9.12. IRRITANTS OF THE RESPIRATORY TRACT

Related titles

Respiratory tract irritant, respiratory tract damage, respiratory damage, respiratory damage, chemical respiratory damage, inhalation of toxins.

Purpose of assistance

Rapid recognition of signs and symptoms of existing or potential respiratory irritants.

Description of the patient

Inclusion criteria

1. Inhalation of various gases, vapors, aerosols or dust can cause irritation or damage to the respiratory tract, pharynx, lungs, asphyxia or other systemic disorders.
2. Inhalation/respiratory irritants can interact with the mucous membrane of the upper and lower respiratory tract depending on solubility, concentration, particle size and duration of damage.
3. The less soluble and smaller the particles, the deeper they will penetrate into the respiratory tract and respiratory system. Therefore, the onset of symptoms is delayed until a critical mass of particles has accumulated that will be able to interact with the connective tissue inside the respiratory system.

Signs and symptoms

1. Since the type, severity and speed of onset of signs and symptoms depends on the substance, water solubility, concentration, particle size, duration of the lesion, the following symptoms and signs are often duplicated and their severity increases.

2. Most irritants to the respiratory system have “warning properties” in the form of a characteristic or unpleasant odor or irritation of the eyes or respiratory tract.

3. Some substances do not have clear warning properties and therefore are characterized by a later onset of signs and symptoms:

a) unusual aroma/smell;
b) watery or itchy eyes;
c) burning sensation or burning of the nose, throat and respiratory tract;
d) sneezing;
e) general excitement;
e) cough;
e) chest discomfort;
e) nausea;
g) shortness of breath;
br />h) wheezing;
y) stridor;
i) dyspnea during inhalation;
i) dizziness;
j) voice change;
k) respiratory obstruction pathways, including laryngospasm and edema;
l) pulmonary edema (non-cardiogenic);
m) convulsions;
n) cardiopulmonary shock.

4. High solubility in water/severe irritation (affects the oral and nasal cavity and pharynx, particle size greater than 10 micrometers):

a) acrolein;
b) ammonium;
c) chloramine;
d) ethylene oxide;
e) formaldehyde;
e) hydrogen chloride;
e) methyl bromide;
e) sodium azide;
g) sulfur dioxide.

5. Average solubility in water (affects bronchi and bronchioles, particle size – 5-10 micrometers):

• • • • chlorine.

6. Low solubility in water/less irritating (affects alveoli, particle size less than 5 micrometers):

a) cadmium vapors;
b) fluorine;
c) hydrogen sulfide (the smell of rotten eggs, weakening of the sense of smell);
d) vapors mercury;
e) mustard gas (also characterized by the late appearance of blisters on the skin);
e) nickel carbonyl;
e) ozone;
e) phosgene.

7. Substances that cause asphyxiation (two types):

a) substances that cause oxygen deprivation by reducing the fraction of oxygen in the air below 19.5% (“simple asphyxiating agents”).
Any gas that reduces fraction of oxygen or displaces oxygen from inhaled air:

• • • • argon;
      • carbon dioxide;
      • ethane;
      • helium;
      • methane;
      • natural gas (e.g. heptane, propane);
      • nitrogen;
      • nitrogen dioxide (late onset of symptoms);

b) chemical obstacles when using oxygen (“chemical asphyxiating substances”):

• • • • carbon monoxide (see the instruction “Smoke/carbon monoxide poisoning”);
      • cyanide (div guideline “Cyanide poisoning”);
      • hydrogen sulfide.

8. Inhalant substances that are often abused:

a) these substances or substances represent several classes of substances, including volatile solvents, aerosols, gases;
b) these chemicals are intentionally inhaled to produce a state similar to alcohol intoxication with initial excitement, dizziness, drowsiness;
c) people who abuse such substances are called sniffers.
These individuals often lose consciousness after inhaling aerosol or gas, with the remains of an aerosol can or paint remains near or in the mouth, nose and oropharynx;
d) typical household products that are abused.
Volatile solvents:

• • • • paint solvents
      • rust solvents
      • water-based liquid detergents
      • gasoline
      • fluid for lighters
      • correctors
      • felt pens
      • glue.

