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					   New                               at Work

Not all H2S comes from the ground
         or from the oilfield
     Some chemicals are fatal

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      Chemical Awareness,
      Research, Education, &
      Solutions for you
      workplace

Toxicological Emergencies
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                                                    1
ABSENCE OF
 EVIDENCE
   IS NOT
EVIDENCE OF
  ABSENCE
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                                              27
                      Poisons
• A poison is a substance that, on ingestion,
  inhalation, absorption, application,
  injection, or development within the body
  in relatively small amounts, may cause
  structural damage or functional
  disturbance




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                                 Poisonings
   • Poisonings may be unintentional or
     intentional
           – Most poisonings are unintentional (accidental)
                  •   Dosage errors
                  •   Idiosyncratic reactions
                  •   Environmental exposure
                  •   Occupational exposure




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                             Poisonings
• Intentional poisonings

       – Acts of terrorism

       – Suicide (self-poisoning)

       – Homicide (murder)


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                                      Chemical poisons in
                                      household cleaning
                                      products and personal
                                      care products are affecting
                                      you and your children.

                   POISON CONTROL CENTER
                   Cases of exposures annually:
Cleaning substances – more than 217,400
Cosmetics (PC) – more than 205,200
Pesticides – more than 78,500
Hydrocarbons – more than 62,000

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                                                                    2
                     Solid Poisons
• Poisons can be found in four
  forms: solid, liquid, spray, or
  gas

   – Solid poisons include medicines, plants,
     powders

   – Examples:
       • Laundry detergent
       • Automatic dishwasher detergent
       • Granular pesticides
       • Fertilizers


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                                Poisons
   • Liquid poisons                  • Poisons in spray form
           –   Lotions                  – Insecticides
           –   Liquid laundry soap      – Spray paint
           –   Furniture polish         – Some cleaning products
           –   Lighter fluid
           –   Syrup medicines




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                             Poisons
      • Gases or vapors that are poisonous
        (invisible poisons) include:

             – Carbon monoxide from hot water
               heaters and furnaces

             – Exhaust fumes from automobiles

             – Fumes from gas or oil burning stoves


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 CONSTANT AND REPEATED EXPOSURE
During one day, we expose ourselves to more
than 200 different chemicals

Perfume              Sunscreen
 Cosmetics           Bubble Bath
  Hand Lotion           Baby Products
   Shampoo                 Dish Detergent
    Toothpaste               Bathroom Cleaner
     Shaving Cream              Air Freshener
       Deodorant                   Carpet Cleaner
         Mouthwash                    Dryer Sheets



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                                                                  12
                             Scene Safety
      • Perform a scene size-up

      • Ensure scene safety before
        proceeding with patient assessment




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• A 14-year-old Japanese girl killed herself in her bathroom by mixing
  laundry detergent with liquid cleanser, releasing fumes that sickened 90
  people in her apartment house.
• The door was closed, and she had affixed a sign on the outside warning,
  "Gas being emitted.”
• None of the sickened neighbors in Konan, southern Japan, were severely
  ill, although about 10 were hospitalized.
• The deadly hydrogen sulfide gas escaped from the girl's bathroom
  window and entered neighboring apartments.
• The girl's suicide was part of an expanding string of similar deaths that
  experts say have been encouraged by Internet suicide sites since last
  summer.


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Common household chemicals have been
linked to allergies, birth defects, cancer, and
psychological abnormalities….
              Of 17,000 household product
              chemicals, very few have been
              tested for toxicity.
              More testing is needed on their
              effects,   AND the results of
              combining multiple chemicals in a
              product.
              Ingredients often interact to
              magnify harmful effects in humans,
              animals, and the environment.
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                                                           35
                           Death
• A 31-year-old man outside Tokyo killed
  himself inside a car by mixing detergent and
  bath salts.




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 Reports of another similar death emerged when the
  body of a 42-year-old woman in Nagoya, central Japan,
  was found in a bathtub.
 According to Kyodo, there was toilet cleaner and bath
  powder nearby, along with a sign outside that read,
  "Poisonous gas being emitted. Caution.“
 Nagoya police said they could not comment on the
  case, but Kyodo said that fire officials called to the
  scene did not detect hydrogen sulfide gas.
 The method has alarmed officials because of the
  danger that bystanders can be hurt.


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   Examples of chemical suicides
• In Arizona one individual manufactured
  hydrogen cyanide instead of hydrogen sulfide.
• It may be rare because chemicals needed for
  the reaction are not as readily available as
  those used to make hydrogen sulfide.




