Phosgene and .0." Related Compounds

,."- .--,-.- "-.-'-' . ----

...

-~-~..,._.~,101n m_. Phosgene and .0." Related Compounds

SUBSTANCE IDENTIFICATION Found as a colorless liquid or gas with a low water solubility. At low air concentrations, compounds have a sweet odor, like hay. A sharp, pungent odor is present at higher concentrations. Can be liberated from the combustion of chlorinated hydrocar- bons. Used in the manufacture of insecticides, plastics. dyes, and pharmaceuticals and in metallurgy Prepared for military use as a choking agent known as CG. ROUTES OF EXPOSURE Skin and eye contact lnhalation lngestion Skm absorption TARGET ORGANS Primary Skin Eyes Resplratory system Secondary Central nervous system Cardiovascular system Gastrointestinal system LlFE THREAT Severe respiratory irritant that can cause damage to the alveoli and resultant pulmonary edema Phosgene has been used as a chemical warfare agent gas and is extremely toxic. SIGNS AND SYMPTOMS BY SYSTEM Cardiovascular: Cardiovascular collapse, hypovolemia, shock, and arrhythmias. Respiratory: Throat dryness, pharyngitis, with primarily lower respiratory tract mucous membrane irritation, including pneumonitis and pneumonia. Acute or delayed pulmonary edema, dyspnea, and tachypnea. Cough with thick, bloody, foamy sputum. Noncardiac chest pain. Pulmonary damage (bronchitis, emphysema, fibrosis) may be late sequelae. CNS: Headache, CNS depresslOn to coma and seizures. Gastrointestinal: Nausea, vomiting, and abdominal pain. Eye: Chemical conjunctivitis. corneal damage, and burns. Lacrimation and spasm of the eyelids (blepharospasm). Skin: Irritant dermatitis and chemical bums. Cyanosis. Other: Ability to detect product by smell may be lost after a relatively brief exposure time (01factory nerve fatigue). SYMPTOM ONSET FOR ACUTE EXPOSURE Irnmediate Some symptoms especially pulmonary edema may be delayed 2 to 24 hours

421 101 Phosgene and Related Compounds

CO-EXPOSURE CONCERNS Chlonne active compounds Corrosive vapors THERMAL DECOMPOSITION PRODUCTS INCLUDE Carbon rnonoxide Chloride Hydrochloric acid if rnoisture or stearn i5 present MEDICAL CONDITIONS POSSIBLY AGGRAVATED BY EXPOSURE Respiratory system disorders DECONTAMINATION . Wear positive-pressure SCBA and protective equiprnent specified by references such as the DOT Emergency Response Guidebook or the CANUTEC lnitial Emergency Response Cuide. If spedal chemical protective clothing is required. consult the chemical manufacturer or specific protective c10thing compatibility chans. . DeIay entry until crained personnel and proper protective equipment are available. o Remove patient from contaminated area. o Quickly remo ve and isolate patient' s dothing, jewelry, and shoes. . Gently blot excess liquids with absorbent material. . Rinse patient with wann water, 300 C/86° F, if possible. o Wash patient with Tincture of Green soap or a mild liquid soap and large quantities of water. o Refer to decontamination protocol in Section Three. IMMEDtATE FIRST AID . Ensure that adequate decontamination has been carried out. o If victim is not breathing, start artificial respiration, preferably with a demand-valve resuscitator, bag-valve-mask devlce, or pocket mask as trained. Perform CPR if necessary. o Immediately ftush contaminated eyes with gently flowing water. . Do not induce vomiting. If vomiting oecurs, lean patient forward or place on left side (head-down position, if possible) to maintain an open airway and prevent aspiration. o Keep victim quiet and rnaintainnormal body temperature. . Obtain medical attention. BASIC TREATMENT o Establish a patent airway. SuctIon if necessary. o Watch for signs of respiratory insufficiency and assist ventilations if necessary. . Administer oxygen by nonrebreather mask at 10 to 15 L/min. o Monitor for pulmonary edema and treat if necessary (refer to pulmonary edema protocal in Section Three). . Anticipate seizures and treat If necessary (refer to seizure protocol in Section Three). . For eye contanunatton, flush eyes immediately with water. Irrigate each eye contmuously with normal saline during transport (refer lO eye irrigation protocol in Section Three). . Do not use emetics. For ingestion, rinse mouth and administer 5 ml/k.g up to 200 mI of water for dilutian if the patient can swallow, has a strong gag reflex, and does not drool (refer to ingestion protocol in Section Three). o Cover skin burns with dry sterile dressings after decontamination (refer to chemical bum protocol in Section Three).

