Management of Chlorine Gas Exposure

P H A R M / T O X C O R N E R

Authors: Cindy Howard, BSN, RN, CSPI, Briggetta Ducre, BSN,

RN, CSPI, Anthony M. Burda, BS Pharm, DABAT, and ArthurKubic, PharmD, Chicago, Ill

Section Editor: Allison Muller, PharmD, DABAT

Cindy Howard is Certified Specialist Poison Information, IllinoisPoison Center, Chicago, Ill.

Briggetta Ducre is Certified Specialist Poison Information, IllinoisPoison Center, Chicago, Ill.

Anthony M. Burda is Chief Specialist, Illinois Poison Center,Chicago, Ill.

Arthur Kubic is Specialist Poison Information, Illinois Poison Center,Chicago, Ill.

For correspondence, write: Cindy Howard, BSN, RN, CSPI, 222 S.Riverside Plaza, Suite 1900, Chicago, IL 60606; E-mail:choward@ilpoison.org.

J Emerg Nurs 2007;33:402-4.

Available online 4 June 2007.

0099-1767/$32.00

Copyright n 2007 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2007.03.010

402

Earn Up to 8 CE Hours. See page 416.

38-year-old woman presents to the emergency

Adepartment shortly after cleaning her bathroom

with a mixture of chemicals. Her symptoms

include cough, chest burning and tightness, and some

shortness of breath along with red, irritated, and tear-

ing eyes. Current vital signs are: blood pressure, 150/

90 mmHg; heart rate, 98 bpm; respiratory rate, 24 per

minute; temperature, 99.08F; and oxygen saturation in

arterial blood, 93% on room air. The patient has no

significant medical history; she is a nonsmoker. According

to the patient, she mixed toilet bowl cleaner and household

bleach together, which then created a yellow-greenish gas.

The containers were brought to the emergency department

and were identified as hydrochloric acid (toilet bowl

cleaner) and regular household bleach, which contains

sodium hypochlorite. Supplemental humidified oxygen

was administered, an arterial blood gas (ABG) test and

chest radiograph were ordered, and the regional poison

control center was contacted.

Chlorine gas exposures are a common poisoning for

which poison control centers are frequently consulted.

Chlorine gas (Cl2) is an irritating yellow-green gas that is

heavier than air. It is a familiar industrial chemical found

in swimming pool preparations and historically has been

used as a chemical warfare agent. The most frequent cause

of chlorine exposure, however, is the generation of chlorine

gas created by mixing sodium hypochlorite—found in

bleach and swimming pool products—with any acid-

containing product, most commonly toilet bowl cleaner or

certain drain openers.

Several hazardous material incidents involving chlo-

rine gas release from railroad tanker cars are reported in the

JOURNAL OF EMERGENCY NURSING 33:4 August 2007

P H A R M / T O X C O R N E R / H o w a r d e t a l

literature.1 In 2002 in Missouri, a railroad tanker released

16,900 pounds of chlorine gas, injuring 67 people. In June

2004, a tanker released 90,000 pounds of chlorine gas and

other chemicals in Texas, resulting in the deaths of 2

nearby residents and injuring 41 others. In South Carolina,

on January 6, 2005, a railroad tanker released 11,500

gallons of chlorine gas, resulting in 9 fatalities and sending

529 people to area hospitals for treatment. Between 1999

and 2004, the Hazardous Substance Emergency Events

Surveillance reported 1165 rail events, 11 (0.8%) of which

involved chlorine gas release.

Augu

Chlorine gas exposures are a commonpoisoning for which poison controlcenters are frequently consulted.

Signs and Symptoms of Exposure

Following inhalation of chlorine gas into the lungs,

chlorine reacts with water to form hydrochloric and hypo-

chlorous acid, the latter of which breaks down to hydro-

chloric acid and oxygen free radicals.2 These chemical-end

products cause damage to cellular proteins, resulting in

direct tissue injury.

Depending on the air concentrations and duration of

exposure to chlorine gas, various degrees of injury may

occur to the eyes and respiratory tract.2-4 Symptoms may

range from irritation of eyes, nose, and throat and a slight

cough in smaller exposures of short duration to shortness of

breath, stridor, wheezing, tachycardia and tachypnea, chest

pain, hypoxemia, and upper airway or pulmonary edema

in more significant exposures of longer duration. Non-

pulmonary symptoms may include headache, nausea, and

skin and eye burns. Cases of hyperchloremic metabolic

acidosis also have been reported in the literature.4

Treatment

Patients with significant ocular symptoms (eg, pain, photo-

phobia, and vision changes) should have their eyes irrigated

with copious amounts of water or saline solution.2,5 The

eyes should be examined for corneal abrasions.

Dermal injury is caused by the caustic nature of the

chlorine gas. Contaminated clothing should be removed,

st 2007 33:4

followed by irrigation with copious amounts of water.

Chemical burns should be treated as thermal burns; severe

burns may need referral to a burn center. Dermal injury is

highly unlikely in a household exposure from mixing

bleach with an acid but can be seen with industrial acci-

dents and chemical warfare.

JOUR

Nonpulmonary symptoms may includeheadache, nausea, and skin andeye burns.

