Patient 1 Zinc Phosphide 23 y/o male ingested rodent pellets: Zn 3 P - PDF document

Using the Poison Center as a Hazmat Resource Susan Smolinske MD, PharmD, DABAT, FAACT Director New Mexico Poison and Drug Information Center Patient 1 Zinc Phosphide  23 y/o male ingested rodent pellets: Zn 3 P 2  Awake but intubated for airway protection  Lavage and WBI  Rectal tube  ICU bed  “Strong odor from room” 1

Patient 1  Negative pressure  Sensor positioned at patients anus room  Repositioned to staff  Phosphine monitoring breathing space commenced  Safe levels  Patient reintubated  SCBA and Level 2 HazMat  Levels rapidly dropped  Level > STEL  Patient recovered  Staff refused to enter  Patient self-extubated Patient 2 Zinc Phosphide  28-year-old man presented after ingestion of an unknown amount of Zn 3 P 2  On arrival stable with no reported odor  Intubated for airway protection  Lavage returned 200 mL of white stuff, WBI  Rectal tube inserted, waste double-bagged  Admitted to ICU rather than isolation room 2

Patient 2  At 18 hours staff report strong odor in room  SCBA and Ph3 sensors brought in by Hazmat team  One sensor had level above STEL  ICU evacuated  Patient moved to negative pressure room  Patient had transient anemia and pulmonary complications. No staff illnesses Patient 3 Zinc Phosphide  36-year-old man presented to ED 2 hours after ingesting 750 grams of 60% AlP pellets  Intubated, profused gray, green material came up esophagus clogging suction tube  Material had garlic odor, causing pulmonary and ocular irritation to staff  Patient moved outdoors, resuscitated 1 hour and died  PPE was gloves, gowns, N-95 masks, higher levels not available 3

Patient 3  Hazmat called initially by canceled by IC when he mistakenly thought it was phosgene and not phosphine  Hazmat reactivated, National Guard called  High phosphine levels detected 11 days later Patient 3  Ventilator and ultrasound left outside in rain with monitors, gurney, pumps due to monitoring inability  Two providers hospitalized for respiratory distress  ED not usable for 2 days  OMI consulted with poison center regarding autopsy and burial precautions 4

Patient 4 Cyanide  31 year old man suicide with KCN  Resuscitated at the scene  Transported to local hospital  Intubated  Supportive care  antidote Portable negative pressure room 5

Patient 4  Poison center advised antidote while en route to hospital (hydroxocobalamin)  Hospital personnel start calling poison center concerned about contamination  Hospital put ambulances on divert but accepting walk-ins with “informed consent” about potential toxic fumes Patient 4  Hazmat was in the area doing a massive preparedness exercise and did testing fairly quickly with negative results  Patient died and concern raised about autopsy; ME was given PPE  The poison center was never given the IC name and only communicated with hospital staff  Hazmat removed remaining packets of KCN from patient’s home 6

Patient 5 Mercury  Patient called 911 reporting mercury poisoning  Paramedics called Poison Center to ask about mercury poisoning  2 paramedics + 1 firefighter arrive on scene.  Patient admitted to ED for bloody diarrhea. Patient reported “working with metals, maybe mercury 3 days ago.” 7

Accidental Mercury Poisoning  Patient brought contaminated grease pan with him, which was doubled bagged at ED as well as clothes. Both bags sent to Safety Risk Services. • DOH received call from UNM about case. • Told patient had been cooking a powdered ore in home oven with mercury to obtain gold Photo of Ore 8

Health Effects: Elemental Mercury  Symptoms may develop within a few hours  Chills, metallic taste, mouth sores, swollen gums, nausea, vomiting, abdominal pain, diarrhea, headache, weakness, confusion, shortness of breath, cough, chest tightness, bronchitis, pneumonia and kidney damage ED Visit by ATSDR  Tests of patient on revealed:  Blood Mercury of 576 ug/L  Urine Mercury of 1827 ug/L  Notifiable Condition Level:  Blood Mercury: >3 ug/L  Urine Mercury: >5 ug/L  Patient started on oral chelation with succimer 9

