Martindale The Complete Drug Reference 38 Edition.rar
Jerrica Ingles
Sodium bicarbonate is a nonspecific antidote effective in the treatment of a variety of poisonings by means of a number of distinct mechanisms. Nebulized sodium bicarbonate serves as a useful adjunct in the treatment of patients with pulmonary injuries resulting from phosgene and chlorine gas inhalation exposures. Inhaled sodium bicarbonate neutralizes the hydrochloric acid that is formed when phosgene or chlorine gas react with the water in the respiratory tree.
Intravenous sodium bicarbonate therapy increases plasma bicarbonate, buffers excess hydrogen ion concentration, raises blood pH and reverses the clinical manifestations of acidosis. Sodium bicarbonate in water dissociates to provide sodium (Na+) and bicarbonate (HCO3-) ions. Sodium (Na+) is the principal cation of the extracellular fluid and plays a large part in the therapy of fluid and electrolyte disturbances. Bicarbonate (HCO3-) is a normal constituent of body fluids and the normal plasma level ranges from 24 to 31 mEq/liter. Plasma concentration is regulated by the kidney through acidification of the urine when there is a deficit or by alkalinization of the urine when there is an excess. Bicarbonate anion is considered "labile" since at a proper concentration of hydrogen ion (H+) it may be converted to carbonic acid (H2CO3) and thence to its volatile form, carbon dioxide (CO2) excreted by the lung.
Nebulized sodium bicarbonate may be another adjunctive treatment for chlorine pulmonary exposures. Theoretically, inhaled bicarbonate can neutralize hypochlorous and hydrochloric acids, decreasing severity of lung injury.
Chlorine gas, a toxic pulmonary irritant, has been used as a chemical warfare agent by the Germans during World War I, and most recently, by insurgents during the Iraq War. Chlorine gas is more commonly released in industrial or residential settings, such as through swimming pool or home-cleaning preparations (Bosse, 1994). Symptoms of chlorine gas inhalation can occur very rapidly and range from dyspnea and nonproductive cough to pulmonary edema and acute respiratory distress syndrome (ARDS) (Chisholm et al., 1989; Vinsel, 1990). Although there is no specific antidote for treatment of chlorine gas exposure, nebulized sodium bicarbonate (NSB) has demonstrated efficacy and safety as an adjunctive treatment for chlorine gas-related pulmonary injuries. NSB neutralizes the hypochlorous and hydrochloric acids that form when chlorine gas comes into contact with water in the airways (Vinsel, 1990; Jones et al., 2010). In a sheep model, 4% inhaled NSB improved arterial blood gas values after chlorine gas inhalation without altering microscopic pathology (Chisholm et al., 1989). After brief exposure to chlorine, three patients who presented to the emergency department (ED) with mild symptoms were given 4 ml of a 3.75% NSB solution (Vinsel, 1990). The effects of NSB treatment were immediate and long-lasting, with complete relief of symptoms within 24 hours. No clinical deterioration to sodium bicarbonate therapy was observed. In a larger retrospective study (n=86) on the treatment of chlorine gas inhalation with 5% NSB, the clinical condition of 53 patients clearly improved upon release from the ED (Bosse, 1994). A small number of patients (n=17) were admitted to the hospital, receiving either a one-time dose of NSB or concomitant NSB therapy with inhaled beta-agonists and intravenous steroids. Gradual improvement occurred in all admitted patients with no observation of adverse effects. Similar therapeutic benefits from NSB administration have been observed in other studies (Douidar, 1997; Aslan et al., 2006; Howard et al., 2007; Cevik, 2009). Whether chlorine gas is released accidentally as a byproduct of a chemical reaction or intentionally as an unconventional weapon, adjunctive NSB therapy appears to be safe and effective for the treatment of potential pulmonary injuries.
...Although controlled clinical trials are lacking, in several published anecdotal case reports and case series, nebulized sodium bicarbonate solution has demonstrated safety and efficacy when administered for chlorine gas inhalation. Some patients were observed to experience rapid and dramatic relief of signs and symptoms. Treatment is based on the assumption that clinical benefit and cessation of tissue damage will occur with neutralization of the acidic byproducts created by inhaled chlorine gas. ... In one anecdotal case report, a markedly symptomatic 7-year-old exposed to chlorine gas experience dramatic relief from administration of nebulized sodium bicarbonate (Class IV).
In this two year retrospective review, 86 cases of chlorine gas inhalation from 49 medical facilities were treated with nebulized sodium bicarbonate on the recommendation of the Kentucky Regional Poison Center. Typical manifestations included cough, chest discomfort, shortness of breath, and wheezing. No patients developed pulmonary edema or respiratory insufficiency requiring ventilatory support. Sixty-three cases (73.3%) were exposures to chlorine producing acid/hypochlorite mixtures. Six (7.0%) were exposed to chlorine gas in industrial settings. Twelve (14.0%) were exposed to chlorine gas in swimming pool settings. Sixty-nine (80.2%) were treated and released from the emergency department. In 53 patients, clinical condition was clearly improved on emergency department discharge. Seventeen (19.8%) were admitted to the hospital. All admitted patients gradually improved and had a mean hospital stay of 1.4 days (range 1 to 3 days). No patients in this study deteriorated clinically after nebulized sodium bicarbonate use. Nebulized sodium bicarbonate appears safe and merits prospective evaluation in the therapy of chlorine gas inhalation (Class IV).
