• At room temperature, anhydrous ammonia is a colorless, highly irritating gas with a pungent, suffocating odor. It is lighter than air and flammable, with difficulty, at high concentrations and temperatures. It is easily compressed and forms a clear, colorless liquid under pressure. Ammonia dissolves readily in water to form ammonium hydroxide - an alkaline solution. The concentration of aqueous ammonia solutions for household use is typically 5% to 10% (weight:volume), but solutions for commercial use may be 25% (weight:volume) or more, and are corrosive. Anhydrous ammonia is stored and shipped in pressurized containers, fitted with pressure-relief safety devices, and bears the label "Nonflammable Compressed Gas". Despite not meeting the Department of Transport definition of flammable it should be treated as such.
• Anhydrous ammonia reacts with moisture in the mucous membranes to produce an alkaline solution (ammonium hydroxide). Exposure to ammonia gas or ammonium hydroxide can result in corrosive injury to the mucous membranes of the eyes, lungs, and gastrointestinal tract and to the skin due to the alkaline pH and the hygroscopic nature of ammonia.
• Responders should obtain assistance in identifying the chemical(s) from container shapes, placards, labels, shipping papers, and analytical tests. General information on these identification technicques is located in the Emergency Response Guidebook.
• Identification Tools - CHEMM-IST, WISER, Phosgene Chemical Properties
• Devices (examples) - HazCat Industrial Chemical and Methamphetamine Identification Kit (Model KT1220) (solid and liquid), ChomAir Badges (vapor or gas), Safe Air Monitoring System (vapor or gas), Kitagawa Gas Detector Tubes (vapor), Sensidyne Gas Detection Tubes (vapor)
• A comprehensive source for the selection of chemical identification equipment is the Guide for the Selection of Chemical Detection Equipment for Emergency First Responders, Guide 100-06, January 2007, 3rd Edition published by the Department of Homeland Security.

Respiratory and Skin Protection: Positive-pressure-demand, self-contained breathing apparatus (SCBA) level A is recommended in response situations that involve exposure to potentially unsafe levels of ammonia liquid or vapor.

PPE required level A

Respiratory Protection: Positive-pressure, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to potentially unsafe levels of ammonia.

Skin Protection: Chemical-protective clothing is recommended because of the potential of inflammatory and corrosive effects.

• Level A - protective clothing is the highest level of protection. Level A includes a Self Contained Breathing Apparatus (SCBA) with a fully encapsulating vapor tight suit with gloves and booties attached to the suit (tanks last from 1/2 hour to 1 hour).
• Link to reference section for acute event PPE related safety information

Chemical casualty triage is based on walking feasibility, respiratory status, age, and additional conventional injuries. The triage officer must know the natural course of a given injury, the medical resources immediately available, the current and likely casualty flow, and the medical evacuation capabilities.

• SALT Mass Casualty Triage - United States Government Recommendation
• START Adult Triage Algorithm
• JumpSTART Pediatric Triage Algorithm

• Check triage tag/card for any previous treatment or triage.
• Survey for evidence of associated traumatic/blast injuries.
• Observe for sweating, labored breathing, coughing/vomiting, secretions.
• Severe casualty triaged as immediate if assisted breathing is required.
• Blast injuries or other trauma, where there is question whether there is chemical exposure, victims must be tagged as immediate in most cases. Blast victim's evidence delayed effects such as ARDS, etc.
• Mild/moderate casualty: self/buddy aid, triaged as delayed or minimal and release is based on strict follow-up and instructions.
• If there are chemical exposure situations which may cause delayed but serious signs and symptoms, then over-triage is considered appropriate to the proper facilities that can observe and manage any delayed onset symptoms.
• Expectant categories in multi-casualty events are those victims who have experienced a cardiac arrest, respiratory arrest, or continued seizures immediately. Resources should not be expended on these casualties if there are large numbers of casualties requiring care and transport with minimal or scant resources available.
• In a given category prioritize a child, pregnant woman over a non-pregnant adult.