Cosmetics/spray paints:

• • • • deodorants in sprays
      • vegetable oil in sprays
      • protective sprays for fabrics
      • spray paint.

Nebulizers/asphyxiants/nitrous oxide:

• • • • propane
      • balloons (with helium)
      • keyboard cleaners
      • ether
      • halothane
      • chloroform
      • butane
      • propane
      • dispenser for whipped cream.

9. Means of riot control (see the guideline “Means of riot control”).

10. The type of substance is recognized through the analysis of the affected areas of the respiratory tract in case of mild and moderate poisoning, since the lesions with a high concentration of most of these substances are very similar in symptoms and signs, the deeper the symptoms appear in the respiratory tract and the slower the symptoms appear, the less soluble in water this is irritant:

a) irritation of the nasal and oropharyngeal cavity – compounds highly soluble in water (ammonia);
b) irritation of the bronchi (chlorine);
c) acute pulmonary edema / damage to alveoli – poor solubility in water (phosgene);
d) direct neurotoxin (hydrogen sulfide); );
e) substances that are abused (volatile substances, cosmetics/paints, aerosols/asphyxiants/nitrogen oxides);
e) means of riot control (see the guideline “Means of riot control”);
br />y) acetylcholinesterase inhibitors (see the instruction “Effect of acetylcholinesterase inhibitors”).

11. Ammonia:

a) immediate recognition due to a sharp smell;
b) inflammation/irritation of the nasopharyngeal area;
c) eye irritation and lacrimation;
d) sneezing;
e) disturbance of consciousness – from drowsiness to excitement;
e) cough;
e) shortness of breath;
e) chest discomfort;
g) bronchospasmous wheezing ;
h) voice change;
y) obstruction of the upper respiratory tract includes laryngospasm and laryngeal edema;
i) corneal burns or ulcers;
i) skin burns;
j) burns of the pharynx, trachea, bronchi;
k) dyspnoea/tachypnea;
l) high concentration or long-term damage can lead to non-cardiogenic pulmonary edema;
m) esophageal burns.

12. Chlorine:

a) all of the above (ammonia);
b) increased probability of the following:

• • • • bronchiol burn
      • bronchospasm and wheezing
      • development of non-cardiogenic pulmonary edema within 6-24 hours in severe poisoning.

13. Phosgene.
The above symptoms usually do not appear during the first 30 minutes or several hours, usually milder until symptoms of damage to the lower respiratory tract begin to develop:

a) a characteristic smell reminiscent of “freshly cut hay”;
b) slight irritation or dryness of the respiratory tract;
c) slight irritation of the eyes;
d) fatigue;
e) chest discomfort;
e) dyspnea/tachypnea;
e) serious delay(up to 24 hours):

• • • • shortness of breath during physical exertion;
      • wheezing due to bronchospasm;
      • hypoxia;
      • severe non-cardiogenic pulmonary edema;
      • cardiopulmonary shock.

14. Hydrogen sulfide is a direct neurotoxin, quickly absorbed by the lungs and causes systemic disorders:

a) the pronounced smell of rotten eggs leads to rapid habituation to the smell and loss of the ability to distinguish smells;
b) cough;
c) shortness of breath;
d) rapid change in perception or consciousness;
e) bronchiole and lung bleeding/hemoptysis;
e) non-cardiogenic pulmonary edema;
e) hydrogen sulfide is known as a gas that “collapses” due to rapid loss of consciousness at high concentrations;
e) asphyxia;
g) death.

15. Nitrogen dioxide (also known as silo worker’s disease):

a) heavier than air, so it displaces it in closed rooms and causes asphyxiation;
b) a small concentration can cause:

• • • • eye irritation;
      • cough;
      • dyspnea/tachypnea;
      • fatigue;

c) high concentration can cause:

• • • • change in the state of consciousness, including excitement;
      • cyanosis;
      • vomiting;
      • dizziness;
      • loss of consciousness;
      • cardiopulmonary shock.

