Toxic Exposures

Chemical Glossary

Acrolein

• Sources: Manufacturing of biocides, pharmaceuticals, textiles, fuels and synthetic rubber
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema (immediate or delayed), pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: Dermatitis; skin and mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline.
• Resources: EPA Substance Registry System (good resource with links to other sites): http://iaspub.epa.gov/srs/srs_proc_qry.navigate?P_SUB_ID=24075.
  Office of Environmental Health Hazard Assessment: http://www.oehha.ca.gov/air/chronic_rels/pdf/107028.pdf

Acrylonitrile

• Sources: Plastics, adhesives, dyes, pharmaceuticals, fumigant
• Onset: Rapid and delayed
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Central Nervous System (CNS): CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Dermatologic: Dermatitis; skin and mucous membrane irritation
• Treatment: Monitor respiratory status. Antiepileptics for seizure activity (benzodiazepines, barbiturates). Intubation and ventilatory support for decreased mental status and/or coma.
  Metabolized to cyanide by the liver; consider cyanide antidote kit or hydroxocobalamin. Flush affected skin and mucous membranes with copious amounts of water or saline.
• Resources: http://www.oehha.ca.gov/air/chronic_rels/pdf/acrylonitrile.pdf
• National Institute of Environmental Health Sciences (good resource): http://ntp.niehs.nih.gov/ntp/roc/eleventh/profiles/s004acry.pdf

Allyl Alcohol

• Sources: Pesticides, plastics, resins, perfume manufacturing
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: Dermatitis; skin and mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline.
• Resources: HazMap (NLM Specialized Information Services which is an excellent resource for rapid data on toxicity for emergency purposes)
  http://hazmap.nlm.nih.gov/cgibin/hazmap_generic?tbl=TblAgents&id=242

Ammonia

• Sources: Explosives manufacturing; pesticides, detergents, fertilizer
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, cough, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Gastrointestinal: Esophageal contamination can lead to strictures.
  • Dermatologic: Irritation and even burns to skin and mucous membranes.
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush all exposed skin and mucous membranes with water. If oral involvement, be sure to have patient “swish and spit” to avoid esophageal contamination. Full depth of chemical burn cannot be fully appreciated until after 24 hours. Treat all chemical burns as thermal burns.
• Resources:
  • ATSDR site: http://www.atsdr.cdc.gov/MHMI/mmg126.html#bookmark04
  • NIOSH (National Institute Occupational Safety Health) has a link to the Inernational Programme on Chemical Safety (IPCS) and its International Chemical Safety Cards (ICSC) where one can get one of these cards for thousands of chemicals in multiple languages from Chinese to English to Russian to Spanish (even Swahili and Urdu). General URL for this site and then can search chemicals: http://www.cdc.gov/niosh/ipcs/icstart.html
  • Specific URL for ammonia (anhydrous) in English:
    http://www.ilo.org/public/english/protection/safework/cis/products/icsc/dtasht/_icsc04/icsc0414.htm
  • Specific URL for ammonia (anhydrous) in Spanish for Ecuadorians (click on “AMONIACO ANIHDRO” on the following page: http://www.mtas.es/insht/ipcsnspn/nspnsyna.htm)

Arsenic

• Sources: Contaminated soil, water and food. Released from different types of minerals and ores.
• Onset: Rapid (10 minutes to several hours) and delayed (days to 3 weeks)
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, cough, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Cardiac: Sinus tachycardia, arrhythmias, orthostatic hypotension and cardiovascular shock.
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression. Seizures occur secondary to microhemorrhages and cerebral edema. They typically occur days after exposure.
  • Peripheral Nervous System: Peripheral neuropathy
  • Hematologic: Leukopenia
  • Renal: Acute renal failure, rhabdomyolysis
  • Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain, hepatitis
  • Dermatologic: Dermatitis; skin and mucous membrane irritation ; patchy alopecia. About 5% will develop Mees lines in the nailbeds (represent disruption of nail matrix keratinization).
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Antiepileptics for seizure activity (benzodiazepines, barbiturates). Dimercaprol or BAL chelation is indicated for acute arsenic poisoning.
• Resources: http://www.cdc.gov/niosh/topics/arsenic/ http://www.emedicine.com/emerg/topic42.htm

