Smoke Inhalation Poisoning English

Smoke Gas Poisoning

Irritant gases can cause tracheitis, bronchitis, and bronchiolitis with hyperemia, bronchospasm, excessive mucus secretion, and edema. In severe cases, an ARDS-like picture can develop with progressive lung fibrosis. Inspection of the pharynx and larynx before intubation should be done if soot and edema are present, using thin fiberoptic bronchoscopy via the nose under light sedation. Singed eyebrows, eyelashes, nasal hair, and beard, conjunctivitis, increased tear flow, photophobia, facial burns, coughing up soot, edema in the throat and nasal passages are symptoms of inhalation injury. The larynx can swell significantly after thermal injuries, and soot can mechanically obstruct the airways. Soot can plug the bronchial tree and cause obstructed airways with auto-PEEP. Other symptoms may include coughing, hoarseness, stridor, and obstructive breathing. If severe edema is present in the airways, the patient should be intubated urgently and cared for in an intensive care unit.

Toxic gases can exert direct toxicity, such as hydrogen cyanide (blocking cellular respiration), carbon monoxide (blocking oxygen transport), or chlorine gas (mucous membrane irritant). Other gases can cause severe hypoxia by displacing oxygen in inhaled air, such as methane, sulfur dioxide, hydrogen sulfide, carbon dioxide, and butane gas.

Inhalation of black soot quickly causes severe shortness of breath, airway irritation, edema, and coughing. The primary action when exposed to irritant gases is, of course, to avoid further exposure and breathe fresh air. If the exposure was short, most people recover quickly without needing medical attention, but sensitive individuals may present with persistent bronchial obstruction and airway irritation. Significant exposure to smoke can cause severe symptoms that may lead to prolonged problems. Inhalation of smoke primarily causes carbon monoxide and hydrogen cyanide poisoning, leading to severe toxic symptoms.

Irritant Gases

Highly Soluble Gases

Highly soluble gases dissolve easily in moist mucous membranes, such as in the upper respiratory tract and eyes. These gases cause immediate symptoms.

Examples of highly soluble gases include:

• Alkali
• Ammonia
• Phenacyl chloride
• Hydrofluoric acid gas
• Formaldehyde
• Gaseous acids
• Sulfur dioxide
• Hydrogen chloride (hydrochloric acid)
• Zinc chloride (used in military smoke grenades)

Moderately Soluble Gases

Gases with moderate solubility in water cause symptoms in both the upper and lower respiratory tracts.

Examples of moderately soluble gases include:

• Phenol
• Sulfur dioxide

Poorly Soluble Gases

Poorly soluble gases do not dissolve easily in moist mucous membranes, so they reach the lower respiratory tract, including the alveoli. These gases cause delayed symptoms, which can appear 30 minutes to 48 hours after exposure, with a risk of late pulmonary edema. The severity of airway damage depends on the gas concentration, exposure duration, and the gas’s solubility. Poorly soluble gases cause deeper injuries that are more likely to result in permanent damage, such as bronchiolitis, granulation with fibrosis, and ARDS. Phosgene and nitrogen gases can cause mild initial symptoms that worsen over time.

Examples of poorly soluble gases include:

• Phosgene
• Isocyanates
• Chlorine
• Chlorine dioxide
• Mercury vapor
• Nitrogen dioxide
• Nitrogen gases
• Hydrogen sulfide (sulfide gas)
• Ortho-chlorobenzylidene malononitrile (tear gas)

Symptoms After Inhalation of Toxic Gases

Inhalation of smoke and other irritant gases usually causes severe irritation in the airways, with persistent coughing, shortness of breath, excessive mucus secretion, and airway obstruction (bronchospasm). Hypoxia, cyanosis, and hypercapnia may follow. Other clinical symptoms include agitation, anxiety, dyspnea, tachypnea, nasal flaring, decreased consciousness, unconsciousness, and intercostal retractions. Note that some toxic gases can be harmful without causing airway irritation, such as carbon monoxide.

Laryngospasm can cause severe hypoxia, fainting, and unconsciousness. When the laryngospasm resolves, reflexive pulmonary edema may occur. Exposure to poorly soluble gases or nitrogen gases can lead to toxic pulmonary edema later in the process, so the patient should be monitored for at least 24 hours.

Treatment After Inhalation of Toxic Gases

Patients who have inhaled toxic gas or smoke are typically treated with both corticosteroids and bronchodilators through inhalation.

Budesonide (Pulmicort) and terbutaline (Bricanyl) or salbutamol (Ventoline) are given in repeated inhalations. Combivent and Sapimol contain both ipratropium and salbutamol. Corticosteroids may need to be given in repeated doses via inhalation, typically not administered systemically. Administer beta-stimulants before corticosteroids to improve steroid distribution to more lung segments.

In severely ill patients, it is better to secure the airway quickly through intubation with controlled ventilation and care in a respirator. Respiratory arrest can occur suddenly in an exhausted patient. Bronchoscopy should be performed for diagnostics and suctioning of mucus and soot. Soot in the airways can plug the bronchial tree and should be removed by bronchoscopy with lavage. Note the risk of early or late pulmonary edema. Be cautious with tracheostomy in patients with burns over the jugular area.

Awake Patient

• Maintain a calm and quiet environment
• After inhaling irritant or toxic gases or smoke, the patient should ideally rest in a sitting position, known as the cardiac position, preferably with oxygen via a tight-fitting mask.
• If there is significant exposure with airway swelling or the presence of soot, the airways should be inspected using fiberoptic bronchoscopy.

Unconscious Patient

• The patient should be placed in the left lateral position or alternatively in the recovery position.
• Initially, 100% oxygen should be administered via a mask, and urgent intubation with controlled ventilation should be performed rapidly if unconsciousness is present. If cardiac arrest occurs after smoke gas poisoning, there is a high risk of global anoxic brain damage.
• If there is significant exposure with airway swelling or the presence of soot, the airways should be inspected with fiberoptic bronchoscopy. There should be a liberal indication for intubation.

Oxygen

Initially, administer 100% oxygen via a tight-fitting mask with a reservoir bag until CO-Hb levels are determined and severe carbon monoxide poisoning is ruled out. If CO-Hb is lower than 10%, oxygen can subsequently be given via a partial-rebreather mask, Optiflow system, or nasal cannula. Via nasal cannula, provide 4-6 liters/min to achieve SaO₂ ≥ 90%. Mask ventilation may be difficult when the patient has a strong need to cough. Coughing can be relieved with morphine and theophylline.

Inhalation Therapy

Inhalation therapy is administered early with beta-stimulants and steroids. Repeated treatments are often necessary.

Beta 2-Stimulants

• Terbutaline (Bricanyl Turbuhaler) 0.5 mg/dose, 2-3 inhalations as soon as possible, alternatively
• Salbutamol (Ventoline) 5 mg/ml, 1-2 ml inhalation solution via nebulizer. The above inhalation can be combined with 2 ml ipratropium bromide (Combivent, Sapimol, Atrovent) inhalation solution 0.25 mg/ml in case of significant mucus secretion.
• If the patient cannot inhale, beta 2-stimulants can be administered parenterally. Injection solution terbutaline (Bricanyl) 0.5 mg/ml, 0.5-1.0 ml subcutaneously. In severe attacks, 1 ml of the injection solution is diluted with 10 ml NaCl and given slowly (over 5 minutes) intravenously.

Steroids

• Indication for corticosteroid treatment exists if the patient has had significant irritant symptoms with intense bothersome coughing or respiratory distress, obstruction, or has been exposed to phosgene or nitrogen gases.
• Steroids are primarily administered by inhalation via nebulizer. Budesonide (Pulmicort) suspension for nebulizer 2 mg x 2 (4 ml x 2).
• In severe symptoms, initially 10 inhalations and if needed 4-5 inhalations x 1-2 within the first hour. After each inhalation, hold the breath for about 10 seconds. The next inhalation should be taken after a few normal breaths. In cases of recurrent symptoms, give an additional 2-3 treatments within the first 24 hours. The doses are halved for children.
• Systemic corticosteroid treatment (intravenous) is generally not recommended. If steroids cannot be administered by inhalation, systemic administration (intravenous/intramuscular) may be considered.

CPAP Treatment

CPAP (Continuous Positive Airway Pressure) with 100% oxygen (BiPAP) can be tried. The resistance is varied between 5 and 10 cm H₂O. Never start with 10 cm H₂O, but typically with 5 cm H₂O. However, note that this involves additional breathing effort and can be an enormous strain on the patient. Sedation is often required. During CPAP treatment, there must be immediate readiness for intubation. A fatigued patient should not be treated with CPAP. Intubation with controlled ventilation is much safer and better if the patient is exhausted.

Nasal High-Flow System – HFNC – “Optiflow System”

An Optiflow system can be advantageously used if the patient has a pronounced cough, as it is difficult to cough in a tight-fitting mask. Optiflow provides increased resistance during exhalation and helps to inflate atelectatic areas. HFNC – High Flow Nasal Cannula.