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HOUSEHOLD PRODUCTS                                       CHEMICALS IMPLICATED
IMPLICATED IN THE                                        IN THE EXPOSURES
EXPOSURES                                                Methylene Chloride

All purpose cleaners                                     Toluene

Drain Cleaners                                           Formaldehyde/formalin

Dishwashing detergents                                   Glycol: Ethylene

Laundry soaps                                            Glycol: Other

Laundry Additives                                        Acetone

Bleaches                                                 Ammonia

Carpet/upholstery cleaners                               Borates/Boric Acid

Glass Cleaners                                           Chlorates

Fabric Softeners                                         Dioxins

Disinfectants (cleaning)                                 Nitrates/nitrites

Air Deodorizers                                          Alkali

Fabric Deodorizers                                       Acids

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                                                                                 36
HOW does your home become so toxic?
HOUSEHOLD                                                JUST SOME OF THE
CLEANING PRODUCTS                                     CHEMICALS IN HOUSEHOLD
                                                        CLEANING PRODUCTS
AND
PERSONAL CARE                                      Methylene Chloride
PRODUCTS                                           Ethylene glycol Toluene /
                                                   Xylene Pentachlorophenol
RELEASE TOXIC                                      Dichlorobenzene
VAPORS INTO                                        Chlorofluoromethane
THE AIR WHEN                                       Phenylphenol Formaldehyde
THEY ARE USED
– AND EVEN
WHEN THEY ARE
STORED. This
process is called
outgassing.

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                                                                               37
THE THREE MOST REPORTED
 POISONING CATEGORIES




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                                                   16
            SKIN absorbs far
            more than you think
            – it’s like a sponge!
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                                            15
Substances get into your body
three ways:

       INGESTION


              INHALATION


                           ABSORPTION
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                                                     13
UP TO 4,000 separate ingredients,
most of them synthetic
Toluene
Methylene chloride
Benzene
Formaldehyde




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                                                      21
Some by accident others on purpose
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  Responding to chemical suicides
• Interview anyone who may have approached the scene to
  learn what they saw or smelled.
• A “rotten egg” smell would indicate hydrogen sulfide.
• An almond odor is typical of cyanide compounds.




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  Responding to chemical suicides
• Look for indications a chemical reaction has been initiated.
• Typically you will find containers of household chemicals and
  pails, buckets, pots or other containers where the chemicals
  have been mixed.
• Improvised “containers”, such as a sink or the glove box of an
  automobile, could be used to mix the chemicals.




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  Responding to chemical suicides
• Air sampling equipment can be used to determine the
  presence or absence of hydrogen sulfide or hydrogen
  cyanide.
• A small hole may be punched in a car or home window, or a
  probe, or colorimetric tube inserted in the gap between a
  door to the room and the floor.
• A hydrocyanic acid tube will detect hydrogen cyanide.
• Hydrogen sulfide is heavier than air, but hydrogen cyanide is
  slightly lighter.



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  Responding to chemical suicides
• If the vapor in the space cannot be identified, or the presence
  of hydrogen cyanide is confirmed entry should only be made
  by individuals protected by fully encapsulated chemical
  protective clothing (level A).
• Hydrogen cyanide is immediately dangerous to life and health
  at concentrations above 50 parts per million.




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  Responding to chemical suicides
 Both hydrogen sulfide and hydrogen cyanide are
  flammable.
 The Lower Explosive Level of hydrogen sulfide is 4% and the
  LEL of hydrogen cyanide is 5.6%.
 There have been no incidents of fire reported with these
  incidents.
 It is believed that concentrations do not typically reach the
  LEL except at close proximity to the mixing container.
 Responders should eliminate ignition sources whenever
  possible.



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  Responding to chemical suicides
• Vapors inside the space should be ventilated to the outside.
• Ensure no one will be endangered by the vapors before using
  natural or forced ventilation to air the space out.
• Anyone who has been exposed to the vapors should be
  decontaminated with soap and water.




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  Paradichlorobenzene poisoning
 Some vacuum cleaners have an attachment for
  killing bugs.
 The attachment holds moth crystals
  (Paradichlorobenzene, pronounced “para-di-
  chloro-benzene”)
 This attachment will convert your vacuum
  sweeper to exterminate insects (spiders, roaches,
  ants, etc.).
 Anything that can walk or crawl.


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     What do the instructions say?
One vacuum instruction book says:

How to use the crystalator:
 Warning: Follow directions and cautions on label of crystal container.
 Keep crystals out of reach of children.
 Crystals may be harmful if taken internally.
 Do not breathe the concentrated gas from the crystalator.
 Do not enter a treated closet until it has ventilated.
 Do not remain in a treated room until gas concentration is reduced to safe
  level.
 If eye, throat, or skin irritation occurs, do not remain in treated area.
 Return unused crystals to closed container and seal tight. In the
  crystalator,




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      Paradichlorobenzene poisoning
• Paradichlorobenzene is a white, solid chemical with a very
  strong odor.
• Poisoning can occur if you swallow this chemical or inhale it in
  a gaseous form.
• Where Found - Toilet bowl deodorizers and Moth repellant.
  (not all-inclusive).




