The correct answer is:

No decontamination necessary; removal from the area of exposure is sufficient.

Educational Objective:

Discuss management of chlorine gas inhalation.

Key Point:

Substances that are exclusively gases at normal temperature and normal pressure (key!), such as chlorine, phosgene, and hydrogen cyanide, usually only require the removal of patients from the source of exposure.

Explanation:

Decontamination is an important step in the care of individuals exposed to chemicals and is a preventive step to avoid exposure to health care staff. However, decontamination should be approached in a logical and thoughtful manner.

In this scenario, the individuals involved in the accident were exposed to normal pressure gas alone. Removal from the source is sufficient; no other decontamination is necessary. Care is supportive.

Patients may experience symptomatic relief from nebulized 2% sodium bicarbonate solution (dilute a given volume of standard 8.4% sodium bicarbonate solution with three equivalent volumes of sterile water, and administer this mixture with standard nebulizer equipment). This only provides symptomatic relief; it does not lessen the progression of pulmonary injury.

If the patients had come in contact with the escaping, highly pressurized gas at the source of the leak or — even worse — with its compressed liquid form (not the case in the above scenario), significant skin/eye contact may have occurred with frostbite or chemical burns of the skin and chemical burns to the eyes. In these cases of contact with a highly pressurized form of chlorine, irrigation with copious amounts of water for 20 minutes is required.

In general, any chemical weapon dispersed as liquid rather than gas requires decontamination in the form of showers and removal of patient clothing.

Special care must be taken to remove liquid or potential liquid exposures to hair, intertriginous areas, axillae, and groin.

References:

Nelson LS. Inhaled Toxins (Chapter 153) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 1926-1933.e2

Suchard JR. Chemical weapons. In: Nelson LS, et al, eds. Goldfrank's Toxicologic Emergencies. 9th ed., 2011.

CHLORINE: Lung Damaging Agent. The National Institute for Occupational Safety and Health (NIOSH). Centers for Disease Control and Prevention.

Vajner JE, Lung D: Case les of the University of California San Francisco Medical Toxicology Fellowship: acute chlorine gas inhalation and the utility of nebulized sodium bicarbonate. J Med Toxicol 9(3):259–265, 2013.