Signs and Symptoms
- Skin:
- Chemical burns; may appear deceptively mild initially
- Visible liquid or powder on skin
- Absorption through skin may cause systemic toxicity
- Mucous membranes (eyes, nasopharynx; see “Corneal Burn”):
- Ranges from subjective irritation to serious mucosal burns
- Potential airway compromise
- Pulmonary:
- Cough
- Pleuritic chest pain
- Bronchospasm
- Dyspnea
- Pulmonary edema (immediate or delayed)
- Systemic (after skin or pulmonary absorption):
- Altered mental status
- Seizures
- Tachy/brady dysrhythmias
- Hypotension/HTN
- GI symptoms
- Electrolyte disturbances
- Carboxyhemoglobinemias and methemoglobinemias
- Cyanide toxicity
- Cholinergic syndrome (see “Chemical Weapons Poisoning,” “Nerve Agents”)
History
Elicit type, circumstances, amount, and duration of exposure
Essential Workup
- Attempt to identify substance using prehospital providers, Material Safety Data Sheet (MSDS), and Chemical Transportation Emergency Center (Chemtrec)
- MSDS:
- Identifies chemicals
- Differentiates vapor vs. skin hazard
- Determines need for decontamination
- Limited treatment data
- Determine route and duration of exposure
- Inhalation injury more likely in an enclosed space
- Determine toxicity using poison control; computerized databases, such as POISINDEX or TOXNET; or stand ard toxicology test
- Observe as needed for systemic toxicity
Diagnostic Tests & Interpretation
Lab
- Depends on substance
- Electrolytes, BUN, creatinine, and glucose levels
- LFTs
- Calcium level
- Magnesium level
- Phosphorus level
- Lactate level
- Arterial blood gases:
- Metabolic acidosis
- Carboxyhemoglobinemias and methemoglobinemias
- Respiratory failure
Imaging
- CXR for pulmonary edema
- Nasopharyngoscopy for lower airway involvement
Differential Diagnosis
- Skin:
- Hypersensitivity reaction
- Thermal burns
- Occular:
- Therman burns
- Infectious causes
- Pulmonary:
- Pneumonia
- Pulmonary embolism
- Anaphylaxis
- Systemic:
- Status epilepticus
- Overdose
- Psychiatric illness
- Myocardial infarction
Prehospital
- Recognize a HAZMAT situation:
- Accident at industrial/agricultural site
- Accident involving transport of hazardous materials
- Suspected terrorist mass casualty incident
- Cholinergic syndrome
- Irritant mucous membrane symptoms
- Chemical burns
- Protect yourself and others:
- Approach from upwind
- Do not enter scene until safety of material is determined
- Use Level A protective gear if safety not established
- Anyone able to walk and talk is minimally contaminated
- Prevent others from entering hot zone unprotected
- 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
- Identify substance:
- Department of Transportation (DOT) placard, MSDS, shipping papers, hazard labels
- If unsuccessful, call Chemtrec (1[800] 424-9300) to determine substance and toxicity
- Hazmat teams can do chemical testing
- Determine toxicity and need for decontamination:
- Poison control (1[800] 222-1222)
- Chemtrec (1[800] 424-9300)
- Decontaminate:
- Hazmat team
- Instruct minimally contaminated patients to perform self-decontamination
- Treat:
- Provide basic life support and advanced life support care as indicated
- Generally basic list support only in a “hot zone”
- Irrigate skin and ocular burns immediately and continue until arrival at hospital
Initial Stabilization/Therapy
- Protect ED personnel:
- Secondary contamination can occur from dermal contact or through inhalation of volatile gases/particles
- Activate hospital disaster policies early
- Keep patients outside in designated hot zones until decontaminated
- When in doubt, decontaminate
- Expect contaminated patients to arrive via emergency medical services but a majority by private vehicle
- If treatment is required before/during decontamination:
- Use minimum necessary staff in appropriate personal protection gear
- Focus on life- and limb-saving care only
- Decontamination:
- Security to enforce hot zone