422 Phosgene and Related Compounds 101

ADVANCED TREATMENT . Consider orotracheal or nasotracheal intubation for airway control in the patient who is unconscious, has severe pulmonary edema, or is in respiratory arrest. , Positlve-pressure ventilationtechniques with a bag-valve-maskdevice may be benefi- ciaL . Monitor cardiac rhythm and treat arrhythmias if necessary (refer to cardiac protocol in Section Three). . Start an IV with DsW TKO. Use lactated Ringer's if signs of hypovolemia are present. Watch for signs of fluid overload. . Consider drug therapy for pulmonary edema (refer to pulmonary edema protocol in Secrion Three). . Treat seizures wlth diazeparn (Valium) (refer to diazepam protocol in Section Four). . Use proparacaine hydrochloride to assist eye irrigation (refer to proparacaine hydrochloride protocol in Section Four). INITIAL EMERGENCV DEPARTMENT CONSIDERATIONS . Useful initiallaboratory studies indude complete blood count, serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, urinalysis, and baseline biochemical profile, including semm aminotransferases (ALT and AST), calcium, phosphorus, and magnesium. Determination of anion and osmolar gaps may be helpfu1. Arterial blood gases (ABOs), chest radiograph, and electrocardiogram may be required. . Obtain serial chest x-rays and monitor ABGs and respiratory function. , Positi ve end-expiratory pressure (PEEP)-assisted ventilauon may be necessary in pa- tients with acute parenchymal injury who develop pulmonary edema or adult respira- tar)' distress syndrome. . Obtain toxicological consultation as necessary. SPECIAL CONSIDERATIONS . Phosgene' s poor water solubility limits its effects on the upper airway, allowmg most of the product to penetrate into the lower airways Phosgene reacts with moisture in the lower airways to form hydrochloric acid and carban dioxide with resultmg pulmonary edema. This is the mechanism far the delayed anset pulmonary edema.

423 Asbestos

SUBSTANCE IDENTIFICATION Found as odorless, grayish-white, flexible fibers wíth a soft texture. Asbestos is a ge- nerie terrn used for a number of naturalIy oceurring amphibole and serpentine hydrated magnesium silicates (hat are incombustible and can be separated into fibers. Types of fibers include aetinolite, amosite (brown asbestos), anthophyIlite, chrysotile (white asbestos), crocidolite (blue asbestos), and tremolite. All fibers belong to the amphibole group: long, straight fibers paeked in parallel rows: wlth the exception of chrysotile, which is the only member of the serpentine group, with wavy fibers packed as intertwined bundles. The most widely used asbestos fiber in the United States was ehrysotile [Mg6Si4ülO(OH)8]' Asbestos has been used in noise and therrnal insulation materials, asbestos (cement products), floor covering material s, friction products (brake linings), gaskets, and fireproof textiles. Asbestos fibers may be finnly bonded in the produet or easily broken aparto The latter are eonsidered to be friable and will generate more airbome fibers. ROUTES OF EXPOSURE Inhalation Ingestian TARGET ORGANS Pnmary Respiratory system Gastrointestinal system LIFE THREAT Asbestosisllung cancer/malignant mesothelioma SIGNS AND SYMPTOMS BY SYSTEM Cardiovascular: None. Respiratory: Irritation of the nase and throat. Gastrointestinal: No acute effects fram ingestion. SVMPTOM ONSET FOR ACUTE EXPOSURE Delayed. Usuallateney period 10 to 20 years for asbestosis. Malignancies may have longer latent periods. CHRONIC EXPOSURE/CARCINOGENIC EFFECTSINCLUDE Asbestosis Pleural plaques Pleural thickenmg Benign pleural effusion Lung cancer Malignant mesothehoma Possibly increased cancer risk of the larynx, GI tract, pancreas, and colon CO.EXPOSURE CONCERNS Smoking Other agents capable of causing pneuIVoconiosls (e.g., barium, beryllium, coal dust, nitrogen oxides, tale)

