Stratify chlorine toxic patients into no symptoms, mild, moderate and severe. Treatment and observation periods can be tailored based on the severity of symptoms.
ARDS. Perform similar ventilation strategies for ARDS, including increased PEEP and low tidal volumes. Evaluate daily for barotrauma. The patient may require high doses of sedatives to maintain synchrony with the ventilator.
Important caveats
A patient who is close to a large, dense chlorine exposure (IED detonated chlorine tank) or suffers a sustained exposure (unconscious in a chlorine filled room) may develop upper airway edema. In these cases, perform early intubation. Examine all exposed patients for eye, mucosal, and skin contamination which is manifested by corneal burns/abrasions, mucosal swelling, and skin erythema, blister, or burns. Decontaminate all symptomatic skin surfaces. Remove all exposed clothing. The trauma evaluation and treatment takes priority over the chlorine toxicity. Nebulized bicarbonate has not been reliably effective. It is made by mixing 1 ml of 8.5% sodium bicarbonate in 3 ml saline to create a 2% solution.
Post discharge follow-up
If available, obtain pulmonary function tests with lung volume assessment and DLCO. If the PFT is abnormal, obtain high resolution pulmonary CT scan to assess or pulmonary fibrosis.
Background and clinical effects
Chlorine is a gas with intermediate water solubility. It will induce mild irritant symptoms (tearing, pungent smell, upper airway irritation), but will also induce delayed pulmonary edema following a dense or sustained exposure. Chlorine dissolution into lung water generates hydrochloric acid and hypochlorous acid. The hypochlorous acid decomposes to HCl and nascent oxygen (O-). The nascent O- produces additional lung damage by free-radical formation. Chlorine was used in World War I as a chemical warfare agent.