Arsine (also known as stibine)

• Sources: Semiconductor and electronics industry
• Onset: Delayed 2-24 hours
• Symptoms:
  • Hematologic: hemolysis
• Treatment: Beware of hemolysis leading to renal failure. Consider urinary alkanization. Blood transfusions as
  needed or even exchange transfusion which may be the treatment of choice for severe cases. Use of BAL chelation is controversial and no controlled trials have shown improved outcome or efficacy. The priority is removal of heme pigment and not necessarily the arsenic metal.
• Resources:
  • ATSDR and CDC are excellent resources with Medical Management Guidelines (MMG)
  • http://www.atsdr.cdc.gov/MHMI/mmg169.html
  • http://www.emedicine.com/emerg/topic920.htm

Botulinum

• Sources: Produced from the bacteria Clostridium botulinum. The toxin can contaminate foods (especially honey and home-canned products) and wounds. This also can be used as a warfare agent when released as an aerosol.
• Onset: Delayed hours to days
• Symptoms:
  • Peripheral Nervous System: double vision, difficulty speaking, dry mouth, drooping eyes, descending motor paralysis. Beware of respiratory paralysis! In infants, presenting symptom can be constipation.
• Treatment: Respiratory support as needed. Do not hesitate to intubate these patients. Trivalent (A, B, E) antitoxin is available from the Centers for Disease Control. When available, give the antitoxin as soon as botulism is suspected.
• Resources:
  • Detection: http://www.cdc.gov/ncidod/EID/vol11no10/04-1279.htm
  • General Information/Treatment: Centers for Disease Control & Prevention: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/botulism_g.htm
  • In general, for bioterrorism resource information go to this excellent site: http://www.bt.cdc.gov/

Carbon Monoxide

• Sources: Engines, stoves, lanterns, burning charcoal and wood, gas ranges and heating systems.
• Onset: Rapid to delayed
• Symptoms:
  • Respiratory: chest pain, shortness of breath
  • CNS: headache, dizziness, weakness, confusion.
  • Gastrointestinal: nausea
  • Dermatologic: “cherry red” appearance to skin
• Treatment: Remove patient from source of exposure ensuring there is plenty of fresh air. Provide supplemental oxygen as needed.

Chlorine

• Sources: Cleaners/disinfectants, water treatments (pools, hot tubs, etc.)
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline.
• Resources:
  • Agency for Toxic Substances and Disease Registry (ATSDR)
  • http://www.atsdr.cdc.gov/MHMI/mmg172.html
  • http://www.atsdr.cdc.gov/MHMI/mmg172.html

Cyanide

• Sources: fumigant, electroplating, chemical synthesis, mineral extraction, photography, manufacturing of textiles, paper and plastics.
• Onset: Rapid (either die quickly or rapidly recover)
• Symptoms:
  • CNS : CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Metabolic: metabolic acidosis, cellular asphyxiant.
• Treatment: Monitor respiratory status. Antiepileptics for seizure activity (benzodiazepines, barbiturates). Intubation and ventilatory support for decreased mental status and/or coma. Correct metabolic acidosis.
• Antidote:
  • Break amyl nitrite ampule and inhale for 30 seconds every minute. Repeat with a new ampule every 3 minutes until IV sodium nitrite can be administered.
  • 3% sodium nitrite – Adult: 10 cc IV, give in 5 minutes or less.
    Pediatric: 0.15–0.33 cc/kg (max. of 10 cc) IV, give in 5 minutes or less.
  • Sodium thiosulfate 25% solution – Adult: 12.5 gm IV, pediatric: 412.5 mg/kg or 1.65 mL/kg of 25% solution IV. Cyanokit® (hydroxocobalamin) released by FDA for use in US has been used for years in UK for fire victims and other cyanide poisonings. Dose: 5 grams IV

Diborane

• Sources: Chemical manufacturing, semiconductor production, rocket propellants
• Onset: Rapid
• Symptoms:
  • Respiratory: respiratory irritant (cough, chest pain, chest tightness, shortness of breath)
  • CNS: headache, drowsiness, shivering
  • Gastrointestinal: nausea, vomiting
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema.

