HAZARDOUS MATERIALS EXPOSURE GUIDE

PATIENT For treatment questons: Poison Control Center 800-222-1222 TREATMENT www.mnpoison.org.

STEPS PLEASE LOOK TO THE APPROPRIATE SECTION FOR DETAILED INSTRUCTIONS.

1. DECONTAMINATE AND COLLECT INFORMATION

2. TREAT THE PATIENT FOR CHEMICAL EXPOSURES

3. COLLECT BLOOD AND URINE SPECIMENS For specimen questions: Collect specimens per your institution’s normal protocols for medical management. Minnesota Department of Health For unusual exposures, please contact MDH with questions about specimen 612-282-3750 collection. www.health.mn.gov/hazmat

This document is a reference and is not intended to replace medical advice.

Specific exposures may require individual recommendations and should be managed with the help of the Poison Control Center. Healthcare workers should avoid becoming contaminated and use appropriate personal protective equipment per their institutional plans.

Produced by the Minnesota Department of Health 2018 www.health.mn.gov/mls SUPPORTIVE TREATMENTS THE FOLLOWING SIX SUPPORTIVE TREATMENT STEPS ARE CRITICAL TO ALL TOXIC EXPOSURES.

1. AIRWAY 2. CIRCULATION 3. SEIZURES 4. POISON 5. ORGANS 6. DISEASE BREATHING CONSULT PROVIDE OXYGEN SUPPORT BLOOD CONTROL CONSULT CONSIDER CONSIDER PRESSURE WITH IV SEIZURES WITH WITH POISON POTENTIAL FOR CONTRIBUTION • Assess for NORMAL SALINE BENZODIAZEPINES CONTROL FOR ALL END-ORGAN OF UNDERLYING respiratory distress EXPOSURES DAMAGE BASED DISEASE TO (includes stridor, • Medications are 1-800-222-1222 UPON AGENT SYMPTOMS OR cough, or wheezing) rarely needed to POTENTIAL FOR maintain blood • Cardiac COMPLICATIONS • Treat with pressure after toxic bronchodilators as exposures. Consult • Pulmonary • Cardiac needed (e.g. ischemia) with Poison Control • Hepatic • Control airway (e.g. and consider central venous monitoring • Pulmonary intubate) as needed • Renal (e.g. asthma) for respiratory for persistent failure, anticipated hypotension. • CNS • Renal progression of • Hematologic symptoms, or coma • Hepatic • Dermatologic • Hematologic (e.g. underlying anemia/ hemoglobinopathy) DECONTAMINATION BASIC STEPS

DECONTAMINATION OF MERCURY FOR ALL OTHER EXPOSURES, THREE STEPS SHOULD BE CONSULT POISON CONTROL FOR ADVICE FOLLOWED TO PERFORM BASIC DECONTAMINATION. PRIOR TO DECONTAMINATION.

DECONTAMINATION OF SOLID METAL SALTS CONSULT POISON CONTROL FOR ADVICE PRIOR TO DECONTAMINATION.

DECONTAMINATION OF RADIOLOGIC MATERIALS CONSULT POISON CONTROL FOR ADVICE PRIOR TO DECONTAMINATION. OBTAIN APPROPRIATE COUNTERS/MONITORING EQUIPMENT. 1. 2. 3. DECONTAMINATION OF Cut or otherwise Seal clothing Use soap and PURE GAS EXPOSURE remove in a bag. water to wash contaminated the affected CONSULT POISON CONTROL FOR ADVICE PRIOR TO DECONTAMINATION. clothing. area(s). Contain Usually this will wastewater if remove 90% or possible. contaminant. Victims exposed to cholinergic/ vapor should receive decontamination. EXPOSURE GUIDE AGENT: EXAMPLES: TOXICITY: SIGNS/SYMPTOMS: ASPHYXIANTS • Cyanide • • Chemical interferes with oxygen • Cyanosis • Methemoglobinemia CHEMICAL • use by body tissue • Severe acidosis • Tachypnea • Methylene chloride (Metabolized to CO in body)

ASPHYXIANTS • Nitrogen • Carbon dioxide • Hypoxemia due to oxygen • Anxiety • Tachycardia • Collapse SIMPLE • Methane • Natural gas displacement in an enclosed Coma • Death environment