Anticholinergics

Anticholinergics are often used to reduce bronchospasm in patients with irritant gas inhalation. They can be combined with beta 2-agonists for a better effect on airway dilation.

Atropine 0.5 mg/ml, 2 ml i.v. or glycopyrron (Robinul) 0.2 mg/ml, 1-2 ml i.v. Note that in rare cases of poisoning with organophosphates, isocyanides, and certain insecticides or pesticides, significantly larger doses of atropine (SIC doses) may be required. Treatment is guided by the clinical picture, including airway mucus secretion or other cholinergic symptoms.

Theophylline

May be given in cases of severe breathing difficulty or persistent coughing. Administer 10 ml (23 mg/ml) of theophylline slowly (10 minutes) i.v. Never administer into a central vein. Overdose can cause life-threatening arrhythmias. Then, add 20 ml of theophylline to 500 ml of 5% glucose over 12 hours. Ideally, monitor theophylline concentration in serum.

Cutaneous Exposure

If the patient has been exposed to chemicals via the skin (cutaneous exposure), possibly in combination with burns, the patient should be decontaminated. Remove all clothing (use sturdy protective gloves when handling chemical liquids). Shoes and jewelry should also be removed. Wash or shower the patient with large amounts of water. Use warm water and ensure the patient does not become hypothermic. In case of chemical exposure, the patient should be decontaminated outdoors first, if possible, and then again indoors. Pay close attention to the eyes. If the patient’s clothes are dry, decontamination is usually unnecessary. Wash exposed skin with soap and water, but do not overdo the procedure.

Some decontamination facilities are located in semi-enclosed rooms, such as ambulance bays. These areas are often cold, so it is essential to quickly provide the patient with warm clothes and blankets to prevent hypothermia. In the case of exposure to strong alkaline chemicals, rinsing should be done for an extended period. Gases and odors from toxic chemicals can be blown away or extracted with fan systems— make sure the air is warm!

If staff members are exposed to irritant gases, they may also need treatment with corticosteroid inhalations! Be aware if anyone has performed mouth-to-mouth resuscitation on the patient.

Eye Irritation

If burning, itching, or redness occurs in the eyes, rinse as soon as possible with running water for 5-15 minutes. Keep the eyelids wide open to ensure effective rinsing. Examples of eye-irritating substances include chlorine gas, lye, or various acids. Exposure to these substances may require longer rinsing than 15 minutes. Eye irritation is common among swimmers in incidents involving chlorine leaks in pools.

Follow-up

Follow-up of patients exposed to smoke is crucial, as respiratory symptoms and shortness of breath can lead to long-term problems and, in some cases, permanent damage. Referral to a pulmonary clinic is essential. In relevant cases, a work injury report must also be filed.

Chemical Pesticides

Several chemical pesticides resemble nerve gases.

Organophosphates

Inhibit acetylcholinesterase.

Organochlorines

These have been banned except in Iran, Sri Lanka, and parts of the former Soviet Union.

Pesticides

• TEPP (tetraethyl pyrophosphate)
• Parathion
• Nicotin sulfate
• DFP (diisopropyl fluorophosphate)

Rehabilitation

Patients who experience significant smoke inhalation or toxic gas exposure may need rehabilitation, especially if there is long-term lung damage such as fibrosis or chronic obstructive symptoms. Pulmonary rehabilitation, including breathing exercises and physical therapy, may be essential for recovery. Long-term follow-up with a pulmonologist may also be necessary to monitor for any delayed complications such as ARDS or chronic bronchitis.

Follow-up Care

Patients who have inhaled toxic gases, smoke, or irritants should receive appropriate follow-up care. This includes monitoring for long-term respiratory effects, such as chronic bronchitis or obstructive lung disease. Pulmonary function tests may be performed to assess the extent of lung damage and to guide treatment. In cases where the patient has experienced significant exposure, regular check-ups with a respiratory specialist may be necessary to track recovery and prevent complications such as fibrosis or recurrent respiratory infections.

Additional Considerations

For patients who have suffered extensive smoke or toxic gas inhalation, psychological support may also be needed. These patients may experience anxiety, post-traumatic stress disorder (PTSD), or other mental health issues related to the incident. Mental health screening and counseling should be part of the comprehensive care plan, especially for those who have survived severe exposure or life-threatening situations.

Preventive Measures

Preventing exposure to toxic gases and smoke is critical, especially in high-risk environments such as industrial settings, firefighting, or chemical plants. Proper use of personal protective equipment (PPE), including respirators and protective clothing, can help reduce the risk. For individuals working in such environments, regular training on the use of protective gear and safety protocols is essential to prevent inhalation injuries.

In residential settings, smoke detectors and carbon monoxide detectors should be installed and maintained to alert occupants of potential exposure to toxic gases. In case of a fire, immediate evacuation is critical to avoid smoke inhalation.

Conclusion

Smoke and toxic gas inhalation can lead to serious respiratory complications, including airway obstruction, pulmonary edema, and in severe cases, death. Early intervention with oxygen therapy, bronchodilators, and steroids is essential in managing acute symptoms. For those with severe exposure, prolonged monitoring and follow-up care are necessary to prevent long-term damage. Preventive measures, such as using proper safety equipment and installing smoke detectors, can significantly reduce the risk of inhalation injuries.

Anticholinergics

Anticholinergics, such as ipratropium bromide (e.g., Atrovent^®), are commonly used to treat bronchospasm caused by irritant gas inhalation. They are often combined with beta-2 agonists like salbutamol (Ventoline^®) for enhanced bronchodilation effects. Administered via nebulizer, these medications help relieve airway constriction and reduce mucus production in the bronchi, improving respiratory function in affected patients.

Other Supportive Treatments

In cases where inhalation injury leads to significant respiratory distress or compromised lung function, supportive treatments such as mechanical ventilation or extracorporeal membrane oxygenation (ECMO) may be considered. These interventions are typically reserved for patients in critical condition who are unresponsive to conventional therapies. Careful monitoring of blood gases, lung function, and oxygen levels is crucial in determining the need for such advanced treatments.

Fluid Management

Inhalation injuries, especially those associated with burns, can lead to fluid imbalances in the body. Careful fluid management is essential to prevent pulmonary edema, which can exacerbate respiratory distress. Fluids should be administered judiciously, balancing the need for hydration with the risk of fluid overload in the lungs. Monitoring urine output, electrolyte levels, and cardiac function is important in guiding fluid therapy.

Antibiotic Therapy

Inhalation injuries, particularly those involving smoke or chemical gases, may increase the risk of secondary infections, such as pneumonia. Prophylactic antibiotic therapy is not routinely recommended but may be necessary in patients showing signs of infection, such as fever, increased white blood cell count, or sputum production. Antibiotic treatment should be guided by culture results and tailored to the specific pathogens present.

Pain Management

Patients with inhalation injuries may experience significant pain, particularly if there are associated burns or airway irritation. Opioids, such as morphine, can be used to manage pain effectively, but care should be taken to avoid respiratory depression. Non-opioid pain relievers, such as acetaminophen or NSAIDs, may also be used in conjunction with opioids to provide additional pain relief without compromising respiratory function.

Sedation and Anxiety Management

Patients with severe respiratory distress, especially those undergoing mechanical ventilation or invasive procedures, may require sedation to reduce anxiety and improve comfort. Benzodiazepines, such as midazolam (Dormicum^®), are commonly used for their anxiolytic and sedative properties. Sedation should be carefully monitored to avoid oversedation, which can lead to respiratory depression or prolonged mechanical ventilation.

Monitoring and Follow-Up

After acute management of inhalation injuries, patients require careful monitoring to detect any delayed complications, such as pulmonary edema, infections, or long-term respiratory impairment. This may involve repeated chest X-rays, pulmonary function tests, and regular assessments by a pulmonologist. Ongoing oxygen therapy or rehabilitation may be necessary for patients with persistent respiratory symptoms or lung damage.

Long-Term Effects

Long-term consequences of smoke or toxic gas inhalation may include chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), bronchiectasis, or pulmonary fibrosis. These conditions can lead to long-lasting difficulty in breathing, reduced exercise tolerance, and a need for ongoing medical treatment. Patients with significant exposure should be educated about these risks and encouraged to seek regular follow-up care to manage any chronic symptoms.

Preventive Care and Education

Educating patients on the importance of avoiding future exposure to smoke or toxic gases is critical. This includes the use of protective gear in work environments, installation of smoke detectors in homes, and awareness of fire safety practices. Patients with chronic lung conditions should be advised to get regular vaccinations, such as the flu vaccine and pneumococcal vaccine, to reduce the risk of respiratory infections.

Psychosocial Support

Inhalation injuries, particularly those resulting from fires or chemical accidents, can be traumatic experiences. Many patients may suffer from anxiety, depression, or post-traumatic stress disorder (PTSD) after their recovery. Providing access to counseling or mental health support is essential in helping patients cope with the psychological aftermath of their injuries.