Ethylene Oxide

• Sources: Rocket propellants, ethylene glycol synthesis, fumigant, medical instrument sterilization
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Dermatologic: Dermatitis; skin and mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Antiepileptics for seizure activity (benzodiazepines, barbiturates). Flush affected skin and mucous membranes with copious amounts of water or saline.

Fluorine

• Sources: Manufacturing of fluorides and fluorocarbons, rocket fuel component
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: corrosive; thermal burns/frostbite, chills
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline. Treat chemical burns as thermal injuries.

Formaldehyde

• Sources: Germicide, fungicide, foam insulation, preservative; paper manufacturing
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema (immediate or delayed), pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: Dermatitis; skin and mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline.

Hydrazines

• Sources: Rocket fuel, solvents, anticorrosives
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Hematologic: Hemolysis, methemoglobinemia
  • Gastrointestinal: Nausea, vomiting, hepatotoxicity for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline. Treat chemical burns as thermal injuries.
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. For CNS symptoms: pyridoxime 25 mg/kg IV. Antiepileptics for seizure activity (benzodiazepines, barbiturates). For symptomatic methemoglobinemia: methylene blue 1-2 mg/kg IV to be given over 5 minutes.

Hydrogen chloride

• Sources: Metal refining, manufacturing of vinyl chloride, rubber and chlorine
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: Dermatitis (skin and mucous membrane irritation)
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious amounts of water or saline.

Hydrogen fluoride

• Sources: Glass etching, rust removers, semiconductor production, volcanic emissions
• Onset: Rapid or delayed (depends on concentration)
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Cardiac: Dysrhythmias
  • Metabolic: Hypocalcemia, hypomagnesemia, hyperkalemia, metabolic acidosis
  • Dermatologic: Corrosive, tissue penetration and destruction
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Place on a cardiac monitor. For hypocalcemia: calcium chloride (10% solution) 2–4 mg/kg IV, repeat as needed. For hypomagnesemia: Adult: magnesium sulfate 2–4 gm IV to be given over 10 minutes. Pediatric: 25–50 mg/kg IV. For topical exposures: topical calcium gluconate gel vs. subcutaneous calcium gluconate. Inhalational exposure: 2.5% calcium gluconate nebulized solution. Flush affected skin and mucous membranes with copious amounts of water or saline. Treat chemical burns as thermal burns.

Hydrogen selenide

• Sources: Glass, pigment and glaze manufacturing, plastic production, steel production and fabrication.
• Onset: Rapid and delayed
• Symptoms:
  • Respiratory: Bitter taste, chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Cardiac: Cardiovascular failure
  • CNS: Headaches, chills
  • Gastrointestinal: Nausea, vomiting
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Place on a cardiac monitor.

Hydrogen sulfide

• Sources: Chemical and heavy water manufacturing; agricultural disinfectant, metallurgy, volcanic emissions.
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • CNS: Headache, CNS depression
  • Metabolic: Cellular asphyxiant, metabolic acidosis
  • Dermatologic: Dermatitis; skin and mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Sodium nitrite may be of some benefit to critically ill patients (see cyanide for dosing). Flush affected skin and mucous membranes with copious amounts of water or saline.

