Langerman

Advanced Chemical [email protected]

Is Water Effective?

Water


Is Water Effective?

Is Water Effective?

Neal Langerman Sharron Sussman

Advanced Chemical Safety


Is Water Effective?

Is Water Effective?

A thorough rinse with water, lasting at least 15 minutes is the accepted procedure for the first response to skin/eye decontamination.

Is this procedure based on fact or fancy?


Is Water Effective?

Is Water Effective?

Acetic acid


Is Water Effective?

Is Water Effective?

Sodium hydroxide


Is Water Effective?

Is Water Effective?

Nitric acid


Is Water Effective?

Is Water Effective?

Sulfuric acid


Is Water Effective?

Is Water Effective?

While reports of injuries can be obtained, reports of successful decontamination are more difficult to document.• Anecdotal• Incomplete• Unreported


Is Water Effective?

1998 – 2001 Hazardous Substances Emergency Events Surveillance (HSEES) Cumulative Report28,767 events8126 persons7759 person were decontaminated• 5116 decon’d at the scene• 2643 decon’d at medical location

• Some decon’d at both132 deaths

Is Water Effective?


Is Water Effective?

ChemicalsBased on the selected incidents

DISTRIBUTION BY CHEMICAL TYPE

ACIDS30%

GASES19%

SOLVENTS14%

CAUSTICS19%

OTHER18%


Is Water Effective?

Injury Type

(Full data set)

INJURY TYPE

0100200300400

TRAUMA EYE IRRITATION BURNS SKINIRRITATION

To tal InjuriesNoneAt SceneAt Med icalBo th


Is Water Effective?

Decontamination Results(based on 102 cases)

05

10152025

NO DECON(1)

AT SCENE (2)

AT MEDIC

AL (3)

BOTH (4)

NO CITE

NOT ADMITTEDADMITTEDFATALITYADVERSE HEALTH IMPACTFIRST AID ON SCENE


Is Water Effective?

Morbidity of Decon'd PatientsFull Data

AdmittedTreated/Released

Is Water Effective?


Is Water Effective?

OBSERVATIONS• Most persons suffer inhalation and eye

irritation.• Most persons do not require decontamination

or medical follow-up.• Effectiveness of decontamination is not

predictable from these data.

Is Water Effective?


Is Water Effective?

LIMITATIONS of DATA• No concentration information• No time of exposure information• All decontamination assumed to be with water

or saline• No detailed outcome information• Data reporting biases

• Reporting frequency and details varies by State• General reporting not mandatory

Is Water Effective?


Is Water Effective?

Is Water Effective?

LITERATURE REVIEW• Primary research via ACS’ STN• Additional data from Eileen Segal (HF) and

Alan Hall• Work performed in 2004 - 2005


Is Water Effective?

Is Water Effective?

Non-HF Cases• 15 reports• 1967 – 2000• Reports (including reviews) discussed

outcomes, insufficient information on deconprocedures


Is Water Effective?

Is Water Effective?*Mozingo, 1988,retrospective review, 87 cases15 agents, white phosphorous most common (49%), military hospital 13.8% mortality rate; • greater than 100% complication rate - 105

complications in 87 patients! Appropriate first aid described for all agents -no data on care actually rendered.No inferences can be made from the results of this study on the impact of pre-hospital care.


Is Water Effective?

Is Water Effective?*Sykes, 1986, retrospective review, 51 cases, 38 requiring hospital admission. • Patients divided into 2 groups,

• 20 adequate (Group A)• 16 inadequate (Group B) emergency treatment.

• 13 agents, alkalis most common, midwestern burn center (agricultural area)

• 13% mortality rate overall • Mortality rate 9.5% in Group A,

• 21% in Group B. • Skin grafting needed in 19% of Group A

• 36% of Group B; • A clear demonstration of the benefits of appropriate first aid. Emphasis

of this study is on the primary importance of emergency treatment, generally water lavage.


Is Water Effective?

Is Water Effective?*Pardoe, 1976, report of 3 cases, literature reviewPhenol, urban university hospital burn center2 patients had 60% and one 80% BSA burns. • All 3 needed intensive treatment of multiple organ system dysfunction

& 2 had skin grafts; • all were discharged in under a month, with eventual full recovery

except for patchy skin pigment changes.A heavy-flow deluge system activated 10-20 seconds after the accident. Boots and clothing were removed only after an interval; • one patient had full-thickness burns of the ankles due to retained

contaminated water.Extensive discussion of the mechanisms of phenol burns, systemic toxicity and treatment, particularly early decontamination.


Is Water Effective?

Is Water Effective?

Horch, 1994, case report, literature reviewphenol,urban burn center (Germany)Complete recovery after 20.5%BSA burnsEarly, repeated PEG & water decontamination thought to have prevented systemic toxicity.Good discussion on specific topical decontamination agents for phenol.