424 Asbestos 102

MEDICAL CONDITIONS POSSIBLY AGGRAVATED BY EXPOSURE Pulmonary dlsease Coal worker' ~ pneumoconiosi ~ Silo Filler's disease (nitrogen oxides) DECONTAMINATION o Wear positive-pressure SCBA and protective equipment specified by references such as the DOT Emergency Response Guidebook or the CANUTEC lnitial Emergency Response Guide. If special chemical protective clothing is required, consult the chemical manufacturer or specific protective clothing compatibilíty charts. o Delay entry until trained personnel and proper protective equipment are available. o Remove patient from contaminated area. . Qmckly remove and lsolate patient's clothing, jewelry, and shoes. - Gently brush away dry partic1es and blot excess liquids with absorbent material. o Rinse patient with warm water, 30° C/86° F, if possible. o Wash patient with Tincture of Green soap or a mild liquid soap and large quantities of water. o Refer to decontammation protocol in Section Three. IMMEDIATE FIRST AID o Ensure that adequate decontammation has been carried out o Obtain medical attentlOn. BASIC TREATMENT o Establish a patent airway. Suction if necessary. o Assist ventilations tf necessary. o Adminisier oxygen by nonrebreather mask at 10 to 15 L/mm. o Treat any associated injury and/or illness if necessary. ADVANCED TREATMENT o Treat any associated injury and/or illness if necessary. INITIAL EMERGENCY DEPARTMENT CONSIDERATIONS . Initial examination should indude a chest x-ray and pulmonary function testing. o Obtain toxicological consultation as necessary. SPECIAL CONSIDERATIONS o Risk of asbestos exposure should be considered in cases of building tires or explo- sions where encapsulated OI prevlOusly unknown!undisturbed sources of asbestos insulation may be released. The risk of asbestos exposure is also increased at asbestos abatement projects where large quantities of removed product may be stored. o Asbestos-related diseases have developed in family members of workers who inad- yertently broughr fibers home on comaminated c1othing. o Hazardous material personnel exposed to asbestos or at risk for asbestos exposure re- qUlre ongoing medical monitoring programs.

425 Boron and Related Compounds

SUBSTANCE IDENTIFICATION Bomn compounds ma)' be found as solids, liquids, or gases. For example, deeaborane (BlOH14) is a colorless, crystalline powder with a strong pungent odor; pentaborane (BsH9) is a colorless, volatile liquid; and bomn hydride (B1Hó, diborane) is a ftammab1e, colorless gas that fumes in moist air with a sharp, irritating odor. Can be found as liquids at low temperatures or when stored under pressure. Used as solvents, in c1eaning operations, in metal treatment, and in various manufaeturing processes. ROUTES OF EXPOSURE Skin and eye contaet Inhalation lngestion Skm absorptíon TARGET ORGANS Primary Skin Eyes Central nervous system Respiratory system Renal Secondary Cardiovascular system Gastrointestlllal system Hepatic LlFE THREAT Resplratory traet imtant that may cause laryngeal spasm, laryngeal edema, and pulmonary edema. May cause severe chemical burns. SIGNS AND SYMPTOMS BY SYSTEM Cardiovascular: Tachycardia and cardiovascular callapse. Respiratory: Severe irritation of the respiratory system, coughing, and choking; causes pulmonary edema, laryngeal spasm. Upper airway abstruction. CNS: CNS depression, coma, dizziness, muscle tremors, ataxia, seizures. Neurobehav- lOral changes. Gastrointestinal: Nausea, vomiting, and abdominal pain. Eye: Chemical conjunctivitis and severe burns, possibly causing permanent loss of Vl- sion. Skin: Irritant dermatitis and severe chemical burns. Renal; Kidney damage. Hepatic: Líver damage. SYMPTOM ONSET FOR ACUTE EXPOSURE Immedlate Some symptoms may be delayed