Lewisite

• Sources: Military agent
• Onset: Rapid (IMPORTANT—sulfur mustard will have delayed pain vs. lewisite victims will have immediate pain to skin).
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Cardiac: Cardiovascular failure
  • Dermatologic: Blistering agent, immediate pain and irritation to skin and mucous membranes (including eyes). Blisters can lead to necrosis. Corneal ulceration and necrosis.
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Give ophthalmic antibiotic ointment as needed. Flush affected skin and mucous membranes with copious amounts of water or saline. If available, apply 5% BAL ointment to affected skin within 15 minutes. Consider IM BAL or oral DMSA for severe exposures (cough with shortness of breath, frothy sputum, skin burn that was not decontaminated within 15 minutes, >5 % body surface area with evidence of immediate skin involvement). BAL: 3 mg/kg deep IM repeated every 4 hours x 2 days, then every 6 hours on the 3rd day, then every 12 hours for up to 10 days. DMSA: 10 mg/kg orally every 8 hours x 5 days, then 10 mg/kg every 12 hours for the next 14 days.

Methyl hydrazine

• Sources: Rocket fuel, solvents, anticorrosives
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Hematologic: Hemolysis, methemoglobinemia
  • Gastrointestinal: Nausea, vomiting, hepatotoxicity
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. For CNS symptoms: pyridoxime 25 mg/kg IV. Antiepileptics for seizure activity (benzodiazepines, barbiturates). For symptomatic methemoglobinemia: methylene blue 1-2 mg/kg IV to be given over 5 minutes.

Methyl isocyanate

• Sources: Pesticide carbamate production
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Dermatologic: mucous membrane irritation
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious water or saline.

Methyl mercaptan

• Sources: Gas odorant; production of pesticides, fungicides and jet fuel.
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis
  • Cardiac: Hypertension
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Hematologic: Hemolysis and methemoglobinemia
  • Gastrointestinal: Nausea, vomiting, diarrhea
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Antiepileptics for seizure activity (benzodiazepines, barbiturates). For symptomatic methemoglobinemia: methylene blue 1-2 mg/kg IV to be given over 5 minutes. Consider urinary alkanization. Blood transfusions as needed.

Mustards

• Sources: Military agent
• Onset: 1-2 hours (IMPORTANT—sulfur mustard will have delayed pain vs. lewisite victims will have immediate pain to skin).
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis. Infection.
  • Hematologic: Bone marrow suppression
  • Gastrointestinal: Nausea and vomiting
  • Dermatologic: Blistering agent, delayed pain and irritation to skin and mucous membranes (including eyes). Blisters can lead to necrosis. Corneal ulceration and necrosis.
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Ophthalmic antibiotic ointment as needed. Flush skin with copious amounts of water or saline even if the patient is asymptomatic. Unroof large bullae only. Do not apply topical antibiotic ointment unless there is a proven source of infection.

Nerve agents (fenthion, tabun, soman, sarin, VX)

• Sources: Military agent
• Onset: Rapid
• Symptoms:
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Peripheral Nervous System:
    • Muscarinic effects: Diarrhea, pinpoint pupils, bradycardia, bronchospasm, vomiting, increased pulmonary secretions, sweating, salivation, tearing eyes
    • Nicotinic effects: Dilated pupils, tachycardia, weakness, hypertension, hyperglycemia, tremors
• Treatment: Atropine (treats muscarinic effects only); dose: 2–5 mg IV/IM slowly. Repeat every 5 to 10 minutes until drying of pulmonary secretions. Pralidoxime (treats muscarinic and nicotinic effects); dose: IV 1–2 gm to be given over 30 minutes every 6 to 12 hours. May repeat in 1 hour if nicotinic symptoms persist. Pralidoxime drip therapy: 1–2 gm IV given over 30 minutes followed by 500 mg/hr drip. IM: 1–2 gm every 6 to 12 hours. May repeat in 1 hour if nicotinic symptoms persists. Antiepileptics for seizure activity (benzodiazepines, barbiturates).

Nitric acid

• Sources: Fertilizer, gun powder and explosives manufacturing; metal etching and cleaning; organic synthesis
• Onset: Rapid
• Symptoms:
  • Respiratory: Delayed respiratory effects. Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis.
  • Dermatologic: Corrosive, tissue penetration and destruction, severe burns.
• Treatment: Immediate wet decontamination. Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious water or saline. Treat chemical burns as thermal burns.

