drink a glass of plain water. Do not induce vomiting. Administer charcoal orally (50 to 60 g of activated charcoal in a water slurry).

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Be certain that victims who require basic decontamination, have undergone it (see Decontamination Zone above). Victims who have been decontaminated or those with exposure to only gas or vapor with no evidence of wet skin or clothing generally pose no serious risk of secondary contamination.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support. Observe for ventricular dysrhythmias.

Advanced Treatment -
Intubate the trachea if indicated.

Treat wheezing with aerosolized bronchodilators; use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias after exposure to certain chemicals.

Treat coma and ventricular dysrhythmias according to standard ALS protocol.

Additional Decontamination -

If skin or eyes remain irritated, continue irrigation until irritation is resolved or the victim is transported.

If the victim has ingested a liquid or solid chemical, insure that decontamination has occurred.

Transport to Medical Facility -

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If the victim ingested a chemical, prepare the ambulance for possible vomiting of toxic material. Cover the floor of the ambulance with plastic or other protective material, and have ready several absorbent towels and opened plastic bags to quickly soak up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

In general, patients with brief exposure to only vapors and without acute symptoms (e.g., dizziness, respiratory distress) can be observed without immediate treatment.

Unidentified Chemical Emergency Department Management

Decontamination Area --

Patients with exposure to only gas or vapors and with no evidence of skin or eye irritation or contamination do not need decontamination. They may be transferred immediately to the Critical Care Area. Other victims will require decontamination as described below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of airway compromise. Monitor cardiac rhythm.

Treat wheezing and bronchospasm with aerosolized bronchodilators if needed.

Treat coma, seizures, hypotension, and ventricular dysrhythmias in the conventional manner.

Basic Decontamination -

If the patient has not been decontaminated, perform basic decontamination immediately. Emergency department staff should don chemical-resistant jumpsuits ( e.g., Tyvek, Seranex ) or butyl rubber aprons, rubber gloves, and eye splash protection. After the patient has been decontaminated, no special protective clothing or equipment is needed for ED personnel.

If the clothing is wet with liquid contamination, remove and double-bag it. Patients who are able and cooperative may remove their own contaminated clothing and assist with basic decontamination.

Skin Contact: Flush exposed skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent materials, use mild soap or shampoo.

Eye Contact: Remove contact lenses and irrigate exposed eyes with water or saline dripped from intravenous tubing or using a Morgan lens. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids. Look for and remove any residual chemical material in the conjunctival sacs. Check conjunctival pH with test paper and continue irrigating until the pH is 7 to 7.5..

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Decontamination Area above.

ABCs -

Evaluate and support airway, breathing, and circulation. Intubate the trachea if indicated. Continuously monitor cardiac rhythm.

Assess and treat hypotension, coma, seizures, and ventricular dysrhythmias in the conventional manner.

For all patients who are unconscious, obtunded, hypotensive, or who may become so, or who have been exposed to a substance that may cause cardiac sensitization or intravascular hemolysis, an intravenous line should be placed as soon as possible. An initial bolus of normal saline or D5 normal saline should be given as appropriate for age, typically 500 mL to 1000 mL in an adult. The fluid should be titrated to maintain urine output and blood

pressure at acceptable levels for age. However, because inhalation injuries may result in the development of pulmonary edema, care must be taken not to overhydrate the patient.

Inhalation Exposure -

Administer supplemental oxygen. Treat wheezing with aerosolized bronchodilators (e.g., metaproterenol or albuterol). Obtain a chest radiograph and measure arterial blood gases.

Observe patients for at least 4 to 6 hours. If there are progressive symptoms or if the chemical agent is suspected of causing delayed pulmonary edema, admit the patient for treatment or further observation.

Skin Exposure -

Ensure that adequate decontamination has been performed. Admit patients with serious chemical burns to a burn center or refer to a qualified burn specialist.

Eye Exposure-

Ensure that adequate eye irrigation has been completed. Test visual acuity and examine the eyes using a magnifying device or a slit lamp and fluorescein staining to evaluate corneal injury. Small corneal defects may be treated with topical ophthalmic antibiotic ointment or drops of a mydriatic agent, an eye patch, and oral analgesic medication. Have the patient return within 24 hours for evaluation. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion Exposure -

Do not induce emesis. Perform gastric lavage using a small flexible tube to remove and dilute the material in the stomach, then administer 50 to 100 g activated charcoal via the gastric tube. If a corrosive material was ingested, consider endoscopy to evaluate the extent of gastrointestinal tract injury.