16. Substances-inhalants that are abused (e.g. the tips of markers, paint in cylinders):

a) physical presence of paint or its remains on the face as a result of use;
b) incoherent speech;
c) altered state of consciousness (excitement, drowsiness or fainting);
d) loss of consciousness;
e) cardiac arrhythmias;
e) cardiopulmonary shock.

Providing assistance to the patient

1. Wear suitable protective equipment – protection of the respiratory system is critical.

2. Remove the patient from the toxic environment:

a) remove the patient’s clothing that may contain gases or carry out decontamination in case of contamination with liquids or solids;
b) wash the irritated/burned areas.

3. Quickly assess the condition of the respiratory tract, consciousness, oxygenation.

4. Provide humidified, if possible, oxygen.

5. Provide in/out access (if possible).

6. Use a heart monitor (if available).

7. Constant and periodic review is critical.

Status assessment

1. Make sure the scene is safe as most gases are heavier than air and will collect near the ground. This is especially true of hydrogen sulfide due to its ability to “knock down”, which leads to the loss of consciousness of unprotected EMD workers and this, in turn, leads to an increase in the number of patients.
2. Use personal protective equipment.
3. Remove the patient from the toxic environment.
4. Conduct disinfection.
5. Do an examination (ABCDE) and, if necessary, remove clothing and then cover the patient to preserve body heat.
6. Assess vital signs, including body temperature.
7. Apply a cardiac monitor, assess for arrhythmias, then obtain a 12-lead ECG.
8. Check your glucose level.
9. Monitor pulse oximetry and ETCO2 to detect respiratory decompensation.
10. Use carboxyhemoglobin and cyanide monitors, if available.
11. Recognize the specific substance that caused the poisoning.
12. Collect anamnesis regarding diseases of the cardiovascular system and drugs prescribed for the treatment of other diseases.
13. Collect medical history relevant to this case.
14. Do a physical examination.

Treatment and intervention

1. Ensure the patency of the respiratory tract.

2. Provide (humidified, if possible) oxygen and in conditions of hypoventilation, inhalation of toxins or desaturation, support breathing:

a) maintain airway patency and assess for stridor, burns, or edema of the airways and, if indicated, perform early intubation (uniquet is recommendedand the use of suprapharyngeal airways – conicotomy may be necessary in rare severe cases);
b) non-invasive ventilation techniques:

• • • • ventilation with a constant positive pressure using a ventilator with a setting of PPTD or DPPTD (biphasic constant positive pressure), a high-flow nasal cannula (HCVP) and/or a nasal cannula with a DPPTD setting should be carried out in severe respiratory disorders or the threat of respiratory failure;
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      • ventilation with an AMBU bag should be carried out in case of hypoventilation, disturbance or cessation of breathing.

3. Salbutamol 5 mg through a nebulizer (6 standard breaths) should be administered to children with severe respiratory distress with signs of bronchospasm by EMD specialists with basic or life support skills, repeated administration of the drug in the same dose with an unlimited frequency if respiratory distress continues.

4. Ipratropium bromide 0.5 mg through a nebulizer up to 3 doses together with salbutamol.

5. Provide intravenous access for the infusion of a combined medicinal product with the composition of sodium chloride + potassium chloride + sodium lactate + calcium chloride or saline, obtain blood for analysis (glucose, lactate, cyanide) to obtain basic indications (before starting treatment).< /p>

6. Administer bolus infusion (20 ml/kg) at signs of hypoperfusion.

7. In case of severe pain, administer analgesics (IV or IM):

a) morphine sulfate 0.1 mg/kg IV or IV; b) fentanyl 1 μg/kg IV or IV.