Herbicides

Insecticides

Chemical Weapons of Terrorism

• Chlorine gas
• Ammonia
• Sulfur dioxide
• Cyanide
• Nerve gases
• Pesticides – insecticides
• Phosgene
• Mustard gas
• BZ
• 3-quinuclidinyl benzilate (QNB)
• Arsine
• Psychoactive drugs
• Synthetic opioids like fentanyl, carfentanil
• Novichok

Nerve Gases

• Extremely toxic synthetic organophosphate compounds
• Nerve gases have been used in warfare and terror attacks but are prohibited under international conventions
• Used as chemical weapons due to their extreme potency as nerve agents
• Liquids that are dispersed as aerosols
• Work by inhibiting the enzyme acetylcholinesterase
• Cause the accumulation of acetylcholine with both peripheral and central effects
• Most nerve gases are colorless with little to no odor

Estimated LC_t50 by Inhalation

• 400 mg-min/m³ for Tabun
• 100 mg-min/m³ for Sarin
• 50 mg-min/m³ for Soman
• 10 mg-min/m³ for VX

Percutaneous LD₅₀

• 1000 mg for Tabun
• 1700 mg for Sarin
• 350 mg for Soman
• 6-10 mg for VX

Symptoms of Nerve Gas Poisoning

• Cholinergic overstimulation
• Muscle twitching
• Sweating
• Diarrhea
• Vomiting
• Miosis (constricted pupils)
• Increased tearing
• Runny nose, mucus, increased salivation
• Shortness of breath
• Bronchospasm, mucus in the airways
• Pulmonary edema
• Bradycardia, cardiac arrest, circulatory collapse

Tabun (G-A)

• Toxic via inhalation
• Easy to produce
• Synthesized as a chemical weapon in 1936
• Estimated LC_t50 by inhalation: 400 mg-min/m³
• Percutaneous LD₅₀: 1000 mg

Sarin (G-B)

• Toxic via inhalation
• Easy to produce
• Volatile
• Synthesized as a chemical weapon in 1938
• Estimated LC_t50 by inhalation: 100 mg-min/m³
• Percutaneous LD₅₀: 1700 mg

Soman (G-D)

• Toxic via inhalation and skin contact
• Fast-acting
• Synthesized as a chemical weapon in 1944
• Estimated LC_t50 by inhalation: 50 mg-min/m³
• Percutaneous LD₅₀: 350 mg

VX

• Toxic via inhalation and skin contact
• Challenging to produce
• Extremely toxic; a few drops can be lethal
• Synthesized as a chemical weapon in 1952
• Estimated LC_t50 by inhalation: 10 mg-min/m³
• Percutaneous LD₅₀: 6-10 mg

Novichok

• Extremely toxic nerve agent developed in the Soviet Union during the 1970s and 1980s
• A series of different agents with cholinergic effects
• Irreversibly binds to acetylcholinesterase, preventing acetylcholine breakdown
• Binary chemical weapon
• Considered the most deadly nerve agent, more lethal than VX and Soman
• Cannot be detected by traditional NATO chemical detection methods
• Penetrates older NATO hazmat suits
• Easy to transport, difficult to manufacture and detect
• Can be inhaled, injected, absorbed through the skin, or ingested

• Neurological symptoms: hallucinations, slurred speech, muscle fasciculations, muscle cramps, paralysis, seizures
• Miosis (pupil constriction)
• Respiratory symptoms: salivation, coughing, bronchospasm, bronchorrhea
• Cardiac symptoms: bradycardia, conduction disturbances, cardiac arrest
• Electrolyte imbalances: hyperglycemia, hypokalemia

Diagnostics

• Measure acetylcholinesterase activity (cholinesterase activity in plasma)

Treatment

• Decontamination before hospital admission!
• If contaminated food is ingested, activated charcoal can be administered before or after gastric lavage
• Atropine
• Reactivation with oxime

Atropine

• Give 2-6 mg every 5 minutes until bradycardia, bronchorrhea, and bronchospasm are resolved
• An 80 kg patient may require approximately 576-1728 mg of atropine per day
• 1152-3456 atropine ampules/day!

Oxime: Reactivation of Acetylcholinesterase

• Obidoxime 250 mg IV, children 4 mg/kg, not effective against Soman (Toxogonin is deregistered)
• Pralidoxime
• HI-6
• Hlö-7

Summary of Nerve Gas Toxicity and Treatment

Nerve agents are extremely dangerous chemicals that can cause severe and often fatal health effects. The effects include respiratory distress, cardiovascular failure, neurological symptoms, and extensive damage to other organs. Prompt diagnosis, decontamination, and treatment are essential for survival. The most effective treatments include the use of atropine, oximes (such as obidoxime or pralidoxime), and supportive measures like oxygen therapy and mechanical ventilation.

Decontamination Process for Nerve Agents

• Ensure personal protective equipment (PPE) is worn by all medical personnel during decontamination.
• Remove the patient’s contaminated clothing and wash the skin thoroughly with soap and water to remove any remaining nerve agents.
• If the nerve agent was ingested, gastric lavage may be performed followed by the administration of activated charcoal.
• Decontaminate open wounds immediately and apply appropriate wound care after removing the nerve agent from the skin.

Immediate Care for Nerve Agent Poisoning

• Administer atropine as a first-line antidote to counteract the cholinergic effects. Continue administration every 5 minutes until symptoms like bradycardia and bronchospasm are relieved.
• Oxime therapy (such as obidoxime or pralidoxime) should be started as soon as possible to help reactivate acetylcholinesterase.
• Provide supportive care, including oxygen therapy and mechanical ventilation, as needed.
• Monitor the patient’s vital signs and symptoms continuously.

Supportive Treatment for Nerve Agent Exposure

After initial decontamination and antidote administration, patients may require ongoing supportive care, including respiratory support, cardiovascular monitoring, and fluid management. Depending on the severity of the exposure, some patients may need intensive care unit (ICU) admission for further observation and treatment.

Protection Against Future Nerve Agent Exposure

Proper training in the use of personal protective equipment and decontamination procedures is essential for preventing nerve agent exposure, especially for emergency responders and medical personnel who may encounter these chemicals in a terrorist attack or industrial accident. Awareness campaigns and preparedness drills should be regularly conducted in high-risk areas, including chemical plants and military facilities, to reduce the risk of accidental exposure and to ensure readiness in case of intentional chemical attacks.

Other Toxic Gases and Chemicals

Acrolein (CH₂CHCHO)

• Acrolein is a colorless or yellow liquid with a strong, pungent odor, commonly produced in combustion processes and used as a pesticide and in chemical manufacturing.
• Inhalation of acrolein can cause severe respiratory irritation, leading to coughing, wheezing, and shortness of breath. High concentrations can cause pulmonary edema and respiratory failure.
• Symptoms include irritation of the eyes, nose, and throat, followed by coughing, chest pain, and difficulty breathing. Prolonged exposure can result in chronic lung damage.
• Treatment includes removing the individual from the source of exposure, administering oxygen, and providing supportive care with bronchodilators and corticosteroids to reduce lung inflammation. In severe cases, mechanical ventilation may be necessary.
• Prevention includes using proper ventilation and personal protective equipment (PPE) in industrial areas where acrolein is present or produced.

Ammonia (NH₃)

• Ammonia is a colorless gas with a strong, irritating odor, commonly used in fertilizers and industrial refrigeration systems.
• Exposure to high concentrations can cause severe irritation of the eyes, throat, and respiratory system, leading to coughing, shortness of breath, and pulmonary edema.
• Symptoms include burning sensations in the eyes, nose, and throat, wheezing, and difficulty breathing. High concentrations can result in chemical burns to the skin and respiratory tract.
• Treatment includes removing the patient from the source of exposure, administering oxygen, and providing bronchodilators and corticosteroids to reduce respiratory distress. In severe cases, mechanical ventilation may be required.
• Ammonia exposure prevention includes proper ventilation and the use of protective gear, especially in industrial and agricultural settings.

Arsine (AsH₃)

• Arsine is a highly toxic, colorless gas with a mild garlic odor, used in the semiconductor industry and as a byproduct in the refining of metals containing arsenic.
• Exposure primarily affects red blood cells, causing hemolysis (the destruction of red blood cells), leading to anemia, jaundice, and kidney failure.
• Symptoms include weakness, headache, dizziness, nausea, abdominal pain, dark urine (due to hemoglobinuria), and in severe cases, kidney failure and death.
• Treatment involves removing the patient from exposure, administering oxygen, and supportive care such as blood transfusions and dialysis in cases of renal failure.
• Preventive measures include proper handling of arsenic-containing materials and using PPE to minimize exposure risks.

