Difference between revisions of "Hazmat exposure"

(Created page which provides an outline for Hazmat exposures presenting to the ED)
 
(Management)
 
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==Background==
 
==Background==
*Definition - exposure to hazardous materials causing local/systemic toxicity.
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*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
 
*Alkalis
 
*Alkalis
**cause liquefaction necrosis that penetrates into deeper tissue. *Other mechanisms: oxidation, protein denaturation, cellular dehydration, local ischemia.
+
**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)
 +
**[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]
  
==History==
+
==Clinical Features==
 +
===History===
 
*Route/duration of exposure
 
*Route/duration of exposure
*Often exposure in household, industry, agriculture, terrorism.
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*Often exposure in household, industry, agriculture, or terrorism
*Identifying the chemical is paramount.
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*Identifying the chemical is paramount
  
==Exam==
+
===Exam===
 
*Skin
 
*Skin
 
**Often appears deceptively normal initially
 
**Often appears deceptively normal initially
**Look for visible remaining liquid/powder on skin.
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**Look for visible remaining liquid/powder on skin
  
 
*Membranes
 
*Membranes
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*Pulm
 
*Pulm
**Bronchospam/cough/pulm edema/cough
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**Bronchospam/cough/pulmonary edema/cough
  
 
*Systemic sigs
 
*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)
+
**altered mental status, seizures, tachy/brady dysrhythmias, hypo/hyper-tensive, GI sx, electrolyte abnormalitiyes, carboxyhemoglobinemia/methemoglobinemia, cyanide tox, toxidromic constellation of signs (e.g. cholinergic)
  
 +
==Differential Diagnosis==
  
==Resources==
+
==Evaluation==
*Resources to determine what is in the offending agent:
 
**Poison control (800 222-1222)
 
**Material Safety Data Sheet (MSDS)
 
***Determines need for decon
 
***http://www.msds.com/
 
**Chemical Transportation Emergency Center (Chemtrec) Emergency Telephone Number: (800) 424-9300.  Interntational and Maritime Telephone Number (collect calls accetped): +1 (703) 527-3887
 
**TOXNET
 
***https://toxnet.nlm.nih.gov/
 
 
 
==Diagnostics==
 
 
*Work up based on chemical culprit
 
*Work up based on chemical culprit
*POC glucose
+
*POC glucose
*BMP Electrolytes, BUN, creatinine, and glucose levels *LFTs
+
*BMP  
 
*Calcium  
 
*Calcium  
 
*Magnesium
 
*Magnesium
 
*Phosphorus
 
*Phosphorus
*ABG - concern for metabolic acidosis, carboxyhemoglobinemias, methemoglobinemias  
+
*LFTs
*CXR - concern for pum edema
+
*VBG - concern for metabolic acidosis, carboxyhemoglobinemias, methemoglobinemias  
 +
*[[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)
**Patients may arrive by EMS, private vehicle, walk ins. Establish security perimeter to enforce hot zone.
+
**Patients may arrive by EMS, private vehicle, walk ins
 +
**Establish security perimeter to enforce hot zone
  
 
*Protect yourself and staff
 
*Protect yourself and staff
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**Level D: Common work clothes
 
**Level D: Common work clothes
  
==Decon==
+
===Decontamination===
 
*Prehospital/In decon areas:
 
*Prehospital/In decon areas:
**Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min). Contraindicated only for elemental metals (Na, K).
+
**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
 
**Can allow patient to wash themselves if limited staff with protective gear
**Dispose of all clothes/bandages/IVs.
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**Dispose of all clothes/bandages/IVs
  
==Management==
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===Management===
*Aggressive supportive care, analgesia
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*Aggressive supportive care, [[analgesia]]
*Antidote, if available
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*[[Antidotes]] if available
*Pulm invovlement
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*Pulmonary involvement
 +
**[[O2]], [[albuterol]], [[intubation|intubate]]
  
**O2, albuterol, intbuate
+
===Specific Conditions===
==Specific Conditions==
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*[[Chemical burns]]
*Chemical burns
 
 
**Strong alkali, needs irrigation for hours
 
**Strong alkali, needs irrigation for hours
**IVF 3cc/kg/TBSA, 1/2 given in first 8 hours
+
**IVF 3cc/kg/[[TBSA]], 1/2 given in first 8 hours
**Hydrofluoric acid burn
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**[[Hydrofluoric acid]] burn
 
***Calcium gluconate via topic gel (10ml 10% sol'n applied topically), SC, or intra-arterial
 
***Calcium gluconate via topic gel (10ml 10% sol'n applied topically), SC, or intra-arterial
 
***IV calcium gluconate and magnesium for systemic toxicity
 
***IV calcium gluconate and magnesium for systemic toxicity
 
**Phenol burns
 
**Phenol burns
***polyethylene glycol 300 +/- isopropyl alcohol to remove phenol from skin
+
***Polyethylene glycol 300 +/- isopropyl alcohol to remove phenol from skin
 
**Nitrites
 
**Nitrites
***concern for methemoglobinemia
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***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)
+
***Treat levels >30% with 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
+
**[[Cyanide]]
***Hydroxocobalamin (5mg IV /5 min, repeat once)
+
***[[Hydroxocobalamin]] (5mg IV /5 min, repeat once)
 
***Elemental metals (Na or K)
 
***Elemental metals (Na or K)
***water is contraindicated
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***Water is contraindicated
***cover with oil under substance can be debrided from skin
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***Cover with oil under substance can be debrided from skin
 +
 
 +
==Disposition==
 +
*[[Burn center criteria|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
  
 +
==See Also==
 +
*[[Caustic burns]]
 +
*[[Toxicology (Main)]]
 +
*[[Weapon of mass destruction]]
  
==Disposition==
+
==External Links==
*Transfer to burn center (if meet criteria)
+
*[http://www.msds.com/ Material Safety Data Sheet (MSDS)]
*Admit if systemic sx, airway concern
+
*[https://toxnet.nlm.nih.gov/ TOXNET]
*Could d/c pts in consultation with poison control after period of obs.  
 
  
 
==References==
 
==References==
Schaider, Jeffrey. Rosen &Barkin's 5-Minute Emergent Medicine Consult
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<references/>
 +
 
 +
[[Category:Toxicology]]

Latest revision as of 17:39, 24 September 2019

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/pulmonary edema/cough
  • Systemic sigs
    • altered mental status, seizures, tachy/brady dysrhythmias, hypo/hyper-tensive, GI sx, electrolyte abnormalitiyes, carboxyhemoglobinemia/methemoglobinemia, cyanide tox, toxidromic constellation of signs (e.g. cholinergic)

Differential Diagnosis

Evaluation

  • 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

Management

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% with 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

See Also

External Links

References