Hazmat exposure: Difference between revisions
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==Background== | ==Background== | ||
*Definition - exposure to hazardous materials causing local/systemic toxicity | *Definition - exposure to hazardous materials causing local/systemic toxicity | ||
==Types of Injury== | ===Types of Injury=== | ||
*Acids | *Acids | ||
**Cause coagulation necrosis which causes an eschar which often limits damage to deeper tissue | **Cause coagulation necrosis which causes an eschar which often limits damage to deeper tissue | ||
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*Other mechanisms: oxidation, protein denaturation, cellular dehydration, local ischemia | *Other mechanisms: oxidation, protein denaturation, cellular dehydration, local ischemia | ||
==History== | ===Resources=== | ||
*Resources to determine what is in the offending agent: | |||
**Poison control (800 222-1222) | |||
**[http://www.msds.com/ Material Safety Data Sheet (MSDS)] | |||
***Determines need for decon | |||
**Chemical Transportation Emergency Center (Chemtrec) Emergency Telephone Number: (800) 424-9300 | |||
***Interntational and Maritime Telephone Number (collect calls accetped): +1 (703) 527-3887 | |||
**[https://toxnet.nlm.nih.gov/ TOXNET] | |||
==Clinical Features== | |||
===History=== | |||
*Route/duration of exposure | *Route/duration of exposure | ||
*Often exposure in household, industry, agriculture, or terrorism | *Often exposure in household, industry, agriculture, or terrorism | ||
*Identifying the chemical is paramount | *Identifying the chemical is paramount | ||
==Exam== | ===Exam=== | ||
*Skin | *Skin | ||
**Often appears deceptively normal initially | **Often appears deceptively normal initially | ||
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**AMS, seizures, tachy/brady dysrhythmias, hypo/hyper-tensive, GI sx, electrolyte abnormalitiyes, carboxyhemoglobinemia/methemoglobinemia, cyanide tox, toxidromic constellation of signs (e.g. cholinergic) | **AMS, seizures, tachy/brady dysrhythmias, hypo/hyper-tensive, GI sx, electrolyte abnormalitiyes, carboxyhemoglobinemia/methemoglobinemia, cyanide tox, toxidromic constellation of signs (e.g. cholinergic) | ||
== | ==Differential Diagnosis== | ||
== | ==Diagnosis== | ||
*Work up based on chemical culprit | *Work up based on chemical culprit | ||
*POC glucose | *POC glucose | ||
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*CXR - concern for pulmonary edema | *CXR - concern for pulmonary edema | ||
==Logistics== | ==Management== | ||
===Logistics=== | |||
*Establish Hazmat Plan | *Establish Hazmat Plan | ||
**Affected patients need to stay in designated hot zones until decontaminated (staff can be injured secondary contamination inhalation of volatile gases) | **Affected patients need to stay in designated hot zones until decontaminated (staff can be injured secondary contamination inhalation of volatile gases) | ||
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**Level D: Common work clothes | **Level D: Common work clothes | ||
== | ===Decontamination=== | ||
*Prehospital/In decon areas: | *Prehospital/In decon areas: | ||
**Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min) | **Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min) | ||
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**Dispose of all clothes/bandages/IVs | **Dispose of all clothes/bandages/IVs | ||
== | ===Treatment=== | ||
*Aggressive supportive care, analgesia | *Aggressive supportive care, analgesia | ||
*[[Antidotes]] if available | *[[Antidotes]] if available | ||
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**O2, albuterol, intubate | **O2, albuterol, intubate | ||
==Specific Conditions== | ===Specific Conditions=== | ||
*[[Chemical burns]] | *[[Chemical burns]] | ||
**Strong alkali, needs irrigation for hours | **Strong alkali, needs irrigation for hours | ||
Revision as of 20:46, 28 June 2016
Background
- Definition - exposure to hazardous materials causing local/systemic toxicity
Types of Injury
- Acids
- Cause coagulation necrosis which causes an eschar which often limits damage to deeper tissue
- Alkalis
- Cause liquefaction necrosis that penetrates into deeper tissue
- Other mechanisms: oxidation, protein denaturation, cellular dehydration, local ischemia
Resources
- Resources to determine what is in the offending agent:
- Poison control (800 222-1222)
- Material Safety Data Sheet (MSDS)
- Determines need for decon
- Chemical Transportation Emergency Center (Chemtrec) Emergency Telephone Number: (800) 424-9300
- Interntational and Maritime Telephone Number (collect calls accetped): +1 (703) 527-3887
- TOXNET
Clinical Features
History
- Route/duration of exposure
- Often exposure in household, industry, agriculture, or terrorism
- Identifying the chemical is paramount
Exam
- Skin
- Often appears deceptively normal initially
- Look for visible remaining liquid/powder on skin
- Membranes
- Potential for airway compromise
- Inspect eyes/nasopharynx/cornea if indicated
- Pulm
- Bronchospam/cough/pulm edema/cough
- Systemic sigs
- AMS, seizures, tachy/brady dysrhythmias, hypo/hyper-tensive, GI sx, electrolyte abnormalitiyes, carboxyhemoglobinemia/methemoglobinemia, cyanide tox, toxidromic constellation of signs (e.g. cholinergic)
Differential Diagnosis
Diagnosis
- Work up based on chemical culprit
- POC glucose
- BMP
- Calcium
- Magnesium
- Phosphorus
- LFTs
- VBG - concern for metabolic acidosis, carboxyhemoglobinemias, methemoglobinemias
- CXR - concern for pulmonary edema
Management
Logistics
- Establish Hazmat Plan
- Affected patients need to stay in designated hot zones until decontaminated (staff can be injured secondary contamination inhalation of volatile gases)
- Patients may arrive by EMS, private vehicle, walk ins
- Establish security perimeter to enforce hot zone
- Protect yourself and staff
- Personal chemical protective equipment:
- Level A: Positive-pressure self-contained breathing apparatus (SCBA), fully encapsulated chemical-resistant suit, double chemical-resistant gloves, chemical-resistant boots, and airtight seals between suit, gloves, boots
- Level B: SCBA, nonencapsulated chemical suit, double gloves, boots
- Level C: Air-purification device, suit, gloves, boots
- Level D: Common work clothes
Decontamination
- Prehospital/In decon areas:
- Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min)
- Contraindicated only for elemental metals (Na, K)
- Can allow patient to wash themselves if limited staff with protective gear
- Dispose of all clothes/bandages/IVs
- Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min)
Treatment
- Aggressive supportive care, analgesia
- Antidotes if available
- Pulmonary involvement
- O2, albuterol, intubate
Specific Conditions
- Chemical burns
- Strong alkali, needs irrigation for hours
- IVF 3cc/kg/TBSA, 1/2 given in first 8 hours
- Hydrofluoric acid burn
- Calcium gluconate via topic gel (10ml 10% sol'n applied topically), SC, or intra-arterial
- IV calcium gluconate and magnesium for systemic toxicity
- Phenol burns
- Polyethylene glycol 300 +/- isopropyl alcohol to remove phenol from skin
- Nitrites
- Concern for Methemoglobinemia
- Treat levels >30% w/ HF O2 and IV methylene blue (1-2mg/kg slow IV, not recommended for <6 y/o, >6 y/o 1mg/kg IV/IM)
- Cyanide
- Hydroxocobalamin (5mg IV /5 min, repeat once)
- Elemental metals (Na or K)
- Water is contraindicated
- Cover with oil under substance can be debrided from skin
Disposition
- Transfer to burn center if criteria met
- Admit if systemic symptoms or airway concern
- Consider discharge of patients in consultation with poison control and/or after period of observation as needed