Arsenic (As)

• Arsenic is a naturally occurring element found in water, soil, and certain industrial processes. It is highly toxic and has been used historically as a pesticide and in wood preservation.
• Chronic exposure to arsenic can cause skin lesions, cancer, cardiovascular disease, and neurological damage. It is also linked to developmental and reproductive issues.
• Symptoms of arsenic poisoning include vomiting, abdominal pain, diarrhea, and in severe cases, shock, convulsions, and death. Chronic exposure leads to skin changes, peripheral neuropathy, and an increased risk of cancer.
• Treatment includes removing the person from exposure, administering chelation therapy, and providing supportive care. Long-term monitoring is necessary for cancer and cardiovascular disease risks.
• Prevention includes ensuring safe drinking water (free from arsenic contamination), reducing occupational exposure, and using protective equipment in industries that handle arsenic.

Benzene (C₆H₆)

• Benzene is a colorless, flammable liquid with a sweet odor, commonly used in the manufacture of plastics, resins, and synthetic fibers.
• Benzene is highly toxic and exposure can lead to serious health effects, including bone marrow suppression, leading to anemia and increased risk of leukemia.
• Short-term exposure to high levels of benzene can cause drowsiness, dizziness, rapid heartbeat, headaches, tremors, and in severe cases, loss of consciousness.
• Treatment includes removing the individual from exposure, administering oxygen, and providing supportive care for symptoms. Chronic exposure may require hematologic monitoring.
• Prevention involves controlling industrial emissions, using appropriate ventilation systems, and wearing personal protective equipment in workplaces where benzene is present.

Cadmium (Cd)

• Cadmium is a toxic heavy metal used in batteries, coatings, and plastics. It is released into the environment through mining, smelting, and manufacturing processes.
• Exposure to cadmium can lead to kidney damage, bone fragility, and respiratory issues. Long-term exposure is associated with an increased risk of cancer, particularly lung cancer.
• Symptoms of cadmium poisoning include nausea, vomiting, diarrhea, lung irritation, and in severe cases, kidney failure and bone weakness (osteomalacia).
• Treatment involves removing the person from exposure, administering chelation therapy, and providing supportive care. Long-term monitoring may be required for kidney function and bone health.
• Prevention includes using proper ventilation in workplaces where cadmium is used and wearing personal protective equipment to reduce exposure risks.
• Silvery-white, soft metal found in the earth’s crust and certain water sources
• Cadmium is one of the most toxic heavy metals, found in batteries and alloys
• Toxic primarily with chronic exposure
• Can damage airways, kidneys, and lungs
• Cadmium accumulates mainly in the kidneys
• May be carcinogenic

Carbon Disulfide (CS₂)

• Carbon disulfide is a colorless, flammable liquid with a sweet, chloroform-like odor, used in the manufacture of viscose rayon and cellophane.
• Exposure to carbon disulfide can affect the nervous system, causing symptoms such as headache, dizziness, confusion, and, with long-term exposure, peripheral neuropathy.
• Chronic exposure is associated with cardiovascular diseases, as well as reproductive toxicity and damage to the liver and kidneys.
• Treatment involves removing the individual from the source of exposure, administering oxygen, and providing supportive care for neurological and cardiovascular symptoms.
• Prevention includes adequate ventilation and the use of PPE in industries where carbon disulfide is used.

Carbon Monoxide (CO)

Carbon monoxide poisoning is common after exposure to smoke and smoldering fires. Accidents often occur during incomplete combustion. Carbon monoxide can leak from gas stoves and heaters, such as in motorhomes, trucks, or outdoor shelters.

• Carbon monoxide is a colorless, odorless, and tasteless gas produced by the incomplete combustion of carbon-containing materials.
• Carbon monoxide binds strongly to hemoglobin, blocking oxygen transport in the blood
• It binds to hemoglobin with an affinity 200 times greater than oxygen, forming carboxyhemoglobin (COHb), reducing oxygen delivery to tissues.
• Symptoms include headache, dizziness, weakness, nausea, vomiting, confusion, chest pain, and in severe cases, seizures, loss of consciousness, and death.
• CO poisoning is diagnosed by measuring COHb levels in the blood, and treatment involves administering 100% oxygen via a tight-fitting mask or intubation.
• Hyperbaric oxygen therapy (HBOT) may be indicated in severe cases.
• Prevention includes installing CO detectors in homes and ensuring proper ventilation in areas where combustion occurs, such as garages and kitchens.
• Flammable, toxic gas produced by incomplete combustion of organic materials. It forms during the combustion of most materials
• Odorless gas
• Used in the manufacture of metals, acetic acid, formic acid, acrylic acid, and propionic acid

Consider hyperbaric oxygen therapy (HBO) and urgent transport to a hyperbaric chamber if the patient is unconscious or has been unconscious. Consult the Poison Information Center if in doubt. CO-Hb levels above 25% indicate severe carbon monoxide poisoning. Treatment primarily consists of oxygen via a tight-fitting breathing mask (NBO, normobaric oxygen therapy). Lactate levels rarely exceed 10 mmol in pure carbon monoxide poisoning cases.

View treatment overview: Carbon monoxide poisoning

Carbon Tetrachloride (CCl₄)

• Carbon tetrachloride is a clear, colorless liquid with a sweet odor, primarily used as a solvent and in the production of refrigerants and propellants for aerosol cans.
• Exposure to carbon tetrachloride can cause severe damage to the liver, kidneys, and central nervous system. Inhalation can lead to dizziness, nausea, and unconsciousness. Chronic exposure increases the risk of liver cancer.
• Symptoms include dizziness, headache, confusion, nausea, and in severe cases, liver failure and coma.
• Treatment involves removing the individual from exposure, administering oxygen, and providing supportive care for liver and kidney damage. In severe cases, hospitalization and monitoring may be required.
• Prevention includes proper ventilation in areas where carbon tetrachloride is used, and wearing appropriate protective equipment to minimize exposure.

Chlorine Gas (Cl₂)

• Chlorine is a yellow-green gas with a pungent, irritating odor, commonly used in water treatment, disinfection, and chemical production.
• Inhalation of chlorine gas can cause severe irritation to the respiratory system, eyes, and skin, potentially leading to pulmonary edema, bronchospasm, and respiratory failure.
• Symptoms include coughing, chest pain, shortness of breath, burning eyes, and throat irritation. Severe cases may result in asphyxiation and death.
• Chlorine gas is heavier than air and can accumulate in low-lying areas, posing a significant risk in enclosed spaces.
• Treatment involves removing the person from exposure, administering humidified oxygen, and providing bronchodilators and corticosteroids to reduce respiratory inflammation. In severe cases, mechanical ventilation may be required.
• Prevention involves ensuring proper ventilation and using protective gear in industrial settings where chlorine gas is used or produced.

Chloroform (CHCl₃)

• Chloroform is a colorless, sweet-smelling liquid once used as an anesthetic and now used in the production of chemicals and refrigerants.
• Inhalation or ingestion of chloroform can cause central nervous system depression, leading to dizziness, fatigue, headache, and loss of consciousness. Chronic exposure can lead to liver and kidney damage and an increased risk of cancer.
• Symptoms include dizziness, fatigue, confusion, and in severe cases, unconsciousness. Prolonged exposure may result in liver and kidney damage.
• Treatment involves removing the person from the source of exposure, administering oxygen, and providing supportive care. Long-term exposure may require monitoring for liver and kidney function.
• Prevention includes proper handling and storage of chloroform in well-ventilated areas, along with the use of PPE.

Chromium

• Silver-shiny heavy metal. Found in the earth’s crust
• Used in alloys, surface treatments, textile dyeing, stainless steel
• Chromates and chromic acid are carcinogenic and can cause allergies

Cyanide (CN⁻)

• Cyanide is a highly toxic chemical found in some industrial processes, including mining, electroplating, and the production of plastics and chemicals. It can also be released during combustion of certain materials, such as plastics and wool.
• Cyanide blocks cellular respiration by inhibiting the enzyme cytochrome c oxidase, preventing cells from using oxygen. This results in rapid cell death, particularly in the brain and heart.
• Symptoms include headache, dizziness, shortness of breath, rapid heart rate, confusion, seizures, and in severe cases, respiratory failure and death.
• Treatment involves administering specific antidotes, such as sodium thiosulfate or hydroxocobalamin (Cyanokit), to neutralize cyanide, along with oxygen therapy and supportive care. Immediate treatment is crucial to prevent fatal outcomes.
• Prevention includes proper handling and storage of cyanide-containing materials and chemicals, using protective equipment in industrial settings, and following safety protocols.
• Lethal dose of hydrogen cyanide is less than 5 mg/kg in gas form
• The lethal dose for humans in acute poisoning has been reported to be 0.5-3.5 mg HCN/kg body weight (1 mg/kg)
• Lactate formation < 5 mmol/l indicates mild poisoning
• 5-10 mmol/l indicates moderate poisoning
• 10-20 mmol/l indicates severe poisoning
• > 20 mmol/l indicates life-threatening poisoning
• Serum cyanide determination is not done routinely

Cyanide Poisoning Symptoms

• Shortness of breath, hyperventilation
• Respiratory failure, respiratory paralysis
• CNS impairment, confusion
• Fainting, dizziness
• Unconsciousness, coma
• Low blood pressure
• Circulatory failure
• Metabolic acidosis
• Small difference in arterial and venous oxygen saturation (<10%, SvO₂>80%)
• Lactatemia
• Smell of bitter almonds
• Important to monitor blood gases
• Metabolic acidosis

Treatment of Cyanide Poisoning

• Immediate decontamination and removal from the source of exposure are critical.
• Administer 100% oxygen to improve oxygenation and reduce symptoms.
• Antidote therapy with sodium thiosulfate should be initiated as soon as cyanide poisoning is suspected. The typical dose is 12.5 g (50 ml of 25% solution) intravenously over 10-20 minutes.
• Hydroxocobalamin (Cyanokit) can also be used as an antidote, which works by binding cyanide to form cyanocobalamin, which is then excreted in urine. Administer 5 g IV over 15 minutes.
• Supportive care, including cardiovascular monitoring and fluid resuscitation, should be provided.
• Monitor lactate levels as cyanide poisoning leads to rapid lactic acidosis. Metabolic acidosis should be corrected with sodium bicarbonate if necessary.
• Severe cases may require mechanical ventilation and ICU care.
• Amyl nitrite or sodium nitrite can be used as an antidote in certain cases, converting hemoglobin to methemoglobin, which binds cyanide.

