APRIL 16, 2015
BLOOMINGDALE, NEW JERSEY
A worker at a local nursing home was hospitalized Wednesday
morning due to a chemical spill that also caused a partial evacuation of the
facility.
According to Police Chief Joe Borell, officers were
dispatched to the Health Center of Bloomingdale at 255 Union Ave. on a report
of a chemical spill at approximately 10:45 a.m. Personnel from the Bloomingdale
Volunteer Fire Department, the Tri-Boro First Aid Squad, and the Passaic County
Hazmat Team were also dispatched.
In addition, SWAT and marine infantry teams arrived, armed with anti-tank missiles, hand grenades and sniper rifles, just in case this was a terrorist act. Some SWAT team members had to expense their laundry bills after brown stuff appeared on their pants when they got really scared because they thought that this was the terrorist attack they trained all their lives for.
A nursing home worker had taken the sick employee to a local
medical facility prior to the police's arrival, said Borell.
"It was determined that a laundry product apparently
mixed with bleach had spilled onto the floor, causing one employee to take ill from
breathing in fumes," said Borell. The
most common cause of that reaction is the mixing of ammonia and bleach.
According to the chief, the first floor of the building was
evacuated, and the facility's air systems were also shut down temporarily. Local firefighters remediated the spill with
Quick Dry and water, and the county hazmat team was recalled.
"Ultimately the scene was deemed safe by the
Bloomingdale Volunteer Fire Department," said Borell.
//------------------------------//
THE INAPPROPRIATE MIXING OF HOUSEHOLD CHEMICALS CAN CAUSE
HAZMAT SITUATIONS
by Louis Cook
In 2006, the American Association of Poison Control Centers
reported 214,091 calls associated with household cleaning products, the number
3 category on its list of the top 25 compounds frequently involved in human
exposures.1
My unit is frequently called
to the scene where civilians have become ill from inappropriately mixing
household cleaning chemicals. Many of these responses are not limited to homes;
they have been to hotels, schools, and even a local hospital. The literature
also contains reports on two separate mass-casualty incidents involving U.S.
Army barracks. What is most troubling to me is the perception among the public
and even some first responders that household cleaning products are not
dangerous, even when they combine and form a noxious vapor cloud.
These
products include household ammonia, household bleach, and acid-based cleaners.
These everyday hazmat incidents do not evoke headlines in the media. Instead,
the EMS and fire crews respond to find one patient, maybe two patients,
seemingly more embarrassed than ill, where a refusal of medical assistance
(RMA) is more likely than decontamination and transport.
A study conducted by the New York State Department of Health
from 1993 to 1998 noted that first responders constituted 15 percent of the
reported injuries from ammonia incidents.2 These injuries and illnesses were
preventable. The cluster of symptoms caused by exposure to these irritant gases
is referred to as “Irritant Gas Toxidrome” (Table 1). Chlorine and ammonia are
two major chemicals that are responsible for irritant gas toxidrome. When
inhaled, they dissolve in the respiratory tract mucosa and cause inflammation.
Damage to the respiratory system is related to the solubility and concentration
of the gas or gases. The signs and symptoms associated with the Irritant Gas
Toxidrome may be acute or delayed. Acute effects include eye, nose, and throat
irritation; dyspnea; cough; stridor, bronchospasm; vomiting in some cases; and
noncardiogenic pulmonary edema. Later, subacutely, opportunistic bacterial
infections can occur with progression to pneumonia and bronchitis.
The duration of exposure and the concentration of the
product will vary according to the concentrations of the individual products
before mixing. Standard household bleach is actually sodium hypochlorite in
solution and ranges from three to 10 percent in solubility, which is described
as moderately water soluble. Household ammonia, known as ammonium hydroxide,
ranges around five to 10 percent, which is still considered highly water
soluble.
Note: Some literature refers to household ammonia as aqua ammonia,
given that it is significantly less concentrated than ammonium hydroxide. There
are many other concentrations of these products available for commercial
purposes; however, most of the incidents to which we respond involve the
household strengths.
Other variables to consider are the relative size and
ventilation of the area where the mixing occurs. Since most of these situations
occur in and around the bathroom, it is no surprise that the relatively high
concentration of vapor in the small area leads to an immediate onset of the
signs and symptoms of exposure that are so noxious that they drive the person
away.
Both ammonia and chlorine vapors dissipate in the atmosphere; therefore,
after ventilation, the area will be habitable in a relatively short time.
Individuals trained in hazardous materials should mitigate the leftover
compounds and acids created.
BLEACH AND AMMONIA
Mixing bleach with ammonia cleaners forms monochloramine (NH2Cl),
dichloramine (NHCL2), and trichloramine (NCL3— nitrogen trichloride) compounds.
