Toxic Industrial Chemicals

Objectives

To guide the management of patients who have been exposed to Toxic Industrial Chemicals (TIC).  
 
These chemicals may be used, or stored for use, for legitimate industrial, commercial, medical, military and domestic purposes as well as for nefarious intent. Their dual purpose reflects that some chemical agents are not prohibited in the CWC due to legitimate industrial use but are then available to used opportunistically. There is significant overlap with other classes of chemical warfare agents e.g. organophosphate pesticides, cyanides, chlorine and phosgene and vesicants. Their release maybe intentional as part of an attack or accidental due to containment failure. It is important to use J2 to identify any potential TIC hazards in your AO prior to any event. 

Scope

This guideline describes the management of patients exposed to TIC in a forward medical context or deployed Emergency Department. Due to their wide availability and range of effects, wherever a TIC produces effects similar to a recognised CRESS toxidrome, the management should follow that toxidrome, e.g. in the case of chlorine release, or symptoms consistent with a pulmonary agent, follow the management for pulmonary agents. 

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location, a resus facility or an Emergency Department on deployed operations. 

Initial Assessment & Management

Casualties and responders should apply GSR/ respiratory protection as per Immediate Action drills, if the casualty has not already been decontaminated or is in the hot or warm zone. If the casualty is incapacitated/obtunded, the responder should apply their IPE for them as required. 
 
Casualties should be treated according to the MARCH paradigm. Combined traumatic and CBRN injuries are likely, and in the event of both being present, serious traumatic injuries often kill first and so must be treated aggressively. 
 
If a TIC is suspected, then a CRESS or CBRN ‘Quick Look’ should take place to try and identify the causative agent during initial assessment. 

Life threatening injuries must always be addressed first, by undertaking appropriate Life Saving Interventions (LSIs), such as tourniquet application, airway management, specific antidotes (if applicable) and chest seal application or needle decompression, the application of oxygen and ventilatory support (if resources allow). 
 
Decontamination by medical or non-medical personnel in suitable IPE must take place in parallel to LSIs and must not cause delay in their administration. 
 
In the case of TIC the CRESS assessment can show any number of effects- follow the management according to CRESS toxidrome. In reality, the care of most TICs is likely to be non-specific and supportive. 
 
There are no generic antidotes for the treatment of all TIC. The mainstay of treatment is appropriate decontamination, good supportive care and where a specific toxidrome is identified (e.g. cyanide or organophosphates) the use of specific antidotes. 

Common CBRN CRESS toxidromes analogous to TIC toxidromes

Massive Haemorrhage 
External haemorrhage due to trauma should be controlled with tourniquets, haemostatic gauze and dressings as appropriate. If previously applied, they should be rechecked for efficacy/ need. They will require changing if applied prior to the Clean-Dirty- Line (CDL) during decontamination. 
 

Airway and Antidotes (MedCM) 
There may be a requirement for airway management in TIC exposure. If there is airway or ventilatory compromise due to high dose exposure (e.g. exposure in an enclosed space with high concentration of agent), or other aetiology then simple airway management, up to and including SGA should be considered prior to the CDL where full decontamination will take place. Definitive airway interventions such as endotracheal intubation should only be consider post CDL if resources allow. There are no generic antidotes for TIC exposure, but specific antidotes may available if an appropriate toxidrome is identified such as in the case of cyanide or organophosphate exposure. Please follow the specific guidance elsewhere in CGOs.

Respirations 
Treat causes of respiratory compromise, such as trauma e.g. tension pneumothorax or medical e.g. exacerbations of asthma as per standard protocols, but avoid complex interventions such as formal chest drain insertion until full decontamination has taken place. 
 
Many TIC cause airway irritation and ventilatory compromise. Manage with appropriate use of high flow oxygen (unless contraindicated) to maintain adequate oxygenation, use of bronchodilators (if bronchospasm) and IV corticosteroid administration. Ventilatory support may be required with simple support such as BVM +/- PEEP valve (as indicated) prior to the CDL. 
 
Endotracheal intubation and ventilation may be required in the event of respiratory embarrassment not responding to simple measures and appropriate specific antidote therapy, only where resources and expertise allow. 
Ventilatory strategies should be titrated and adjusted to standard lung protective measures, including PEEP. Where a toxidrome can be identified, the ventilation strategies for that presentation should be followed. 

Circulation 
There may be a requirement for circulatory support in the form of titrated parenteral fluids in TIC exposure. IO administration prior to the CDL is preferred, and IV if required thereafter. Vasopressors may be required in the event of adequate filling, but inadequate clinical response. This should follow standard practice. 
In the case of chemical burns the Parkland formula should be applied. 
 
Circulatory compromise due to another aetiology should be assessed and treated as per standard protocols. 
If point of care testing and ECGs are available a VBG/ ABG and ECG can be useful in helping identifying the causative agent, the extent of any intoxication and titrating care for the subsequent sequalae. 

 
Head Injury / Hypothermia & Decontamination 
Standard protocols for decontamination should be followed, according to the guidance for the analogous toxidrome. 
 
In the event of an altered conscious level or seizures not responding to supportive measures, standard medical protocols, including the use of benzodiazepines and antiepileptic medications, should be considered along with intubation and ventilation as resources and expertise allow. 
 
Where specific antidotes exist (e.g. for organophosphates) they are the mainstay of treatment and intubation and intubation and ventilation should be avoided unless absolutely necessary. 
 
In the event of burns or ongoing painful airway irritation, analgesia should be administered by an appropriate route and titrated to response. 
 
Thermoregulatory support may be required in the event of extensive chemical burns, with burns being dressed with a non-adherent dressing such as cling film. Any dressings placed prior to decontamination should be replaced as part of the decontamination process. 
 
Remain vigilant to the risk of hyperthermia due to IPE use and hypothermia due to wet decontamination. 
 
Many TICs (e.g. ammonia) cause revulsion and avoidance at concentrations well below the LD50. With no developing sequelae, sustained normal vital signs, normal VBG and ECG (no QT interval or QRS changes) after a period of observation (typically 4-6 hours) it may be possible to avoid evacuation to higher care, particularly if the TIC concerned has been identified and is known not to cause delayed sequelae. In the event of an unknown pulmonary agent or vesicant, a prolonged period of observation may be required, of up to 48 hours to ensure no further symptoms develop. Where a patient has been exposed to an agent with known delayed sequelae (e.g. phosgene), follow the specific advice for that agent. 

Advanced Assessment & Management

As per Initial Assessment & Management

Prolonged Casualty Care

Thermoregulatory support may be required in the event of extensive chemical burns, with burns being dressed with a non-adherent dressing such as cling film. Any dressings placed prior to decontamination should be replaced as part of the decontamination process. 
 
Remain vigilant to the risk of hyperthermia due to IPE use and hypothermia due to wet decontamination. 
 
Many TICs (e.g. ammonia) cause revulsion and avoidance at concentrations well below the LD50. With no developing sequelae, sustained normal vital signs, normal VBG and ECG (no QT interval or QRS changes) after a period of observation (typically 4-6 hours) it may be possible to avoid evacuation to higher care, particularly if the TIC concerned has been identified and is known not to cause delayed sequelae. In the event of an unknown pulmonary agent or vesicant, a prolonged period of observation may be required, of up to 48 hours to ensure no further symptoms develop. Where a patient has been exposed to an agent with known delayed sequelae (e.g. phosgene), follow the specific advice for that agent. 

Paediatric Considerations

As per adult and drug dosing iaw page per age