Antidote Therapy for Cyanide Poisoning

• Amyl nitrite inhalation
• Hydroxocobalamin intravenously
• Sodium thiosulfate intravenously

Antidote therapy for cyanide poisoning can be started on-site in cases of exposure to smoke or hydrogen cyanide but usually, treatment begins after arrival at the hospital, guided by an arterial blood gas test measuring SvO₂ and lactate. Cyanide is generally not measurable.

Antidote for cyanide poisoning is given if the victim has been or is unconscious and has been pulled out of a burning building with soot in their nostrils or coughing soot. Lactate levels below 10 mmol/l indicate that severe cyanide poisoning is not present and antidote treatment is not needed. Severe cyanide poisoning is usually associated with fainting and unconsciousness. If the patient is conscious, severe cyanide poisoning is less likely. Hydroxocobalamin (Cyanokit) is given intravenously for poisoning with hydrogen cyanide (smoke inhalation) or other cyanide compounds.

Treatment with hydroxocobalamin (Cyanokit):

• Adults: 5 g administered intravenously as an infusion over 15-30 minutes, repeated if necessary
• Children: 70 mg/kg body weight

Note that after treatment with hydroxocobalamin, the skin, urine, and other body fluids will turn bright red. This should be communicated to staff and the patient to avoid surprise or concern. The color can affect chemical analyses based on chromatography.

If Cyanokit is not available, treatment can also be given with sodium thiosulfate.

• Adults: sodium thiosulfate 150 mg/ml: 15 g (100 ml) administered intravenously over 5-10 minutes. May be repeated
• Children: 375 mg (= 2.5 ml)/kg body weight

Dichloromethane (DCM, CH₂Cl₂)

• Dichloromethane is a colorless liquid with a mild, sweet odor, used as a solvent in paint removers, adhesives, and aerosol sprays, as well as in the production of plastics and pharmaceuticals.
• Short-term exposure to dichloromethane can cause dizziness, headaches, and nausea. Long-term exposure is associated with liver and lung damage, as well as an increased risk of cancer.
• Symptoms include coughing, wheezing, shortness of breath, headaches, and confusion. Severe exposure may result in unconsciousness and respiratory failure.
• Treatment involves removing the person from exposure, administering oxygen, and providing supportive care. In severe cases, hospitalization may be necessary for respiratory and neurological support.
• Prevention includes using proper ventilation in areas where dichloromethane is used and wearing appropriate personal protective equipment to minimize exposure.

Ethylene Glycol (C₂H₆O₂)

• Ethylene glycol is a colorless, odorless liquid used in antifreeze, coolant systems, and hydraulic brake fluids.
• Ingestion of ethylene glycol is extremely toxic, leading to metabolic acidosis, kidney failure, and potentially death. It is commonly found in antifreeze poisoning cases.
• Symptoms include nausea, vomiting, confusion, rapid breathing, and kidney damage. In severe cases, seizures, coma, and death can occur.
• Treatment includes administering ethanol or fomepizole to inhibit the metabolism of ethylene glycol into toxic metabolites, and hemodialysis may be necessary to remove the substance from the body.
• Prevention involves proper storage of ethylene glycol-containing products, such as antifreeze, away from children and pets, and using less toxic alternatives where possible.

Ethylene Oxide (C₂H₄O)

• Ethylene oxide is a colorless gas with a faintly sweet odor, used primarily in sterilization processes for medical equipment and in the production of chemicals such as antifreeze and detergents.
• Ethylene oxide is classified as a carcinogen, and chronic exposure can increase the risk of cancers such as leukemia and lymphoma. Short-term exposure causes irritation of the eyes, skin, and respiratory system.
• Symptoms include eye irritation, skin burns, coughing, difficulty breathing, headaches, and dizziness.
• Treatment involves removing the person from exposure, administering oxygen, and providing supportive care. Long-term monitoring may be required for individuals exposed to high levels of ethylene oxide.
• Prevention includes ensuring proper ventilation in sterilization facilities and industrial areas, and using appropriate PPE to minimize exposure.

Formaldehyde (CH₂O)

• Formaldehyde is a colorless, strong-smelling gas used in building materials, disinfectants, and in the manufacture of resins and plastics. It is also used as a preservative in medical laboratories.
• Exposure to formaldehyde causes irritation of the eyes, nose, and throat, and long-term exposure is associated with cancer risk.
• Symptoms include burning sensations in the eyes and throat, coughing, and wheezing. Prolonged exposure may lead to chronic respiratory conditions such as asthma or bronchitis.
• Treatment focuses on removing the individual from the source of exposure, administering oxygen, and providing symptomatic relief for respiratory irritation.
• Prevention includes proper ventilation in workplaces where formaldehyde is used, and adhering to safety regulations to reduce occupational exposure.
• Formaldehyde is a flammable, reactive, and easily polymerizing gas at normal temperature and pressure
• The substance has a strong irritating odor
• Colorless gas extracted from methanol. Easily soluble in water
• Used in the production of plastics, disinfectants, and insecticides
• Respiratory irritant, damages cilia. May be carcinogenic
• Formaldehyde causes irritation of the eyes, skin, and mucous membranes
• Ingestion of aqueous solutions can cause kidney damage and lead to elevated levels of formate in the urine.

The toxic effects after exposure to formaldehyde (through inhalation) can, depending on the dose, include weakness, headache, abdominal pain, fainting, anxiety, burning sensation in the nose and throat, thirst, moist skin, effects on the central nervous system, cyanosis, diarrhea, dizziness, irritation and necrosis of the mucous membranes and throat, vomiting, nausea, coma, and shock.

Formic Acid (CH₂O₂)

• Formic acid is a colorless liquid with a pungent odor, used in leather tanning, dyeing textiles, and as a preservative in animal feed.
• Exposure to formic acid can cause skin burns, respiratory irritation, and in severe cases, damage to the kidneys and nervous system.
• Symptoms include coughing, shortness of breath, burning sensations on the skin, and irritation of the eyes, nose, and throat.
• Treatment includes removing the individual from the source of exposure, washing the skin with water in cases of contact, and administering oxygen for respiratory symptoms.
• Prevention includes proper handling procedures, adequate ventilation, and using PPE in industrial settings where formic acid is used.

Hexane (C₆H₁₄)

• Hexane is a colorless liquid with a mild odor, used as a solvent in the production of adhesives, varnishes, and paints, and in the extraction of vegetable oils.
• Inhalation or skin contact with hexane can cause nerve damage, resulting in peripheral neuropathy, muscle weakness, and decreased sensation in the limbs.
• Symptoms of hexane exposure include headaches, dizziness, nausea, and in severe cases, numbness, tingling, and muscle weakness in the extremities (peripheral neuropathy).
• Treatment involves removing the person from exposure, providing supportive care for neurological symptoms, and long-term monitoring for nerve damage.
• Prevention includes ensuring proper ventilation in areas where hexane is used, and wearing appropriate personal protective equipment to minimize exposure.

Hydrazine (N₂H₄)

• Hydrazine is a colorless, flammable liquid with an ammonia-like odor, used as a rocket fuel, in chemical synthesis, and in industrial boilers.
• Exposure to hydrazine can cause irritation of the respiratory tract, eyes, and skin. Prolonged exposure can lead to liver and kidney damage and an increased risk of cancer.
• Symptoms include coughing, shortness of breath, nausea, dizziness, and in severe cases, seizures, liver damage, and respiratory failure.
• Treatment involves immediate removal from the source of exposure, administration of oxygen, and supportive care for respiratory and neurological symptoms. In cases of severe exposure, hospitalization may be required for further treatment and monitoring.
• Prevention involves ensuring proper ventilation in industrial areas where hydrazine is used and wearing appropriate protective gear to minimize exposure risks.