Ambulance  DOH urged paramedics and firefighters to be tested for mercury  Ambulance used to transport patient temporarily ‘retired’ until ambulance could be tested  Jerome analyzer rented and ambulance was found ‘negative’ for mercury  Results for paramedics and firefighter were not received until one month after the tests were run All results below notifiable condition level. Mercury Levels in House  Patient’s house (a rental) was cordoned off after informing home owner  DOH paid for an environmental consulting company to monitor house outside and inside  Patient discharged on same day, under supervision of physician  EPA uses ATSDR mercury action levels: <= 1 ug/m 3 : Level acceptable for occupancy of any  structure after a spill  < 10 ug/m 3 : Level acceptable for objects (air around) 10

Mercury Levels in House  In the kitchen, levels were 420 ug/m 3  Other areas lower (23 ug/m 3 by washer/dryer)  Homeowner then wanted to know what DOH could do about the house  Patient wanted his things out of house  NMED was contacted but they could not use emergency funds EPA National Response Network  DOH discovered the EPA has a National Response Network and a Mercury Team  Team mobilized to residence.  EPA contractors conducted mercury monitoring in the ambulance and ER  They tested the grease pan and clothes (bagged) and both were hot (about 50 ug/m 3 ) for mercury.  Also tested the ER chair where patient sat (clothes had not been removed before transport). The chair was below 10 ug/m 3 11

EPA National Response Network  Ambulance tested and the biohazard bag was > 10 ug/m 3 .  No New Mexico protocol for clearing ambulance  EPA suggested action level of 3 ug/m3 for “an occupational or commercial setting where mercury is not usually handled.”  Once bag removed, air in ambulance below 3 ug/m 3  DOH + EMS Bureau then cleared (via letter) the ambulance to resume service 12

EPA National Response Network  EPA Team conducted air monitoring for mercury vapors with a Lumex Mercury Analyzer— capable of detecting nanogram/m 3 levels of Hg mercury vapor EPA National Response Network  Just inside doorway, levels were 15 ug/m 3  In order to reduce mercury levels, house was actively vented  Heaters inside home set up with copious blowers/fans to push vapors out of windows.  Vented air monitored to ensure permissible exposure levels weren’t exceeded 13

Complications  Homeowner was given choice: EPA can clean up or she could pay to do it herself  She had house cleaned up but did not coordinate with EPA  Homeowner-hired environmental company: reported 0.00 ug/m3 mercury in the house  BUT, used Jerome meter and detection limit is 1 ug/m 3 Patient 6 Mercury: Day 1  2 children playing with vial, broke in bed, estimate 1 tsp spilled  Recommendations:  Clean up per MI guidelines  Shower and change clothes (resulted in drain being contaminated)  Stat blood mercury  Provided DOH phone number 14

Follow up on Day 1  Caller states still beads visible in planks of wood floor; she was going to vacuum  Recommended against vacuum  Keep door closed and stay out of room until plan for cleanup 15

Follow up on day 4  Detailed self clean-up advice given  Contact insurance  Remove carpeting  Take remaining Hg to hazmat site (gave address) Follow up on day 5  Lab results on two less exposed children return  Both 8 mcg/L (nl < 10)  Normals are based on adult occupational exposures  NHANES data shows 95% of children have levels < 1)  The fact that index child’s level not back likely indicates it is hig 16

Follow up day 5 continued  Asked for seafood history; if negative evacuate home, call contractor  Mother states no seafood; additional history is that home has no AC, temperatures are 75 degrees or higher  Home evacuated; went to grandmother’s on same property  On hold with Tricore 15 minutes or more lab tech did not return to phone Day 6  MD calls with mercury level of 67 mcg/L  Chelation recommended directly to MD from consultant  Began to initiate process to obtain succimer  Family calls and still seeing beads in flooring after extensive cleanup effort (ignored recommendation to call consultant)  History obtained that child has baseline developmental disorders (spatial anxiety, abnormal sensory processing)  Child goes to ED to get Rx and resident says admission needed 17

Day 7  EPA notified and agreed to send a team  NRC notified (required to get EPA involved)  DOH notified Toxicology met EPA at patient’s home  Bedroom level exceeded limit of Lumex (> 50,000)  Required self-contained breathing protection  Clean-up efforts included Mercury binding solution   Mercury vacuum  Heat and vent cycles  Entire room drywall and insulation removed  Two washing machines disposed (tried wash cycle with binding solution)  Wood flooring deemed the cause of remaining vapors  Sealed floor with polyurethane (ineffective) Sealed floor with DuraPoxy (certified barrier)  Declared clear after 17 days of cleaning  EPA START team 18