Bathrooms and Nerve Agents
Given the recent chemical attack using chlorine gas and nerve agents in Douma, Syria on April 7th 2018, we wanted to go over the differences between the exposure to chlorine gas (used as a chemical weapon) versus chloramine gas (from inadvertent combination of household cleaners).
Chlorine gas:
Chlorine gas (Cl2) is a toxic yellow-green gas that is denser than air and has an irritating odor. It is used widely in chemical manufacturing, in bleaching, and in swimming pool disinfectants and cleaning agents (as hypochlorite).
Mechanism of toxicity: Chlorine gas produces a corrosive effect on contact with moist tissues such as those of the eyes and respiratory tract.
Presentation: Symptoms are rapid in onset. Immediate burning of the eyes, nose and throat occurs, as well as coughing. Serious corrosive burns may occur to the eyes and skin. With serious exposure, upper airway swelling may rapidly cause airway obstruction. With massive exposure, as is suspected in the most recent Syria attack, pulmonary edema and ARDS may also occur.
Treatment: Treatment is limited, and unfortunately there is no antidote:
#1. Decontaminate!
#2. Provide humidified supplemental oxygen
#3. Use bronchodilators and treat pulmonary edema
A few studies show possible benefit with inhalation of sodium bicarbonate, although benefits are modest. Avoid inhaled and systemic steroids given concern for perforation and serious infections in chlorine gas exposure.
Chloramine gas:
Chloramine gas (NH2Cl and NHCl2) is an odor-less and color-less gas formed most commonly when bleach (sodium hypochlorite) and ammonia are combined (both common in household cleaning products).
Mechanism of Toxicity: When inhaled, chloramines react with the moisture of the respiratory tract to release ammonia and hydrochloric acid as well as oxygen free radicals.
Presentation: In low concentrations, this causes only mild respiratory tract irritation. In high concentrations, this causes cellular injury and corrosive effects, leading to pneumonitis and pulmonary edema.
Treatment: Treatment is all supportive. Similar to chlorine gas, decontaminate, provide oxygen and airway support, use bronchodilators and treat pulmonary edema.
Sources:
- Tanen, David et al. “Severe Lung Injury after Exposure to Chloramine Gas from Household Cleaners.” N Engl J Med 341; 1999:848-9.
- Olson, Kent et al. “Poisoning and Drug Overdose, 7th edition” McGraw Hill Education, 2018.
This Question was prepared by: Maureen Saint Georges Chaumet, MD, VUMC Pediatrics Emergency Medicine Fellow
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Donna Seger, MD
Medical Director
Tennessee Poison Center
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