426 Boron and Related Compounds 103

CO-EXPOSURE CONCERNS Corrosives Other boron compounds THERMAl DECOMPOSITION PRODUCTS INCLUDE Ammonia Hydrochloric acid Nitrogen oxides Oxides MEDICAl CONDITIONS POSSIBlV AGGRAVATED BY EXPOSURE Respiratory system disorders Skm disorders DECONTAMINATION o Wear positive-pressure SCBA and protective equipment specífied by references such as the DOY Emergency Response Guidebook or the CANUTEC lmtial Emergency Response Guide. If special chenucal protectlve c10thing is required, consult the chemical manufacturer or specific protective clothing compatibiluy charrs. o Delay entry until trained personnel and proper protective equipment are available. o Remove patient fram contamínated area. o Quickly remove and iso late patient' s clothing, jewelry. and shoes. o Gently brush away dry partic1es and blot excess liquids with absorbent material. o Rinse patient with warm water, 30° C/86° F, if possible. o Wash patient with Tincture of Oreen soap or a míld liquid soap and large quantities of water. o Refer to decontamination protocol in Section Three. IMMEDIATE FIRST AID o Ensure that adequate decontamination has been carried out. o If victim is not breathing, start artificial respIration, preferably with a demand-valve resuscítator, bag-valve-mask device, or pocket mask as trained. Perform CPR if necessary. o Immediarely flush contaminated eyes wíth gently ftowrng water. o Do not wduee vomiting. If vomiting oecurs, lean patient forward or place on left side (head-down position, if possible) to maintain an open airway and prevent aspirauon. o Keep victim guiet and maintain normal body temperature. o Obtain medical attention. BASIC TREATMENT . Establish a patent airway. Suction if necessary. o Aggresslve airway rnanagement may be necessary.

o Watch for signs of respíratory insufficiency and assist ventilations if necessary. . Administer oxygen by nonrebreather mask at 10 to 15 L/min. o Monitor for pulmonary edema and treat if necessary (refer to pulmonary edema protocol lO Section Three). o MonitOr for shock and treat if necessary (refer to shock proteeol in Section Three). o For eye contamination, flush eyes irnrnediately wlth water. Irrigate each eye continu- ously with normal saline during transport (refer to eye irrigatíon protoeol in Section Three) . . Do not use emetics. For ingestion, rinse mouth and administer 5 ml/kg up to 200 mI of water for dilution if the patient can swallow, has a strong gag reftex, and does not

427 103 Boron and Related Compounds drooL Administer activated charcoal (refer to ingestion protocol in Section Three and activated charcoal protocol in Section Four). . Cover skin burns with dry sterile dressings after decontamination (refer to chemical bUIDprotocol in Section Three). ADVANCED TREATMENT . Conslder orotracheal or nasotracheal intubation for airway control in the patient who is unconscious, has severe pulmonary edema, or is in respiratory arresto Early intubation at the first sign of upper airway obstruction may be necessary. . Positive-pressure ventilation techniques with a bag-valve-mask device may be benefi~ cial. . Monitor cardiac rhythm and treat arrhythmias If necessary (refer to cardiac protocol in Section Three). . Start an IV with DsW TKO. Use lactated Ringer's if signs of hypovolemia are presento Watch for signs of ftuid overload. . Consider drug therapy for pulmonary edema (refer to pulmonary edema protocol in Section Three). . Consider vasopressors to treat hypotension without signs of hypovolemia (refer to shock protocol in Section Three). . Use proparacaine hydrochloride tú assist eye irrigation (refer to proparacaine hydrochloride protocol in Section Four). INITIAL EMERGENCY DEPARTMENT CONSIDERATIONS . U seful initial laboratory studies include complete blood count, serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, urinalysis, and baseline biochemical profile, including serum aminotransferases (ALT and AST), calcium. phosphorus, and magnesium. Determination of anion and osmolar gaps may be helpful. Arterial blood gases (ABGs), chest radlOgraph, and electrocardiogram may be required. . Positive end-expiratory pressure (PEEP)-assisted ventilation may be necessary in pa- tients with acute parenchymal injury who develop pulmonary edema or adult respiratory distress syndrome. . Obtain toxicological consultation as necessary. SPECIAL CONSIDERATIONS . Some producIs may cause olfactory fatigue and therefore have poor warning prop- erties.