8. Wash your eyes as soon as possible.

9. Treat local chemical burns (see appropriate guidance in the Toxins and Environment section).

10. For severe respiratory irritation, especially hydrogen sulfide in the presence of an altered state of consciousness and no improvement after removal from the toxic environment, give oxygen (humidified, if possible) to raise saturation to 94-98%, consult before possible transfer to the department for hyperbaric oxygen therapy .

Introduction of medical drugs

1. For shortness of breath, use salbutamol in the form of a spray (2.5-5 mg) or 4-8 standard doses from an inhaler.
2. Ipratropium bromide 0.5 mg through a nebulizer up to 3 doses together with salbutamol.

Patient safety

1. Usually, when talking to patients who have been exposed to highly soluble compounds/respiratory irritants), you will know that they have left the toxic environment on their own by the appearance of a specific odor, rapid onset of irritation, and other symptoms.
2. Less soluble substances can cause only a specific smell (the smell of freshly cut hay under the influence of phosgene), and more severe symptoms, such as acute pulmonary edema, hypoxia, shortness of breath with minimal physical exertion, appear later.

Useful information for training

Key points

1. Respiratory irritants can worsen existing diseases (asthma, COPD) and weaken or intensify bronchospasm, respiratory distress and hypoxia.
2. While the patient is exhaling residual gas (especially with hydrogen sulfide and hydrogen cyanide poisoning) in the back of the ambulance, it is important to provide adequate ventilation where the patient is.
3. Evacuation from the toxic environment, oxygen therapy (humidified, if possible, oxygen), general supportive therapy, the use of bronchodilators, respiratory support and time are the main elements of care, since there are no specific antidotes for any of these substances, with the exception of heavy metals , which can be dissolved or disinfected in the hospital after their identification.
4. Hydrogen sulfide deactivates the cells responsible for smell recognition, so poisoning with a small amount will result in the loss of the ability to smell and the unprotected victim will continue to inhale the gas because it is still there.
5. Inhalants have become a popular tool for committing suicide. If any form of suicide warning signs, hoses or buckets with visible substances are present when approaching a vehicle or residence, immediately retreat to a well-ventilated area, use a self-contained breathing apparatus before opening the door of the car or house, as these gases in high concentration carry mortal threat to EMD workers.
6. Home remedies for cleaning baths, kitchens and stoves when mixed can generate different amounts of respiratory irritants (ammonia, chloramine, chlorine – these substances are the most common). Most often, chlorine poisoning occursramin – a gas that is formed after the combination of bleach (hypochloride) and ammonia. Chloramine in the lungs and alveoli is split into ammonia and hypochloric acid by hydrolysis.
7. Sudden death can occur with a single inhalation of substances that are often abused:

a) some inhalants cause rapid heartbeat and eventually lead to cardiac arrest;
b) this syndrome is often associated with the abuse of butane, propane and the effects of chemicals that contained in aerosols.

Corresponding evaluation results

1. The patient can describe a specific smell (chlorine – the smell of a swimming pool, ammonia smell, the smell of freshly cut hay – phosgene), this is useful information, however, it should not be blindly relied on, since the human nose does not distinguish smells very well.
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2. Respiratory distress (retractions, wheezing, stridor).
3. Decreased oxygen saturation.
4. Skin color.
5. Evaluation of the neurological condition.
6. Decreased respiratory effort after treatment.
7. Improving oxygenation after breathing.

Key elements of documentation

Document the main details of the review to check for changes after the interventions:

1. ChD.
2. Oxygen saturation.
3. Use of auxiliary respiratory muscles or displacement of the trachea.
4. Breathing noises.
5. Air intake/stridor.
6. Level of consciousness.
7. Skin color.
8. Decreasing the feeling of inflammation in the respiratory tract/pharynx.

Criteria for the effectiveness of aid provision

1. Clinical improvements in the patient’s condition and response to therapy.
2. Survival rates of patients.
3. Long-term consequences of poisoning victims.
4. Absence of injuries to EMD workers while providing care to such patients.