Aleksander Rutkiewicz1, Agnieszka Misiewska-Kaczur1, Katarzyna Kuchnicka2, Filip Szeremeta1, Paweł Schab1
1 Anesthesiology and Intensive Care Unit, Śląski Hospital in Cieszyn; head: Agnieszka Misiewska-Kaczur MD, PhD
2 Anesthesiology and Intensive Care Unit, Provincial Hospital in Bielsko-Biała; head: Assoc. Prof. Dariusz Maciejewski MD, PhD
Abstract. The article presents a case of severe accidental inhalation chlorine poisoning. The initially good clinical condition of the patient became aggravated within a few hours after the gas inhalation. The patient was admitted to the anesthesiology and intensive therapy unit. His clinical condition, along with additional clinical tests (incl. imaging), led to the diagnosis of acute respiratory distress syndrome in adults. The patient underwent mechanical ventilation (incl. high frequency oscillation ventilation), was treated with bronchodilatators and antibiotics, and his circulatory system was supported by catecholamine infusion. After several days of hospitalization in intensive therapy units, the patient was transferred to the pulmonary diseases department. Finally, the patient was discharged home in good general condition.
Key words: chlorine intoxication, acute respiratory distress syndrome in adults, high frequency oscillation ventilation, HFOV
Streszczenie. W artykule zaprezentowano przypadek ciężkiego przypadkowego zatrucia parami chloru. Pierwotnie stosunkowo dobry stan kliniczny pacjenta po kilku godzinach od aspiracji gazu uległ szybkiemu pogorszeniu. Chory został przyjęty na oddział anestezjologii i intensywnej terapii. Objawy oraz wyniki badań dodatkowych (m.in. obrazowych) pozwoliły na postawienie rozpoznania zespołu ostrej niewydolności oddechowej dorosłych (ARDS). W leczeniu zastosowano wentylację mechaniczną (w tym wentylację oscylacyjną), leki rozkurczające oskrzela i antybiotykoterapię, a układ krążenia wsparto wlewem amin katecholowych. Po kilkunastu dniach leczenia na oddziałach intensywnej terapii pacjent został przekazany na oddział chorób płuc. Ostatecznie opuścił szpital w stanie ogólnym dobrym.
Słowa kluczowe: zatrucie chlorem, zespół ostrej niewydolności oddechowej dorosłych, wentylacja oscylacyjna, HF0V
Delivered: 14/05/2016 Accepted for print: 09/09/2016 No conflicts of interest were declared.
Mil. Phys., 2016; 94 (4): 386-392 Copyright by Military Institute of Medicine
Corresponding author Aleksander Rutkiewicz MD
Anaesthesiology and Intensive Care Unit, Śląski Hospital in Cieszyn
4 Bielska St., 43-400 Cieszyn e-mail: olorut@o2.pl
Introduction
Although we associate chlorine poisoning mainly with the atrocities of World War I, the widespread use of this element in industry, workplaces and the home is still associated with a risk of severe inhalation poisoning. This thesis is illustrated by the present case of a young man poisoned with chlorine vapor, and then treated in our center.
Case report
During the evening, a 31-year-old man was brought to the Hospital Emergency Department (HED) with a preliminary diagnosis of chemical burns to the face. As an employee of a water supply and sanitation company, the patient was pouring sodium hypochlorite into a container where previously an herbicide containing glyphosate (commercial name: Roundup) had been stored. As a result of the violent reaction between the residues of the herbicide and the sodium hypochlorite, large amounts of volatile chlorine and heat were released. The patient, who was leaning over the containers, had his face burnt, and aspired chlorine vapors.
Inhalation chlorine poisoning complicated by severe Acute Respiratory Distress Syndrome (ARDS) - a case report 387 Figure 1. Chest X-ray taken on admission to emergency
department. Note the massive bilateral pulmonary infiltrates.
Rycina 1. Zdjęcie RTG klatki piersiowej wykonane przy przyjęciu na SOR. Warto zwrócić uwagę na obustronne masywne nacieki tkanki płucnej.