Chloramines are inorganic nitrogen compounds that contain one or more chlorine
atoms attached to a nitrogen atom.3 The chloramines are alkaline but are
slightly less water soluble than ammonia, causing them to bubble out of
solution. Many victims have reported seeing a milky white solution that bubbles
and creates a noxious cloud.
In the commercial and industrial setting, chloramines are
used as a bacteriocidal agent to treat water, since they stay in the water
distribution system longer than chlorine. They are also used in the synthesis
of many chemicals and plastics. Trichloramine is the most volatile of the three
compounds and is more readily released into the air. The chloramine compounds
are responsible for what is described as that typical “indoor swimming pool
smell.”
They decompose in water to form hypochlorous acid and free ammonia gas;
the former combines with moisture and forms hydrochloric acid. The latter is a
respiratory and mucous membrane irritant and can cause ulcerative
tracheobronchitis, chemical epiglottitis in the pediatric population,
noncardiogenic pulmonary edema (NCPE), and pneumonitis. Persistent hypoxemia as
a consequence of exposure to irritant gases is associated with a high
mortality. Ocular burns and corneal abrasions have occurred with serious
exposure, but damage is rarely permanent.
Patients will often report a burning pain in the chest and
upper airway and stinging eye irritation. Those who have asthma or chronic
obstructive pulmonary disease will most likely experience an exacerbation of
these conditions. Children exposed to the same levels of ammonia vapor as
adults may receive a larger dose because they have greater lung surface area to
body weight ratios and increased minute volumes per kilogram weight. In
addition, they may be exposed to higher levels than adults in the same location
because of their short stature and the higher levels of ammonia vapor found
nearer to the ground.
Also, humans exposed to ammonia vapors experience
olfactory fatigue, making it difficult to further detect the smell of ammonia,
which can in turn increase exposure time. Finally, since chloramines have
nitrogen in their chemical composition, it is possible that methemoglobinemia
will develop, although the exposure would likely be severe, if not fatal.
BLEACH AND ACID
Another common occurrence is the mixing of bleach and an
acid-containing cleaner, which often causes a violent reaction. This generally
occurs when the do-it-yourselfer is attempting to clear a stubbornly clogged
drain at 3 a.m. In the end, it would have been cheaper and less painful to call
a plumber. Common household toilet bowl cleaners and fungicides are usually
moderately strong acids like phosphoric acid and sodium bisulfate, which have a
pH around two.
Drain cleaners, like the stronger sulfuric acid, are dense, oily
liquids with a pungent odor. Depending on its purity, sulfuric acid may be
colorless to dark brown. Simply mixing sulfuric acid and water can be
particularly dangerous because the mixing produces a large amount of heat,
which can cause violent spattering. Add an alkaline or another product, and you
have a fuming corrosive.
Bleach mixed with an acid creates an acid halide that
liberates chlorine vapors as well as some water. Chlorine reacts with the water
to form hydrochloric and hypochlorous acids. Chlorine gas, which is less
alkaline than ammonia, is 30 times more irritating to skin tissues than
straight hydrochloric acid. Remember that this substance, which was once used
as a weapon in World War I, causes a variety of symptoms in accordance with the
severity of the exposure.
Hydrochloric acid is created when chlorine contacts
the moisture in the respiratory mucosa, causing a burn injury. Toxic, free-radical
oxygen is released, which also causes tissue inflammatory response and damage.
Some bleach and toilet bowl cleaner labels warn against mixing with other
chemicals. However, human nature being what it is, these warnings are often
unheeded.
The chlorine vapors that are liberated have a detectable
odor (odor threshold) as low as 0.021 parts per million (ppm) in air; mild
mucous membrane irritation may occur at levels as low as one ppm. A level of at
least three ppm may cause extreme irritation of the eyes and respiratory tract.
Symptoms following exposure to chlorine include irritation of the eyes, nose,
and throat; dizziness; cough; bronchospasm, epigastric burning; and chest pain
and atelectasis.4
Chlorine is transformed into chloride ions (normal
components of human biochemistry) in the body. An enormous amount of chlorine
has to be inhaled or ingested to detect a significant increase in chloride ions
in the blood, which leads to a severe metabolic acidosis.
Severe exposure may
cause pulmonary edema and bronchiolar and alveolar damage; the literature
contains reports of pneumomediastinum, presumably from the corrosive tissue
destruction by the inhaled product.5 Only four case reports on chlorine
toxicity from mixing bleach with acid cleaning agents have been published,
including one that describes near-fatal pulmonary edema and, two,
pneumomediastinum. Chlorine irritates the skin and can cause burning pain,
inflammation, and blisters.
