Medical Aspects of Chemical Warfare (2008) - The Black Vault

Toxic Inhalational Injury and Toxic Industrial Chemicalsmay cause hypotension that may be exacerbated bypositive airway pressure. Due to fluid shifts, urgentintravenous administration of either crystalloidor colloid solution (which in this situation appearequally effective) and the use of a pulmonary arterycatheter monitor (to avoid excessive fluid administration)may be required to maintain appropriatefluid balance while treating hypotension. The useof vasopressors is a temporary measure until fluidscan be replaced.Clinical CareAcute lung injury is one of the causes of noncardiogenicpulmonary edema, which causes an increase inlung vascular permeability, leading to accumulationof protein-rich edema in the interstitial and air spaces.Cardiogenic or high-pressure pulmonary edema iscaused by elevated pulmonary venous pressure fromleft ventricular dysfunction, valvular disease, or intravascularvolume overload. In addition to ARDS,noncardiogenic pulmonary edema is referred to as“clinical acute lung injury.” The care of these patientsrequires careful attention to the underlying causessuch as a treatable pulmonary infection. The modesof mechanical ventilation and hemodynamic managementin ARDS patients have been controversial foryears, although the National Institutes of Health andother institutions have established a protocol for ARDSpatients on mechanical ventilation. Discussion of thisprotocol and any other strategies is beyond the scopeof this chapter; however, one certainty is that ARDSmanagement demands quick recognition and intensivecare protocols. 100,101Patient TransportLung-damaging TIC casualties may need to beevacuated to a higher level of care if the receiving facilitydoes not have an intensive care setting. When acasualty is transferred to a higher level of care, supplementaloxygen and appropriate evaluation monitorsmust be provided.Long-Term EffectsThe replacement of damaged airway epitheliumwith granular tissue is one of the major etiologiesof chronic lung disease following centrally actingchemical agents such as ammonia. 91 See Chapter 9,Long-Term Health Effects of Chemical Threat Agents,for more detail.SUMMARYThe respiratory system, both the central and peripheralcompartments, can efficiently absorb inhaled lungdamagingagents, leading to airway and pulmonaryinjury. Few specific antidotes exist for treating inhaledtoxicants. Common pathophysiologic pathways linkthe syndrome of acute inhalation injury to preferentialmethods of clinical treatment. Understandingthe mechanisms of inhalation injury can simplify thedecision-making process for treating a casualty with apotential lung-damaging TIC inhalation exposure.AcknowledgmentThe authors wish to thank the following individuals for their efforts: Jennifer L Collins, biologist(USAMRICD), for reviewing the manuscript, and Peter Hurst, graphic designer (USAMRICD), forartwork.REFERENCES1. US Army Medical Research Institute of Chemical Defense. Medical Management of Chemical Casualties Handbook. 4thed. Aberdeen Proving Ground, Md: USAMRICD, Chemical Casualty Care Division; 2007.2. Beswick FW. Chemical agents used in riot control and warfare. Hum Toxicol. 1983;2:247–256.3. Stockholm International Peace Research Institute. Chemical/Biological Weapons and Biological Warfare. Vol 1 in: The Problemof Chemical and Biological Warfare. New York, NY: Humanities Press, 1971.365