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Home , CR gas, CS gas, Mace (spray)

56 Case reports

9 Selbst SM, De Maio JG, Boenning D. Mouth wash poison- 13 Simon HK, Cox JM, Sucov A, Linakis JG. Ethanol ing. Clin Pediatr 1985;24:162-3. clearance in intoxicated children and adolescents present- 10 Wright J. Ethanol-induced hypoglycaemia. Br J Alcohol ing to the ED. Acad Emerg Med 1994;1:520-4. Alcoholism 1979;14:174-6. 14 Gibson PJ, Cant AJ, Mant TGK. Ethanol poisoning. Acta 11 Ricci LR, Hoffman S. Ethanol induced hypoglycaemic Paediatr Scand 1985;74:977-8. J Accid Emerg Med: first published as 10.1136/emj.15.1.56 on 1 January 1998. Downloaded from coma in a child. Ann Emerg Med 1982;1 1:203-4. 15 Pollack CV, Jorden RC, Carlton FB, Baker ML. Gastric 12 Gershman H, Steeper J. Rate of clearance of ethanol from emptying in the acutely inebriated patient. J Emerg Med the blood of intoxicated patients in the emergency depart- 1992; 10: 1-5. ment. J Emerg Med 199 1;9:307-1 1. See also letters on p00

CS exposure in a crowded night club: the consequences for an accident and emergency department

A Breakell, G G Bodiwala

Abstract respiratory problems, seven required supple- A case is reported of deliberate release of mental oxygen. Two of these patients suffered CS gas (O-chlorobenzylidene malononi- from asthma. Clinically none of the patients trile) in an enclosed space and the conse- developed wheeze but one asthmatic patient quences for an accident and emergency required a nebuliser for chest tightness. One department. patient was admitted to hospital with persistent (7AccidEmergMed 1998;15:56-64) chest tightness and sore throat. He was discharged after 24 hours with resolution ofhis Keywords: CS gas chest tightness, but the sore throat persisted.

Case report Discussion Twenty three people (eight males, 15 females) While CS gas attacks are rare in this country at attended the accident and emergency (A&E) present, increasing availability ofthis substance department at the Leicester Royal Infirmary at home and across Europe is likely to increase following exposure to CS gas (O-chloro- "the practical joke" and more serious cases of benzylidene ) in a local night and criminal attacks. The club. The average age ofthe males was 22 years National Poisons Information Service and of the females, 21. There were two known () is currently attempting to monitor asthmatics in the group. The patients attended the number of incidents involving CS gas.2 At http://emj.bmj.com/ the A&E department approximately 20 min- present it is one of three agents used in crowd utes after exposure to the CS gas and were in control, the others being 1-chloroacetophenone contact with the gas for 10 to 15 minutes while (CN gas) and dibenzoxazepine (CR gas). The in the night club. use of CN and CR has decreased because of their toxic effects. Although called "gas," the TRIAGE chemicals are solids and are used in powder On arrival at the A&E department, individuals form. They are sprayed from liquid for were assessed at triage by an experienced convenience. The most toxic of these agents is on September 29, 2021 by guest. Protected copyright. nurse. Their clothes were removed and placed CN gas which is a constituent of , the self in plastic bags. Patients were triaged into two defence spray, and deaths from pulmonary areas. The recovery ward of the A&E depart- injury and have been reported; CN gas ment received those patients with minor symp- is also capable of causing serious damage to the toms and the windows were opened for eyes.3 CR gas is the most potent lacrimator but ventilation. Patients with difficulty in breath- has the least systemic effects. CS gas is a potent ing, chest tightness, and choking sensation also lacrimator and is the least toxic of the chemical Accident and had severe eye symptoms and were seen in the compounds. Emergency resuscitation room. The effects of exposure to CS gas vary Department, Leicester depending upon the concentration to which the Royal Infirmary, Leicester, UK CLINICAL ASSESSMENT person is exposed. On exposure even to low A Breakell Twelve of the 23 patients who attended the concentrations, the onset of symptoms is GG Bodiwala department discharged themselves before immediate. The effects usually settle within 15 being seen by the doctor but had been assessed to 30 minutes after removal from exposure. Correspondence to: by a senior nurse on the recovery ward. Eye, nose, mouth, respiratory tract, and skin Dr A Breakell, Accident and Emergency Department, Patients seen in the resuscitation room had eye symptoms predominate.4 Lacrimation, pain, Royal University and breathing problems. Irritation to the eyes blepharospasm, conjunctival erythema, and Hospital, Prescot Street, was initially treated by blowing cold air from an periorbital oedema develop, along with pain Liverpool L7 8XT, UK. electric fan onto the face.' Six patients had eye and discomfort in the nose, a burning sensation Accepted for publication irrigation with normal saline with considerable in the mouth, nausea and rarely vomiting, and 29 September 1997 improvement in symptoms. Of those with respiratory symptoms ofsore throat, tight chest, Case reports 57

coughing, bronchospasm, and occasionally treated as thermal burns, and topical steroids laryngospasm. There is no evidence that may be used for contact dermatitis.