Antidotes and Other Treatments -

There are very few established antidotes or specific treatments for chemical poisonings. Contact the regional poison control center for advice if the specific chemical agent is known.

Laboratory Tests -

Depending on the chemical exposure and the patient's symptoms and signs of toxicity, useful routine tests include CBC, glucose, electrolytes, renal function tests, liver enzymes, urinalysis, and ECG. Chest radiographs and measurements of arterial blood gases are recommended for severe inhalation exposure. Occasionally, a specific blood or urine toxicologic test may be indicated.

Disposition and Follow-up --

Hospitalization should be considered for all patients with a suspected serious exposure and those with persistent or progressive symptoms.

Delayed Effects -

If there is a possibility of delayed onset of serious effects, the patient should be observed for an extended period or admitted. Consult the specific protocols for possible delayed effects.

Patient Release -

Asymptomatic patients with minimal exposure, a normal initial examination, and no signs of toxicity after a period of observation may be discharged with instructions to seek medical care promptly if symptoms develop. These symptoms are listed in the patient follow-up instructions on the Patient Information Sheet that accompanies each chemical protocol.

For all acute inhalation injuries, and all ingestion injuries where there is a possibility of chemical pneumonitis, patients should be advised to refrain from smoking for up to 72 hours after exposure.

Follow-up -

Provide follow-up instructions to return to the emergency department or a private physician as needed for additional testing or to reevaluate initial findings.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Health Hazard Evaluation Division of NIOSH. Consult the appendices for agencies that may be of assistance.

Chemical Protocols

Ammonia NH(3)

Synonyms include ammonia gas, anhydrous ammonia, liquid ammonia, aqueous ammonia, ammonia solution and ammonium hydroxide.

• Victims exposed to only ammonia gas do not pose a significant risk of secondary contamination to personnel outside the Hot Zone. However, victims whose clothing or skin is contaminated with liquid ammonium hydroxide can secondarily contaminate response personnel by direct contact or through off-gassing ammonia vapor.
• Ammonia is a gas that dissolves readily in moisture to form an alkaline, corrosive solution. It can result in fatalities if inhaled.
• Ammonia's pungent odor and irritating properties usually provide adequate warning of its presence; however, olfactory fatigue may occur.

At room temperature, anhydrous ammonia is a colorless, highly irritating gas with a pungent, suffocating odor. It is lighter than air and flammable at high concentrations and temperatures. It is easily compressed and forms a clear, colorless liquid under pressure. Ammonia dissolves readily in water to form ammonium hydroxide--an alkaline, corrosive solution. The concentration of aqueous ammonia solutions for household use is typically 5% to 10%, but solutions for commercial use may be 25% to 30% or more.

Routes of Exposure --

Inhalation -

Exposure to ammonia may be fatal if it is inhaled. Ammonia's odor threshold is sufficiently low to provide adequate warning of its presence; however, olfactory fatigue or adaptation can occur, making its presence less detectable.

Skin/Eye Contact -

Even fairly low airborne concentrations of ammonia produce rapid eye and nose irritation. Contact with concentrated ammonia solutions, such as some industrial cleaners, can cause serious corrosive injury. Contact with liquefied ammonia may cause frostbite.

Ingestion -

Ingestion of ammonia solution occurs occasionally.

Sources/Uses --

Ammonia is manufactured by reacting hydrogen with nitrogen. It is among the five most abundantly produced chemicals in the world. About 80% is used in fertilizers; it also is used as a refrigerant gas, and in the manufacture of plastics, explosives, pesticides, detergents, and other chemicals. Small amounts of ammonia occur naturally from decomposition of organic matter.

Properties of Ammonia --

Appearance: Clear, colorless gas at room conditions; easily liquefied; readily dissolves in water to form caustic solutions.

Warning properties: Sharp, pungent odor at = 5 ppm; eye and throat irritation at = 20 to 50 ppm

OSHA STEL (Short Term Exposure Limit) = 35 ppm

NIOSH IDLH (Immediately dangerous to life or health ) = 500 ppm

Molecular weight = 17.0

Boiling point (760 mm Hg) = -28 degrees (F), -33.4 degrees (C)

Vapor pressure 67.1 degrees (F) = > 6000 mm Hg

Vapor density = 0.59 (air = 1)

Water soluble (34 g/100 mL)

May burn, but does not ignite readily

Health Effects

• Ammonia vapor is highly irritating to the eyes and upper respiratory tract. Upper airway obstruction, bronchospasm, and noncardiogenic pulmonary edema may occur.
• If skin contact is prolonged (more than a few minutes), ammonia causes severe burning pain and corrosive injury.