Children may be more vulnerable than adults to chlorine’s
corrosivity because of the smaller diameter of their airways. Children may also
be more vulnerable to gas exposure because of increased minute ventilation per
kilogram.
BOTTLE BOMBS
Also known as improvised chemical devices (ICD), bottle
bombs most often are created by children who are showing their mastery of
chemistry on YouTube or in an attempt to get out of that midterm examination.
Reactive chemicals that are mixed begin to combust in a process known as a
“hypergolic reaction.”
The chemical reaction progresses within the container,
causing it to bulge or expand until it ruptures explosively. Since force is
amplified several times in enclosed spaces, the potential for injuries grows.
It takes only one to five pounds per square inch (psi) to break a window or
your tympanic membrane. During the New York City crack cocaine epidemic of the
1990s, one form of ICD was deployed at locations where drugs were sold or made,
as a deterrent to rival dealers and investigating police officers.
These
devices can be made with any size of plastic soda or drink bottle—from 20-ounce
to three-liter bottles to larger containers. After these devices explode,
people usually report a strong or unusual chemical odor near the location. Most
times, however, the shattered remains of a soda bottle are the only remaining
evidence.
Medical management of these patients is consistent with that for
blast trauma. Responders are also reminded to be sure to address the potential
inhalation injuries from the liberated gases and chemicals as well as the
dermal and ocular chemical splash burns of the caustics involved.6
FUNGICIDES AND CLEANERS
In August 2008, police and fire units in Pasadena,
California, responded to a suicide involving hydrogen sulfide. The victim,
found dead in his car, had mixed a fungicide and an acid toilet bowl cleaner in
a plastic tray. First responders saw the tray with a “bright blue liquid” in
the back seat of the vehicle. It was learned in the ensuing investigation that
he may have visited one or more of the numerous Japanese Web sites that provide
information on how to commit suicide using hydrogen sulfide.
In Japan, press
reports indicated that during the first six months of 2008, more than 100
people had committed suicide by inhaling hydrogen sulfide produced by mixing
commonly available chemicals. Mixing acids with certain fungicides, pesticides,
dandruff shampoos, and other products containing sulfur or sulfates can
liberate hydrogen sulfide gas.
Hydrogen sulfide (H2S), also known as sewer gas, is a highly
toxic gas with an odor of rotten eggs at low concentrations. At higher
concentrations, olfactory fatigue rapidly occurs, making odor a poor warning
symptom of danger. All of these compounds are direct irritants, but their major
method of toxicity is interference with the cells’ use of oxygen. Low-level
exposures irritate the eyes, nose, and throat and cause a cough, headache,
nausea, and dizziness. Higher exposures can cause syncope, seizures, coma,
tracheobronchitis, and pulmonary edema (which may occur up to 48 to 72 hours
later). Death may occur within minutes of an acute massive exposure.
MANAGEMENT
The first-arriving units must adequately size up the
situation, transmit this information to the dispatcher, and request the
response of the local hazardous materials unit. By taking into consideration
the time of day, the occupancy type, and the victims’ signs and symptoms, you
can immediately get a rough idea of how large this incident is and how large an
event it can evolve into.
It is imperative that you set up and enforce hazard
control zones. Only responders with appropriate personal protective equipment
and respiratory protection should enter the area. Protecting yourself and your
crew is paramount. Do not rely on odor as a means of determining whether it is safe
to enter an area or, worse, to identify the product. Hazardous materials
responders should perform air monitoring for chlorine and ammonia and determine
if the area is safe to enter.
If you suspect that a bottle bomb has gone off, if you find
a suspicious bottle, or if you observe a bottle that is fuming or bulging, do
not handle it, because it is impossible to tell when it will detonate. Isolate
the device as if it were any other type of explosive. Decontamination is
generally done by removing the individual’s outer garments, since the weave of
certain fabrics can trap gases and lead to continued exposure by “off-gassing.”
Decontaminate individuals with splash injuries in the usual manner—hazardous
materials personnel using soap and water. Manage the patient as a caustic
injury.
Care in the prehospital setting is generally supportive
while following local protocols. However, it is compulsory to monitor oxygen
saturation. Textbooks and the literature cite the efficacy of treating
symptomatic patients with beta-2 agonists; administer this therapy as per local
protocol.
Treatment of hydrogen sulfide patients consists of administering the
contents of the cyanide kit without the sodium thiosulfate; the patients may
also benefit from hyperbaric therapy.
Some authors suggest using nebulized sodium bicarbonate in
symptomatic chlorine-injured patients; however, the experts do not agree on its
benefit for chloramine exposures. They cite a lack of clinical evidence for
this therapy. Be aware that this therapy is nothing more than neutralizing an
acid in-vitro, creating an exothermic reaction.