patients who suffer from pre-existing lung J Accid Emerg Med: first published as 10.1136/emj.15.1.56 on 1 January 1998. Downloaded from disease (for example, asthma or chronic bron- chitis) are at increased risk of an exacerbation.3 Lessons from our experience On contact with the skin a burning sensation (1) Expect large numbers of patients when and erythema occurs, which settles in 24 hours. exposure to CS gas occurs in closed Prolonged exposure and wet clothing can result spaces. The problems of exposure in in a chemical burn. CR gas can affect the skin closed spaces have been addressed3 and upon contact with water 24 hours later. CN gas the indications are that an exposure of is a skin sensitiser and can produce allergic 6000 mg/min/m3 would encroach on the contact dermatitis within 72 hours of margin of safety but would still be several exposure.5 Allergic contact dermatitis has been times less than the level at which fatalities reported following exposure to CS gas. might occur providing the subject is healthy and can escape. RECOMMENDED AFTERCARE OF SUBJECTS WHO (2) Triage to separate the mild from the mod- HAVE BEEN EXPOSED TO CS GAS erate and severe exposure. Mild symptoms In the majority of cases the effects resolve involve irritation to the mucous mem- spontaneously within 15 to 30 minutes once branes; severe symptoms represent an the person is removed from the contaminated exaggeration of these. Remember that area and exposed to cool fresh air. This will panic and hysteria can supervene4 but be permit CS particles to be blown off the body. vigilant when dealing with patients with Studies by the military endorse these first aid eye and respiratory complications. measures.6 Clothing should be removed and (3) If eye symptoms persist for longer than 30 sealed in plastic bags and patients should be minutes after exposure we recommend placed in a well ventilated area. They should be irrigation of the eyes using normal saline, advised not to rub their face or eyes as this followed by visual acuity testing. If prob- increases the effects ofthe CS. The face should lems persist the patient should be referred be wiped with gauze, particularly the thin skin to an ophthalmologist. Blowing cold air around the eyes, to remove CS particles before onto the face did not result in clinical washing the face. Patients with respiratory improvement. The electric fan distributed symptoms should be admitted for observation. CS particles from the patients' skin and Humidified oxygen provides symptomatic re- hair and increased contamination of the lief. Following eye exposure, natural tear secre- resuscitation room. tions are normally sufficient to remove the (4) In accordance with findings from chemical from the eye, but where ocular effects Londonderry,' our patients with asthma persist the National Poisons Information Serv- were no more sensitive to CS gas than the ice (London) recommends eye irrigation using normal individuals, though reports from saline or water, and the information given to unclassified information on the use of CS forces around the United Kingdom sug- gas in , ,8 claim that a gests the "use ofcopious amounts ofcool tap water deterioration in lung function occurs in http://emj.bmj.com/ to flush CS from the face and eyes." It has been patients with asthma and chronic obstruc- reported' that blowing air directly onto the eye tive lung disease. Our only admission was a with an electric fan is the preferred treatment previously healthy man with persistent following persistent irritation to the eyes, but it sore throat and chest tightness unrelieved is difficult to see how a powder that dissolves in by oxygen. Peak flow values were un- solution on the surface of the eye can be changed between admission and discharge in patients with respiratory symptoms.

converted into a gas at normal temperature on September 29, 2021 by guest. Protected copyright. and pressure and relieve irritation. CN gas (5) Educate A&E staff in dealing with chemi- being a constituent of Mace and a severe eye cal attacks from crowd control agents. irritant, others have recommended saline 1 Yih JP. CS gas injury to the eye. BMJ 1995;311:276. irrigation.7 Subjects who have been sprayed 2 Wheeler H, Murray V. Treating CS gas injuries to the eye. Poisons centre will monitor cases. BMJ 1995;311:871. should be asked if they wear contact lenses. 3 Himsworth H, Black DAK, Crawford T, Dornhorst AC, People wearing contact lenses may experience Gilson JC, Neuberger A, et al. Report of the enquiry into the medical and toxicological aspects of CS. London: HMSO, greater discomfort, and these should be 1971. removed immediately. Exposure to CS gas, in 4 Beswick FW. Chemical agents used in control and war- fare. Hum Toxicol 1983;2:247-56. common with other substances-for example, 5 Leenutaphong V, Goerz G. Allergic contact dermatitis from the methyl iso-butyl ketone currently chloroacetophenone (). Contact Dermatitis 1989; 20:316. on trial with some police forces in the United 6 Punte CL, Owens E, Gutentag PJ. Exposures to ortho- Kingdom-may cause damage to certain types chlorobenzylidene malononitrile. Arch Environ Health 1963;6:366-74. of lens. 7 Scott RA. Treating CS gas injuries to the eye. Illegal "Mace" Following exposure to the skin, washing with contains more toxic CN particles. BMJ 1995;311:87 1. 8 Hu H, Fine J, Epstein P, Kelsey K, Reynolds P, Walker B. soap and water normally settles the burning Tear gas-harassing agent or toxic ? JAMA sensation. Any chemical burns should be 1989;262:660-3.