Chlorine gas is a potent pulmonary irritant that affects the mucous membranes and induces severe disturbances of pulmonary gas exchange within minutes of inhalation. The present study evaluated an extraordinary type of mass inhalational exposure. Clinical reports of 25 soldiers who were admitted to the emergency department of Maresal Cakmak Military Hospital, Erzurum were retrospectively evaluated. All patients were exposed to chlorine gas as a result of mixing sodium hypochlorite with hydrochloric acid during cleaning activities. All patients were male and the mean age of patients was 22.04+/-2.98 years. The main symptoms were coughing and dyspnea in 18 patients (72%). Forced expiratory volume in 1 second (FEV1) and FEV1/forced volume capacity (FVC) ratio were found to be normal in all patients but FVC and peak expiratory flow (PEF) were below the normal range (80%) in 9 patients (36%). All patients received warmed humidified oxygen combined with nebulized salbutamol. Inhaled budesonide and nebulized sodium bicarbonate were ordered additionally for 19 patients (76%). Thirteen patients (52%) were discharged from the emergency department and 12 patients (48%) were hospitalized. No mortality was observed. Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tract. We suggest that inhaled steroids combined with nebulized sodium bicarbonate could be a safe and effective alternative for the treatment of symptomatic patients. Education of the public about the dangers of mixing of hypochlorite bleach with acidic cleaning agents is also very important (Class IV).
Chlorine is one of the most common substances involved in toxic inhalation. As with all irritant gases, the airway injuries caused by chlorine gas may result in clinical manifestations similar to those of asthma. In this study, we investigated the effect of nebulized sodium bicarbonate (NSB) on the treatment and quality of life (QoL) of victims exposed to chlorine gas. Forty-four consecutive patients with reactive airways dysfunction syndrome (RADS) due to chlorine inhalation (40 females and 4 males, age range 17-56 yr) were included in this study. Patients were placed in control and treatment groups in a sequential odd-even fashion based on their order of presentation. Treatment of all patients included corticosteroids and nebulized short-acting beta2-agonists. Then the control group (n = 22) received nebulized placebo (NP), and the NSB group (n = 22) received NSB treatment (4 cm3 of 4.20% sodium bicarbonate solution). A quality of life (QoL) questionnaire and pulmonary function tests (PFTs) were performed before and after treatments in both groups. The most common symptoms were dyspnea (82%) and chest tightness (82%). Baseline characteristics of both groups were similar. Compared to the placebo group, the NSB group had significantly higher FEV1 values at 120 and 240 min (p < .05). Significantly more improvement in QoL questionnaire scores occurred in the NSB group compared to the NP group (p < .001). Thus, NSB is a clinically useful treatment, as tested by PFTs and QoL questionnaire, for patients with RADS caused by exposure to chlorine gas (Class III).
Aslan S, Kandiş H, Akgun M, Cakir Z, Inandi T, Gorquner M. The effect of nebulized NaHCO3 treatment on "RADS" due to chlorine gas inhalation. Inhal Toxicol. 2006 Oct; 18 (11): 895-900. [PubMed Citation]
Three male patients, 19 to 20 years old, were exposed to chlorine gas secondary to a leak in the chlorination system of an indoor pool. All of the patients were symptomatic with cough, chest pain, and shortness of breath. Physical examinations, arterial blood gases, and chest radiographs were normal. All patients were given a nebulized solution of 3.75% sodium bicarbonate which resulted in prompt relief of their symptoms. None of the patients suffered from prolonged symptomatology. This therapy appears to be useful in treating chlorine gas inhalation; however, it cannot be routinely recommended without prospective clinical studies evaluating its efficacy and safety (Class IV).
Mass exposure to chloramine gas has not been reported. We report two groups of 36 patients (72 total) suffering from acute inhalation of chloramine gas. Chloramine gas is produced from mixing common household cleaning agents containing sodium hypochlorite (bleach) and ammonia. The first mass casualty event occurred when 36 male soldiers were exposed during a "cleaning party" in their barracks. Ten days later, 36 female soldiers were exposed in a similar manner and presented to our emergency department. In each event, commonly available cleaning agents--liquid bleach and ammonia--were mixed together, liberating toxic chloramine gas. Nebulized sodium bicarbonate solution has been suggested for treatment of chlorine gas inhalation, but no report of nebulized sodium bicarbonate for treatment of chloramine gas inhalation injury exists. In our series, 22 patients exposed to chloramine gas were treated with a nebulized solution of 3.75% sodium bicarbonate. This treatment made no significant statistical or clinical difference in outcome. We present the largest case series of patients presenting to an emergency department for treatment of acute inhalation of chloramine gas (Class IV).
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