Chlorine poisoning is an acute intoxication that occurs when the victim is in an area with a gas concentration above 8 mg / m3. Signs of damage develop when inhaling the toxicant and its contact with unprotected skin. Main symptoms: chest pain, cough without sputum separation, lacrimation, signs of conjunctivitis, coordination disorder. Toxic pulmonary edema may develop. It is diagnosed according to anamnesis and clinical picture. Laboratory and hardware methods are of auxiliary importance. First aid: administration of sodium bicarbonate, dark blindfold, clean air. Treatment is symptomatic. There is no specific antidote.
ICD 10
T59.4 Toxic effect of chlorine gas
General information
Poisoning develops when the maximum permissible concentration of chlorine in the surrounding space is exceeded. The MPC for residential rooms is 0.03 mg / cubic meter, for industrial premises – 1 mg/ m3. An irritating dose is considered to be 10 mg / meter in a cube, a lethal dose is 100-200 mg when exposed for an hour. The concentration of 2500 mg/m3 leads to the death of the victim after 5 minutes. Chlorine belongs to the category of unstable high-speed emergency chemical toxic substances (ECTS). When leaking, it forms a cloud with a high concentration, which persists for 10-30 minutes, after which it dissipates. The time of existence of such a zone is enough to provoke symptoms of acute chemical damage in the victim.
Causes
Chlorine poisoning most often occurs when this component leaks during accidents at industrial enterprises. The first category of danger is assigned to organizations in whose territory 250 or more tons of liquefied Cl are stored. Damage to large containers with a toxicant leads to massive damage to employees, chemical contamination of nearby reservoirs, settlements, and natural resources. The area of such territories depends on the volume of emission, ambient temperature, wind speed. Other possible reasons:
- Laboratory leak. The accumulation of chlorine can occur during scientific experiments accompanied by the release of this gas. Provoking factors of such intoxications: lack of respiratory protection and insulating clothing, poor ventilation in the room, refusal to use equipment that signals the excess of the maximum permissible concentration of toxic substances.
- Visiting the pool. When using the old technology of disinfection of walls with chlorine gas, poisoning of workers is possible. If high doses of hypochlorite are used as an antiseptic, there is a risk of damage to visitors. The largest amount of xenobiotic accumulates near the surface of the water or in its upper layers.
- The use of chlorine-containing detergents. Symptoms of poisoning occur in cleaners, orderlies in hospitals where chlorine tablets are used. The main cause of the lesion is exceeding the recommended dosages and non–compliance with the rules for working with antiseptic formulations. With a long stay in the rooms where the treatment was carried out, patients may suffer.
- Military actions. Chlorine compounds were used as a chemical warfare agent during the First World War. They had low efficiency, because it is technically difficult to create a cloud on the ground with a concentration sufficient to penetrate through the gas mask filters. Today, similar methods of warfare are sometimes used in third world countries.
Risk factors include prolonged stay in medical institutions, visits to swimming pools and water parks, work in laboratories and in industries using chlorine. People suffering from permanent diseases of the respiratory system are affected: chronic obstructive bronchitis, atopic bronchial asthma. Children are more sensitive to the effects of the toxicant than adults. Signs of intoxication occur in them even with a relatively low content of the toxic substance.
Pathogenesis
Chlorine belongs to the group of suffocating and metabolic poisons. When exposed to small doses of a gaseous toxicant, the victim has signs of chemical irritation of the mucous membrane of the eyes, respiratory tract. At concentrations above 40-80 mg/m3, respiratory tract spasm and reflex respiratory arrest develop. There is a lesion of the trachea, bronchi, larynx, which creates a mechanical obstacle to the flow of air. In severe cases, the patient has symptoms of alveolar pulmonary edema.
Insufficient gas exchange provokes the occurrence of respiratory acidosis. The production of carbon dioxide at the same time exceeds the level of its removal through the lungs. The work of all receptor systems of the body is disrupted, significant deviations of homeostasis from normal indicators are noted. The activity of the cardiovascular and central nervous system suffers first. Irreversible brain changes associated with prolonged oxygen starvation often occur.