The following exposed persons should be evaluated at a medical facility:

• Symptomatic patients complaining of persistent shortness of breath, severe cough, or chest tightness should be admitted to the hospital and observed until symptom-free. Pulmonary injury may progress for several hours.
• Those who have eye or skin burns that cover a large surface area.
• Those who have ingested ammonia.

Patient Release

• In a mass casualty situation, asymptomatic patients who are reliable historians and those who experienced only minor sensations of burning of the nose, throat, eyes, and respiratory tract (with perhaps a slight cough) may be released. In most instances, these patients will be free of symptoms in an hour or less. They should be advised to seek medical care promptly if symptoms develop or recur.
• If the treater feels that the patient has been exposed to a significant amount of ammonia, despite a relatively benign clinical appearance, if the incident involved a small number of patients, or the victims included young kids (especially infants or patients with special needs), they should be monitored in an ED "extended care" area for 6-12 hrs).

ABC/ALS Reminders - Initial stabilization - Evaluate and support the airway, breathing, and circulation. Intubate the trachea in cases of respiratory compromise (avoid blind nasotracheal intubation or use of an esophageal obturator). Use Bag Valve Mask (BVM) if unable to secure airway. Maintain adequate circulation. If trauma is suspected, maintain cervical immobilization manually and apply a decontaminable cervical collar and a backboard, when feasible. Apply direct pressure to stop arterial bleeding, if present.

• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

• Inhalation of ammonia may cause nasopharyngeal and tracheal burns, bronchiolar and alveolar edema, and airway destruction resulting in respiratory distress or failure. Ammonia's odor threshold is sufficiently low to acutely provide adequate warning of its presence (odor threshold = 5 ppm; OSHA PEL = 50 ppm). However, ammonia causes olfactory fatigue or adaptation, making its presence difficult to detect when exposure is prolonged. Anhydrous ammonia is lighter than air and will therefore rise (will not settle in low-lying areas); however, vapors from liquefied gas are initially heavier than air and may spread along the ground.
• Skin/Eye Contact - the extent of injury produced by exposure to ammonia depends on the duration of the exposure and the concentration of the gas or liquid. Even low airborne concentrations (100 ppm) of ammonia may produce rapid eye and nose irritation. Higher concentrations may cause severe eye injury. Contact with concentrated ammonia solutions, such as some industrial cleaners (25%), may cause serious corrosive injury, including skin burns, permanent eye damage, or blindness. The full extent of damage to the eyes may not be clear until up to 1 week after the injury is sustained. Contact with liquefied ammonia can cause frostbite injury.
• Ingestion - ingestion of ammonium hydroxide, while uncommon, results in corrosive damage to the mouth, throat, and stomach. Ingestion of ammonia does not normally result in systemic poisoning.

• Respiratory - the extent of injury produced by exposure to ammonia depends on the duration of the exposure, the concentration of the gas, and the depth of inhalation. Even fairly low airborne concentrations (50 ppm) of ammonia produce rapid onset of eye, nose, and throat irritation; coughing; and narrowing of the bronchi. More severe clinical signs include immediate narrowing of the throat and swelling, causing upper airway obstruction and accumulation of fluid in the lungs. This may result in low blood oxygen levels and an altered mental status. Mucosal burns to the tracheobronchial tree can also occur. Immediate onset of laryngospasm with respiratory arrest can occur.
• Dermal - dilute aqueous solutions (less than 5%) rarely cause serious burns, but can be moderately irritating. Exposure to concentrated vapor or solution can cause pain, inflammation, blisters, necrosis and deep penetrating burns, especially on moist skin areas. Skin contact with compressed, liquid ammonia (which is stored at -28 °F) causes frostbite injury, and may also result in severe burns with deep ulcerations.
• Ocular - ammonia has a greater tendency to penetrate and damage the eyes than does any other alkali. Even low concentrations of ammonia vapor (100 ppm) produce rapid onset of eye irritation. Contact with high concentrations of the gas, or with concentrated ammonium hydroxide, may cause swelling and sloughing of the surface cells of the eye, which may result in temporary or permanent blindness.
• Gastrointestinal - nausea, vomiting, and abdominal pain are common symptoms following ingestion of ammonia. Ingestion of household ammonia (5-10%) has resulted in severe esophageal burns. Esophageal pain with swallowing, drooling and refusal of food suggest a more significant injury. Substernal chest pain, abdominal pain and rigidity suggest profound injury and potential perforation of the esophagus and/or stomach.
• Link to Hospital Clinical Signs and Symptoms
• Link to Toxic Syndromes
• Link to Primary and Secondary Survey

