Case Study: Chlorine Gas Toxicity
You’re dispatched to a 16yom complaining of shortness of breath and and a sore throat. It is 15:15pm, and the patient has been at work as an assistant swim instructor. When you arrive, the staff advise that the patient suddenly began crying, coughing, complaining of a sore throat, nausea and dizziness about 20 minutes prior to calling 000.
On arrival at the local pool, you’re taken around the back of the site where the patient is standing beside shed. He is anxious and distressed, pacing and coughing.
D- Nil obvious, chemicals inside of shed.
R- When you approach, the patient looks up at you and states “I can’t breathe”. (A)VPU
C- Regular, strong radial pulse.
A- Patient able to speak and swallow, patent.
B- Spontaneous and adequate.
ECG4- sinus tachycardia at 115bpm
Head: Patient has tears streaming down his cheeks, red cheeks. Pt reports his vision is blurry due to the tears. Nil foreign body present in eyes.
S- lacrimation, shortness of breath, dizziness, 4/10 throat pain described as burning, eye pain described as itchy, coughing, flushed skin
P- tonsillectomy 6 months ago, nil episodes similar to today
E- patient was pouring chemicals into the pool pump when he suddenly noticed his throat felt irritated. He then felt dizzy and his eyes began producing tears. Staff state the patient accidentally used undiluted chlorine instead of diluted chlorine.
3. Other assessments you want to perform?
Appearance- moderately anxious
Pulse- as described above
Effort- accessory muscle use present
Sounds- bilateral basal inspiratory and expiratory wheeze
History: What time did the patient enter the shed/pour the chemicals? How long was he inside? What time was symptom onset? Did he suffer any ingestion or direct skin contact?
4. Provisional Diagnosis Chlorine gas toxicity
1. Contact OpCen for firefighter/CBRIE assistance to manage risk of further exposure to others
2. Position patient sitting upright and provide reassurance
3. Nebulise Salbutamol to manage bronchospasm
4. If SPO2 doesn’t improve and respiratory distress remains after wheeze has resolved, provide supplemental O2.
5. Irrigate eyes using water (drinkable water is acceptable) or normal saline.
The patient responds well to 5mg of nebulised salbutamol, resolving his wheeze. His RR reduces to 24. His SPO2 improves to 94% on room air. With supplemental oxygen via nasal cannula at 2lpm his SPO2 improves to 97%. His ocular irritation continues but it relieved with ongoing irrigation and then keeping his eyes closed.
On arrival at hospital, the patient has a second episode of bronchospasm, which increased RR and wheeze. The hospital staff manage him with nebuilsed sodium bicarbonate, which resolves his symptoms.
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