428 Ozone (03) and Related Compounds .

SUBSTANCE IDENTIFICATION A colorless gas \Viril a sharp odor. At very low temperatures. ozone ís found as a dark blue IIquid. Used for purifying air and water; as an oxidizing agent. disinfectant, and bleaching agent; and in the trcatment 01' industrial wastes. ROUTES OF EXPOSURE Skin and eye contact Inhalation TARGET ORGANS Prima ry Skin Eyes Respiratory system Secondary Central nervous system Cardiovascular systcm Gastrointestinal sysLem LlFE THREAT Pulrnonary edema and airway obstruction SIGNS AND SYMPTOMS BY SYSTEM Cardiovascular: Cardiovaseu]ar collapse and hypotension. Respiratory: Irritation of respiratory traet, coughing, choking, dyspnca, and in severe exposures, pulmonary edema. Chest pain or tightness of the chest may be present. CNS: Headache, fatigue, dizziness, insornnia, inability lO concentrate, and drowsiness. Gastrointestinal: Gastroenteritis s)'mptoms including nausea and vomiting. Eye: Chemlcal conjunctivitis. Skin: Dermatitis. burns wlth liquid product exposure. Expanding gases may cause frostbite. Other: The ability to detect the product by smell rnay be lost shorLly a1'ter exposure. SYMPTOM ONSET FOR ACUTE EXPOSURE Irnmediate CO-EXPOSURE CONCERNS Other airway irritants MEDICAL CONDITIONS POSSIBLY AGGRAVATED BY EXPOSURE Respíratory system dlsorders AsthmalreacL1veairways disease dlsorders DECONTAMINATION . Wear positive-pressure SCBA and protective equipment specified by references such as (he DOT Emergency Response Cuidebook or the CAl'lUTEC lnitial Emergency Response Cuide. [f special chemical protectíve clothing is required, consult the chemical manufacturer or specific protective clothing compatibilíty charts. . Delay entry until trained personnel and proper protective equipment are available. . Remove patient from contammated area. 429 104 Ozone (O3) and Related Compounds . If concurrent liquid or salid exposure exists: . Quickly remove and lsolate patient's clothing, Jewelry, and shoes. . Gently brush away dry particles and blot excess hquids with absorbent material. o Rinse patient with warm water, 30° C/86° F, if possible. . Wash patient with Tmcture of Green soap or a mild liquid soap and large quantities of water. . Refer to decontamination protocal in Section Three. IMMEDIATE FIRST AID o Ensure thar adequare decomaminaIion has been carried om. . If vietlm is not breathing, start artificial respiration, preferably with a demand-valve resuscitator, bag-valve-mask device, or pocket mask as trained. Perform CPR if neeessary. . Immediately flush contaminated eyes with gently flowing water. o Do not induce vomiting. If vomiting oecurs. lean patient forward or place on left side (head-down position, if possible) to maintain an open airway and prevent aspiration. . Keep victim quiet and maintain normal body temperature. . Obtam medical attention. BASIC TREATMENT . Establish a patent alrway. Suction if necessary. o Watch for signs of respira10ry insufficlency and asslst ventilations if necessary. . Adrninisrer oxygen by nonrebreather mask at 10 10 15 L/min. o Monitor for pulmonary edema and treat if necessary (refer to pulmonary edema protocol in Section Three). . Monitor for shock and treat if neeessary (refer to shock protocol in Section Three). . Por eye eontamination, flush eyes irnmediately with water. Irrigate each eye continu- ously with normal saline during transport (refer to eye irrigation protocol in Section Three) . . Use rapid rewarming techniques for frostbite (refer to frostbite protocol in Section Three). ADVANCED TREATMENT . Consider orotracheal or nasotracheal mtubation for airway control in the patient who is unconscious or has severe pulmonary edema. o Positive-pressure ventilation techniques wlth a bag-valve-mask device may be benefi- eial. . Monitor cardiac rhythm and treat arrhythmias if necessary (refer to cardiac protocol in Section Three). . Start an IV with DsW TKO. Use lactated Ringer's if signs of hypovolemia are present. Watch for signs of fluid overload. . Consider drug therapy for pulmonary edema (refer to pulmonary edema protocol in SectlOn Three). . Consider vasopressors to treat hypotension without signs of hypovolemia (refer to shock protocol m Section Three). . Use proparacaine hydrochloride to assist eye imgatíon (refer to proparacaine hydrochloride protocol in Section Four). INITIAl EMERGENCY DEPARTMENT CONSIDERATIONS . Useful initial laboratory studies indude complete blood count, serum electrolytes, blood urea nitrogen (BUN), creatmllle, glucose, urinalysis, and baseline biochemical profile, includlllg serum aminotransferases (ALT and AST), calcium, phosphorus, 430 Ozone (°3) and Related Compounds 104 and magnesium. Determination of anion and osmolar gaps may be helpful. Arterial blood gases (ABGs), chest radiograph, and electrocardiogram may be required. . Positive end-expiratory pressure (PEEP)-assisted ventilation may be necessary in pa- tients with acute parenchymal injury who develop pulmonary edema or adult resplra- to0' distress syndrome. . Asthmalreactive airways disease symptoms may require inhaled bronchodilator therapy. Pulmonary function testing is recommended. . Obtain toxicological consultation as necessary.