Ammonia gas dissolves in moisture to produce an alkaline solution. Exposure to ammonia gas or an aqueous solution of ammonia can result in corrosive injury to the eyes, skin, or gastrointestinal tract.

Respiratory -

Even fairly low concentrations of ammonia produce rapid onset of eye, nose, and throat irritation; coughing; and bronchospasm. More severe clinical signs include immediate laryngospasm and laryngeal edema resulting in upper airway obstruction. Pulmonary edema can occur.

Dermal -

Dilute aqueous solutions (less than 5%) rarely cause serious burns but are moderately irritating. Exposure to concentrated vapor or solution can cause stinging pain, erythema, and vesiculation, especially on moist skin areas. Skin contact with compressed, liquid ammonia causes frostbite injury; severe burns with deep ulcerations may result.

Ocular -

Even low concentrations of ammonia produce rapid onset of eye irritation. Contact with high gas concentrations or with concentrated ammonium hydroxide may cause conjunctival edema and corneal erosion.

Gastrointestinal -

Swallowing ammonium hydroxide causes immediate burning in the mouth and throat. Concentrated solutions cause severe pain in the mouth, chest, and abdomen with swallowing difficulty, drooling, and vomiting. Perforation of the esophagus or stomach may occur.

Potential Sequelae -

Survivors of severe inhalation injury often suffer residual chronic lung disease. In cases of eye contact, ulceration and perforation of the cornea can occur after weeks or months, and blindness may ensue. Cataracts and glaucoma have been reported in persons acutely exposed.

Chronic Exposure --

Repeated exposure to ammonia may cause chronic irritation of the respiratory tract. Chronic bronchitis and airway hyperactivity have been noted in several case reports. Chronic irritation of the conjunctiva also has been reported.

Ammonia is not considered to be carcinogenic. At doses that do not cause maternal toxicity, ammonia is not likely to have adverse reproductive and developmental effects. If maternal pulmonary function becomes severely compromised because of irritation or corrosion, there is a possibility of nonspecific effects on the unborn.

Prehospital Management

• Ammonia muses rapid onset of a burning sensation in the eyes, nose, and throat, accompanied by lacrimation, rhinorrhea, and coughing. Upper airway swelling may lead to airway obstruction.
• Ammonia gas or solution can cause serious corrosive burns on contact.
• There is no specific antidote for ammonia poisoning. Treatment consists of supportive measures.

Hot Zone --

Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing and gloves are required if contact with anhydrous ammonia gas or concentrated ammonium hydroxide is possible.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. If a victim is unable to walk, remove him or her on a backboard or gurney. If there is no means of transport, carefully drag the victim out.

Decontamination Zone --

Victims with exposure to only ammonia gas and with no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. For all others see Basic Decontamination on the following page.

Rescuer Protection -

Rescuers in the decontamination zone should wear self-contained breathing apparatus (SCBA) and chemical-protective clothing and gloves if they will be caring for victims with ammonia-soaked clothing or skin. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization. If the decontamination area is outdoors and has good natural ventilation, a lesser level of respiratory protection may suffice.

ABCs -

Quickly establish a patent airway in the patient. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen

if available. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Basic Decontamination -

Rapid skin decontamination qs critical. Remove and double-bag contaminated clothing while flushing exposed areas. Patients who are able and cooperative may remove their own clothing and assist with basic decontamination.

Flush liquid-exposed skin and hair with plain water for at least 5 minutes.

Flush exposed or irritated eyes with plain water or saline for 3 to 5 minutes. Remove contact lenses if present.

In case of ammonia ingestion, do not induce emesis. If the patient is conscious and able to swallow, administer 1 to 2 glasses of plain water to dilute stomach contents.

Transfer to Support Zone -

As soon as basic decontamination is completed, move the patient to the Support Zone.

Support Zone --

Be certain that patients have undergone basic decontamination (see Decontamination Zone above). Patients who have undergone proper decontamination or have been exposed to only vapor pose no serious risk of causing secondary contamination. Support Zone personnel require no specialized protective gear in such cases.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Watch for signs of laryngeal edema and airway compromise such as progressive hoarseness, stridor, or cyanosis. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device as needed. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment -

Intubate the trachea if necessary (severe respiratory distress or coma). When endotracheal intubation cannot be performed due to airway obstruction, perform cricothyroidotomy if equipped and trained to do so.