- Remove, label, and double-bag clothing (including contact lens)
- Copious irrigation with soap and water for 10-15 min with special attention to obviously contaminated areas, wounds, and exposed eyes
- Recapture water to prevent contamination of the sewer and downstream areas:
- In an emergency or mass casualty situation, it is acceptable to let water drain into sewer
- Hydrotherapy:
- Mainstay of therapy for chemical burns
- Contraindicated only for elemental metals (sodium and potassium)
- Allow patient to decontaminate himself or herself or use trained decontamination team
- Decontaminate children, dependent elderly, mentally/physically challenged and their appliances (e.g., wheelchairs) with caregivers
- Gloves, masks, goggles, and disposable gowns provide some protection
- Remove/replace band ages, tourniquets, airway adjuncts, IV sets
- Prevent decontamination-induced hypothermia
- Retriage after decontamination
ED Treatment/Procedures
- Provide supportive care as needed
- Determine if antidotal treatment would be effective and available
- Hazmat incidents provoke extreme fear:
- Expect casualties suffering from collective hysteria
- Knowledge of toxicologic profile can exclude contamination in these patients
- ED staff may become symptomatic even if chemical concentrations in the air are below toxic levels and may need to be escorted to fresh air
- Chemical burns:
- Irrigation should be started as soon as possible and , if owing to a strong alkali, may need to be continued for hours
- Aggressive fluid resuscitation with 2-4 mL/kg lactated Ringer solution per total burn surface area (TBSA) percent over 24 hr with 1/2 given over the first 8 hr
- Pain control
- Pulmonary symptoms:
- Bronchodilators, oxygen, intubation, and mechanical ventilation
- Selected special treatments:
- Hydrofluoric acid burns:
- Calcium gluconate via topical cutaneous gel, SC, or intraarterial
- For systemic toxicity: IV calcium gluconate and magnesium
- Phenol burns:
- Nitrates:
- Elemental metals (sodium/potassium):
- Water lavage is contraindicated and dangerous
- Cover with oil until substance can be debrided from skin
- Cyanide toxicity:
- Organophosphates/carbamate insecticides (see “Chemical Weapons Poisoning”)
Medication
- Albuterol: 2.5-5.0 mg nebulized
- Calcium gluconate: 10 mL of 10% solution applied topically. Consult poison center for instructions
- Magnesium: 2 g IV over 20 min
- Methylene blue: 1-2 mg/kg slow IV (peds: Not recommended for <6 yr old; >6 yr old: 1 mg/kg IV/IM over 5 min)
- Hydroxocobalamin: 5 mg IV over 5 min, repeat once
Disposition
Admission Criteria
- Airway compromise, respiratory difficulty (hypoxia)
- Significant systemic symptoms
- Admit patients with chemical burns to burn center
Discharge Criteria
- Patients who are well after a period of observation and consultation with poison control
- Superficial chemical burns owing to a toxin without potential for systemic toxicity (weak acid/alkali)
Follow-up Recommendations
Psychiatric or social work referral for victims of chemical terrorist attacks
- CibulskySM, SokolowskiD, LafontaineM, et al. Mass casualty decontamination in a chemical or radiological/nuclear incident with external contamination: Guiding principles and research needs . PLoS Curr. 2015. Edition 1.:7. doi: 10.1371/currents.dis.9489f4c319d9105dd0f1435ca182eaa9.
- HoffmanRS, Howland MA, LewinNA, et al. Goldfrank's Toxicologic Emergencies. 10th ed.New York: McGraw-Hill; 2014.
- Holland MG, CawthonD. Personal protective equipment and decontamination of adults and children . Emerg Med Clin North Am. 2015;33(1):51-68.
- MonteithRG, PearceLDR. Self-care decontamination within a chemical exposure mass-casualty incident . Prehosp Disaster Med. 2015;30(03):288-296.
- ZhaoX, DughlyO, SimpsonJ. Decontamination of the pediatric patient . Curr Opin Pediatr. 2016;28(3):305-309.
See Also (Topic, Algorithm, Electronic Media Element)