• Phosgene is distinguished by its smell in high concentrations and delayed onset of pulmonary edema.
• Riot agents cause an acute onset of burning sensation in the eyes and upper airway without progression of symptoms. Riot agents do not cause laryngospasm except in hugh doses and patients never develop symptoms of peripheral pulmonary edema.
• Nerve agents induce watery secretions as well as respiratory distress, but have a host of other symptoms, such as miosis, seizures, rapidity of onset, that can distinguish them from pulmonary agents.
• The respiratory toxicity of vesicants (i.e. mustard) is usually delayed, but affects the central rather than the peripheral airway. Vesicant toxicity severe enough to cause dyspnea typically causes airway necrosis often with upper airway obstruction.
• Link to Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST)

Children are more vulnerable to ammonia because:

• Infants, toddlers, and young children do not have the motor skills to escape from the site of an incident.
• The vapors from liquefied gas are initially heavier than air and may spread along the ground high which is in the breathing zone of small children.
• Children exposed to ammonia are likely to experience increased severity of the same clinical effects seen in exposed adults.
• Exposure may be greater due to the higher number of respirations per minute in children.
• The smaller airway diameter, anatomic subglottic narrowing, omega shaped epiglottic structure, relatively large tongue size, less rigid ribs and trachea make them more vulnerable to nerve agent induces pathology i.e. stridor, bronchospasm, copious secretions.
• Vesicants and corrosives produce greater injury to children because of poor keratinization of their skin.
• Children, because of their relatively larger body surface area, lose heat quickly when showered. Consequently, decontamination may result in hypothermia unless heating lamps and other warming equipment are used.
• Having less fluid reserve increases the child's risk of rapid dehydration or shock after vomiting and diarrhea.
• Link to Primary and Secondary Survey

Antidotes - there are no specific antidotes for ammonia.

Supportive

Intubate the trachea in cases of coma or respiratory compromise (avoid blind nasotracheal intubation or use of an esophageal obturator). Use Bag Valve Mask (BVM) if unable to secure airway). If upper airway is obstructed perform cricothyroidotomy or place 14 gauge angiocatheter in crico-thyroid membrane (if equipped and trained to do so). Frequent suctioning of the airways may be necessary to remove mucous secretions.

Link - placement of 14 gauge angiocatheter in cricothryroid membrane

Treat patients who have bronchospasm with aerosolized bronchodilators. The use of bronchial sensitizing agents in situations of multiple chemical exposures may pose additional risks. Consider the health of the myocardium before choosing which type of bronchodilator should be administered. Cardiac sensitizing agents may be appropriate; however, the use of cardiac sensitizing agents after exposure to certain chemicals may pose enhanced risk of cardiac arrhythmias (especially in the elderly). Ammonia poisoning is not known to pose additional risk during the use of bronchial or cardiac sensitizing agents.

Consider racemic epinephrine‡ aerosol for children who develop stridor. Dose 0.25 - 0.75 mL of 2.25 % racemic epinephrine solution in 2.5 cc water, repeat every 20 minutes as needed, cautioning for myocardial variability.

Patients who are comatose, hypotensive, or are having seizures or cardiac arrhythmias should be treated according to advanced life support (ALS) protocols.