Upon their arrival, the specialist medical emergency team recognized 1st and 2nd degree burns to the skin of the face, neck, tongue and eyes. In the ambulance the burnt areas were intensively rinsed with 0.9% NaCl solution. At the Hospital Emergency Department the above diagnosis was confirmed; upper and lower respiratory tract burns were also suspected. It was established that the patient was receiving treatment due to bronchial asthma. A consulting ophthalmologist found conjunctival and retinal burns of both eyes, more pronounced on the right side. Due to the good general condition of the patient, absence of dyspnea, blood saturation by indirect measurement (SpO2) >90% and normal results of laboratory tests, the patient was admitted to the Department of General Surgery. Bronchodilatory and anti-inflammatory treatments were introduced (fenoterol inhalation, dexamethasone intravenously), as well as an antibiotic therapy (amoxicillin with clavulanic acid), the previous asthma treatment was continued (salmeterol inhalation and montelucast orally), intravenous pantoprazole was administered, anticoagulation prophylaxis with low molecular weight heparin was implemented, and fluids were replaced intravenously. Following the recommendations of the ophthalmologist, dexpanthenol, ofloxacin and combined hyaluronic acid with trehalose were administered into the eyes. Intravenous ketoprofen was used for an analgesic effect. A burn treatment center was called for phone consultation.
During the night, the patient's condition worsened, and dyspnea occurred, so passive oxygen therapy with the use of a facial mask was implemented. In the morning the consulting
laryngologist noticed redness of the pharyngeal and laryngeal mucosa, without clear edema. Due to continued worsening of the patient's clinical condition, with SpO2 of approx. 85% and massive bilateral infiltrations visible in the thoracic X-ray (Figure 1), consultation with an anesthesiologist was requested. The clinical picture was consistent with acute respiratory distress syndrome (ARDS). The patient was admitted to the Anaesthesiology and Intensive Care Unit (AICU).
On admission to the AICU the patient was conscious, and fully verbally responsive. He reported dyspnea and the feeling of "congestion of the chest with mucus". The symptoms of increasing respiratory failure were dominant.
Over the lung fields diffuse crackling and wheezing sounds were audible. Arterial blood gasometry revealed hypoxemia.
The patient was intubated (propofol, succinylcholine, no. 9.0 tube), and BiLevel mechanical ventilation started. The patient received sedation (midazolam and fentanyl in continuous infusion), muscle relaxant (pipecuronium) and 1 g of methylprednisolone and 1 mg of salbutamol intravenously. A central catheter and femoral artery catheter were placed.
Hemodynamic monitoring with the use of transpulmonary thermodilution was introduced (PICCO2). The measurement demonstrated low peripheral vascular resistance and an excess of pulmonary extravascular fluid (signs of non-cardiogenic pulmonary edema). Pressor amines and inotropic positive drugs (noradrenaline, dobutamine) were introduced. Diuresis was stimulated with crystalloid infusion, mannitol and furosemide. A bronchofiberoscopy was performed, in which the bronchi were rinsed first with a 0.9%
NaCl solution, then with a 20% albumin solution.
Tracheostomy was performed percutaneously (Figure 2).
Computed tomography of the chest revealed perihilar merging densities in all the pulmonary segments, with a tendency to consolidated inflammatory lesions (Figure 3).
Due to the increasing pulmonary edema and deteriorating ventilatory parameters, despite escalation of peak end-respiratory positive pressure (PEEP) and inhalatory oxygen concentrations, the decision was made to transfer the patient to an intensive therapy center, where alternative methods of mechanical ventilation could be provided (Figure 4).
Transportation lasted 30 minutes, and it was uncomplicated (fentanyl and midazolam infusion was continued in the ambulance, ventilation was provided with the use of transport ventilator). After admission of the patient to the department, his condition was assessed at an APACHE II score of 31 points. Sedation was modified (propofol, ketamine, sufentanyl), BIPAP mechanical ventilation was introduced, and empirical wide spectrum antibiotic therapy (ceftriaxone) was implemented. Conventional ventilation was initially effective, as it reduced inhalatory oxygen concentrations, but at night the patient's general condition deteriorated, and the oxygen index reached < 100, which prompted the diagnosis of severe ARDS.
Figure 2. After admission to anesthesiology and intensive therapy unit, the patient was intubated, sedated, and mechanically ventilated. A decision to undertake tracheostomy was made immediately - the procedure involved Griggs technique controlled with bronchofiberoscopy. The patient was mechanically ventilated this way for the next few days.
Observe the burns to the face.
Rycina 2. Pacjent po przyjęciu na OAilT został zaintubowany, wdrożono sedację oraz wentylację mechaniczną. Bardzo szybko podjęto decyzję o wytworzeniu tracheostomii - zabieg wykonano metodą Griggsa pod kontrolą bronchofiberoskopii.