For minor inhalations, with symptoms of upper airway

irritation, humidified oxygen and throat lozenges or spray

should be administered.2,5 For significant cough, difficulty

breathing, or bronchospasm, 100% humidified oxygen and

an inhaled h2 agonist such as albuterol sulfate should be

administered. Systemic corticosteroid therapy may be

considered. A baseline chest radiograph should be obtained

if the patient is symptomatic and respiratory functions

should be monitored, including ABGs and pulse oximetry.

Patients with acute lung injury and/or upper airway

burns may require endotracheal intubation and mechanical

ventilation. Positive end-expiratory pressure may be useful

in enhancing oxygenation. Because pulmonary edema may

be delayed, patients with significant symptoms should be

admitted for observation and further symptomatic care for

24 hours. Asymptomatic patients may be discharged home

with close follow up.

Dermal injury is caused by the causticnature of the chlorine gas.

Although controlled clinical trials are lacking, in sev-

eral published anecdotal case reports and case series, nebu-

lized sodium bicarbonate solution has demonstrated safety

and efficacy when administered for chlorine gas inhala-

tion.3-6 Some patients were observed to experience rapid

and dramatic relief of signs and symptoms. Treatment is

based on the assumption that clinical benefit and cessa-

tion of tissue damage will occur with neutralization of the

acidic byproducts created by inhaled chlorine gas. In one

case series of 86 patients, nebulized sodium bicarbonate

was used in patients whose ages ranged from 5 to 71 years.

NAL OF EMERGENCY NURSING 403

P H A R M / T O X C O R N E R / H o w a r d e t a l

In one anecdotal case report, a markedly symptomatic

7-year-old exposed to chlorine gas experienced dramatic

relief from administration of nebulized sodium bicarbonate.

Solutions of nebulizable sodium bicarbonate are

prepared by the addition of sterile normal saline solution

to the ampules of injectable sodium bicarbonate com-

monly available in the hospital setting to achieve a con-

centration of between 3.75% and 5% sodium bicarbonate.

For example, a mixture of 3 mL of 8.4% sodium bicar-

bonate with 2 mL of normal saline solution creates 5 mL

of a 5% sodium bicarbonate solution.4 A 3.75% solution

may be prepared by mixing 2 mL of a 7.5% solution

with 2 mL of normal saline solution.5 A standard sodium

bicarbonate vial found on ED crash carts is a 7.5% solu-

tion (50mEq per 50 mL).

Nebulized sodium bicarbonate should be administered

over 20 minutes. Typically, patients improve with one dose

of nebulized sodium bicarbonate; however, some patients

need a repeated dose if there is incomplete resolution of

symptoms with the first dose.5 This solution should be

administered by nebulization separately from albuterol

sulfate inhalation treatments because compatibility studies

show that formation of a precipitate can occur when the

solutions are mixed.7

Consultation with the poison control center resulted

in the recognition of chlorine gas as the cause of the pa-

tient’s symptoms. Nebulized albuterol sulfate followed by

nebulized sodium bicarbonate was advised, along with

eye irrigation with normal saline solution. The initial

ABG report showed pH, 7.36; pco2, 42 mmHg; po2,

89 mmHg; and bicarbonate, 24 mEq/L. The patient’s

chest radiograph was unremarkable. Following treat-

ment, the patient demonstrated dramatic improvement of

all signs and symptoms and was discharged 3 hours

after presentation.

Conclusion

Chlorine gas exposure presents a potential for moderate to

severe morbidity because of its strongly irritant properties.

Management consists of removal to fresh air, supple-

mental oxygen, inhaled h2 agonists, and other supportive

measures. Nebulized sodium bicarbonate offers a reason-

able, safe, and effective adjunct to therapy and should be

404 J

considered in any patients exposed to chlorine gas who

present to the emergency department. At the Illinois Poison

Center, our experience with recommending nebulized

sodium bicarbonate has been favorable, and it is recom-

mended frequently in symptomatic chlorine exposures.

REFERENCES

1. Centers for Disease Control and Prevention. Public healthconsequences from hazardous substances acutely released duringrail transit—South Carolina, 2005; selected States, 1999-2004.MMWR 2005;44:64-7.

2. Winder C. The toxicology of chlorine. Environ Res 2001;85:105-14.

3. Vinsel PJ. Treatment of acute chlorine gas inhalation withnebulized sodium bicarbonate. J Emerg Med 1990;8:237-9.

4. Bosse GM. Nebulized sodium bicarbonate in the treatment ofchlorine gas inhalation. J Toxicol Clin Toxicol 1994;32:233-41.

5. Klasco RK, editor. POISINDEX System. Greenwood Village(CO): Thomson Micromedex; edition expires 2006.

6. Douidar SM. Nebulized sodium bicarbonate in acute chlorineinhalation. Pediatr Emerg Care 1997;13:406-7.

7. Owsley HD, Rusho WJ. Compatibility of common respiratorytherapy drug combinations. Int J Pharm Compound 1997;2:121-2.

Submissions to this column are welcomed and encouraged. Sub-missions may be sent to:

Allison A. Muller, PharmD, DABATThe Children’s Hospital of Philadelphia, 34th and Civic CenterBlvd, Philadelphia, PA 19104

215 590-2004 . mullera@email.chop.edu

OURNAL OF EMERGENCY NURSING 33:4 August 2007