Treat hypotension and seizures in the conventional manner. Treat bronchospasm with aerosolized bronchodilators.

Additional Decontamination -

If skin or eyes remain irritated, continue flushing with plain water or saline until pain is relieved or definitive medical treatment is obtained. Remove contact lenses if present.

In case of ammonia ingestion, do not induce emesis. If the patient is alert and able to swallow, administer 1 or 2 glasses of water to dilute stomach contents. Charcoal is ineffective.

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a patient has ingested ammonium hydroxide, prepare the ambulance for possible vomiting of toxic material. Have ready several towels and opened plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

The following persons exposed to ammonia should be evaluated at a medical facility: those with persistent upper respiratory irritation or other acute symptoms of severe inhalation exposure, persons with eye or skin burns that cover a large surface area, and persons who have ingested ammonia. Persons who have been exposed to only ammonia gas and are currently asymptomatic are not likely to develop complications. After recording their names, addresses, and telephone numbers, they may be released from the scene with follow-up instructions. (See Ammonia Patient Information Sheet.)

Emergency Department Management

• Inhaling ammonia causes rapid onset of a burning sensation in the eyes, nose, and throat, accompanied by lacrimation, rhinorrhea, and coughing. Upper airway swelling may lead to airway obstruction.
• Ammonia gas or solution can cause serious corrosive burns on contact.
• There is no antidote for ammonia poisoning. Treatment consists of supportive measures.

Decontamination Area --

Patients exposed to only ammonia gas and with no skin or eye irritation do not need decontamination. They can be transferred immediately to the Critical Care Area. Other patients will require rapid decontamination as described in Basic Decontamination below.

ABCs -

Evaluate and support airway, breathing, and circulation. Watch for signs of laryngeal edema and airway compromise. Monitor cardiac rhythm.

Treat seizures in the conventional manner. Manage hypotension and shock with IV fluids; pressor agents may be required.

Basic Decontamination -

If the patient has not been decontaminated, perform the decontamination procedure immediately. Patients exposed to only vapor do not require decontamination unless they have skin or eye irritation.

Since contacting clothing or skin wet with ammonium hydroxide may cause burns, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek*, Saranex*) or butyl rubber aprons, rubber gloves, and eye protection. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.

If the patient's clothing is wet with ammonia solution, quickly remove and double-bag the contaminated clothing and all personal belongings while cleansing the skin. A water wash using copious water (preferably under a shower) should be instituted without delay.

Remove contact lenses and irrigate exposed eyes with water for at least 15 to 30 minutes. An ophthalmic anesthetic, such as 0.5% tetracaine, may be necessary to alleviate blepharospasm, and lid retractors may be required to allow adequate irrigation under the eyelids.

Critical Care Area --

Be certain that appropriate decontamination has been carried out. See Basic Decontamination above.

ABCs -

Evaluate and support airway, breathing, and circulation as above. Continuously monitor cardiac rhythm.

Assess and treat hypotension, seizures, and ventricular dyshythmias in the conventional manner. Patients with significant and persistent CNS depression should be evaluated for the presence of intercurrent disorders (e.g., trauma, hypoglycemia, and drug intoxication).

Inhalation Exposure -

Observe patients carefully for 6 to 12 hours for signs of upper airway obstruction. Administer supplemental oxygen by mask to patients with respiratory complaints. Patients who have received severe exposure may develop noncardiogenic pulmonary edema.

Skin Exposure -

If ammonia solution or ammonia gas was in contact with the skin, chemical burns may result.

Eye Exposure -

If eye irritation or injury is evident, test visual acuity and examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein staining. Small corneal defects may be treated with topical ophthalmic antibiotic ointment or drops and analgesic medication. Immediately consult an ophthalmologist for patients with severe corneal injury.

Ingestion -

Give water or milk by mouth to dilute stomach contents. Do not induce emesis because the patient is at risk of abrupt seizures or coma. Do not administer activated charcoal. Gastric lavage with a small nasogastric tube is recommended to remove caustic material from the stomach and to prepare for endoscopic examination.

Antidotes and Other Treatments -

There is no specific antidote for ammonia poisoning. Although administration of corticosteroids is favored by many toxicologists in an attempt to limit esophageal scarring, this treatment is unproven and may be harmful in patents with perforation or serious infection. Hemodialysis is ineffective.

Laboratory Tests -

Chest radiography and ABGs are recommended for severe inhalation exposure or if pulmonary aspiration is suspected. There are no blood levels specific for ammonia exposure that indicate degree of ammonia toxicity.

