If ophthalmologic consultation is not immediately available, patients with corneal defects should receive topical antibiotic prophylaxis to prevent bacterial superinfection. These patients also require ophthalmologic follow-up within the next few days.
Mild respiratory symptoms and bronchospasm can be treated with aerosolized beta-agonists. Patients may develop ARDS, with its characteristic bilateral infiltrates on chest x-ray and hypoxia that does not improve with increased inspired oxygen concentration.
There is no specific antidote for chlorine exposures. Several studies have suggested that inhaled or parenteral steroids are effective at decreasing respiratory complications after chlorine exposure. This same study showed a significant decrease in improvement if treatment was delayed to 60 minutes, which suggests that steroids should be administered soon after an exposure when feasible.
Theoretically, inhaled bicarbonate can neutralize hypochlorous and hydrochloric acids, decreasing severity of lung injury. One non-randomized, placebo-controlled study of chlorine exposure reported improved pulmonary function tests PFT , but patient-oriented benefits and long-term outcomes were not determined.
Another case series utilized bicarbonate without beta-agonists or steroids in patients with mild chlorine exposures. All three patients subjectively improved after treatment with a 3. A reasonable dose is 3. Because precipitates can form if combined, it is important that nebulized sodium bicarbonate be administered separately from nebulized albuterol sulfate. Although some data from animal models exists, there is currently not enough information to support the use of anti-oxidants in a clinical setting.
Some patients will present with minimal or no symptoms. A small percentage who are minimally symptomatic on presentation may go on to develop delayed pulmonary edema over a period of several hours.
Personnel moving into areas of higher concentration or prolonged exposure time will need appropriate HAZMAT equipment for respiratory and skin protection. First responders must be equipped with and trained to use this PPE prior to a major chlorine release. Because of the potential for large numbers of exposed patients who may require treatment and monitoring, a hospital can become overwhelmed.
It is important that hospitals and municipalities have mutual-aid agreements that coordinate the transfer of medications, equipment and personnel to the areas they are most needed.
Especially important is respiratory support equipment. Triage is an ongoing process, and must be repeated as patients move through the levels of decontamination. This area can restrict patient flow and may be an appropriate time to re-triage. People working or living in areas being evacuated must be notified of the need to leave, as well as safe evacuation routes that avoid exposure. There must also be a point of contact for friends and families seeking missing loved ones. The best mechanism for the spread of such information will vary, depending on the size and demographics of a given community.
In addition to the occult HAZMAT threat, the intentional use of chlorine as an unconventional weapon is now occurring. Large chlorine stores in the U. Operation Iraqi Freedom has demonstrated multiple events of successful use of weaponized chlorine transport vehicles, resulting in hundreds of casualties. As for all HAZMAT responses, proper equipment and training for first responders and a network of supporting medical facilities are needed to provide adequate care.
Management of chlorine exposure involves decontamination and treatment of potential pulmonary injuries. Beta-agonists can be helpful for bronchospasm. Nebulized bicarbonate may decrease symptoms and prevent lung injury. Early corticosteroid use may play a role in treating lung inflammation and, possibly, preventing post-injury scarring. Severe cases may require endotracheal intubation and mechanical ventilation.
While all these measures may prove useful in the treatment of patients after a chlorine exposure, further research is needed to delineate the optimal treatment regimen.
Recognizing the evolving threat posed by chlorine, both in the form of an accidental release as well as an unconventional weapon, is an important first step to being prepared for this type of incident. Conflicts of Interest : By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources, and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. National Center for Biotechnology Information , U.
West J Emerg Med. Author information Article notes Copyright and License information Disclaimer. Email: lim. This article has been cited by other articles in PMC. Abstract Chlorine gas represents a hazardous material threat from industrial accidents and as a terrorist weapon. February 12, , Tacoma, WA Due to technician error when transferring chlorine from a rail car to storage containers in a bleach factory, over pounds of chlorine gas were released, forcing the closure of the Port of Tacoma.
Operation Iraqi Freedom, Insurgents in Iraq have recently executed multiple attacks using chlorine tanker trucks. Symptoms of chlorine exposure by concentration level. Open in a separate window. PPM , parts per million. Chlorine and water interact forming acid and oxidant byproducts. Clinical Effects Local irritation from acid results in an inflammatory response of the upper and lower airways leading to bronchospasm, cough and dyspnea.
Treatment Pre-hospital support of respiratory injuries involves removing patients from the source of exposure, providing supplemental oxygen, and administering inhaled beta-agonists for patients with bronchospasm. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med. Gussow L. Emergency Medicine News.
Acute Health effects after exposure to chlorine gas released after a train derailment. Am J Emerg Med. Rapid assessment of exposure to chlorine released from a train derailment and resulting health impact.
Public Health Rep. Wald M, Hart A. Accessed December 2, Gordon S. Chlorine has caused quite a stir among researchers over the years because of certain harmful effects it may have on human health.
Those effects, however, remain debatable. Chlorine is one of the atoms in a toxin that some South American frogs have in their skin.
It can paralyze or even kill large animals, according to the American Chemistry Council. Natives of the Colombian tropical rainforest used to rub the tips of their arrows on the skin of these " poison-dart frogs.
However, by rearranging the compound on the atomic level, chemists hope they can eventually find a version that is a potent pain reliever. Previous research has linked drinking chlorinated water to an increased cancer risk.
For example, in a study published in in the American Journal of Public Health, researchers found that people who drank chlorinated water had a 21 percent higher risk of getting bladder cancer, and a 38 percent higher risk of getting rectal cancer, than people who drank non-chlorinated water.
And, in another study, published in in the journal Environmental Health Perspectives, investigators found that people who swam in a chlorinated pool for 40 minutes had increased biomarkers i. However, a study published in the same journal found that while there is a higher bladder cancer risk when drinking chlorinated water, there was little to no evidence linking swimming in a chlorinated pool and bladder cancer risk in a study that looked at the number of hours in the swimming pool during summer and non-summer months and during different age ranges.
The U. Environmental Protection Agency have not classified chlorine as a human carcinogen, according to the Centers for Disease Control and Prevention. So, is chlorine bad for your health? Not exactly, said Preston J. In fact, the lack of appropriate chlorination to kill harmful bacteria, such as E.
For example, in May , in Walkerton, Ontario, seven people died and more than 2, got sick after the town's water supply became infected with E.
These figures do not include the U. Army's Edgewood, Maryland Arsenal plant's annual chlorine gas production capacity of 36, tons.
In his report on the Economics of Chlorine, D. Pritchard concludes "The [chlor-alkali] industry in North America has had to manufacture and sell cheaply, find markets and new uses, switch largely from bleaching powder to liquid chlorine, provide technical service, and adjust more or less imperfectly the economics of three distinct substances evolved in one major operation to a rapidly changing industrial structure, and do it all in about 16 years.
A capacity bearing a reasonable relation to consumption, a decent return on its capital, and the continuance of research are essential to this key industry. In January , when Eben C. Speiden was contacting chlorine producers in the U. The original activities of the Chlorine Institute, therefore, were structured as the charter dictated, " The first three committees remained active through , and CI's Transportation Committee remains active to this day as the Transportation Issue Team.
Development of a practical method of bleaching 'kraft' pulp, which makes possible the production of heavy-duty paper in white and pastel shades.
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