431 u--1 05 Sulfur and Related Compounds

SUBSTANCE IDENTIFICATION Sulfur compounds are cornmonly found as odorless, brown-to-yellow solids or as a yellow dispersion. Used in the manufacture of insecticides, chemicals, gunpowder, plastlcs. dyes. rubber. matches, pharmaceuticals. sulfunc acid. enamels, and metal-glass cement and in wood pulp processes. Organic sulfur compounds such as methyl mer- captan are added as odorants to natural gas. Sulfur dioxide (S02) is a colorless gas with a sharp, irritating odor. lt is commonly used as a dismfectant; for bleaching textile fibers; in wood pulp treatment; in ore and metal refining; and in the manufacture of preservatives. bleaches, and glues. A by-produet of coal-buming power plants, sulfur dioxide contributes to air pollution. Sulfites are used as food preservatives and parental medicarion additives. ROUTE OF EXPOSURE Skin and eye contact Inhalation Ingestion TARGET ORGANS Primary Skin Eyes Respiratory system Secondary Central nervous systern Cardiovascular systern Gastrointestinal system Renal Metabolism lIFE THREAT Respiratory tract irritation leading to pulmonary edema. Anaphylaxis. SIGNS AND SYMPTOMS BY SYSTEM Cardiovascular: Tachycardia, hypotension, and eardiovascular collapse. Respiratory: Respiratory traet irritation, rhinitis, sinusitis. pharyngitls, upper airway edema, coughing, bronchoconstrietlon, chest discomfort. and fmIure. Pulmonary edema. Exposure may cause asthmalreactive airways disease. CNS: Headaehes, vertlgo, memory loss, decreased level of consciousness, seizures. and coma. Gastrointestinal: Nausea, vomiting, and abdornmal pam. Eye: Irritation, lacrimation, and chemical bums Skin: Irritation and chemical bums. Frostbite may occur fram exposure to Iiquefied product or expanding gas. Urticaria and allergic reactions with sulfites. Renal: Kidney damage. Metabolism: Acidosi~ and hyperkalemia.

