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

Patient 1 Zinc Phosphide  23 y/o male ingested rodent pellets: Zn 3 P 2  Awake but intubated for airway protection Using the Poison Center as a  Lavage and WBI Hazmat Resource  Rectal tube  ICU bed Susan Smolinske MD, PharmD,  “Strong odor from room” DABAT, FAACT Director New Mexico Poison and Drug Information Center Patient 1 Patient 2 Zinc Phosphide  Negative pressure  Sensor positioned at  28-year-old man presented after ingestion patients anus room of an unknown amount of Zn 3 P 2  Repositioned to staff  Phosphine monitoring breathing space  On arrival stable with no reported odor commenced  Safe levels  Intubated for airway protection  Patient reintubated  SCBA and Level 2  Lavage returned 200 mL of white stuff, WBI HazMat  Levels rapidly dropped  Rectal tube inserted, waste double-bagged  Level > STEL  Patient recovered  Admitted to ICU rather than isolation room  Staff refused to enter  Patient self-extubated Patient 2 Patient 3 Zinc Phosphide  At 18 hours staff report strong odor in room  36-year-old man presented to ED 2 hours after ingesting 750 grams of 60% AlP pellets  SCBA and Ph3 sensors brought in by Hazmat  Intubated, profused gray, green material came up team esophagus clogging suction tube  One sensor had level above STEL  Material had garlic odor, causing pulmonary and ocular  ICU evacuated irritation to staff  Patient moved outdoors, resuscitated 1 hour and died  Patient moved to negative pressure room  PPE was gloves, gowns, N-95 masks, higher levels not  Patient had transient anemia and pulmonary available complications. No staff illnesses 1

Patient 3 Patient 3  Ventilator and ultrasound left outside in  Hazmat called initially by canceled by IC rain with monitors, gurney, pumps due to when he mistakenly thought it was monitoring inability phosgene and not phosphine  Two providers hospitalized for respiratory  Hazmat reactivated, National Guard called distress  High phosphine levels detected 11 days  ED not usable for 2 days later  OMI consulted with poison center regarding autopsy and burial precautions Patient 4 Cyanide Portable negative pressure room  31 year old man suicide with KCN  Resuscitated at the scene  Transported to local hospital  Intubated  Supportive care  antidote Patient 4 Patient 4  Hazmat was in the area doing a massive  Poison center advised antidote while en preparedness exercise and did testing fairly route to hospital (hydroxocobalamin) quickly with negative results  Hospital personnel start calling poison  Patient died and concern raised about autopsy; center concerned about contamination ME was given PPE  Hospital put ambulances on divert but  The poison center was never given the IC name accepting walk-ins with “informed consent” and only communicated with hospital staff about potential toxic fumes  Hazmat removed remaining packets of KCN from patient’s home 2

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

Ambulance Mercury Levels in House  Patient’s house (a rental) was cordoned off after  DOH urged paramedics and firefighters to be informing home owner tested for mercury  DOH paid for an environmental consulting  Ambulance used to transport patient temporarily company to monitor house outside and inside ‘retired’ until ambulance could be tested  Patient discharged on same day, under supervision of physician  Jerome analyzer rented and ambulance was  EPA uses ATSDR mercury action levels: found ‘negative’ for mercury  <= 1 ug/m 3 : Level acceptable for occupancy of any  Results for paramedics and firefighter were not structure after a spill received until one month after the tests were run  < 10 ug/m 3 : Level acceptable for objects (air around) All results below notifiable condition level. Mercury Levels in House EPA National Response Network  DOH discovered the EPA has a National  In the kitchen, levels were 420 ug/m 3 Response Network and a Mercury Team  Other areas lower (23 ug/m 3 by  Team mobilized to residence. washer/dryer)  EPA contractors conducted mercury monitoring in the ambulance and ER  Homeowner then wanted to know what  They tested the grease pan and clothes DOH could do about the house (bagged) and both were hot (about 50 ug/m 3 ) for mercury.  Patient wanted his things out of house  Also tested the ER chair where patient sat  NMED was contacted but they could not (clothes had not been removed before transport). The chair was below 10 ug/m 3 use emergency funds 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 4

EPA National Response Network EPA National Response Network  Just inside doorway, levels were 15 ug/m 3  EPA Team conducted air monitoring for mercury vapors with a Lumex Mercury Analyzer—  In order to reduce mercury levels, house capable of detecting nanogram/m 3 levels of Hg was actively vented mercury vapor  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 Complications Patient 6 Mercury: Day 1  Homeowner was given choice: EPA can  2 children playing with vial, broke in bed, estimate 1 tsp spilled clean up or she could pay to do it herself  Recommendations:  She had house cleaned up but did not  Clean up per MI guidelines coordinate with EPA  Shower and change clothes (resulted in drain being  Homeowner-hired environmental contaminated) company: reported 0.00 ug/m3 mercury in  Stat blood mercury the house  Provided DOH phone number  BUT, used Jerome meter and detection limit is 1 ug/m 3 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 5

Follow up on day 4 Follow up on day 5  Detailed self clean-up advice given  Lab results on two less exposed children return  Contact insurance  Remove carpeting  Both 8 mcg/L (nl < 10)  Normals are based on adult occupational  Take remaining Hg to hazmat site (gave exposures address)  NHANES data shows 95% of children have levels < 1)  The fact that index child’s level not back likely indicates it is hig Day 6 Follow up day 5 continued  MD calls with mercury level of 67 mcg/L  Chelation recommended directly to MD from consultant  Asked for seafood history; if negative  Began to initiate process to obtain succimer evacuate home, call contractor  Mother states no seafood; additional history is  Family calls and still seeing beads in flooring after that home has no AC, temperatures are 75 extensive cleanup effort (ignored recommendation to call degrees or higher consultant)  Home evacuated; went to grandmother’s on  History obtained that child has baseline developmental disorders (spatial anxiety, abnormal sensory processing) same property  Child goes to ED to get Rx and resident says admission  On hold with Tricore 15 minutes or more lab needed tech did not return to phone Day 7 EPA START team 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 6