What is the appropriate emergency evaluation and management for an adult worker who develops chest pain after occupational exposure to tetrachloroethane, trichloroethylene, tetrachloroethylene, and methyl‑methacrylate monomer?

Emergency Evaluation and Management of Chest Pain After Solvent Exposure

Immediate Assessment and Cardiac Evaluation

Chest pain following acute exposure to trichloroethane, trichloroethylene, tetrachloroethylene, or tetrachloroethane requires immediate cardiac monitoring and assessment for chemical-induced cardiotoxicity, as these solvents can cause cardiac arrhythmias and myocardial sensitization to catecholamines. 1

Initial Emergency Department Workup

• Obtain continuous cardiac monitoring immediately – chlorinated solvents sensitize the myocardium to endogenous catecholamines, potentially triggering fatal ventricular arrhythmias 1
• Perform 12-lead ECG to evaluate for arrhythmias or ischemic changes 1
• Assess arterial blood gas and pulse oximetry – trichloroethane aerosol exposure can cause significant hypoxemia and respiratory compromise 1
• Obtain chest radiograph to evaluate for atelectasis or pulmonary infiltrates, which have been documented with trichloroethane exposure 1

Specific Clinical Features to Evaluate

• Constricting chest pressure and chest pain are characteristic presenting symptoms of acute trichloroethane toxicity 1
• Associated respiratory symptoms including severe shortness of breath, cough, and hypoxemia may accompany the chest pain 1
• Systemic symptoms such as fever, myalgia, headache, nausea, sleepiness, and burning eyes are common with trichloroethylene exposure 2

Respiratory Assessment

Evaluate for hypersensitivity pneumonitis and acute pulmonary toxicity, as both trichloroethylene and trichloroethane can cause severe respiratory complications beyond simple irritation. 3, 1

Pulmonary Evaluation Components

• Assess for hypersensitivity pneumonitis – TCE exposure can trigger HP presenting with dry cough, night sweats, and weight loss over weeks to months 3
• Monitor oxygen saturation closely – significant hypoxemia requiring supplemental oxygen has been documented with trichloroethane aerosol exposure 1
• Consider high-resolution chest CT if symptoms persist beyond initial presentation or if hypersensitivity pneumonitis is suspected 3
• Obtain pulmonary function testing if chronic exposure is documented and respiratory symptoms persist 4

Supportive Management

Treatment is primarily supportive with immediate removal from exposure, supplemental oxygen for hypoxemia, and cardiac monitoring for arrhythmias. 1

Acute Management Protocol

• Remove patient from exposure immediately and ensure adequate ventilation 1
• Administer supplemental oxygen to maintain oxygen saturation >94% 1
• Avoid sympathomimetic agents (epinephrine, dopamine) if possible due to myocardial sensitization 1
• Consider corticosteroid pulse therapy if hypersensitivity pneumonitis is confirmed by clinical presentation and imaging 3
• Monitor for 24-36 hours minimum – complete recovery from acute trichloroethane toxicity typically occurs within 36 hours but requires observation 1

Occupational Medicine Considerations

Document the specific chemicals and duration of exposure, as these workers require long-term hepatic surveillance given the established hepatotoxic effects of these solvents. 5, 6

Long-term Monitoring Requirements

• Provide written documentation listing all chemicals the worker was exposed to, as recommended by the European Association for the Study of the Liver 5
• Arrange hepatic surveillance with ultrasound and liver function testing, as tetrachloroethylene, trichloroethylene, and tetrachloroethane cause hepatocellular necrosis, steatosis, and periportal fibrosis 5, 6
• Ensure permanent removal from exposure – continued exposure after initial sensitization can lead to progressive hypersensitivity pneumonitis 3
• Screen for systemic sclerosis and pulmonary veno-occlusive disease in workers with chronic TCE exposure, as these are the most consistent respiratory associations 4

Critical Pitfalls to Avoid

• Do not dismiss chest pain as simple anxiety – documented cases show real cardiopulmonary toxicity with objective findings of hypoxemia and atelectasis 1
• Do not assume symptoms are purely neurological – while CNS effects (headache, sleepiness) are common with TCE exposure at 100-300 ppm, chest pain indicates more serious cardiopulmonary involvement 2
• Do not overlook individual susceptibility – approximately 10% of individuals show heightened susceptibility to tetrachloroethylene vapor with subjective complaints at standard exposure levels 7
• Do not focus solely on acute management – these solvents cause chronic liver disease requiring long-term surveillance 5