Miscellaneous Injury

Miscellaneous blast-related injuries include: inhalations and exposures of toxic substances such as asbestos dust, carbon monoxide, cyanide, white phosphorus, and phosgene gas; burns from direct flashes and burning buildings; and crush injuries from the collapse of buildings. Oxygen therapy is the main treatment for most of the miscellaneous blast-related injuries. Patients exposed to cyanide would be expected to have an anion gap metabolic acidosis, and sodium thiosulfate therapy would be indicated as it causes less hypotension compared to sodium nitrite.

Phosgene gas is a unique exposure because it may cause severe delayed pulmonary edema. It was the most lethal of the World War I gases. Phosgene is currently used in the manufacture of dyestuffs, pharmaceuticals, polyurethanes, and metallur-gic applications, with an estimated worldwide production of five billion pounds. Treatment is mainly supportive, with oxygen, steroids, and inhaled beta-2 agonists. The key point is to first suspect phosgene gas exposure and then admit the patient for close monitoring for 24 hours.

White phosphorus is also a unique chemical exposure because it is found in munitions, industrial accidents, and fireworks. White phosphorus ignites on contact with air, creating heat and releasing phosphorus pentoxide, a pulmonary irritant. In addition, it can cause severe hypocalcemia and hyperphosphatemia. Treatment involves copious lavage of any exposed areas and placing any raw particles in water to prevent further combustion. Additionally, a 1% copper sulfate solution should be applied to the skin to neutralize the white phosphorus.

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