(“DUMBELS” mnemonic) CHOLINERGICS • Nerve agents • Pesticides • Acetylcholinesterase inhibition • Diarrhea • Urination • Miosis • Organophosphates: Diazinon, causing uncontrolled persistent • Bradycardia,Bronchorrhea, Malathion nerve stimulation Bronchospasm • Emesis • Carbamates: Sevin • Lacrimation • Salivation, Secretion, Sweating CORROSIVES • Acids: Hydrochloric, Nitric, • Tissue damage • Local pain • Respiratory, Sulfuric, Hydrofluoric (HF) • Acids: Surface oral, ocular involvement • Alkalies: Sodium hydroxide, • Alkalies: Deep • Esophageal burns Potassium hydroxide • Oxidizers: Thermal and • Alkalies: May have no initial • Oxidizers: White phosphorus chemical burns symptoms HYDROCARBONS • Gasoline • Toluene • Lamp oil • Agent-specific toxic effects • Somnolence • Agitation & HALOGENATED • Carbon tetrachloride • Myocardial & CNS depressants • Vomiting • Hypoxia HYDROCARBONS • Refrigerants + risk of dysrhythmias with • Severe GI burns possible adrenergic drugs • Tachycardia, dysrythmias

IRRITANT GASES • Ammonia • • • Respiratory tract irritation Airway irritation • Stridor • High water solubility= • Airway swelling • Eye irritation upper airways • Immediate/delayed pulmonary • Low water solubility= edema • Coughing, wheezing lower airways ASPHYXIANTS CHEMICAL EXAMPLES: CYANIDE | HYDROGEN SULFIDE | CARBON MONOXIDE | METHYLENE CHLORIDE

TOXICITY SIGNS AND SYMPTOMS TREATMENT Chemically interferes Anxiety, tachycardia, eventual Cyanide: Remove from environment. Provide airway support and oxygen. with use syncope, coma, and death if Antidotal treatment for confirmed CN exposures or for confined of oxygen by body not removed from exposure space smoke exposure with acidosis and/or hemodynamic instability/ tissues. environment. dysrhythmia: Hydroxycobalmin (Cyanokit®) – 70 mg/kg to max 5 grams IV (expect reddened skin and possible hypertension) Sodium nitrite – if Closed space Peripheral or central cyanosis hydroxycobalmin unavailable –1 amp IV over 5-10 minutes (peds 0.2 ml/kg). exposures or ‘chocolate brown’ blood may May repeat x1 at 30 minutes if still unstable. Induces methemoglobinemia, indicate methemoglobinemia. thus expect oxygen situations in 85% range (consider transfer to hospital Consult Poison Control. with hyperbaric oxygen capability). May also be used for symptomatic hydrogen sulfide (HS) exposures. Sodium thiosulfate – given for cyanide Tachypnea poisoning in addition to either of above treatments 1 amp IV over 5 minutes Cyanide – severe acidosis. (peds 1.6 mg/kg of 25% preparation)

Methylene chloride produces Carbon Monoxide: Consider hyperbaric oxygen for significant exposure (loss carbon monoxide in body. of consciousness, cardiac complications, pregnancy, other severe symptoms or prolonged (>5h exposure). Consult HCMC: 612-873-3132

Methemoglobinemia: Treatment is methylene blue. Starting dose 1-2mg/ kg. Complication may be hemolysis. Contact Poison Control for treatment considerations. ASPHYXIANTS SIMPLE EXAMPLES: NITROGEN | CARBON DIOXIDE | METHANE | NATURAL GAS