Disposition and Follow-up --

Consider hospitalization for patients with evidence of respiratory distress or significant skin burns or who have ingested ammonia solution.

Delayed Effects -

Pulmonary injury may continue to evolve over 18 to 24 hours. Inhalation patients who are initially symptomatic should be observed carefully and reexamined periodically. Patients who develop pulmonary edema should be admitted to an intensive care Unit.

Patient Release -

Patients who are currently asymptomatic are not likely to develop complications. They may be released and advised to rest and to seek medical care promptly if symptoms develop. (For a list of symptoms, see the reverse side of Ammonia Patient Information Sheet.)

Follow-up -

Patients whose eyes have contacted ammonia but who have no signs of irritation after treatment may be released. Patients with eye injury should be reevaluated in 24 hours by an ophthalmologist.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other people may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH.

Ammonia Patient Information Sheet

What is ammonia?

Ammonia is a colorless, highly irritating gas with a sharp, suffocating odor. It easily dissolves in water to form a caustic solution called ammonium hydroxide. Ammonia is among the five most abundantly produced chemicals in the world. About 80% of the ammonia produced is used in fertilizers. It is also used as a refrigerant and in the manufacture of plastics, explosives, pesticides, and other chemicals. It is found in many household and industrial-strength cleaning solutions.

What immediate health effects may result from ammonia exposure? Most exposures to ammonia are by breathing the gas. Even with very short or low-level exposures, most people will notice the pungent odor and experience burning of the eyes, nose, and throat. With higher doses, coughing or choking may occur. Severe exposure can cause death from throat swelling or from chemical burns to the lungs. Skin contact with ammonia containing liquids may cause burns. Contact with rapidly escaping ammonia gas from a leaking pressurized cylinder can cause frostbite injury. Eye exposure to concentrated gas or liquid can cause serious corneal burns or blindness. Drinking a concentrated ammonia solution can cause burns to the mouth, throat, and stomach.

What is the treatment for ammonia poisoning?

There is no antidote for ammonia poisoning, but its effects can be treated and most people do recover fully. Persons who have experienced serious signs and symptoms (such as severe or persistent coughing, tearing eyes or running nose) may require close medical observation for several hours.

Are any future health effects likely to occur?

After a single, short exposure with rapid recovery, no delayed or long-term effects are likely to occur. After a severe exposure, symptoms may progress over 18 hours. Following is a list of some signs and symptoms to watch for. If any of them occur, seek medical care.

What tests can be done if a person has been exposed to ammonia? There are no specific blood and urine tests that can indicate recent exposure to ammonia. Generally, the severity of burns is the best indicator of the seriousness of the exposure. Blood tests and a chest X ray may be done to evaluate possible lung injury, but testing is not needed in every case.

If ammonia contacts the eyes, the doctor may put an orange dye in the eyes and examine them with a magnifying lamp.

Where can more information about ammonia be found?

More information about ammonia may be obtained from your regional poison control center,, your state, county, or local health department; or your doctor. If the exposure happened at work, talking with your employer and coworkers may help prevent future exposures.

Ammonia Follow-up Instructions -

Please follow the instructions indicated below by the doctor.

( ) Call your doctor or the Emergency Department if you develop any of the
following signs or symptoms within the next 24 hours:

  * cough
  * difficulty breathing or shortness of breath
  * wheezing or high-pitched voice
  * chest pain
  * increased pain or discharge from your eyes
  * increased redness, pain, or pus-like discharge in the area of a skin
    burn
  * belly pain, vomiting, diarrhea

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr.____________ in the practice of
_________. When you call for your appointment, please tell the
receptionist/nurse that you were treated in the Emergency Department at
_________ Hospital by ________ and were advised to be seen again in ___ days.

( ) Return to the Emergency Department/___________Clinic on_______ (date)
at_____AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for 1 to 2 days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for ___ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) Avoid drinking alcoholic beverages or taking aspirin for 24 hours since
these substances may aggravate injury to your stomach lining or may have
other effects.

( ) You may continue taking the following medication(s) that your doctor(s)
prescribed for you:____________________________________________________
_______________________________________________________________________
_______________________________________________________________________ 

( )
Other instructions:____________________________________________________
_______________________________________________________________________

Signature of patient___________________________ Date______________________

Signature of physician_________________________ Date______________________

Arsine AsHJ(3)

Synonyms include arsenic hydride, arsenic trihydride, arseniuretted hydrogen, arsenous hydride, and hydrogen arsenide.

