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Medic Electives: Pulmonary Intoxicants

Level 1

EMT Refresher Continuing Education: Pulmonary Intoxicants

Overview | Assessment | Treatment | Roles

Objectives

In this PULMONARY INTOXICANTS course you will earn 1 CE hour. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • Define technical medical terms related to pulmonary intoxicants.
  • Identify characteristics of exposure to pulmonary intoxicants.
  • Assess effects of exposure to phosgene.
  • Clarify what to use and what not to use in treating symptoms.
  • Know limits of roles and responsibilities.

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

EMS Course Levels

Overview

Phosgene

Phosgene is widely used today in the manufacturing of dyes, coal tar, pesticides, and pharmaceuticals. It was widely used in WWI until mustard was introduced on the battlefield. The Bhopal, India disaster of 1984, at a Union Carbide plant, involved the release of 50,000 pounds of methylisocyanate. This chemical is composed of phosgene and methylamine. There were 150,000 people affected, 10,000 severely injured, and 3,300 killed. The effects of the release were thought to be due to a combination of isocyanate and phosgene.

 

Definitions

  • Apnea - suspending external breathing
  • Hypoxia - low oxygen in the body
  • Laryngeal Spasm - involuntary muscular contraction bringing vocal chords together, often occurring to prevent liquids from entering into the lungs
  • PEEP - mechanical ventilation or positive end-expiratory pressure
  • Pulmonary Edema - fluid accumulating in the lungs
  • Pulmonologist - physician specializing in the diseases of the respiratory tract or lungs.
Emergency Stop
Assessment

Pulmonary intoxicants cause severe life‑threatening lung injury after inhalation. These effects are generally delayed several hours after exposure. Pulmonary intoxicants included with this group are phosgene and chlorine.

Characteristics

Phosgene has a characteristic odor of freshly mown hay and is four times heavier than air. It is a gas above 47 ºF, and is principally a hazard by inhalation.

There is a symptom‑free period of 2 to 24 hours. Over the first several hours, the carbonyl group from the phosgene attacks the surface of the alveolar capillaries. Eventually, this causes the leakage of serum from the capillaries in the lung into the alveoli and interstitial space. The fluid fills the tissues, causing severe hypoxia and apnea. As the fluid leaks into the alveoli, massive amounts of fluid (up to 1 liter per hour) pour out of the circulation. The patient develops a severe non‑cardiogenic pulmonary edema.

Mechanism of Action and Clinical Effects

Phosgene dissolves slowly in water to form carbon dioxide and hydrochloric acid (HCl). In contact with the moist mucosa the HCl causes a transient irritation of the eyes, nose, sinuses, and throat. It can also irritate the upper airway and bronchi, causing a dry cough. However, the primary damage from phosgene is from the carbonyl group, which destroys the alveolar capillary membrane. (Perflouroisobutylene, PFIB, the combustion product of burning Teflon, found in many military vehicles, has a similar action as phosgene, but is more toxic.) Phosgene penetrates poorly into the airways due to its poor water solubility.

 
Treatment

Treatment is usually supportive and may require advanced intensive care techniques including intubation, use of a mechanical ventilation and PEEP.

The leakage of fluid in the lungs causes volume depletion. Although the patient may clinically look like traditional heart failure, DO NOT USE DIURETICS. Diuretics such as Lasix are contraindicated because of the hypotension and the noncardiac nature of the pulmonary edema.

These patients are volume depleted. Treat hypotension with fluids. If the victim develops severe dyspnea due to upper airway irritation, early intubation should be considered to manage oxygen delivery and to prevent laryngeal spasm.

The airway should be suctioned frequently to remove secretions. According to some authorities, antibiotic use should be guided by Gram stain and culture results. Another source recommends prophylactic antibiotics, as autopsy studies show uniform evidence of pneumonia and bronchitis.

Fluid hydration may be necessary to treat the hypotension, bradycardia, or impending renal failure. Standard bronchodilators will usually control bronchospasm, but if not, steroids may be needed for this purpose. Routine steroid use is controversial, but steroids seemed to offer some efficacy after the Bhopal tragedy.

 

Roles and Responsibilities

Ventilator management, PEEP, and oxygen administration might require consultation with a pulmonologist.

In the hospital, the initial examination of a patient, symptomatic or not, should include–(as a minimum): auscultation, chest x‑ray, and arterial blood gases.

Once the patient recovers, there should be little residual pulmonary effect.

 

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