TOXICITY SIGNS AND TREATMENT SYMPTOMS Asphyxiants displace oxygen in an enclosed Remove victim from exposure environment atmosphere causing hypoxemia Anxiety Administer oxygen Toxicity worse in closed spaces (or below grade Tachypnea and tachycardia due spaces for gases denser than air) to hypoxia Condition should not deteriorate after removal from exposure environment unless due to Compressed liquid gases (e.g. nitrogen and Eventual collapse, coma and death underlying disease complications propane) may cause frostbite to skin if in close if not removed from exposure (e.g. cardiac disease) proximity to source of leaking gas environment. CHOLINERGICS EXAMPLES: NERVE AGENTS ORGANOPHOSPHATES: DIAZINON | MALATHION CARBAMATES: SEVIN TOXICITY SIGNS AND TREATMENT SYMPTOMS Allows uncontrolled persistent DECONTAMINATION: Soap and water wash the patient. Bag and seal nerve simulation by poisoning “D U M B E L S” clothing to prevent off-gassing. Body fluids may contain high levels of agent in acetylcholinesterase ingestion cases. (Poses threat to rescuers from contact/vapor.) Diarrhea INTUBATION, ANTIDOTAL THERAPY: Urination Atropine 3-5mg per dose IM/IV (0.1mg/kg) repeat as needed to control secretions and allow ventilation. Miosis - Small pupils (critical finding!) Pralidoxime 1-2g IV or 25mg/kg (not required for carbamate exposure) over 10 min, repeat at 30 min if still critically ill or exhibiting fasciculations, Bradycardia, seizures, or weakness. Bronchorrhea Bronchospasm Duodote or Mark 1 kit autoinjectors (2PAM 600 mg/atropine 2 mg) 2 kits/sever poisoning, 1 kit for <10 years old or mild poisoning. (High potential Emesis for healthcare worker contamination and toxicity – decontaminate patient and Lacrimation wear personal protective equipment as required.) Salivation Benzodiazepines should be given to all severely poisoned patients and for Secretion seizures. Sweating Consult Poison Control regarding decontamination and further therapy. CORROSIVES EXAMPLES: ACIDS: HYDROCHLORIC ACID | NITRIC ACID | SULFURIC ACID | HYDROFLUORIC (HF) ACID BASES: SODIUM HYDROXIDE | POTASSIUM HYDROXIDE OXIDIZERS: WHITE PHOSPHORUS

TOXICITY SIGNS AND TREATMENT SYMPTOMS Damage to tissues Irrigate copiously with water. If a chemical alkali is involved, irrigate Pain may be minimal early after continuously until the surface pH remains neutral 5 min after last Alkalies penetrate exposure, especially to alkalies irrigation. For eye irrigation, use topical anesthetic; consider Morgan lens. tissues deeply, acids May require admission for ongoing irrigation. Consult ophthalmology for affect surface tissues White phosphorous – anemia from eye injuries. Oxidizers: consult Poison Control. (except HF, which hemolysis, ‘chocolate’ colored can cause deceptively blood from methemoglobinemia HF – Calcium replacement (large doses of Ca may be needed), also Mg severe burns and and K. Topical and IV calcium, may need intra-arterial calcium treatment. hypocalcemia) HF - profound pain at exposure site, weakness, muscle twitching/ Consult Poison Control immediately. Oxidizers cause thermal tetany Electrocardiogram changes White phosphorus – Calcium replacement and further treatment per burns in addition to (long QT, AV block) or Poison Control. Assess for hemolysis, methemoglobinemia and treat as chemical burns dysrhythmia from low calcium indicated. White phosphorus Eye burns - pain, tearing, vision Decontaminate, then treat tissue injury as you would treat thermal burns. can cause hemolysis, changes Assure re-evaluation in 24 hours (or sooner methemoglobinemia, if any worsening or new symptoms/signs). and hypocalcemia Ingestions may have severe esophageal burns with normal oral Consult Poison Control and consider GI consult for ingestions. exam HYDROCARBONS HALOGENATED HYDROCARBONS EXAMPLES: GASOLINE | TOLUENE | L AMP OIL | CARBON TETRACHLORIDE | REFRIGERANTS

TOXICITY SIGNS AND TREATMENT CNS and myocardial depressants, but SYMPTOMS Control flammable and explosive residues on increased risk of dysrhythmias Somnolence clothing. (e.g. VF) with adrenergic drugs (e.g. albuterol, epinephrine, exercise, emotional/excitement Agitation Provide supportive treatment; avoid beta- reactions) agonists (albuterol, epi, etc.) if possible. Emesis Certain halogenated hydrocarbons have If ocular exposure, irrigate eyes to preclude specific toxic effects (e.g. methylene chloride Hypoxia corneal damage. produces carbon monoxide in the body) Some agents may cause severe GI Follow ACLS algorithms for ventricular burns - Consult Poison Control. dysrhythmias (e.g. lidocaine, amiodarone), consider consultation or beta-blockade (e.g. Inhaled can cause hypoxemia esmolol) for refractory or recurrent ventricular dysrhthmia. IRRITANT GASES EXAMPLES: AMMONIA, CHLORINE, PHOSGENE