W ten sposób pacjent byt wentylowany przez kilkanaście kolejnych dni. Uwagę zwracają oparzenia skóry twarzy.
Figure 3. Chest CT-scan taken on the first day of patient hospitalization in anesthesiology and intensive therapy unit
Rycina 3. Tomografia klatki piersiowej wykonana w pierwszej dobie pobytu pacjenta na OAilT
Figure 4. Diagram showing changes in arterial blood carbon dioxide tension and oxygenation index (PaO2/FiO2, PaO2-arterial blood oxygen tension, FiO2 - inspiratory concentration of oxygen) within the first twelve hours of hospitalization in the anesthesiology and intensive therapy units. Note the rapidly increasing hyperkapnia. At night, oxygenation was 51 and severe ARDS diagnosis could be established according to the Berlin definition.
Rycina 4. Wykres przedstawiający zmiany prężności dwutlenku węgla we krwi tętniczej (pCO2) oraz wskaźnika tlenowego (Pa02/Fi02, gdzie Pa02 jest prężnością tlenu we krwi tętniczej, a Fi02 stężeniem wdechowym tlenu) w pierwszych dwunastu godzinach pobytu na OAilT. Warto zwrócić uwagę na szybko narastającą hiperkapnię. W godzinach nocnych wskaźnik tlenowy wyniósł 51, co według definicji berlińskiej pozwoliło na rozpoznanie ciężkiego ARDS.
389 MILITARY PHYSICIAN 4/2016
Figure 5. During hospitalization in the intensive therapy units, the patient underwent bronchofiberoscopy several times. In the photo, a moment when the bronchofiberscope is over the carina of trachea can be seen. We can see extensive coagulative necrosis of the airway epithelium. This bronchoscopy was undertaken three days after the trauma.
Rycina 5. W trakcie pobytu pacjenta na OIT kilkakrotne wykonywano bronchofiberoskopie. Ujęcie przedstawia moment, gdy narzędzie znajduje się w tchawicy powyżej ostrogi. Widoczne są rozległe skupiska martwicy skrzepowej nabłonka dróg oddechowych. Ten konkretny zabieg wykonano trzy doby od urazu.
Due to hypoxemia, which persisted despite ventilation with 100% oxygen, and high PEEP values, the team on duty decided to use high frequency oscillatory ventilation delivered at a frequency of 5.5 Hz. On the basis of hemodynamic measurements (PICCO2) fluid therapy was administered, and the circulatory system was supported by noradrenaline infusion. Following the change in the type of ventilation, a gradual improvement in gas exchange was obtained, with decreased inhalatory oxygen concentrations. Oscillatory ventilation was maintained for two days, and then the patient was switched back to classic ventilation (BI-PAP). Due to massive densities in the back areas, revealed in a control computed tomography test, the patient was put in a prone position – in four sessions, 10-12 hours each. Several bronchofiberoscopy examinations revealed a massive injury to the tracheal and bronchial epithelium, with areas of thrombotic necrosis (Figure 5). Improvement in the macroscopic picture of the respiratory tract was visible on day 8 after the injury. On the same day the sedatives were discontinued, with the exception of dexmedetomidine.
Figure 6. Control chest X-ray taken shortly before discharging the patient
Rycina 6. Kontrolny rentgenogram klatki piersiowej wykonany niedługo przed wypisaniem pacjenta ze szpitala do domu
On the next day the patient regained consciousness. The respiratory support was gradually reduced, the ventilation mode was changed from BIPAP to APRV, followed by a smooth transition to spontaneous breathing with positive pressure in the respiratory tract. Due to stabilization of the circulatory system, dose reduction and discontinuation of noradrenaline was possible. On day 12 after the injury the tracheostomy tube was removed.
After 14 days of hospitalization in the intensive therapy departments, the patient – conscious, fully verbally responsive, cardiovascularly and respiratorily stable, without signs of infection – was transferred to the Department of Pulmonary Diseases for further treatment and rehabilitation. A control bronchofiberoscopy did not reveal post traumatic lesions in the larynx, whereas in the bronchi thickened, partially reddened mucosa with individual necrotic bands was demonstrated, without clear narrowing. The thoracic image performed 17 days after the injury did not show any significant abnormalities (Figure 6).
The patient was discharged in a good general condition.
Follow-up examinations in an ophthalmology clinic and pulmonology clinic was recommended, as well as continuation of the asthma treatment.