Hydrofluoric Acid (HF)

• Hydrofluoric acid is a highly corrosive and toxic chemical used in industrial applications such as glass etching and metal cleaning. It can penetrate tissues deeply, causing severe chemical burns and systemic toxicity.
• Exposure to hydrofluoric acid affects not only the skin but also deeper tissues, including bones. It can disrupt calcium levels in the body, leading to life-threatening hypocalcemia and cardiac arrhythmias.
• Symptoms include severe pain at the exposure site, skin burns, and systemic effects such as muscle cramps, confusion, and heart problems if absorbed into the bloodstream.
• Treatment involves immediate decontamination by washing the affected area with water and applying calcium gluconate gel to neutralize the acid. In severe cases, calcium gluconate may be administered intravenously to counteract systemic effects.
• Proper handling and storage procedures, including using specialized PPE, are essential in preventing hydrofluoric acid exposure.

Hydrogen Chloride (HCl)

• Hydrogen chloride is a colorless gas with a pungent odor, which forms hydrochloric acid when dissolved in water. It is used in industrial processes such as metal refining and the production of plastics.
• Inhalation of hydrogen chloride gas causes severe irritation of the respiratory system, eyes, and skin. At high concentrations, it can lead to pulmonary edema and respiratory failure.
• Symptoms include coughing, shortness of breath, burning sensations in the throat, and eye irritation. In severe cases, exposure can result in chemical burns and tissue damage.
• Treatment includes immediate removal from exposure, administering oxygen, and providing supportive care such as bronchodilators and corticosteroids to manage airway inflammation.
• Prevention includes proper ventilation in industrial settings and using personal protective equipment (PPE) to minimize exposure.

Hydrogen Sulfide (H₂S)

• Hydrogen sulfide is a colorless, toxic gas with the smell of rotten eggs, produced during the breakdown of organic matter in the absence of oxygen.
• It is heavier than air, accumulating in low-lying areas and confined spaces.
• Exposure can result in irritation of the eyes and respiratory tract, leading to pulmonary edema, coma, and death at high concentrations.
• Symptoms include headache, dizziness, nausea, cough, dyspnea, and in severe cases, loss of consciousness.
• Treatment involves immediate removal from exposure, administration of oxygen, and supportive care. Cyanosis and respiratory failure may require mechanical ventilation. Inhaled amyl nitrite may be used in some cases to prevent H₂S binding to hemoglobin.

Hydrogen sulfide is a highly toxic gas that is dangerous to inhale. It is heavier than air and has a very unpleasant smell. The odor resembles rotten eggs and is nauseating. In high concentrations, the smell can be hard to detect. The gas is poorly soluble and can cause severe and delayed lung damage. Hydrogen sulfide affects the eyes and lungs and inhibits the blood’s ability to transport oxygen. Symptoms of exposure include headaches, nausea, eye irritation, and fatigue. Hydrogen sulfide can be explosive.

Inhalation of high concentrations causes rapid onset of unconsciousness, respiratory arrest, and arrhythmias. Hydrogen sulfide is sometimes called “knockdown gas.”

Isocyanates

• Found in paints and plastics
• Can cause skin allergies
• Evaporates and can form toxic gases at temperatures above 160 degrees
• Was the main substance responsible for over 2,000 deaths following a leak from an industrial plant in Bhopal, India, in 1984
• Exposure to isocyanates can cause permanent asthma disease even in people who previously had healthy airways
• Methyl isocyanate is strongly irritating and corrosive to the eyes, airways, and skin
• Acute exposure to high concentrations can cause pulmonary edema and damage to the lungs’ alveoli, severe corneal injury, and death

Lead (Pb)

• Lead is a heavy metal found in various industrial processes, including battery manufacturing, paint production, and plumbing. It is highly toxic, especially to the nervous system, kidneys, and reproductive system.
• Long-term exposure to lead can cause neurological damage, kidney dysfunction, anemia, and reproductive issues. In children, lead exposure is associated with developmental delays and learning disabilities.
• Symptoms of lead poisoning include abdominal pain, fatigue, irritability, headaches, memory problems, and in severe cases, seizures, coma, and death.
• Treatment involves removing the person from exposure, administering chelation therapy to bind and remove lead from the body, and providing supportive care for neurological and other symptoms.
• Prevention includes using proper ventilation and protective equipment in areas where lead is processed, and reducing lead exposure through safe disposal of lead-containing materials.

Mercury (Hg)

• Mercury is a toxic heavy metal found in thermometers, dental amalgam, and industrial processes. It exists in various forms, including elemental mercury, inorganic mercury compounds, and organic mercury compounds (e.g., methylmercury).
• Exposure to mercury can cause neurological, renal, and respiratory damage. Organic mercury compounds are particularly dangerous, as they bioaccumulate in the food chain and affect brain development.
• Symptoms of mercury poisoning include tremors, memory loss, irritability, vision and hearing loss, kidney damage, and in severe cases, respiratory failure and death.
• Treatment involves removing the person from exposure, administering chelation therapy for certain forms of mercury, and providing supportive care for symptoms. Long-term monitoring may be required for neurological effects.
• Prevention includes proper handling and disposal of mercury-containing products, avoiding fish with high mercury levels, and using personal protective equipment in industrial settings.

Methyl Bromide (CH₃Br)

• Methyl bromide is a colorless, odorless gas used as a pesticide and fumigant for soil, grain storage, and quarantine treatments. It is also used in the manufacturing of certain chemicals.
• Exposure to methyl bromide can cause serious health effects, including respiratory irritation, neurological symptoms such as headache, dizziness, and tremors, and in severe cases, pulmonary edema and convulsions.
• Chronic exposure can result in damage to the lungs, kidneys, and nervous system, as well as reproductive toxicity.
• Treatment involves removing the individual from exposure, administering oxygen, and providing supportive care for respiratory and neurological symptoms. In severe cases, mechanical ventilation may be required.
• Prevention involves the use of personal protective equipment (PPE) and proper ventilation in areas where methyl bromide is used, particularly in fumigation processes.

Methyl Ethyl Ketone (MEK, C₄H₈O)

• Methyl ethyl ketone is a colorless, flammable liquid with a sharp, sweet odor, commonly used as a solvent in the production of paints, varnishes, and adhesives.
• Exposure to methyl ethyl ketone can cause irritation of the eyes, nose, and throat, along with dizziness, headaches, and nausea. Prolonged exposure may result in central nervous system depression and liver and kidney damage.
• Symptoms include coughing, eye irritation, headaches, dizziness, and confusion. In severe cases, unconsciousness may occur.
• Treatment involves removing the person from exposure, providing fresh air, and administering oxygen. Supportive care for neurological symptoms may be required in severe cases.
• Prevention includes using appropriate ventilation in workplaces where methyl ethyl ketone is used, and wearing protective equipment to minimize exposure.

Methyl Isocyanate (MIC, CH₃NCO)

• Methyl isocyanate is a colorless, highly toxic gas with a sharp, pungent odor, used in the production of pesticides and polyurethane foams.
• Exposure to methyl isocyanate can cause severe respiratory and eye irritation, leading to coughing, wheezing, and shortness of breath. High concentrations can cause pulmonary edema, chemical burns, and death.
• Symptoms include coughing, chest tightness, eye irritation, and in severe cases, pulmonary edema, bronchospasm, and chemical burns to the skin and eyes.
• Treatment involves removing the individual from the exposure site, administering oxygen, and providing supportive care, including bronchodilators and corticosteroids to reduce inflammation. In severe cases, hospitalization and intensive care may be required.
• Prevention involves using protective equipment in industrial settings where methyl isocyanate is handled and ensuring proper safety protocols are followed to prevent accidental release.

Mustard Gas (Sulfur Mustard, HD)

• Mustard gas is a chemical warfare agent that causes severe blistering on the skin and mucous membranes upon contact.
• It is a colorless, odorless liquid at room temperature, but in its gas form, it has a faint garlic or mustard odor.
• Symptoms of exposure include severe skin burns and blisters, eye irritation and blindness, respiratory tract damage, and in severe cases, death from respiratory failure.
• There is no specific antidote for mustard gas exposure. Treatment is symptomatic, focusing on decontamination, pain management, and wound care. Respiratory symptoms may require oxygen therapy or mechanical ventilation.
• Mustard gas was widely used in World War I, and although its use is banned under the Chemical Weapons Convention, it remains a threat in certain conflict zones.

