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 | ||
*Alkalis | *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) | |||
**[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 | *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 | ||
**Look for visible remaining liquid/powder on skin | **Look for visible remaining liquid/powder on skin | ||
*Membranes | *Membranes | ||
Line 24: | Line 34: | ||
*Pulm | *Pulm | ||
**Bronchospam/cough/ | **Bronchospam/cough/pulmonary edema/cough | ||
*Systemic sigs | *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 | *Work up based on chemical culprit | ||
*POC glucose | *POC glucose | ||
*BMP | *BMP | ||
*Calcium | *Calcium | ||
*Magnesium | *Magnesium | ||
*Phosphorus | *Phosphorus | ||
* | *LFTs | ||
*CXR - concern for | *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 | **Patients may arrive by EMS, private vehicle, walk ins | ||
**Establish security perimeter to enforce hot zone | |||
*Protect yourself and staff | *Protect yourself and staff | ||
Line 62: | Line 66: | ||
**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) | ||
***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 | **Dispose of all clothes/bandages/IVs | ||
==Management== | ===Management=== | ||
*Aggressive supportive care, analgesia | *Aggressive supportive care, [[analgesia]] | ||
* | *[[Antidotes]] if available | ||
* | *Pulmonary involvement | ||
**[[O2]], [[albuterol]], [[intubation|intubate]] | |||
===Specific Conditions=== | |||
==Specific Conditions== | *[[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 | **[[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 | ||
**Nitrites | **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 | **[[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 | ||
*** | ***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]] | |||
== | ==External Links== | ||
* | *[http://www.msds.com/ Material Safety Data Sheet (MSDS)] | ||
* | *[https://toxnet.nlm.nih.gov/ TOXNET] | ||
==References== | ==References== | ||
<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
- Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min)
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