What is the first line management for chlorine gas chemical inhalation?

First-Line Management of Chlorine Gas Inhalation

Immediately remove the patient from the chlorine source, remove all contaminated clothing and jewelry, and administer humidified supplemental oxygen while providing supportive respiratory care. 1

Immediate Decontamination (First Priority)

• Remove the patient from the exposure source immediately and strip all contaminated clothing and jewelry to prevent continued exposure 2, 1
• Irrigate exposed skin with copious running water for at least 15 minutes 2
• For eye exposure, flush eyes immediately with tepid water for at least 15 minutes 1
• Decontamination should occur outside the medical facility to prevent secondary contamination of healthcare staff 2
• Healthcare personnel must wear appropriate personal protective equipment including organic vapor cartridge respirators or powered air-purifying respirators with acid-gas filters, as ordinary surgical masks provide inadequate protection from chlorine vapor 2

Respiratory Support (Second Priority)

• Administer humidified supplemental oxygen immediately if dyspnea or hypoxemia is present 3
• Use oxygen with caution: while it improves short-term survival (87% vs 42% in animal studies), it may paradoxically worsen respiratory acidosis and hypercapnia in massive exposures 4
• Assess early for need of assisted ventilation, as oxygen alone does not improve cardiac output or neuromuscular dysfunction in severe exposures 4
• Monitor oxygen saturation, vital signs, and arterial blood gases hourly in severe cases 4

Bronchodilator Therapy (Third Priority)

• Administer nebulized bronchodilators immediately to counteract bronchoconstriction 3
• The combination of ipratropium bromide with beta2-agonists (such as albuterol/salbutamol) is standard therapy and effectively reverses bronchoconstriction and increased airway resistance 3
• This represents the most evidence-based pharmacologic intervention for chlorine exposure 3

Corticosteroid Administration (Fourth Priority)

• Administer systemic corticosteroids early (intravenous dexamethasone or prednisolone) 3, 5
• In animal studies, dexamethasone 100 mg/kg given within 1 hour reduced lung edema, and within 6 hours significantly decreased bronchoalveolar lavage leukocyte counts (p<0.01) 3
• While corticosteroids have never been studied alone in clinical trials, they are routinely used as part of standard management 3, 5

Adjunctive Therapies to Consider

• Nebulized sodium bicarbonate may provide modest additional benefit: in the only randomized controlled trial, it increased forced expiratory volume at 2 and 4 hours compared to standard therapy alone 3
• Standard ARDS management protocols (lung-protective ventilation, prone positioning if intubated, inhaled pulmonary vasodilators like epoprostenol) should be implemented for severe cases 5

Critical Monitoring Parameters

• Call emergency services or poison control center immediately 1
• Avoid public transportation; use ambulance or private vehicle with windows open 1
• Monitor for progression to acute respiratory distress syndrome, which can develop within hours 5
• Assess for reactive airway dysfunction syndrome and chronic hyperreactivity in survivors 6, 7
• Do not administer prophylactic antibiotics, as studies have failed to demonstrate benefit 3

Common Pitfalls

• Failing to adequately decontaminate patients before hospital entry, which can cause secondary exposure of healthcare staff and disrupt hospital operations 2
• Over-reliance on oxygen therapy without recognizing its potential to worsen respiratory acidosis in massive exposures 4
• Delaying bronchodilator therapy, which is the most evidence-based pharmacologic intervention 3
• Using inadequate personal protective equipment (ordinary surgical masks are insufficient for chlorine vapor) 2