Nitrogen dioxide

• Sources: Chemical synthesis; nitric acid production; explosives
• Onset: Delayed
• Symptoms:
  • Respiratory: High concentrations can cause upper airway irritation. Delayed respiratory effects. Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis.
• Treatment: Make patient rest. Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema.

Organophosphates

• Sources: Pesticides
• Onset: Rapid
• Symptoms:
  • Peripheral Nervous System:
    • Muscarinic effects: Diarrhea, pinpoint pupils, bradycardia, bronchospasm, vomiting, increased pulmonary secretions, sweating, salivation, tearing eyes
    • Nicotinic effects: Dilated pupils, tachycardia, weakness, hypertension, hyperglycemia, tremors
• Treatment: Atropine (treats muscarinic effects only); dose: 2–5 mg IV/IM slowly. Repeat every 5 to 10 minutes until drying of pulmonary secretions. Pralidoxime (treats muscarinic and nicotinic effects); dose: IV 1–2 gm to be given over 30 minutes every 6 to 12 hours. May repeat in 1 hour if nicotinic symptoms persist. Pralidoxime drip therapy: 1–2 gm IV given over 30 minutes followed by 500 mg/hr drip. IM: 1–2 gm every 6 to 12 hours. May repeat in 1 hour if nicotinic symptoms persist.

Phosgene/Diphosgene

• Sources: Organic compound synthesis, burning of foam; military agent
• Onset: Delayed (24–48 hours)
• Symptoms:
  • Respiratory: High concentrations can cause upper airway irritation. Forms hydrochloric acid in the lungs. Delayed respiratory effects. Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis. Can be fatal even with small exposures.
• Treatment: Make patient rest. Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema.

Phosgene oxime

• Sources: Military agent
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis.
  • Dermatologic: Corrosive, tissue penetration and destruction, immediate severe burns. Urticant.
• Treatment: Immediate decontamination. Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. Flush affected skin and mucous membranes with copious water or saline. Symptomatic wound care. Treat chemical burns as thermal burns.

Phosphine

• Sources: Manufacturing of semiconductors; fumigant
• Onset: 1–2 hours and delayed
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, delayed pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis.
  • Cardiac: Cardiogenic shock, hypotension
  • CNS: CNS depression, possible coma, seizures, confusion, dizziness. Beware of respiratory depression.
  • Metabolic: Cellular asphyxiant; decreases ATP production, metabolic acidosis.
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema.Anticipate need for circulatory support. Antiepileptics for seizure activity (benzodiazepines, barbiturates).

Ricin

• Sources: Military agent; derived from the processing of castor beans.
• Onset: Delayed (hours)
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, pneumonitis, acute lung injury leading to lung necrosis. Respiratory failure.
  • CNS: Headaches, weakness c. Gastrointestinal: With ingestion, can see gastrointestinal bleeding, shock, hepatic, splenic and renal necrosis.
• Treatment: For inhalational exposures give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema. For oral exposures do GI decontamination, give blood transfusions as needed and provide supportive care.

Sulfur oxides/Sulfur dioxide

• Sources: Disinfectant, preservative, bleaching agent
• Onset: Rapid
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, bronchoconstriction, pneumonitis, acute lung injury leading to lung necrosis
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema.

Toluene

• Sources: Gasoline, household products and cigarette smoke
• Onset: Delayed (24 hours)
• Symptoms:
  • Respiratory: Chest pain, shortness of breath, pulmonary edema, bronchoconstriction, pneumonitis, acute lung injury leading to lung necrosis
• Treatment: Give supplemental oxygen, bronchodilators, intubation and ventilatory support as needed. Consider diuretics for pulmonary edema.

Toluene diisocyanate

• Sources: Toner, clay, and glass products, manufacturing of miscellaneous plastic products, and petroleum refining
• Onset: Delayed (24 hours)
• Symptoms:
  • Cardiac: Dysrhythmias
• Treatment: Place on a cardiac monitor.