• Arsine presents little risk of secondary contamination to personnel outside the Hot Zone.
• Arsine is a flammable and highly toxic gas with a garlic-like or fishy odor that does not provide adequate warning of dangerous levels.
• Inhalation is the major route of arsine exposure. It has no toxic effects on the skin or eyes, and it is not absorbed through the skin.

Industrial arsine is a colorless, flammable and highly toxic gas. It has a garlic-like or fishy odor at concentrations of O.5 ppm and above. Because it is nonirritating, persons exposed to dangerous levels may experience no immediate symptoms.

Routes of Exposure --

Inhalation -

Inhalation is the major route of exposure. The odor threshold of arsine is 1O-fold greater than the OSHA permissible exposure limit. Odor is not an adequate indicator of arsine's presence and does not provide reliable warning of dangerous concentrations. Serious exposure can occur even if the garlic-like odor is not smelled. Arsine is heavier than air and may cause asphyxiation in enclosed, poorly ventilated, or low-lying areas.

Skin/Eye Contact -

Arsine has no toxic effects on the skin or eyes, and it is not absorbed through the skin.

Ingestion -

Ingestion of arsine itself is unlikely since it is a gas at room temperature. However, metal arsenides are solids that can react with the gastric mileux and release arsine gas in the stomach.

Sources/Uses --

Arsine gas is formed when arsenic-containing materials react with water or acids. Accidental exposures have occurred during refining of ores (e.g., lead, copper, zinc, iron, and antimony ores) that are contaminated with arsenic. Arsine is used as a dopant in the semiconductor industry and in the manufacture of crystals for fiberoptics and computer chips. It has minor uses in galvanizing, soldering, etching, and lead plating.

Properties of Arsine --

Appearance: Colorless, nonirritating gas at room temperature

Warning properties: Inadequate; garlic-like or fishy odor at 0.5 ppm

OSHA PEL (Permissible Exposure Limit) =0.05 ppm (averaged over an 8-hour workshift)

OSHA Ceiling Limit = 0.002 ppm (15-minute sample)

NIOSH IDLH (Immediately Dangerous to life or Health) = 6 ppm

Molecular weight = 78.0

Boiling point (760 mm Hg) = --80.4 degrees F (-55 degrees C)

Vapor pressure (67.1 degrees F) = >760 mm Hg

Vapor density = 2.7 (air = 1)

Water soluble (20% at 67 degrees F)

Extremely flammable; may be ignited by heat, sparks, or flames. Vapors may travel to a source of ignition and flash back.

Health Effects

• Arsine is a highly toxic gas. Its primary toxic effect after inhalation is massive intravascular hemolysis resulting in acute renal failure.
• Signs and symptoms of acute arsine poisoning are usually delayed for 2 to 24 hours, depending on exposure intensity.

After absorption by the lungs, arsine enters red blood cells and inhibits red cell catalase, which leads to accumulation of hydrogen peroxide. Hydrogen peroxide, in turn, destroys red cell membranes and causes massive intravascular hemolysis. Arsine produces no adverse effects on the skin or eyes, and contact with these organs does not result in systemic toxicity. Gastrointestinal effects from ingestion of arsine are unlikely, but ingestion of metallic arsenides can lead to arsine intoxication.

Respiratory -

Delayed pulmonary edema has been described after massive exposure. Respiratory effects may be secondary to hemolysis hypoxia.

Hematologic -

Acute intravascular hemolysis develops within hours and continues for up to 96 hours. Haptoglobin levels decline rapidly. Plasma free hemoglobin rises, with greater than 2 g/dL reported. Anemia develops; the peripheral smear shows anisocytosis, poikilocytosis, red-cell fragments, basophilic stippling, and ghost cells. The bone marrow usually shows no abnormalities. Coomb's and Ham's tests are negative, and RBC fragility is normal.

Renal -

Renal failure due to acute tubular necrosis is a significant sequela of arsine exposure. Hemoglobinuria is thought to be the major insult, but a direct toxic effect of arsine or deposition of the arsine- hemoglobin- haptoglobin complex may also play a role. Urinalysis shows large amounts of methemoglobin, protein, and hemoglobin without intact RBCs. Urine may be colored (brown, red, orange, etc.) Oliguria or anuria may develop within 24 to 48 hours.

Gastrointestinal -

Nausea, vomiting, and crampy abdominal pain are among the first signs of arsine poisoning. Onset varies from a few minutes to 24 hours after exposure.

Dermal -

The skin bronzing noted with arsine toxicity is not true jaundice due to the presence of bilirubin but is induced by hemolysis.

