Phosgene Exposure: A Case of Accidental Industrial Exposure

Abstract

Introduction Phosgene is a rare exposure with strong clinical implications. We report a phosgene exposure that resulted in the patient's death. Case Report A 58 year-old man arrived to the emergency department 1 hour after exposure to phosgene with complaints of a sore throat. Initial vital signs were blood pressure 175/118 mmHg, heart rate 98/min, respirations 12/min, and oxygen saturation of 93% on room air. Physical exam revealed few scattered rhonchi, without signs of distress. Initial arterial blood gases (ABG's) revealed pH 7.42, pCO2 43 mmHg, pO2 68 mmHg, HCO3 27 meq/L, and oxygen saturation of 93% on room air. Initial chest x-ray 2 hours after the exposure demonstrated clear lung fields. Approximately 2.5 hours after the exposure, he began complaining of dyspnea, restlessness and his oxygen saturation dropped below 90%.He received nebulized albuterol, 1 gram intravenous methylprednisolone, and 100 % oxygen via face mask. Minimal improvement was noted and he was intubated. The post intubation chest x-ray, 3.5 hours after the exposure, revealed diffuse alveolar infiltrates. Acetylcysteine, terbutaline, and IV steroids were administered without improvement. The patient died 30 hours after exposure. Discussion There are many misunderstandings concerning phosgene due to its rare presentation. Traditional treatment modalities are often unproven in human trials and were unsuccessful in this case. Conclusion This case highlights the significant toxicity that results from phosgene exposure and the challenges of the limited treatment modalities. There is concern for the use of this agent in chemical terrorism.

Potential for release of pulmonary toxic ketene from vaping pyrolysis of vitamin E acetate

“…Thus, it is unknown whether odor detection and minor irritation would provide adequate warning of ketene exposure, especially given the potential for delayed pulmonary toxicity. The toxicity of ketene has been assessed in various animal species and these studies indicate that it has similar clinical effect and mode of action as phosgene (COCl 2 ) (16). In toxicity studies with primates, the minimum lethal in-air concentration was determined to be 200 ppm, causing death after a single 10-min exposure (17).…”

Hazardous Chemical Emergencies and Poisonings

“…Inciting agents include oxides of nitrogen (causing silo filler's disease) and phosgene. 37,38,43,44 Patients may be unaware of exposure, presenting hours to days later with increased sputum production, chest tightness, and dyspnea on exertion. Clinical findings include dyspnea, tachypnea, wheezes, and rales; pulse oximetry or blood gas analysis may show decreased oxygen saturation with activity.…”

“…Additional therapies of potential benefit include inhaled betaagonists and N-acetylcysteine, as well as ibuprofen. 37,38,[43][44][45] After phosgene exposure, bed rest and close observation are recommended, with oxygen supplementation delayed until it is clinically required to prevent hypoxemia. If oxygen therapy is necessary, it should target oxygen saturation at the low end of the normal range in order to mitigate oxidant-induced injury.…”

“…If oxygen therapy is necessary, it should target oxygen saturation at the low end of the normal range in order to mitigate oxidant-induced injury. 43,44 Delayed or persistent effects of respiratory irritants include airway hyperreactivity, or reactive airways dysfunction syndrome, characterized by acute bronchoconstrictor responses to otherwise innocuous concentrations of inhaled agents, 46,47 as well as interstitial pulmonary fibrosis, emphysema, bronchiectasis, and bronchiolitis obliterans. 37,39,45…”

Phosgene

“…Reports of human phosgene poisoning present a relatively consistent set of clinical effects and sequelae (Delephine, 1922;Hegler, 1928;Galdston et al, 1947a,b;Herzog and Pletscher, 1955;Everett and Overholt, 1968;Henschler, 1971;Stavrakis, 1971;Diller et al, 1979;Bradley and Unger, 1982;Misra et al, 1985;Regan, 1985;Wells, 1985;Cordasco et al, 1986;Kaerkes, 1992;Hardison et al, 2014). After acute phosgene exposure, brief (20 min) ocular and throat irritation, cough, nausea and vomiting, and dizziness are experienced, followed by a period (24 h) of apparent well-being.…”