If ammonia was swallowed, immediately give the person water or milk, unless instructed otherwise by the Emergency Department or Poison Control. DO NOT give water or milk if the patient is having symptoms (such as vomiting, convulsions, or a decreased level of alertness) that make it hard to swallow. The addition of water or milk following the ingestion of a large amount of industrial strength ammonia will have no therapeutic benefit. DO NOT place a nasogastric tube.

Frostbite - Always handle frostbitten skin and eyes with caution. Place frostbitten skin in warm water (108 degrees). Do not allow the skin to touch the sides of the container. If hot water is not available wrap the affected area gently in warm blankets. Encourage exercise of the affected part while it is being warmed.

• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

‡ Not FDA approved for this indication/Off-label use

If victims can walk, lead them out of the Hot/Warm Zones to the Decontamination Zone (they should not walk long distances if at all possible, as physical exertion may worsen and/or accelerate the development of non-cardiogenic pulmonary edema). Victims who are unable to walk may be removed on backboards or gurneys; if these are not available, carefully carry or drag victims to safety. Should there be a large number of casualties, and if decontamination resources permit, separate decontamination corridors should be established for ambulatory and non-ambulatory victims.

Consider appropriate management of chemically contaminated children, such as measures to reduce separation anxiety if a child is separated from a parent or other adult.

• Link to Management of the Deceased

Personnel should continue to wear the same level of protection as required in the Hot/Warm Zones.

Link to Hot/Warm Zones - Rescuer Protection

If exposure levels are determined to be safe, decontamination may be conducted by personnel wearing a lower level of protection than that worn in the Hot/Warm Zones. However, do not attempt resuscitation without a barrier.

Speed is critical. If the victim is symptomatic, immediately institute emergency life support measures. Treatment should be given simultaneously with decontamination procedures. Quickly ensure that the victim has a patent airway and is ventilating well. Assist ventilation with a bag-valve-mask device equipped with a canister or air filter, if necessary (avoid blind nasotracheal intubation or use of an esophageal obturator). Maintain adequate circulation. Stabilize the cervical spine with a decontaminable collar and a backboard if trauma is suspected. Direct pressure should be applied to control heavy bleeding, if present.

• Link to Supportive Treatment in the Hot/Warm Zones
• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

Antidotes - there are no specific antidotes for ammonia.

Set up Considerations

• Use pictorial and written posted instructions for victims to self decontamiate when able, use locale-appropriate multilingual signage.
• Double bag contaminated clothing etc. (place hearing aids, valuables in small bag). Place bag in container by showers.
• Victims who are able may assist with their own decontamination.
• Children and the elderly are at increased risk for hypothermia - provide warm showers, blankets.
• Privacy must be considered, if possible.
• The decontamination system should be designed for use in children of all ages, by parentless children, the non-ambulatory child, the child with special needs, and also allow families to stay together.
• Use step-by-step, child-friendly instructions that explain to the children and parents what they need to do, why they are doing it, and what to expect.
• Take into consideration that infants when wet are slippery and will need a way to get them through the decontamination process - i.e. plastic buckets, car seats, stretchers...
• Designate a holding area and provide staff to support and supervise the children.
• Recommended age appropriate staffing ratios for untended children:
  • 1 adult to 4 infants
  • 1 adult to 10 preschool children
  • 1 adult to 20 school-age children

