Ver el código de «Hazmat exposure»


==Background==
*Definition - exposure to hazardous materials causing local/systemic toxicity

==Types of Injury==
*Acids
**Cause coagulation necrosis which causes an eschar which often limits damage to deeper tissue
*Alkalis
**Cause liquefaction necrosis that penetrates into deeper tissue. 
*Other mechanisms: oxidation, protein denaturation, cellular dehydration, local ischemia

==History==
*Route/duration of exposure
*Often exposure in household, industry, agriculture, or terrorism
*Identifying the chemical is paramount

==Exam==
*Skin
**Often appears deceptively normal initially
**Look for visible remaining liquid/powder on skin.

*Membranes
**Potential for airway compromise
**Inspect eyes/nasopharynx/cornea if indicated

*Pulm
**Bronchospam/cough/pulm edema/cough

*Systemic sigs
**AMS, seizures, tachy/brady dysrhythmias, hypo/hyper-tensive, GI sx, electrolyte abnormalitiyes, carboxyhemoglobinemia/methemoglobinemia, cyanide tox, toxidromic constellation of signs (e.g. cholinergic)


==Resources==
*Resources to determine what is in the offending agent:
**Poison control (800 222-1222)
**[http://www.msds.com/ Material Safety Data Sheet (MSDS)]
***Determines need for decon
**Chemical Transportation Emergency Center (Chemtrec) Emergency Telephone Number: (800) 424-9300
***Interntational and Maritime Telephone Number (collect calls accetped): +1 (703) 527-3887
**[https://toxnet.nlm.nih.gov/ TOXNET]

==Diagnostics==
*Work up based on chemical culprit
*POC glucose
*BMP 
*Calcium 
*Magnesium
*Phosphorus
*LFTs
*VBG - concern for metabolic acidosis, carboxyhemoglobinemias, methemoglobinemias 
*CXR - concern for pulmonary edema

==Logistics==
*Establish Hazmat Plan
**Affected patients need to stay in designated hot zones until decontaminated (staff can be injured secondary contamination inhalation of volatile gases)
**Patients may arrive by EMS, private vehicle, walk ins
**Establish security perimeter to enforce hot zone

*Protect yourself and staff
*Personal chemical protective equipment:
**Level A: Positive-pressure self-contained breathing apparatus (SCBA), fully encapsulated chemical-resistant suit, double chemical-resistant gloves, chemical-resistant boots, and airtight seals between suit, gloves, boots
**Level B: SCBA, nonencapsulated chemical suit, double gloves, boots
**Level C: Air-purification device, suit, gloves, boots
**Level D: Common work clothes

==Decon==
*Prehospital/In decon areas:
**Hydrotherapy - irrigate skin and ocular burns immediately and continuously (>15 min)
***Contraindicated only for elemental metals (Na, K)
**Can allow patient to wash themselves if limited staff with protective gear
**Dispose of all clothes/bandages/IVs

==Management==
*Aggressive supportive care, analgesia
*[[Antidotes]] if available
*Pulmonary involvement
**O2, albuterol, intubate

==Specific Conditions==
*[[Chemical burns]]
**Strong alkali, needs irrigation for hours
**IVF 3cc/kg/TBSA, 1/2 given in first 8 hours
**[[Hydrofluoric acid]] burn
***Calcium gluconate via topic gel (10ml 10% sol'n applied topically), SC, or intra-arterial
***IV calcium gluconate and magnesium for systemic toxicity
**Phenol burns
***Polyethylene glycol 300 +/- isopropyl alcohol to remove phenol from skin
**Nitrites
***Concern for [[Methemoglobinemia]]
***Treat levels >30% w/ HF O2 and IV methylene  blue (1-2mg/kg slow IV, not recommended for <6 y/o, >6 y/o 1mg/kg IV/IM)
**[[Cyanide]]
***Hydroxocobalamin (5mg IV /5 min, repeat once)
***Elemental metals (Na or K)
***Water is contraindicated
***Cover with oil under substance can be debrided from skin

==Disposition==
*[[Burn center criteria|Transfer to burn center if criteria met]]
*Admit if systemic symptoms or airway concern
*Consider discharge of patients in consultation with poison control and/or after period of observation as needed

==See Also==
*[[Caustic burns]]
 
==External Links==
**[http://www.msds.com/ Material Safety Data Sheet (MSDS)]
**[https://toxnet.nlm.nih.gov/ TOXNET]

==References==
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