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
*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.
*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
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*Pulm
*Pulm
**Bronchospam/cough/pulm edema/cough
**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.
**Dispose of all clothes/bandages/IVs


==Management==
===Management===
*Aggressive supportive care, analgesia
*Aggressive supportive care, [[analgesia]]
*Antidote, if available
*[[Antidotes]] if available
*Pulm invovlement
*Pulmonary involvement
**[[O2]], [[albuterol]], [[intubation|intubate]]


**O2, albuterol, intbuate
===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
***Polyethylene glycol 300 +/- isopropyl alcohol to remove phenol from skin
**Nitrites
**Nitrites
***concern for methemoglobinemia
***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
***Water is contraindicated
***cover with oil under substance can be debrided from skin
***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
<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