Washing Instructions

• If there will be a significant delay to decontamination, have the victims rinse off with water exposed skin surfaces and disrobe (disposable clothing kits should be available).
• Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag (removal of clothing, at least to the undergarment level will reduce victim's contamination by 85%).
• If clothes have been exposed to contamination, then care must be taken when undressing to avoid transferring chemical agents to the skin - i.e. any clothing that has to be pulled over your head should be cut off instead of being pulled over your head.
• If exposure to liquid agent is suspected, cut and remove all clothing and wash skin immediately with soap and water.
• If exposure to vapor only is certain, remove outer clothing and wash exposed skin with soap and water.
• Cover all open wounds with plastic wrap prior to performing head to toe decontamination (particular attention should be made to open wounds because ammonia is readily absorbed through abraded skin).
• Flush the exposed skin and hair with plain water for 2 to 3 minutes then wash twice with mild soap. Rinse thoroughly with water. Be careful not to break the patient/victim's skin during the decontamination process.
• Flush exposed or irritated eyes with plain water or saline for at least 15 minutes by tilting the head to the side, pulling eyelids apart with fingers, and pouring water slowly into eyes. Remove contact lenses if easily removable without additional trauma to the eye. If a corrosive material is suspected or if pain or injury is evident, continue irrigation while transferring the victim to the Support Zone.
• Do not irrigate eyes that have sustained frostbite injury
• Scraping with a wooden stick, i.e. a tongue depressor or popsicle stick, can remove bulk agent.
• Caution - many people shower as they do it at home rather than conducting a rapid decontamination of their bodies. Too aggressive scrubbing can lead to further damage to skin and open wounds.
• Utilizing large amounts of water by itself is very effective (limit pressure in infants).
• If water supplies are limited, and showers are not available, an alternative form of decontamination is to use absorbent powders such as flour, talcum powder, or Fuller's earth.
• Certification of decontamination is accomplished the following: processing through the decontamination facility; utilization of a device designed for confirmation of successful decontamination such as a Draeger Gas Detector that detects ammonia gas.
  A comprehensive source for the selection of chemical identification equipment is the Guide for the Selection of Chemical Detection Equipment for Emergency First Responders, Guide 100-06, January 2007, 3rd Edition published by the Department of Homeland Security.
• If still contaminated, repeat shower procedure.
• Victims should be kept warm and quiet; any activity subsequent to exposure may increase the likelihood of death.

Decontamination of First Responder:

• Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
• Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE has been removed.
• Place all PPE in labeled durable 6-mil polyethylene bags.

Decontamination of Infants and Children

• Video: Decontamination of Infants and Children (HHS/AHRQ, Children's Hospital Boston) (Watch video)
  • Decontamination of Children (HHS/AHRQ) provides a step-by-step decontamination demonstration in real time, and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination.

Wound Management

• Link to Wound Management

References

• Medical Management of Chemical Casualties Handbook, 2nd edition, September, 1995
• Braue EH, Boardman CH. Decontamination of Chemical Casualties
• Jagminas L. CBRNE - Chemical Decontamination (eMedicine)

Following decontamination, the patient should be reassessed; noting changes in triage category (if any), the need for, or the modification of, supportive therapy (See ABC Reminders/Advanced Treatment).

Quickly access airway patency. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Ensure adequate respiration and pulse. Document oxygen saturation. Place on a cardiac monitor.

Link to Primary and Secondary Survey

If the patient is symptomatic, immediately institute emergency life support measures.

Advanced Treatment

Supportive

In cases of respiratory compromise, secure airway and respiration via endotracheal intubation or laryngeal mask airway (LMA) (use Bag Valve Mask (BVM) if unable to secure airway). Suctioning may be required for excessive bronchial secretions. If upper airway is obstructed, perform cricothyroidotomy, or place 14 gauge intracath in the cricothryroid membrane. Patients who are in cardiorespiratory failure or have seizures should be treated according to advanced life support (ALS) protocols.

Frostbite - Always handle frostbitten skin and eyes with caution. Place frostbitten skin in warm water (102 - 108 degrees) for 20 to 30 minutes and continue until a flush has returned to the affected area. Do not allow the skin to touch the sides of the container. If hot water is not available wrap the affected area gently in warm blankets. Encourage exercise of the affected part while it is being warmed.

Link to 14 gauge intracath placement instructions

Link to supportive treatment in the hot/warm zones

Link to Basic and Advanced Life Support

Antidotes

Antidotes - there are no specific antidotes for ammonia.

Only decontaminated patients, or patients not requiring decontamination, should be transported to a medical facility. "Body bags" are not recommended. If a corrosive material is suspected or if pain or injury is evident, continue eye irrigation while transferring the victim to the Support Zone (see Patient Information Sheet ).

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