Treatment After Mustard Gas Exposure

• No antidote available
• Decontamination of victims is crucial
• Important to prevent injury to rescue personnel
• Remove contaminated clothing and seal in double plastic bags
• Generously apply decontamination powder
• Chlorine lime
• Magnesium oxide
• Scrape or cut away thickened mustard gas
• Thoroughly wash the body with soap and water
• Standard burn treatment
• Rehydration
• Analgesics
• Other symptomatic treatment

Nickel

• Silver-shiny heavy metal. Found in the earth’s crust
• Stainless steel and alloys
• Damages airways. Carcinogenic. Skin allergies

Nitric Oxide (NO)

• Nitric oxide is a colorless gas used in various industrial processes, including the manufacturing of nitric acid, explosives, and fertilizers. It is also used as a medical gas to treat respiratory failure in newborns and adults.
• Exposure to high levels of nitric oxide can cause respiratory irritation, coughing, and shortness of breath. Prolonged exposure can lead to the development of methemoglobinemia, a condition that reduces the blood’s ability to carry oxygen.
• Symptoms of exposure include cyanosis, confusion, headache, dizziness, and in severe cases, respiratory failure.
• Treatment includes administering oxygen and, in cases of methemoglobinemia, methylene blue may be given as an antidote to reverse the condition.
• Prevention includes proper handling and storage of nitric oxide in industrial and medical settings, along with the use of protective equipment.

Nitrobenzene (C₆H₅NO₂)

• Nitrobenzene is a pale yellow, oily liquid with an almond-like odor, used in the production of aniline, dyes, and other chemicals.
• Exposure to nitrobenzene can lead to methemoglobinemia, reducing the oxygen-carrying capacity of the blood. It can also affect the liver, kidneys, and central nervous system.
• Symptoms include cyanosis (bluish skin), fatigue, dizziness, headache, confusion, and shortness of breath. Severe cases can result in coma and death.
• Treatment involves removing the individual from exposure, administering oxygen, and providing methylene blue to treat methemoglobinemia. Supportive care may be necessary for neurological and respiratory symptoms.
• Prevention includes proper handling procedures, ventilation, and the use of personal protective equipment in areas where nitrobenzene is used.

Nitrogen Dioxide (NO₂)

• Nitrogen dioxide is a reddish-brown gas with a strong, sharp odor, commonly produced by vehicle exhaust and industrial emissions.
• It causes lung irritation and inflammation, leading to pulmonary edema, chemical pneumonitis, and chronic respiratory diseases with prolonged exposure.
• Acute symptoms include coughing, wheezing, dyspnea, and chest pain, with severe exposure potentially causing pulmonary edema and respiratory failure.
• Treatment includes removing the patient from the exposure, administering humidified oxygen, bronchodilators, and corticosteroids to manage lung inflammation. In severe cases, mechanical ventilation may be required.
• Preventive measures include proper ventilation in industrial areas and minimizing exposure to vehicle exhaust and industrial emissions.

Ozone (O₃)

• Ozone is a pale blue gas with a strong odor, formed naturally in the upper atmosphere and produced by electric discharge in air (e.g., welding and photocopiers). It is also a common air pollutant, especially during smog conditions.
• Ozone exposure irritates the respiratory system, causing coughing, throat irritation, chest tightness, and shortness of breath. Chronic exposure can worsen respiratory conditions such as asthma and bronchitis.
• Symptoms of ozone exposure include coughing, shortness of breath, chest pain, and wheezing. In severe cases, pulmonary edema and respiratory failure may occur.
• Treatment involves removing the person from exposure, administering oxygen, and using bronchodilators and corticosteroids to manage respiratory symptoms.
• Prevention includes reducing outdoor activities during high-ozone periods (smog), improving air quality, and using proper ventilation in indoor settings where ozone is generated (e.g., during industrial processes).

Perchloroethylene (C₂Cl₄)

• Perchloroethylene, also known as tetrachloroethylene, is a colorless liquid with a sweet odor, primarily used in dry cleaning and metal degreasing processes.
• Short-term exposure to high levels of perchloroethylene can cause dizziness, headaches, confusion, and loss of consciousness. Chronic exposure is associated with damage to the liver and kidneys and an increased risk of cancer, particularly esophageal cancer.
• Symptoms of exposure include respiratory irritation, dizziness, nausea, and in severe cases, liver and kidney damage.
• Treatment involves removing the individual from the source of exposure, providing oxygen, and supportive care for symptoms. In cases of chronic exposure, long-term health monitoring may be necessary.
• Prevention includes proper ventilation in dry cleaning and industrial facilities and using appropriate protective equipment to reduce exposure.

Phenol

• Strongly corrosive and toxic substance that forms colorless crystals
• At room temperature, phenol is a transparent, colorless crystalline mass, white powder, or thick syrupy liquid
• Used in the manufacture of plastics, dyes, explosives, medicines, and detergents
• All forms of phenol cause irritation, and acute toxic effects of phenol often occur through skin contact. Even dilute solutions (1% to 2%) can cause severe burns if contact is prolonged
• Systemic toxicity can result from exposure to skin or eyes
• Several phenols can contribute to cancer. One gram has caused fatalities
• Phenol is a flammable, highly corrosive chemical with a sweet, sharp odor
• The smell of phenol usually provides sufficient warning of dangerous concentrations
• The crystals are hygroscopic and turn pink to red in air. When pure, phenol has a sweet, tar-like odor that can be easily detected at low concentrations (0.05 ppm in air)
• Accidental and intentional ingestion of phenol has been reported. As little as 50 to 500 mg has been fatal in infants. Deaths in adults have occurred after ingesting 1 to 32 g

Phosgene (COCl₂)

• Phosgene is a highly toxic gas with a smell reminiscent of freshly cut hay, used in the production of plastics, pesticides, and dyes. It was also used as a chemical weapon during World War I.
• Inhalation of phosgene gas can lead to severe respiratory damage, including pulmonary edema, pneumonitis, and respiratory failure. Symptoms may be delayed for up to 48 hours after exposure.
• Symptoms include coughing, chest tightness, difficulty breathing, and in severe cases, frothy sputum and respiratory distress.
• Treatment involves removing the person from the exposure site, administering oxygen, and providing bronchodilators and corticosteroids to reduce lung inflammation. Severe cases may require hospitalization and mechanical ventilation.
• Prevention involves using proper ventilation in industrial settings, following safety protocols when handling phosgene, and using appropriate PPE.

Phosgene Oxime (CX, C₂Cl₂NO₂)

• Phosgene oxime is a highly toxic chemical warfare agent that causes severe skin and respiratory irritation. Unlike other chemical agents, it acts as a vesicant, producing immediate pain and damage upon contact.
• Symptoms include intense pain at the site of contact, skin lesions, blistering, and respiratory distress. Inhalation can lead to pulmonary edema and respiratory failure.
• Treatment involves removing contaminated clothing, decontaminating the skin with soap and water, and administering oxygen for respiratory symptoms. Supportive care for pain and respiratory distress may be necessary in a hospital setting.
• Prevention involves avoiding exposure to phosgene oxime, using protective equipment in areas where there is a risk of contamination, and following decontamination protocols in case of exposure.
• A condensed, highly toxic irritating gas
• High toxicity upon inhalation
• Used in the chemical industry to produce plastics and insecticides
• In contact with air, it forms a white cloud
• Smells like freshly cut hay
• Low solubility causes symptoms in the lower airways rather than the upper airways
• Toxic pulmonary edema may occur after a latent period of 24-48 hours
• Patients should be monitored for 48 hours

Treatment After Phosgene Injury

• Treatment similar to other irritating gases
• Bronchodilators and corticosteroids via inhalation should be administered liberally
• If ARDS develops in the lungs, pulmonary hypertension progresses rapidly
• Significantly increased pulmonary vascular resistance (PVR)
• Treat with Nitric Oxide (NO), prostacyclin (epoprostenol – Flolan), or bosentan (Tracleer)

Phosphine (PH₃)

• Phosphine is a colorless, flammable, and highly toxic gas with a smell resembling garlic or decaying fish. It is used in pest control and semiconductor manufacturing and can be released during the production of certain chemicals.
• Exposure to phosphine gas primarily affects the lungs and central nervous system, causing respiratory distress, nausea, dizziness, and in severe cases, pulmonary edema and death.
• Symptoms include coughing, shortness of breath, chest pain, headache, and confusion. At high concentrations, phosphine can lead to organ failure and death.
• Treatment involves immediate removal from exposure, administration of oxygen, and supportive care for respiratory and cardiovascular symptoms. There is no specific antidote for phosphine poisoning.
• Prevention includes proper ventilation in areas where phosphine is used, along with strict adherence to safety protocols and use of PPE.

Polychlorinated Biphenyls (PCBs)

• PCBs are a group of man-made chemicals that were widely used in electrical equipment, heat transfer fluids, and industrial products before being banned due to their environmental persistence and toxic effects.
• Exposure to PCBs can lead to skin conditions such as chloracne, liver damage, immune system suppression, and an increased risk of cancer, particularly liver cancer.
• Symptoms of PCB exposure include skin rashes, fatigue, liver dysfunction, and, in severe cases, neurological damage and cancer.
• Treatment for PCB exposure includes removing the person from exposure, providing supportive care for symptoms, and long-term monitoring for liver function and cancer risks. There is no specific antidote for PCB poisoning.
• Prevention involves proper disposal of PCB-containing materials and using protective equipment when handling or working in areas contaminated with PCBs.