432 Sulfur and Related Compounds 105

SYMPTOM ONSET FOR ACUTE EXPOSURE Immediate Some symptoms (renal) may be delayed CO-EXPOSURE CONCERNS Other respiratory irritants THERMAL DECOMPOSITION PRODUCTS INCLUDE Carbon disulfide Hydrogen sulfide Sulfur dlOXtde MEDICAL CONDITIONS POSSIBLY AGGRAVATED BY EXPOSURE Respiratory system disorders Cardiovascular disorders DECONTAMINATION o Wear positlve-pressureSCBA and protectlve equipment specifiedby references such as the DOT Emergency Response Guidebook or the CANUTEC Imtzal Emergency Response Guide. If special chemical protective clothing is required, consult the chemical manufacturer or specific protective clothing compatibility charts. . Delay entry until trained personnel and proper protective equipment are available. . Remove patient frarn contaminated area. . Quickly remove and isolate patient's clothing, jewelry. and shoes. . Gently brush away dry particles and blot excess liquids with absorbent material. . Rmse patient with warm water, 30° C/86° F, if possible. . Wash palient with Tincture of Green soap or a mild liquid soap and large quantities of water. o Refer to decontamination protocol in Section Three. IMMEDIATE F'RST AID o Ensure that adequate decontamination has been carried out. . lf victim is not breathing, start artificial respiration, preferably with a demand-valve resuscitator, bag-valve-rnask device, or pocket mask as trained. Perform CPR if necessary. o Irnmediately flush contammated eyes with gently flowmg water. . Do not mduce vomiting. If vomiting occurs, lean patient forward or place on left side (head-down position, if possible) to mamtain an open mrway and prevent aspiration . Keep victim quiet and maintain normal body temperature- o Obtain medical attention. BASIC TREATMENT o Establish a patent airway. Suction if necessary. . Watch for signs of respiratory insufficiency and assist ventrlations if necessary. o Administer oxygen by nonrebreather mask at 10 to 15 L/min. o Monitor for pulmonary edema and treat If necessary (refer to pulmonary edema protocol in Section Three). o Anticípate seizures and treat If necessary (refer to seizure protocol in Section Three). o Monitor for shock and treat if necessary (refer to shock prmocol in Section Three). . For eye contamination, flush eyes imrnedIately wIth water. Irrigate each eye continu- ously with normal saline during transport (refer to eye irrigation protocol in Section Three) . . Do not use emetics. For ingestion, rinse rnouth and adrninister 5 rnl/kg up to 200 mI of water for dilution if the patient can swallow, has a strong gag reftex, and does not 433 105 Sulfur and Related Compounds drool. Administer actlvated charcoal (refer to ingestíon protocol In Section Three and activated charcoal protocol m Section Four). . Cover skin bums with sterile dressmgs after decontammation (refer to chemlcal bum protocol in Section Three). ADVANCED TREATMENT . Consider orotracheal or nasotracheal intubation [or airway control in the patient who is unconscious. EarIy intubation at the first sign of upper airway obstruction may be necessary. . Momtar cardlac rhythm and treat arrhythmias if necessary (refer to cardiac protocol in Section Three). . 5taft an IV with DsW TKO. Use lactated Ringer's if signs of hypovolemia are present. Watch for signs of fluid overload. . Consider drug therapy for pulmonary edema (refer to pulmonary edema protocol in Section Three). . Treat seizures with diazepam (Valium) (refer to diazepam protocol in Section Four). . For hypotension with signs of hypovolemia, administer flUld cautiously. Conslder vasopressors for hypotenslOn wíth a nonnal fluid volume. Watch for signs of flUld overload (refer to shock protocol in Section Three). . Use proparacaine hydrochloride to assist eye irrigatlOn (refer to proparacaine hydrochloride protocol m Section Four). INITIAl EMERGENCY DEPARTMENT CONSIDERATIONS . Useful initial laboratory studies ínclude complete blood count. semm electrolytes, blood urea nitrogen (BUN), creatinine, glucose, urinalysis, and baseline blOchemical profile, including serum amínotransferases (ALT and AST), calcium, phosphorus, and magnesium. Detennination of anion and os molar gaps may be helpful. Arterial blood gases (ABGs), chest radiograph, and electrocardiogram may be required. . Posluve end-expiratory pressure (PEEP)-assisted ventilatíon may be necessary in pa- tients with acute parenchymal mjury who develop pulmonary edema or adult respira- tOl) distress syndrome. . BronchodilaIOr therapy may be indicared in cases of severe bronchospasm. Observe for slgns of anaphy laxis. . Products may cause acidosis; hyperventílation and sodium bicarbonate may be ben- eficiaL Bicarbonate therapy should be guided by patient presentatlOn, ABG determination, and serum electrolyte consideratlons. . Obtain toxicological consultation as necessary. SPECIAl CONSIDERATIONS . Sulfite compounds may cause bronchospasm andJor allergic reactions in asthmatics. Individuals not known to be asthmatlc or allergic to sulfites may develop anaphylaxis or anaphylactoid reactions as welL

434 .

" Tri-Ortho-Cresyl Phosphate 106 (TOCP) and Related Compounds

SUBSTANCE IDENTIFICATION Found as a colorless. odorless liquido Used as a ftame retardant; a plasticizer in lac- quers and vamishes; and a gasolinelhydraulic fluid additive. Tri-Ortho-Cresyl Phosphate (TOCP) is an organophosphate compound that may cause a peripheral ax.on- opathy without the acute symptoms of cholinergic poisoning (SLUDGE syndrome) that are commonly seen in cases of other organophosphate insecticide poisonings. ROUTES OF EXPOSURE Skin and eye contact Inhalation Ingestion Skin absorptlOn TARGET ORGANS Primal}' Central nervous system Secondary Skin Eyes Gastrollltestlllal system LlFE THREAT A delayed neurotoxin that causes an ascending paralysis of the extremities SIGNS AND SYMPTOMS BY SYSTEM Cardiovascular: Acute symptoms unlikely. Respiratory: Acute symptoms unlikely. CNS: Delayed 3 to 30 days; sharp, cramping pain in the calves and sensory distur- bances, mcluding paresthesias of the lower extremities. There is an abrupt onset of flaccid paralysls of the extremities, 10 to 14 days later. The paralysis can spread to the upper extremities. Upper extremity recovery may occur with a resultant, permanent lower-extremity paralysis with spasticity, hyperreflexia, hypertonicity, c1onus, and slap- ping gait. Gastrointestinal: Sudden onset of nausea, vomiting, diarrhea, and abdominal palll starting shortly after exposure. ThlS lasts for approximately 48 hours and is followed by an asymptomatic, latent period of 8 to 35 days. Eye: Conjunctivitis after latent periodo Skin: Excessive sweating with cold, cyanotic, and moist hands and feet. Other: Symptoms are generally nonfatal, but may take years to recover from and may leave permanent damage. SYMPTOMONSET FOR ACUTE EXPOSURE Delayed

