Interactive Case Study: A Hazardous Materials Incident at a Metal Plating Shop

1. Interactive Case Study:A Hazardous Materials Incident at a Metal Plating Shop Dennis Shusterman, MD, MPH* Kent R. Olson, MD, FACEP** *Division of Occupational & Environmental Medicine **California Poison Control System University of California, San Francisco With video editing assistance from: Alan Barr (UCSF) & Joel Hagemeyer (Univ. of Washington) PowerPoint Beta Version 3.0

2. Instructions • Tap on right arrow (or hit “return” key) to proceed to next slide. • Tap on left arrow to go back one slide. • Tap on picture to activate video clip. • Keep track of your responses to questions as you go along; PowerPoint does not register or record your responses.

4. 1. Of the following, which single agent would be of greatest concern for acute toxicity in a hazardous materials incident at a plating shop? a. Lead b. Chromium c. Hydrogen cyanide d. Sodium hydroxide e. Hydrochloric acid

5. 1. Of the following, which single agent would be of greatest concern for acute toxicity in a hazardous materials incident at a plating shop? a. Lead b. Chromium c. Hydrogen cyanide d. Sodium hydroxide e. Hydrochloric acid

6. 2. Why would this toxicant be of concern? a. Skin burns b. Bronchospasm c. Reproductive toxicity d. Systemic toxicity (asphyxia)

7. 2. Why would this toxicant be of concern? a. Skin burns b. Bronchospasm c. Reproductive toxicity d. Systemic toxicity (asphyxia)

9. 3. What is the major mechanism of toxicity of hydrogen cyanide (HCN) gas? a. Interferes with oxygen binding to hemoglobin. b. Interferes with cytochrome oxidase function. c. Interferes with aminolevulinic acid dehydrogenase (ALA-D) and ferrochelatase function. d. Direct corrosive action on mucous membranes.

10. 3. What is the major mechanism of toxicity of hydrogen cyanide (HCN) gas? a. Interferes with oxygen binding to hemoglobin. b. Interferes with cytochrome oxidase function. c. Interferes with aminolevulinic acid dehydrogenase (ALA-D) and ferrochelatase function. d. Direct corrosive action on mucous membranes.

11. 4. What are the three most common early symptoms of acute cyanide toxicity? a. Headache b. Nausea/vomiting c. Diarrhea d. Dizziness e. Tinnitus

12. 4. What are the three most common early symptoms of acute cyanide toxicity? a. Headache b. Nausea/vomiting c. Diarrhea d. Dizziness e. Tinnitus

13. 5. Which three physical signs may be found early on in acute cyanide intoxication? a. Bradycardia b. Tachycardia c. Bradypnea d. Tachypnea e. Confusion f. Cherry red mucous membranes

14. 5. Which three physical signs may be found early on in acute cyanide intoxication? a. Bradycardia b. Tachycardia c. Bradypnea d. Tachypnea e. Confusion f. Cherry red mucous membranes

15. 6. Which four laboratory findings are common in acute cyanide intoxication? a. Increased lactic dehydrogenase (LDH) b. Increased anion gap c. Increased osmolar gap d. Increased plasma lactate level e. Increased whole blood cyanide level f. Arteriolization of venous blood (increased venous oxygen saturation).

16. 6. Which four laboratory findings are common in acute cyanide intoxication? a. Increased lactic dehydrogenase (LDH) b. Increased anion gap c. Increased osmolar gap d. Increased plasma lactate level e. Increased whole blood cyanide level f. Arteriolization of venous blood (increased venous O2 saturation).

17. 7. Which of the following cyanide antidote regimens is (are) currently approved by the US Food and Drug Administration (FDA)? a. Sodium nitrite and sodium thiosulfate b. Hydroxocobalamin c. Dimethylaminophenol (DMAP) d. Stroma-free methemoglobin

18. 7. Which of the following cyanide antidote regimens is (are) currently approved by the US Food and Drug Administration (FDA)? a. Sodium nitrite and sodium thiosulfate b. Hydroxocobalamin c. Dimethylaminophenol (DMAP) d. Stroma-free methemoglobin

20. Mixing Incompatibilities: 1. Sodium hypochlorite (bleach) and ammonia ___ 2. Sodium hypochlorite (bleach) and acids (e.g., toilet bowel cleaners) ___ 3. Cyanide salts and acids (e.g., hydrochloric acid) ___ 4. Metallic ores/slags and acids ___ Toxic reaction products: a. Hydrogen cyanide (HCN) b. Arsine gas (AsH3) c. Chlorine gas (Cl2) d. Chloramine gases (NH2Cl and NHCl2) 8. Match the following chemical mixing incompatibilities with the corresponding toxicant(s) produced:

21. Mixing Incompatibilities: 1. Sodium hypochlorite (bleach) and ammonia d 2. Sodium hypochlorite (bleach) and acids (e.g., toilet bowel cleaners) c 3. Cyanide salts and acids (e.g., hydrochloric acid) a 4. Metallic ores/slags and acids b Toxic reaction products: a. Hydrogen cyanide (HCN) b. Arsine gas (AsH3) c. Chlorine gas (Cl2) d. Chloramine gases (NH2Cl and NHCl2) 8. Match the following chemical mixing incompatibilities with the corresponding toxicant(s) produced:

23. 9. What precautions are necessary when a worker enters an enclosed space in which chemical asphyxiants, oxygen deficient atmospheres, and/or dermally absorbed toxicants may be present? a. Impermeable gloves b. Impermeable clothing and footwear c. Air-supplied respirator d. Safety line e. Hazardous materials training f. All of the above

24. 9. What precautions are necessary when a worker enters an enclosed space in which chemical asphyxiants, oxygen deficient atmospheres, and/or dermally absorbed toxicants may be present? a. Impermeable gloves b. Impermeable clothing and footwear c. Air-supplied respirator d. Safety line e. Hazardous materials training f. All of the above

25. 10. Which three agencies are directly responsible for regulating the use, storage, handling and disposal of hazardous materials in California? a. NIOSH (National Institute for Occupational Safety and Health) b. US OSHA (US Occupational Safety and Health Administration) c. Cal-OSHA (California Occupational Safety and Health Admin.) d. California Environmental Protection Agency, Department of Toxic Substances Control (DTSC) e. Local firefighting / hazardous materials mgmt. authorities.

26. 10. Which three agencies are directly responsible for regulating the use, storage, handling and disposal of hazardous materials in California? a. NIOSH (National Institute for Occupational Safety and Health) b. US OSHA (US Occupational Safety and Health Administration) c. Cal-OSHA (California Occupational Safety and Health Admin.) d. California Environmental Protection Agency, Department of Toxic Substances Control (DTSC) e. Local firefighting / hazardous materials mgmt. authorities.

27. For further reading: • Cyanide Intoxication 1. Blanc PD: Cyanide intoxication among silver-reclaiming workers. JAMA 1985; 253:367-371. 2. Ballantyne B, Varrs TC (eds.): Clinical and Experimental Toxicology of the Cyanides. Bristol, UK, Wrignt, 1987. • Mixing Incompatibilities - General 1. Olson KR, Shusterman, D: Mixing incompatibilities and toxic exposures. Occup Med 1993; 8(3):549-560. 2. Faigel HC: Mixtures of household cleaning products. NEJM 1964; 271:618. 3. Centers for Disease Control: Chlorine bleach toxicity from mixture of bleach with other cleaning products - California. MMWR 1991; 40:619-621;627-629. 4. Doig AT: Arseniuretted hydrogen poisoning in tank cleaners. Lancet 1958; ii:88-92.

28. Epilog