TOXICITY SIGNS AND TREATMENT SYMPTOMS Irritates respiratory tract, but causes Provide supportive airway management no major systemic effects Airway irritation (may include intubation, oxygen, bronchodilators, BiPAP). Make sure HF is not involved Stridor (see corrosives) For eye injuries, administer analgesia and Airway swelling anesthetic eye drops, irrigation. Ammonia is highly water soluble = immediate CONTACT POISON CONTROL. upper airway symptoms Eye irritation For exposure to lower solubility agents Chlorine moderately water soluble = upper Immediate or delayed pulmonary (e.g. phosgene), observe for 6h for delayed and lower airway symptoms edema symptoms. Phosgene is less water soluble = delayed and lower airway symptoms INFORMATION TO GATHER

EXPOSED INDIVIDUAL EXPOSURE DATE & TIME DURATION OF EXPOSURE SECONDS MINUTES HOURS DAYS WEEKS MONTHS PATIENT ARRIVAL DATE & TIME ROUTE OF EXPOSURE INHALATION CONTACT INGESTION COMBINATION OTHER WHERE EXPOSURE OCCURED CLOSED SPACE OUTSIDE COMBINATION OTHER NAME & PHONE NO. OF FIRST RESPONDER CHEMICAL NAME OF SUSPECTED SUBSTANCE IS SAMPLE AVAILABLE FOR TESTING? YES NO SUBSTANCE PROPERTIES POWDER LIQUID SOLID GAS ODOR COLOR VOLUME SPILLED DESCRIBE DECONTAMINATION PROVIDED AT THE SITE OF EXPOSURE

PRE-HOSPITAL CARE Collect specimens from each person involved in an BLOOD unusual chemical-exposure event.Please consult with SPECIMEN the Minnesota Department of Health 612-282-3750

PEDIATRIC: COLLECT URINE ONLY UNLESS OTHERWISE DIRECTED BY THE CDC. (SEE URINE SPECIMEN CARD) ADULT: FOR EACH PATIENT, COLLECT SAMPLES IN THE FOLLOWING ORDER: 1. COLLECT A MINIMUM OF 12 mL OF BLOOD IN PURPLE-TOP EDTA TUBES. 2. COLLECT 3 mL OF BLOOD IN ONE GREEN OR GREY-TOP TUBE. 3. COLLECT AT LEAST 25 mL OF URINE IN A SCREW-CAP URINE CUP. (SEE URINE SPECIMEN CARD)

COLLECT LABEL MIX STORE 1. FIRST DRAW 2. THEN DRAW USING INDELIBLE MIX EACH STORE PURPLE TOP TUBES GRAY OR GREEN TOP TUBES INK, LABEL EACH TUBE BY BLOOD (DO NOT USE GEL SEPARATORS) (DO NOT USE GEL SEPARATORS) BLOOD TUBE IN INVERTING SAMPLES COLLECT A MINIMUM OF 12 mL COLLECT 3-7 mL IN ONE TUBE ORDER OF 5-6 TIMES. AT 4-80C COLLECTION, 1-3 OR 4. DO NOT FREEZE.

PLACE HOSPITAL OR CLINIC LABEL ON BLOOD TUBES Collect specimens from each person involved in an URINE unusual chemical-exposure event.Please consult with SPECIMEN the Minnesota Department of Health 612-282-3750

PEDIATRIC: COLLECT URINE ONLY UNLESS OTHERWISE DIRECTED BY THE CDC. ADULT: IN ADDITION TO THE BLOOD TUBES (SEE BLOOD SPECIMEN CARD), COLLECT AT LEAST 25 mL OF URINE IN A SCREW CAP URINE CUP FOR EACH PATIENT.

COLLECT LABEL STORE

MINIMUM 25 mL SPECIMEN LABEL THE URINE CUP WITH THE APPROPRIATE FREEZE URINE SPECIMENS AT -70C. HOSPITAL/CLINIC LABEL AS SHOWN. COLLECT IN A SCREW-CAP IF -70C IS NOT AVAILABLE, PLACE IN URINE CUP INDICATE HOW THE COLDEST LOCATION AVAILABLE. THE SAMPLE RAPID FREEZING IS RECOMMENDED. WAS COLLECTED IF METHOD WAS OTHER THAN “CLEAN CATCH”.