435 106 Tri-Ortho-Cresyl Phosphate (TOCP) and Related Compounds

CO-EXPOSURE CONCERNS Carbamates Organophosphates THERMAL DECOMPOSITION PRODUCTS JNCLUDE Phosphorus fumes MEDICAL CONDITIONS POSSIBLV AGGRAVATED BY EXPOSURE NeuroIogical disorders DECONTAMINATION o Wear positive-pressure SCBA and protective equipment specified by references such as the DOY Emergency Respanse Guidebook or the CANUTEC lnitial Emergency Response Guide. If speciaI chemical protective clothing is required, consult the chemical manufacturer or specific protective clothing compatibility charts. . Delay entry until trained personnel and proper protective equipment are available. o Remove patient from contaminated area. o Quickly remove and isolate patient' s clothing, jewelry, and shoes. . Gently blot excess liquids with absorbent material. o Rinse patient with wann water, 30°C/86°F, if possible. o Wash patient with Tincture of Green soap or a mild liquid soap and large quantities of water. o Refer to decontamination protocol in Section Three. IMMEDlATE FIRST AID . Ensure that adequate deconramination has been camed out. o lf victim is not breathing, start artificial respiration, preferably with a demand-valve resuscitator, bag-valve-mask device, or pocket mask as trained. Perforro CPR if necessary. . Irnmedlately ftush contaminated eyes with gentIy flowing water o Do nOt induce vomiting. If vomiting occurs, lean patiem forward or place on left sirle (head-down position, if possibIe) to maintain an open airway and prevent aspiration. . Keep victim quiet and maintain normal body temperature. o Obtain medical attention. BASIC TREATMENT . Establish a patent airway. Suction if necessary. o Watch for signs of respiratory insufficiency and assist ventilations if necessary. o Administer oxygen by nonrebreather mask at 10 to 15 L/min. o For eye contamination, flush eyes irnmediateIy with water. Irrigate each eye continu- ousIy with nonnal saline during transport (refer to eye irrigation protocol in Section Three) . o Do not use emetlcs. For ingestion, rinse rnollth and administer 5 m1fkg up to 200 mI of water for dilution if the patient can swallow, has a strong gag reflex, and does not drooL Adrnmister activated charcoal (refer to ingesrion protocol in Section Three and activated charcoal protocoI in Section Four). ADVANCED TREATMENT o Use proparacaine hydrochloride to assist eye irrigation (refer to proparacaine hydrochloride protocol in Section Four). INITIAL EMERGENCV DEPARTMENT CONSIDERATIONS o Careful history and baseline neuroIogical examination should be done. o Useful initiallaboratory studies include complete bIood count, serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, urinaIysis, and basehne biochemicaI 436 Tri-Ortho-Cresyl Phosphate (TOC?) and Related Compounds 106 profile, including semm aminotransferases (ALT and AST), calcium, phospharus. and magnesium. Obtain baseline plasma and red blood cell cholinesterase levels. Base- hne chest radiograph, and electrocardiogram may be required. o Treatment IS supportl ve. o For additional informaÜon on organophosphate poisoning see guideline 49. . Obtain toxicological consultatian as necessary. SPECIAL CONSIDERATIONS . Smce the only symptoms in the acute phase are GI 1ll nature, treatment should be supportive and to ensure follow-up medical treatment. . In L930, during prohibition, an epidemic known as "ginger jake paralysis" occurred in over 15,000-20,000 individual s consuming Jamaica gmger extraet contaminated with TOCP. Similar outbreaks have occurred with ingestion of similarly adulterated products. o Tri-tolyl phosphate is made up of three Isomers. Only the ortho isomer (TOCP) is re- sponsible for the delayed neurotoxicity.

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