Toxic Exposures
12. Case resolution
Case 1.
You learn that these persons have been huddled in a partially damaged school. A group of about 30 to 40 individuals had gathered in a classroom and used two gas-powered generators to provide heat.
These patients’ symptoms are probably due to carbon monoxide intoxication, caused by gas combustion of the powered generators used in a closed shelter.
In the physical examination, look for signs associated with intoxication: ataxia, nausea/ vomiting, headache, dizziness, malaise, seizures or syncope.
When patients left the likely exposure site, they were able to breathe fresh air which is the initial management for carbon monoxide intoxication. If signs of severe intoxication are found, then give 100% oxygen supplement via face mask. Pulse oximetry is not useful for these patients, and carboxyhemoglobin level should be obtained.
Case 2.
You suspect the gas released is chlorine, and you contact the Poison Control Center (PCC), requesting management guidelines for chlorine gas exposure. Some of your colleagues do likewise. A similar incident occurred in 2004 near San Antonio, TX, that released 60 tons of chlorine. The electronic national surveillance system for the PCC, contacts the medical director of the local PCC and questions why they have an inordinate number of irritant gas reports being entered on the electronic database.
Field data has been compiled and reported to the Incident Commander. The disaster is considered to be most likely accidental. Support personnel from EMS units in the county have arrived to assist in field triage and emergency care. Many victims are undergoing onsite decontamination, with special care in eyes flushing, as well as oxygen administration via face mask.
The PCC sends you a facsimile document stating the variables which affect the severity of chlorine gas exposure and the appropriate management for this type of exposure.
About that time, multiple private vehicles pull up to the ambulance bay. Security and local police have set up controlled access to the ED. The Mayor has requested assistance of the Governor to supply National Guard troops to aid in the crowd control. Meanwhile, patients already in the ED are complaining that they have not been seen yet.
There should be a decontamination area in your ED with enough oxygen tanks and hand-held nebulizers to administer supplemental oxygen and bronchodilators in patients with severe clinical symptoms. Also, consider nebulized sodium bicarbonate.