Classification
For reasons of chlorine poisoning is divided into combat, industrial, domestic, accidental. This criterion has no great practical significance. It is important solely as a statistical indicator that is evaluated when developing preventive measures. Clinically significant is the five-stage classification of poisoning, which is based on the severity of the lesion:
- Easy. Occurs when located in areas with a gas content of up to 0.012 g / m3. The level of consciousness of the victim is preserved, the primary signs are weak or absent. Hospitalization is not required. Symptoms disappear on their own 24-48 hours after stopping contact with the xenobiotic.
- Average. The Cl content is not more than 0.09 g/m3. Consciousness is not disturbed, there are moderate systemic and local signs of intoxication. My health is getting worse. There are specific complaints that disappear within 72 hours. The decision on the need for delivery to the hospital is made by the doctor who received first aid.
- Heavy. The concentration is 0.1-0.5 g/m3. Psychomotor agitation is noted, which is later replaced by a sopor or coma. There are signs of severe respiratory failure, laryngospasm. After 3-8 hours, symptoms of pulmonary edema may occur. First aid should be provided immediately, hospitalization is mandatory.
- Deadly. The volume of chlorine in the surrounding space is 0.51-1.2 g / cubic meter. The death of the victim occurs 10-15 minutes after poisoning. There is persistent laryngospasm, which cannot be removed with medications, severe respiratory failure, coma. The cause of death is increasing asphyxia.
- Lightning fast. Chlorine poisoning, occurring in a special form. The sudden intake of a large volume of toxicant causes a reflex stop of respiratory and cardiac activity. From the time of inhalation of the poison to the onset of death, 30-60 seconds pass, sometimes 2-4 minutes. Cardiopulmonary resuscitation measures are unsuccessful in 98% of cases.
Symptoms
The clinical picture depends on the degree of intoxication. With a slight lesion, there is burning in the eyes, sore throat, acute rhinitis. Possible headaches, subjective feeling of suffocation. On examination – salivation, lacrimation. The general condition is satisfactory. Chlorine poisoning of moderate severity is characterized by the appearance of a barking cough. There is hoarseness of voice, psychomotor agitation, vomiting, nausea, pain in the epigastric region. Objectively: breathing is rapid, with auscultation – dry scattered wheezing. The body temperature is lowered, the throat is swollen.
Severe poisoning at the initial stage proceeds in the same way as intoxication of the average level. The symptoms are more pronounced. After a while, there comes a period of remission, which lasts from 2-3 to 8 hours. The cough stops, the victim calms down. After the end of this stage, the patient’s signs of shortness of breath increase, dry and wet wheezing resume, tachycardia develops. Foamy sputum is released from the mouth, sometimes pink in color. A decrease in blood pressure is determined. Toxic alveolar pulmonary edema develops.
Fatal poisoning leads to clonic-type seizures. Involuntary urination and defecation occur. On examination – diffuse cyanosis, neck vein swelling, exophthalmos, limb convulsions, loss of consciousness. First aid with the use of bronchodilators does not allow to stop laryngospasm. Death occurs after a few minutes. The cause is progressive asphyxia, cardiopulmonary insufficiency. With the lightning-fast variety, there are no signs of hypoxia and convulsions. At the time of examination – asystole, lack of consciousness, breathing.
Complications
Severe chlorine poisoning leads to the development of pulmonary edema in 75-80% of cases. This is due to the irritating effect of the toxicant, which, upon contact with the mucous membranes, breaks down into hydrochloric acid and oxygen. It is manifested by characteristic symptoms: shortness of breath, foaming from the mouth, wet wheezing, sweating, bluish skin tone. Represents an immediate threat to the patient’s life. Urgent first aid is required on the spot, followed by hospitalization in a hospital. 30% of patients who have suffered from pulmonary edema later suffer from emphysema or pneumosclerosis.
A delayed complication of chlorine intoxication is posthypoxic encephalopathy. It occurs in 25-30% of patients who have suffered severe poisoning. The main symptoms are: weakening of mental abilities, headaches, paresis, paralysis, dysfunction of internal organs, absent-mindedness, lack of concentration. It is difficult to correct, it is usually irreversible or partially reversible.