Neurologic -

Acute encephalopathy can develop several days after severe exposure. Signs include restlessness, memory loss, disorientation, agitation, and psychosis. Some victims suffer peripheral neuropathy beginning 1 to 2 weeks after exposure.

Musculoskeletal -

Skeletal muscle injury has been reported in some patients. Findings include severe myalgia, myoglobinuria, and elevated serum CPK and aldolase levels.

Chronic Exposure --

Chronic exposure to arsine can result in gastrointestinal distress and anemia. Repeated exposure may cause damage to lungs, kidneys, liver, nervous system, heart, and blood and blood-forming organs.

Arsine has been associated with skin and lung cancers. IARC states that sufficient evidence exists to conclude that arsine is a human carcinogen.

Arsine should be treated as a potential teratogenic agent. Although the reproductive effects of acute or chronic exposure to arsine are unknown, some related inorganic arsenicals produce a broad spectrum of adverse developmental effects in animals.

Prehospital Management

• Even if arsine's odor is not detected by persons at the scene, victims could have received a serious exposure. All exposure victims should be evaluated at a medical facility.
• Signs of hemolysis and pulmonary edema may be delayed 2 to 24 hours.
• There is no specific antidote for arsine poisoning. Treatment is supportive.

Hot Zone --

Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained to use it, call for assistance from a local or regional hazmat team or other properly equipped response organization.

Rescuer Protection -

Rescuers in the Hot Zone should wear self-contained breathing apparatus (SCBA). Chemical-protective clothing is not required.

ABCs -

Quickly establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary.

Victim Removal -

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. If a victim is unable to walk, remove him or her on a backboard or gurney. If there is no means of transport, carefully drag the victim out. Decontamination Zone --

Victims with exposure to only arsine gas do not need decontamination. They may be transferred immediately to the Support Zone.

Support Zone --

Support Zone personnel require no specialized protective gear if the patient has been exposed to only arsine.

ABCs -

Establish a patent airway. Stabilize the cervical spine with a collar if trauma is suspected. Administer supplemental oxygen and assist ventilation with a bag-valve-mask device if necessary. Evaluate the need for an intravenous line, cardiac monitor, and life support.

Advanced Treatment --

Intubate the trachea if indicated (respiratory distress or apnea). If massive exposure is suspected or if the patient is hypotensive, infuse intravenous saline or lactated Ringer's solution (adult dose: 500 to 1000 mL).

Transport to Medical Facility -

Report to the base station and receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

Multiple Casualty Triage --

If possible, consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

It is difficult to determine at the scene which patients have had the most serious exposure and are likely to develop severe hemolysis; therefore, all patients with potential exposure should be evaluated at a medical facility.

Patients whose history indicates massive exposure and those who have smelled a garlic- or fish-like odor should be transported first.

Emergency Department Management

• Arsine poisoning causes acute intravascular hemolysis, which may lead to renal failure. Arsine gas does not produce arsenic intoxication.
• Even if arsine's odor was not detected by persons at the scene, victims could have had a serious exposure. All exposure victims should be evaluated and observed.
• There is no specific antidote for arsine poisoning. Treatment is supportive.

Critical Care Area --

Patients with exposure to only arsine gas do not need decontamination.

ABCs -

Evaluate and support airway, breathing, and circulation. Monitor cardiac rhythm.

Observe inhalation patients for up to 24 hours. Follow-up as clinically indicated.

Treatment for Hemolysis -

If hemolysis develops, initiate urinary alkalinization. Add 50 to 100 mEq of sodium bicarbonate to one liter of 5% dextrose in 0.25 normal saline and administer intravenously at a rate that maintains urine output at 2 to 3 mL/kg/hr. Maintain alkaline urine (i.e., pH>7.5) until urine is hemoglobin free. Closely monitor serum electrolytes, calcium, BUN, and creatinine.

Antidotes and Other Treatments -

Although BAL (dimercaprol) and other chelating agents are useful in arsenic poisoning, they are not effective antidotes for arsine poisoning. Consider hemodialysis if renal failure is severe. (Although hemodialysis will assist the patient with renal failure, it will not effectively remove the arsine-hemoglobin or arsine-haptoglobin complexes deposited in the renal tubules.)

Blood transfusions may be necessary if hemolysis causes severe anemia.

