• Phosgene is colorless, fuming liquid below 47°F (8.2°C) and a colorless, nonflammable gas above 47°F with a suffocating odor like new mown hay. The odor threshold for phosgene is significantly higher than current inhalation exposure limits. Thus, odor provides insufficient warning of hazardous concentrations.
• 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 Emergency Response Guidebook.
• Identification Tools - CHEMM-IST, WISER, Phosgene Chemical Properties
• Devices - Chemical Agent Detector C2 Kit (liquid and vapor), M256A1 chemical agent detector kit (liquid and vapor), M18A3, M90 chemical agent detectors (vapor), Draeger CDS Kit (vapor and aerosol)
• 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 to assist with this process.

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 phosgene 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 phosgene.

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.

• Immediate irritant effects such as conjunctivitis, rhinitis, pharyngitis, bronchitis, lacrimation, blepharospasm conjunctival hyperemia, and upper respiratory tract irritation may occur after exposure to concentrations of 3 to 5 ppm.
• Severe pulmonary toxicity may develop after exposure to higher concentrations or following exposures for longer periods of time.
• A phosgene casualty who develops respiratory distress within 4 hours of exposure has probably inhaled an LD50 dose and is at severe risk if not properly supported.
• Signs and symptoms of toxicity may be delayed, although rare, for 24 to 72 hours and include choking, chest tightness, cough, severe dyspnea, production of foaming bloody sputum, and pulmonary edema. Non-respiratory symptoms include nausea and anxiety. Cardiac failure has occasionally occurred as a complication of severe pulmonary edema. Concentration-response guidelines include:
• Victims with inhalation doses of < 25 ppm/min and without clinical signs and symptoms require no immediate medical attention. Exposure to a cumulative dose of 50 ppm x minutes may cause pulmonary edema; a dose of 150 ppm x min will probably cause pulmonary edema and a dose of 300 ppm x min is likely to be fatal.
• Brief exposure to 500 ppm or greater may be rapidly fatal. Prolonged exposure to low concentrations (e.g. 3 ppm for 170 min) can also be fatal. Exposure to concentrations less than 3 ppm may not be immediately accompanied by irritant symptoms; delayed effects usually occur within 24 hrs of exposure.
• Victims with unknown phosgene exposure must be closely observed.

Quickly ensure that the victim has a patent 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 - Inhalation is the major route of phosgene exposure. Phosgene's effects as a respiratory irritant can be mild and delayed, which may result in a lack of immediate avoidance leading to exposure for prolonged periods. Phosgene is heavier than air and may cause asphyxiation due to oxygen displacement in poorly ventilated, low-lying, or enclosed spaces.
• Skin/Eye Contact - When phosgene gas contacts moist or wet skin, it may cause irritation and erythema. High airborne concentrations can also cause corneal inflammation and opacification. Direct contact with liquid phosgene under pressure can cause frostbite as well as severe irritation and corrosive effects.
• Ingestion - Ingestion of phosgene is unlikely because it is a gas at room temperature.

• Inhaling low concentrations may cause no signs or symptoms initially or cause symptoms that are secondary to mild irritation of the eyes and throat - some coughing, choking, feeling of tightness in the chest, nausea and occasional vomiting, headache, and lacrimation.
• Respiratory - after an asymptomatic period for 30 minutes to 48 hours, in those developing severe pulmonary damage, a progressive pulmonary edema ensues with increasing work of breathing and subsequent hypoxia.
• Cardiovascular - circulatory collapse secondary to severe pulmonary edema.
• Dermal - phosgene can cause skin irritation and with sufficient concentration can cause, burning pain, inflammation, and blisters. Liquefied phosgene can cause frostbite injury.
• Ocular - high vapor concentration can cause tearing and blood in the eye. Contact with liquid phosgene may result in clouding of the cornea and delayed perforation.
• Link to Hospital Clinical Signs and Symptoms
• Link to Toxic Syndromes
• Link to Primary and Secondary Survey

• Since phosgene is a respiratory tract irritant, but has unique toxicological concerns due to the latency of onset of pulmonary edema, differentiating it from the typical presentation of symptoms from other common chemical irritants is an important consideration.
• Phosgene is distinguished by its smell in high concentrations and delayed onset of pulmonary edema.
• Chlorine has a characteristic odor even in low concentrations, immediate onset of respiratory distress, bronchospasm, eye, skin, and upper airway irritation.
• Riot agents cause an acute onset of burning sensation in the eyes and upper airway without progression of symptoms with ongoing exposures.
• 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 Gas) 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 pulmonary agents because:

• They are lower to the ground and are exposed to an increased concentration of most pulmonary agents.
• They have a higher respiratory rate and inhale a greater volume per minute.
• They have smaller diameter airways, anatomic subglottic narrowing, omega shaped epiglottic structure, relatively large tongue size, less rigid ribs and trachea which make them more vulnerable to pulmonary agent induced pathology such as bronchospasm, copious secretions, and pulmonary edema.
• Their skin is thinner and has more moisture content therefore being more vulnerable to inflammatory effects.
• Link to Primary and Secondary Survey

Antidotes - there are no specific antidotes for phosgene.

Supportive

Intubate the trachea in cases of coma or respiratory compromise, or to facilitate removal of excessive pulmonary secretions. If not possible, perform cricothyroidotomy or place 14 gauge angiocatheter in crico-thyroid membrane (if equipped and trained to do so). Frequent suctioning of the airways will 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). Phosgene 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.

Enforce rest - Even minimal physical exertion may shorten the clinical latent period and increase the severity of respiratory symptoms and signs in a lung-damaging agent casualty. Physical activity in a symptomatic patient may precipitate acute clinical deterioration and even death. Strict limitation of activity are strongly recommended for patients suspected of having inhaled phosgene.

• 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. 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 phosgene.

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 phosgene 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.
• 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 (0.5% sodium hypochlorite solution is contraindicated).
• Sodium hypochlorite is not recommended for use in infants and young children.
• Certification of decontamination is accomplished by any of the following: processing through the decontamination facility; M256A1 kit, M18A2, M90 chemical agent detectors.
• If still contaminated repeat shower procedure.

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). If clinically indicated, 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 (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.

Enforce rest - Even minimal physical exertion may shorten the clinical latent period and increase the severity of respiratory symptoms and signs in a lung-damaging agent casualty. Physical activity in a symptomatic patient may precipitate acute clinical deterioration and even death. Strict limitation of activity are strongly recommended for patients suspected of having inhaled phosgene.

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 phosgene.

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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