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       Paradichlorobenzene poisoning
Symptoms:
   – Burning in mouth
   – Breathing problems (rapid, slow, or painful)
   – Cough
   – Shallow breathing
   – Changes in alertness
   – Headache
   – Slurred speech
   – Weakness
   – Yellow skin (jaundice)
   – Abdominal pain
   – Diarrhea
   – Nausea
   – Vomiting

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                  WORKPLACE PROHIBITED CHEMICALS
BIOTHIONOL
MERCURY COMPOUNDS
VINYL CHLORIDE
HALOGENATED SALICYANILIDES
ZIRCONIUM COMPLEXES (in aerosols)
CHLOROFORM
METHYLENE CHLORIDE
CHLOROFLUOROCARBON (in aerosols)
HEXACHLOROPHENE
METHYL METHACRYLATE MONOMER (in nail products)




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                                                                 5
           Anticholinergic
Signs/     Agitation or reduced responsiveness,
Symptoms     tachypnea, tachycardia, slightly elevated
             temperature, blurred vision, dilated
             pupils, urinary retention, decreased
             bowel sounds; dry, flushed skin
Typical
Agents     Atropine, diphenhydramine, scopolamine
Primary
Antidote   Physostigmine



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                 Cholinergic
Signs/     Altered mental status, tachypnea,
Symptoms      bronchospasm, bradycardia or tachycardia,
              salivation, constricted pupils, polyuria,
              defecation, emesis, fever, lacrimation,
              seizures, diaphoresis
Typical    Organophosphate insecticides (malathion),
Agents       carbamate insecticides (carbaryl), some
             mushrooms, nerve agents
Primary
Antidote   Atropine


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                           Opioid

Signs/   Altered mental status, bradypnea or apnea,
Symptoms    bradycardia, hypotension, pinpoint
            pupils, hypothermia
Typical    Codeine, fentanyl, heroin, meperidine,
Agents       methadone, oxycodone,
             dextromethorphan, propoxyphene
Primary    Naloxone
Antidote




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                             Anticholinergic Syndrome

   • Mad as a hatter – confused delirium

   • Red as a beet – flushed skin

   • Dry as a bone – dry mouth

   • Hot as Hades – hyperthermia

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   • Blind as a bat – dilated pupils
Alberta Canada
                             Cholinergic Syndrome
  • “SLUDGE”                            • “DUMBELS”
         – Salivation                     – Diarrhea
         – Lacrimation                    – Urination
         – Urination                      – Miosis (pinpoint
         – Defecation                       pupils)
         – Gastrointestinal               – Bronchospasm/
           distress                        Bronchorrhea/
         – Emesis                          Bradycardia
                                          – Emesis
                                          – Lacrimation
                                          – Salivation
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                      Odors and Toxins
Odor             Toxin
Acetone          Acetone, isopropyl alcohol, salicylates
Alcohol          Ethanol, isopropyl alcohol
Bitter almonds   Cyanide
Carrots          Water hemlock
Fishy            Zinc or aluminum phosphide
Fruity           Isopropyl alcohol, chlorinated hydrocarbons (e.g.,
                    chloroform)
Garlic           Arsenic, organophosphates, DMSO, phosphorus,
                    thallium
Glue             Toluene
Mothballs        Camphor
Pears            Chloral hydrate, paraldehyde
Rotten eggs      Sulfur dioxide, hydrogen sulfide
Shoe polish      Nitrobenzene
Vinyl            Ethchlorvynol
Wintergreen      Methyl salicylates
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               General Management Guidelines

• Frequently monitor vital signs and ECG

• Safely obtain any substance or substance
  container of a suspected poison and
  transport it with the patient




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                             Decontamination

   • Decontamination methods used depend
     on the toxin and type of exposure




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                             Decontamination – Skin

• Don appropriate personal protective
  equipment (PPE)
       – May include specific clothing and respiratory gear
• Remove child’s clothing and place it in plastic
  bags
• Flood exposed areas of the skin with water to
  remove residual material from the skin
       – Avoid contaminating uninvolved areas
• Wash exposed areas with soap and water for
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  10 to 15 min with gentle sponging
Alberta Canada
    CAUSTICS

(ACIDS, ALKALIS)




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              Caustics (Acids, Alkalis)

Description      Alkaline agents cause deep penetration
                  injury; tissue destruction continues until
                  substance is significantly neutralized or
                  concentration is greatly reduced
                 Common alkaline products: bleach,
                  ammonia, dishwasher detergent, laundry
                  detergent, drain and oven cleaners
                 Acids cause an immediate superficial
                  injury; injury may continue to evolve for
                  up to 90 min after the ingestion
                 Common acid products: sulfuric,
                  hydrochloric, or hydrofluoric acid