Most recently, the Louisiana
Department of Public Health’s Morbidity Report on the effects of exposure to
bleach/ammonia and bleach and acid exposures during the Hurricane Katrina
cleanup recommended that care providers combine three milliliters of sodium
bicarbonate 8.4 percent with two milliliters of normal saline for patients
experiencing symptomatic exposures to inhale by nebulizer.7
Nelson writes in Goldfrank’s Toxicology that nebulized four
percent sodium bicarbonate given to chlorine-poisoned sheep improved
oxygenation but failed to reduce overall mortality.8 The use of inhaled or
parenteral steroids is reportedly not shown to be helpful in victims of
irritant gas explosions.
Patients who develop pulmonary edema benefit from positive
end expiratory pressure ventilation and not standard diuresis and nitrate
therapy, as in cardiogenic pulmonary edema. Here, the heart is not failing as a
pump, but the pathology is a result of an overwhelming inflammatory response
and damage to the alveolar basement membrane.
The issue of noncardiogenic pulmonary edema post exposure
(NCPE) is most perilous for EMS providers. Mildly symptomatic patients can
resolve over time, and many will refuse care and transportation to the
hospital. However, the onset of NCPE can depend on the length and severity of
the exposures and the patients’ co-morbidities. It could happen within minutes
of exposure or can be delayed up to 24 hours.
Doctor W.P. Herringham explained
in the Lancet that the onset of NCPE in chlorine-exposed World War I casualties
was hastened by moderate exercise, such as the effort exerted in escaping from
a vapor cloud. (3)Therefore, it is perilous to accept an RMA out of hand; it is
prudent to consult with your online medical control physician to execute an
RMA. Remember the TEST acronym widely used in WMD/hazmat awareness programs: If
you don’t Touch, Eat, Smell, or Test a product, you will not end up a patient.
In this case, it is the secret to going home with an intact respiratory tract.
References
1. “Bronstein A. et al. (2007) “2006 Annual Report of the
American Association of Poison,” Control Centers’ National Poison Data System
(NPDS), Clinical Toxicology, 45:8, 815-917. Available online:
http://dx.doi.org/10.1080/15563650701754763.
2. “Hazardous Substance Emergency Events Surveillance
Project Report, Ammonia Spills, New York State 1993-1998,” New York State
Department of Health. Available online: http://www.health.state.ny.us/environmental/chemicals/hsees/ammonia.htm/.
3. Pascuzzi TA, AB Storrow, “Mass casualties from acute
inhalation of chloramine gas,” Military Medicine 1998, 163 (2):102-104.
4. “Homemade Chemical Bomb Events and Resulting
Injuries--Selected States, January 1996-March 2003,” CDC MMWR. July 18, 2003;
52(28):662-664.
5. Gapany-Gapanavicius M, A Yellin, S Almog, M Tirosh,
“Pneumomediastinum--a complication of chlorine exposure from mixing household
cleaning agents,” JAMA 1982; 48:349-50.
6. New Jersey Dept. of Community Affairs, Division of Fire
Safety, “Bottle Bombs,” 2003, http://www.state.nj.us/dca/dfs/bombs.htm/.
7. Louisiana Dept. of Public Health. Morbidity Report, 17:2,
March-April 2006. Accessed at
http://www.dhh.louisiana.gov/offices/publications/pubs-205/marapr06DontMixWithBleach.pdf/.
8. Goldfrank L, et al. Goldfrank’s Toxicological Emergencies,
7th edition (USA: McGraw Hill), 1457-1561.
Additional References
Centers for Disease Control and Prevention, “Ocular and
Respiratory Illness Associated with an Indoor Swimming Pool—Nebraska, 2006,” MMWR
2007; 56:929-932.
Faigel, HC, “Hazards to health: mixtures of household
cleaning agents,” N Engl J Med 1964; 271:618
Gapany-Gapanavicius M, M Molho, M Tirosh,
“Chloramine-induced pneumonitis from mixing household cleaning agents,” Br Med
J 1982; 285:1086.
Jones, FL, “Chlorine poisoning from mixing household
cleaners” [Letter]. JAMA 1972; 222:1312.
Reisz, GR, RS Gammon, “Toxic Pneumonitis from Mixing
Household Chemicals,” Chest 1986; 89:49-52.
Urbanetti, S, “Toxic Inhalational Injuries,” Medical Aspects
of Chemical and Biological Warfare. Textbook of Military Medicine. Accessed at
http://www.au.af.mil/au/awc/awcgate/medaspec/Ch-9electrv699.pdf/.
LOUIS COOK, EMT-P, is a 22-year veteran of EMS and a
lieutenant assigned to the Fire Department of New York Special Operations
Command, Haz Tac Battalion. He is a rescue technician, hazmat technician, and
diver medical technician.