Laboratory Tests -

If significant exposure is a possibility and transfusion may be necessary, immediately obtain blood type and screen (cross match, if needed). Laboratory tests to determine hemolysis include CBC with peripheral smear, urinalysis with hemoglobin quantitation, and plasma free hemoglobin and haptoglobin analyses. Other useful tests include renal function tests (BUN, creatinine), Serum electrolytes, and unconjugated bilirubin levels.

Disposition and Follow-up --

Decisions to admit or discharge a patient should be based on exposure history, physical examination, and test results.

Delayed Effects -

All patients with suspected arsine exposure should be carefully observed for 24 hours, including hourly urine monitoring to assure absence of hemolysis. Onset of hemolysis may be delayed up to 24 hours, and acute renal failure may not become evident for as long as 72 hours after exposure.

Patient Release -

Patients with no signs of hemolysis may be discharged after 24 hours of observation with instructions to return to the ED if symptoms of toxicity develop (see the reverse side of Arsine--Patient Information Sheet). Released patients should be instructed to rest and to drink plenty of fluids.

Follow-up -

All patients should receive repeat laboratory tests in 12 to 24 hours.

Reporting --

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. OSHA may be contacted for assistance in evaluating workplace conditions, or an appropriate public agency can be notified if a public health risk exists. If appropriate, inform patients that they may request an evaluation of their workplace from the Hazard Evaluation Division at NIOSH. See Appendix XX for a list of these and other agencies that may be of assistance.

Arsine Patient Information Sheet

What is arsine?

Arsine is a colorless gas that does not burn the eyes, nose, or throat like some other dangerous gases. It has a garlic-like or fishy smell, but only at relatively high concentrations. A person can be exposed to a high concentration of arsine and not be able to smell it.

Certain ores or metals may contain traces of arsenic. If water or acid contacts these ores or metals, they may release small amounts of arsine gas. Arsine is widely used in manufacturing of fiberoptic equipment and computer microchips. It is sometimes used in galvanizing, soldering, etching, and lead plating.

What immediate health effects may result from arsine exposure? Besides the odor, there may be no other immediate sign that a person is breathing arsine. Its main effect is to destroy red blood cells, causing anemia (destruction of red blood cells) and kidney damage (from red blood cell debris). Within hours after a serious exposure, the victim may develop dark red or brown urine, back pain or belly pain, weakness, or shortness of breath. The skin or eyes may become yellow or bronze in color. Although arsine is related to arsenic, it does not produce the usual signs of arsenic poisoning.

What is the treatment for arsine poisoning?

There is no antidote for arsine poisoning, but its effects can be treated. The doctor may give the exposed patient fluids through a vein to protect the kidneys from damage. For severe poisoning, blood transfusions and cleansing of the blood (hemodialysis) may be needed.

Are any future health effects likely to occur?

After a serious exposure, symptoms usually begin within 2 to 24 hours. People who have no signs of poisoning during this time probably have not breathed a large amount of arsine and may be sent home with instructions for follow-up medical care (see the reverse side of this page). Most people do not have long term effects from a single, small exposure to arsine. In rare cases, permanent kidney damage or nerve damage has developed after a severe exposure.

Repeated exposure to arsine may cause skin and lung cancer.

What tests can be done if a person has been exposed to arsine? The are no specific tests for arsine exposure. However, blood, urine and other tests may show if there has been any serious injury to the lungs, blood cells, kidneys, or nerves.

Where can more information about arsine be obtained?

More information about arsine may be obtained from your regional poison control center; your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to contact the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). Ask the doctor who gave you this form for help in locating these telephone numbers.

Arsine Follow-up Instructions --

( ) Call your doctor or the Emergency Department if you develop any of the
following symptoms within the next 24 hours:

  * unusual fatigue or weakness
  * shortness of breath
  * abnormal urine color (red, brown, etc.)
  * belly pain or tenderness

( ) No follow-up appointment is necessary unless you develop any of the
symptoms described above.

( ) Call for an appointment with Dr. __________ in the practice of ________
When you call for your appointment, please tell the receptionist/nurse that
you were treated in the Emergency Department at __________________ Hospital
by __________ and were advised to be seen again in ___ days.

( ) Return to the Emergency Department/__________ Clinic on (date) ________
at AM/PM for a follow-up examination.

( ) Do not perform vigorous physical activities for __ days.

( ) You may resume everyday activities including driving and operating
machinery.

( ) Do not return to work for__ days.

( ) You may return to work on a limited basis. See instructions below.

( ) Avoid exposure to cigarette smoke for 24 hours since smoke may worsen
injury to your lungs.

( ) You may continue taking the following medication(s) that your doctor(s)

prescribed for you: _______________________________________________