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           Caustics (Acids, Alkalis)
Signs/        Severe burns to the stomach or esophagus
Symptoms       may be present with little external evidence
               of the severity of the injury

              Upper airway obstruction with difficulty
               breathing, speaking, or swallowing; GI
               hemorrhage, esophageal or gastric
               perforation

              Vomiting, stridor, drooling – if 2 of these 3
               symptoms are present, likelihood of GI
               burns is high (vomiting powerful predictor of
               severe esophageal injury)
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                    Caustics (Acids, Alkalis)

Interventions       Protective equipment, ABCs, O2, IV
                    Priority = airway management
                    Flexible fiberoptic intubation over an endoscope is
                     preferable to standard orotracheal intubation
                    Emergent cricothyrotomy may be necessary
                    Do NOT induce vomiting
                    Activated charcoal contraindicated
                    Controversy exists regarding whether or not attempts
                     should be made to neutralize the caustic substance
                     with water or milk
                    If a history of significant ingestion with oral lesions or
                     if child is otherwise symptomatic, perform endoscopy
                     to determine extent of injury



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  ETHYLENE GLYCOL (ANTIFREEZE)


           METHANOL
(METHYL ALCOHOL, WOOD ALCOHOL)



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              Ethylene Glycol, Methanol

Description       Ethylene glycol ingestion leads to profound
                   metabolic acidosis and coma; as little as 5
                   mL may be toxic to an infant

                  Methanol, found in window-washer fluid or
                   gas-line antifreeze, is metabolized to formic
                   acid, with the same effect as ethylene
                   glycol; as little as 15 mL may be toxic to an
                   infant




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           Ethylene Glycol, Methanol

Signs/         Altered mental status with appearance of
Symptoms        inebriation or reduced responsiveness, or
                coma

               Tachypnea, tachycardia, nausea and
                emesis; abdominal pain, muscle
                incoordination, seizures

               Blurred vision possible with methanol




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                Ethylene Glycol, Methanol

Interventions      ABCs, O2, IV
                   Administer glucose if hypoglycemia present
                   Fomepizole antidote for methanol and ethylene glycol
                    poisoning, indications for use are levels ≥20 mg/dL or
                    high anion gap metabolic acidosis
                      Ethanol may be used when fomepizole is not
                       available
                   Consider hemodialysis in severe cases
                   Methanol level, glucose




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    HYDROCARBONS

(PETROLEUM DISTILLATES)




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                        Hydrocarbons
Description      Toxic dose varies depending on agent involved and
                  whether it was aspirated, ingested, or inhaled

                 Common products:
                    Lamp oil
                    Gasoline
                    Lighter fluid
                    Kerosene
                    Furniture polish
                    Turpentine
                    Pine oil
                    Phenol




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                  Hydrocarbons
Signs/        Coughing and choking on initial ingestion;
Symptoms       gradual increase in work of breathing
              Odor of hydrocarbon on breath
              Dry, persistent cough; crackles, wheezes,
               diminished breath sounds, tachypnea
              Nausea/vomiting, dizziness, altered mental
               status, dysrhythmias possible
              May cause skin surface burns




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                     Hydrocarbons
Interventions      Protective equipment, remove
                    contaminated clothing and wash skin with
                    soap and water
                   ABCs, O2, assist ventilations as
                    necessary, anticipate need for intubation
                   Activated charcoal contraindicated
                   Consult Poison Control




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An excerpt from the MSDS for an ingredient
in many brand name toothpastes….
SODIUM HYDROXIDE MSDS Number: S4034 Effective
Date: 08/20/98
3. Hazards Identification
Emergency Overview
--------------------------
POISON! DANGER! CORROSIVE. MAY BE FATAL IF
SWALLOWED. HARMFUL IF INHALED. CAUSES BURNS
TO ANY AREA OF CONTACT. REACTS WITH WATER,
ACIDS AND OTHER MATERIALS.

Health Rating: 3 - Severe (Poison)



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                                                                         31
“Not a single child today is
born   free   of    synthetic
chemicals”
“There is a lot we don’t know about chemicals. What we do know is that:
• breast cancer rose steadily over the last four decades
• over 40,000 women will die of it this year. Brain cancer in children is up
by 26%
• testicular cancer in older teenage boys has doubled
• infertility in young adults is up, and so are learning disabilities in young

children…




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                                                                                 9
    PLEASE NOTE AND TAKE HEED!


Responding to chemical suicides
•Look for indications a chemical reaction has been
initiated.
•Typically you will find containers of household chemicals
and pails, buckets, pots or other containers where the
chemicals have been mixed.
•Improvised “containers”, such as a sink or the glove box
of an automobile, could be used to mix the chemicals.




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Time for Questions




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