Diagnostics
The diagnosis is made by a doctor or paramedic who was the first to arrive at the scene. As a rule, this is done by an employee of the ambulance or a full-time medic of the organization in whose territory the gas leak occurred. After first aid is implemented, the patient is taken to the ICU. Here the assumption is confirmed by a toxicologist, an anesthesiologist-resuscitator. You may need to consult a pulmonologist, neurologist. Differential diagnosis is made with poisoning by other ECTS, primarily ammonia. Survey methods are used:
- Physical. With mild intoxication, the blood pressure is 140/90 or higher, the pulse is more than 90 beats / minute, the skin is normal or pale. The person is somewhat excited, but adequate. There are no pronounced wheezing during auscultation. In severe poisoning, blood pressure is reduced by 20 or more units from the usual, there is bradycardia, cyanosis of the skin.
- Blood test. An electrolyte imbalance is detected in the blood, the pH of the internal environment is less than 7.3. The amount of oxygen is sharply reduced, carbon dioxide is increased. The hematocrit increases, the volume of the liquid fraction of blood becomes insufficient. Coagulopathy, increased clotting is registered.
- Hardware. The saturation index, determined using an external pulse oximeter, is less than 94-95%. Against the background of pronounced respiratory insufficiency, it can decrease to 60-80%. ECG: reduction of the RR interval in tachycardia and its growth in bradycardia, complete or partial AV block. With a lightning–fast form, small-wave fibrillation or asystole.
Treatment
Chlorine intoxication is treated in several stages: first aid, inpatient therapy, rehabilitation. It takes about 1.5-2 weeks for moderate lesions and up to 1 month for severe ones. Lightning-fast forms have a 100% lethality, except for casual situations. It is not possible to save such patients. In all cases, before the arrival of doctors, it is necessary to remove the victim from the source of chemical contamination, unbutton clothes, provide fresh air.
First aid
Signs of conjunctivitis are stopped using a 2% sodium bicarbonate solution. They wash their eyes abundantly. Similarly, the affected areas of the skin that have been exposed to a high concentration toxicant are treated. If breathing is difficult, soda is inhaled using a nebulizer. To eliminate bronchospasm, inhalations with salbutamol, berodural are prescribed. Intravenous infusion of eufillin is allowed. The introduction of oxygen through nasal cannulas or a facial mask is contraindicated at the initial stage.
Chlorine poisoning is accompanied by pain syndrome. To eliminate it, dicaine is instilled into the eyes, non-narcotic analgesics are injected intramuscularly. With severe soreness, morphine or promedol can be used. They should be used with caution, under the control of breathing. A person is given to drink alkaline mineral water or milk with the addition of table soda. Sedatives are indicated for psychomotor agitation. Transportation is carried out on a stretcher, independent movement is prohibited regardless of well-being.
Therapy in the hospital
In a hospital setting, the patient receives antibiotics, antispasmodics, bronchodilators, expectorant medications, hormones. Alkaline inhalations are indicated. It is recommended to prescribe calcium gluconate intravenously, antihistamines. To correct the water-salt balance, an infusion of crystalloid solutions is carried out. With pulmonary edema, diuretics, distracting drugs, albumin are used. It is necessary to transfer the victim to a ventilator. Some clinics use magnetohemotherapy, ultraviolet irradiation of blood, infusion of sodium hypochlorite.
Rehabilitation
After the symptoms of exotoxicosis disappear and the patient is discharged from the hospital, a rehabilitation course is prescribed. To accelerate regenerative processes, nootropic drugs, antiplatelet agents, and medications that improve microcirculation are introduced. Taking into account possible complications, monthly visits to the doctor for 6-12 months are indicated. It is recommended to visit sanatoriums, medical and rehabilitation institutions. In case of severe posthypoxic disorders, the patient should be placed in a specialized rehabilitation center.
Prognosis and prevention
Mild and moderate chlorine poisoning has a favorable prognosis. The condition of the victim is restored in a few days even without medical assistance. With severe lesions, the mortality rate during the initial 1-2 hours reaches 27-34%. In the late stages, about 8% of the victims die. Timely and competently provided first aid can significantly reduce this indicator. Some residual changes are noted in more than half of the surviving patients.
Prevention consists in observing safety precautions when working with chlorine. During your stay in areas contaminated with ECTS, it is recommended to use insulating protective equipment. Their effectiveness is much higher than that of filter gas masks. Cl tanks must not be heated to high temperatures. Containers should not contain more than 1.25 kg of liquid substance per 1 dm3 volume. During the treatment of pools and surfaces with chlorine antiseptics, it is necessary to adhere to the dosages recommended by Sanpin.