Styrene (C₈H₈)

• Styrene is a colorless, oily liquid used in the manufacture of polystyrene plastics and resins. It is released into the air during the production of plastic products.
• Inhalation of styrene can cause irritation of the eyes, nose, and throat, as well as effects on the central nervous system, leading to headache, dizziness, fatigue, and nausea.
• Long-term exposure may increase the risk of cancer, and it has been associated with damage to the liver, kidney, and nervous system.
• Treatment involves removing the individual from the source of exposure and providing supportive care for symptoms such as headache and nausea. Chronic exposure may require further medical monitoring.
• Prevention includes proper ventilation in manufacturing areas and the use of protective equipment to minimize exposure.

Sulfuric Acid (H₂SO₄)

• Sulfuric acid is a colorless, odorless, highly corrosive liquid used in a wide range of industries, including battery manufacturing, fertilizer production, and chemical synthesis.
• Exposure to sulfuric acid can cause severe burns to the skin and mucous membranes, respiratory irritation, and damage to the eyes, potentially leading to blindness.
• Symptoms of exposure include coughing, wheezing, shortness of breath, and severe pain at the site of contact. Inhalation can lead to respiratory distress and chemical burns in the airways.
• Treatment involves removing contaminated clothing, flushing the affected areas with water, and providing medical care for burns and respiratory symptoms. In severe cases, hospitalization may be required for decontamination and further treatment.
• Prevention includes proper handling and storage procedures, along with the use of personal protective equipment (PPE) to prevent skin and respiratory exposure.

Sulfur Dioxide (SO₂)

• Sulfur dioxide is a colorless gas with a pungent, irritating odor, primarily produced by burning fossil fuels like coal and oil.
• It irritates the respiratory system, eyes, and skin. Exposure can lead to coughing, wheezing, shortness of breath, and in severe cases, bronchospasm and pulmonary edema.
• Chronic exposure is linked to respiratory diseases like chronic bronchitis and asthma.
• Treatment includes removing the patient from exposure, administering oxygen, bronchodilators, and corticosteroids to manage symptoms.
• Industrial settings should have proper ventilation, and workers should use personal protective equipment (PPE) to reduce exposure risks.

Tear Gas

• CS gas – used as an incapacitating agent during demonstrations and riots
• Usually contains 2-chlorobenzylidene malononitrile

The substance is used as an aerosol dissolved in acetone. Tear gas is highly irritating to the respiratory system, causing intense burning and itching in the eyes and mucous membranes, with copious tear secretion. Tear gas usually does not cause severe poisoning symptoms, but rare deaths have occurred. Swedish police now primarily use pepper spray, which contains capsaicin, a component of pepper.

Toluene (C₇H₈)

• Toluene is a clear, colorless liquid with a distinctive smell, commonly used in paint thinners, adhesives, and the production of various chemicals and fuels.
• Exposure to toluene can affect the central nervous system, causing symptoms such as headache, dizziness, confusion, and in high concentrations, loss of consciousness.
• Chronic exposure can result in damage to the liver, kidneys, and nervous system, and long-term inhalation may lead to permanent brain damage.
• Treatment includes removing the individual from the source of exposure, administering oxygen, and providing supportive care for neurological symptoms.
• Prevention involves adequate ventilation in workplaces where toluene is used, proper storage, and the use of personal protective equipment (PPE).

Toluene Diisocyanate (TDI, C₉H₆N₂O₂)

• Toluene diisocyanate is a colorless to pale yellow liquid with a sharp, pungent odor, used primarily in the production of polyurethane foams, coatings, and adhesives.
• Exposure to TDI can cause severe irritation of the respiratory system, skin, and eyes. Long-term exposure may lead to asthma, hypersensitivity pneumonitis, and other respiratory diseases.
• Symptoms include coughing, wheezing, chest tightness, skin rashes, and in severe cases, asthma and lung damage.
• Treatment involves removing the individual from exposure, administering oxygen, and providing bronchodilators and corticosteroids to manage respiratory symptoms. In cases of skin exposure, washing the affected area with soap and water is necessary.
• Prevention includes using appropriate ventilation, protective clothing, and respiratory protection in areas where TDI is used, and adhering to safety protocols to prevent exposure.

Trichloroethylene (TCE, C₂HCl₃)

• Trichloroethylene is a clear, colorless liquid with a sweet odor, used primarily as a solvent in degreasing metal parts and in the manufacturing of adhesives and refrigerants.
• Short-term exposure to trichloroethylene can cause dizziness, headaches, and confusion, while long-term exposure is associated with liver, kidney, and nervous system damage, as well as an increased risk of cancer.
• Symptoms include dizziness, headaches, nausea, confusion, and in severe cases, unconsciousness. Chronic exposure may lead to organ damage and cancer.
• Treatment involves removing the individual from exposure, administering oxygen, and providing supportive care for neurological and respiratory symptoms. Long-term monitoring may be necessary for individuals exposed to high levels of trichloroethylene over extended periods.
• Prevention includes ensuring proper ventilation in areas where trichloroethylene is used, as well as wearing protective clothing and respiratory protection to reduce exposure risks.

Vinyl Chloride (C₂H₃Cl)

• Vinyl chloride is a colorless gas with a mild sweet odor, used in the production of polyvinyl chloride (PVC) plastics and other chemicals.
• Exposure to high levels of vinyl chloride can cause dizziness, headaches, and loss of consciousness. Long-term exposure is linked to an increased risk of a rare form of liver cancer known as angiosarcoma, as well as other forms of cancer, including brain and lung cancer.
• Symptoms of exposure include respiratory irritation, dizziness, fatigue, and in severe cases, loss of consciousness. Chronic exposure can result in liver damage and cancer.
• Treatment involves removing the individual from exposure, administering oxygen, and providing supportive care for symptoms. Long-term monitoring is required for individuals exposed to high levels of vinyl chloride over extended periods.
• Prevention involves controlling emissions from industrial processes, ensuring proper ventilation, and using personal protective equipment in areas where vinyl chloride is produced or used.

Xylene (C₈H₁₀)

• Xylene is a colorless, sweet-smelling liquid used as a solvent in the printing, rubber, and leather industries, and in the production of paints and coatings.
• Short-term exposure to xylene can cause headaches, dizziness, drowsiness, and nausea. Long-term exposure may lead to liver and kidney damage, as well as respiratory problems.
• Symptoms of exposure include irritation of the eyes, nose, and throat, confusion, and in high doses, respiratory failure.
• Treatment includes removing the individual from the source of exposure, administering oxygen, and providing symptomatic relief for respiratory and neurological symptoms.
• Prevention involves using proper ventilation and personal protective equipment in areas where xylene is used.

Zinc Chloride (ZnCl₂)

• Zinc chloride is a white, crystalline solid or a clear liquid, used in soldering fluxes, galvanizing, and chemical production. It is highly corrosive and can cause severe irritation upon contact.
• Inhalation of zinc chloride fumes can cause serious respiratory issues, including pulmonary edema, bronchitis, and in severe cases, respiratory failure.
• Symptoms include coughing, wheezing, shortness of breath, and chest pain. Severe exposure may lead to pulmonary edema and respiratory distress.
• Treatment involves removing the person from exposure, administering oxygen, and providing supportive care for respiratory symptoms. In severe cases, hospitalization and mechanical ventilation may be necessary.
• Prevention includes using proper ventilation in workplaces where zinc chloride is used, and wearing appropriate protective equipment to avoid skin and respiratory exposure.

ICD-10

• Gases, smoke, and vapors, unspecified T59.9
• Bronchitis and pneumonitis caused by chemicals, gases, smoke, and vapors J68.0
• Inflammation of the upper respiratory tract caused by chemicals, gases, smoke, and vapors not classified elsewhere J68.2

References

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2. Toxic smoke inhalation and cyanide poisoning. Merril A, Cohen MD, Lawrence J, Guzzardi MD. The American Journal of Emergency Medicine Volume 6, Issue 2, March 1988, Pages 203-204, Link.
3. Chlorine Gas Exposure and the Lung: A Review Rupali Das, Paul D. Blanc. Toxicology and Industrial Health Vol 9, Issue 3, 1993, Link.
4. The Role of Bronchoscopy in Pulmonary Complications due to Mustard Gas Inhalation. Freitag L, Firusian N, Stamatis G, Greschuchna D. Chest Volume 100, Issue 5, November 1991, Pages 1436–1441, Link.
5. Treatment Guidelines for Chemical Incidents. Approved by RKMK 206-05-10. Revised 2011.
6. Wang J, Winskog C, Edston E, Walther SM. Inhaled and intravenous corticosteroids both attenuate chlorine gas-induced lung injury in pigs. Acta Anaesthesiol Scand 2005;49:183–190.
7. Wang J, Zhang L, Walther SM. Inhaled budesonide in experimental chlorine gas lung injury: influence of time interval between injury and treatment. Inte