Is Water Effective?

Is Water Effective?*Latenser, 2000, “case controlled” report of 2 cases exposed in single industrial spillAnhydrous Ammonia, urban trauma center.Patient A hospitalized overnight for corneal abrasions, face & neck redness. Patient B hospitalized 13 days, needed intubation, ventilator, debridement, STSG. Both men had similar exposures, by history. • Patient A showered & changed clothing immediately.• Patient B did neither, came to hospital 90 minutes after spill.

Good anecdotal evidence for critical importance of early decontamination.


Is Water Effective?

Is Water Effective?Husain, 1989, report of 7 cases. Only one case, by far the most severe, fully documentedConcentrated sulfuric acid, university hospital (Saudi Arabia)The patient, a 4-yr-old male with 60% BSA 3rd degree burns, had 10 procedures during 166 days in hospital; required 2 readmissions and more surgery for hand & shoulder contractures.No first aid given, not even removal of contaminated clothing.Discussion of recommended pre-hospital treatment -removal of clothing, copious water lavage.


Is Water Effective?

Is Water Effective?Wang, 1985, report of a caseHot Chromic acid, university hospital burn unitPatient had 40% BSA burns, died 6 days post-injury from multiple organ system failure due to chromium toxicity.Immediate copious water lavage at the scene did not prevent absorption of lethal dose of chromium.Discussion of toxic effects of chromium, medical & surgical treatment methods.


Is Water Effective?

Is Water Effective?

HF Cases• 34 reports• 1939 – 1999• Reports (including reviews) discussed

outcomes, insufficient information on deconprocedures

• Significant discussions on using Calcium gluconate or alternatives to water


Is Water Effective?

Is Water Effective?Browne, 1974, retrospective review of 53 cases43 splashes, 10 vapour burns, no details on severity or distribution, chemical plant medical facility (England).38 of 43 splashes, all 10 vapour burns treated successfully by Ca gluconate gel alone. • (28 burns initially self-treated by workers.)

Plant protocol calls for shorter water lavage time, early and prolonged inunction with the gel, till pain gone.Gives details of successful use of Ca gluconate gel in industrial setting.


Is Water Effective?

Is Water Effective?Dibbell, 1970, retrospective review of 45 cases, 3 cases presented All were hand injuries in industrial and househould users• no details on severity, university hospital plastic surgery

service. 13 pts treated with immediate Ca gluconate injection had no tissue loss & no complications. • 3 injected >24 hrs after burns required debridement.

29 treated by other means had high incidence of tissue loss.3 representative cases presented show effectiveness of adequate initial treatment, dangers of inadequate treatment.Supports Ca gluconate injection treatment.


Is Water Effective?

Is Water Effective?Jones, 1939, retrospective review of 12 casesMostly small splash burns of upper extremities, face & neck with concentrated HF, chemical plant medical facility (England).Except for the first pt in this series, all 2nd degree burns due to HF were injected with Ca gluconate & had immediate pain relief & good recovery.Impact of pre-hospital care is not directly addressed.This is the earliest well-documented report of a series of patients treated by a rationally conceived method. Classic description of 2nd degree HF burns.


Is Water Effective?

Is Water Effective?

Standards Status


Is Water Effective?

Is Water Effective?

29 CFR 1910.151(c)• Where the eyes or body of any person may

be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.


Is Water Effective?

Is Water Effective?ANSI Z358.1• Flushing Fluid: Potable water, preserved water,

preserved buffered saline solution or other medically acceptable solution manufactured in accordance with applicable government regulations.

• Personal wash: A supplementary device that supports plumbed and/or self-contained units, by delivering immediate flusing fluid to the eyes or body.

• Personal Wash Units shall have the capacity to deliver immediate flushing fluid without being injurious to the user. Personal wash units do not meet the criteria of plumbed or self-contained eyewash equipment.


Is Water Effective?

Is Water Effective?


Is Water Effective?

Is Water Effective?

Alternatives• Diphoterine and Hexafluorine• D-Tam, Skin Swypes, etc.• Ca salts


Is Water Effective?

Is Water Effective?

Moving forward with alternatives to water:• Education of industrial/institutional users• Determine the applicability of the ANSI

language “other medically acceptable solution manufactured in accordance with applicable government regulations”

• Examine applicability of State OSHA rules


Is Water Effective?

Is Water Effective?

Solid Research is Needed• Good documentation on pre-hospital care• Good documentation on outcomes• Ability to correlate pre-hospital care with

outcomes


Is Water Effective?

Is Water Effective?

Is water effective?• YES, if used promptly on dilute agents• NO, when the agent is very aggressive due to

concentration, temperature or reactivity• MAYBE, under moderate circumstances

Is there a better alternative?


Is Water Effective?

Is Water Effective?

Support was generously provided by Prevor Laboratories

Langerman

Technology

Transcript of Langerman