Nebulized Sodium Bicarbonate

[thegreypilgrim]

I've recently discovered that Austin-Travis EMS has a protocol for its HazMat paramedics to administer nebulized sodium bicarb for chlorine gas inhalation (although for the life of me I can no longer find a link to their protocol manual).

This is interesting and seems logical considering the pathophysiology of chlorine gas exposure. I haven't found too many contemporary studies on its effectiveness, however; in fact, this is all I've found thus far:

[1] Howard, C, Ducre, B, Burda, A, & Kubic, A. Management of Chlorine Gas Exposure. (2007). Journal of Emergency Nursing, 33(4), 402-404.doi:10.1016/j.jen.2007.03.010

[2] Batchinsky, AI, Martini, DK, Jordan, BS, ****, EJ, Fudge, J, Baird, CA, Hardin, DE, & Cancio, LC. Acute Respiratory Distress Syndrome Secondary to Inhalation of Chlorine Gas in Sheep. (2006). Journal of Trauma-Injury Infection & Critical Care, 60(5), 944-957. DOI: 10.1097/01.ta.0000205862.57701.48

[3] Douidar, S. Nebulized sodium bicarbonate in acute chlorine inhalation. (1997). Pediatric Emergency Care, 13(6), 406-407.

[4] Bosse, GM. (1994). Nebulized Sodium Bicarbonate in the Treatment of Chlorine Gas Inhalation. Clinical Toxicology, 32(3), 233-241. DOI: 10.3109/15563659409017956

[5] Vinsel, PJ. (1990). Treatment of acute chlorine gas inhalation with nebulized sodium bicarbonate. Journal of Emergency Medicine, 8(3), 327-329. DOI: 10.1016/0736-4679(90)90014-M

[6] Chisholm, CD, Singletary, EM, Okerberg, CV, & Langlinais, PC. (1989). Inhaled sodium bicarbonate therapy for chlorine inhalation injuries. Annals of Emergency Medicine, 18(4), 466. DOI: 10.1016/S0196-0644(89)80754-1

So yeah, some of those are reaching way back but for the most part conclude that nebulized sodium bicarb is a safe and effective treatment option for chlorine gas exposure. This, however, isn't in any protocol in any area where I work; and, ATCEMS is the only provider to my knowledge that uses this modality.

Anyone else know of anyone doing this? Anyone who works in a hospital ever do this?

 

[iamajammer]

I can't say that i've ever nebulized bicarb, then again i'm in the ICU most of the time. I'll ask around tomorrow.

 

[usafmedic45]

I've heard this before but never seen it used. Keep in mind that most of these articles are case reports. The Vinsel article discusses three patients and the abstract carries the following caveat:

however, it cannot be routinely recommended without prospective clinical studies evaluating its efficacy and safety.

The Bosse article is a review of 86 cases over two years from around Kentucky, but tells us nothing to compare the use of bicarbonate to. It too carries the following closing statement:

...merits prospective evaluation in the therapy of chlorine gas inhalation

An article you didn't come across (Sexton JD, Pronchik DJ: Chlorine inhalation: the big picture. J Toxicol Clin Toxicol. 1998;36(1-2):87-93) flat out states:

Beta agonist administration and humidified oxygen remains the mainstay of treatment; steroid therapy and bicarbonate inhalation are still inadequately supported.

Basically, it seems that it's not harmful, but the benefit is up for debate.

 

[mycrofft]

Sounds like all kinds of potential bad.

1. Doesn't address damage already done.
2. Will create an exothermic rxn forming NaCl, water, and carbon dioxide?
3. But, is there anything better?

Nebs need the solution defined as parts or totals of each component and total dose. Also, is this delivered with oxygen or room air as the nebulizing force, or is it an ultrasonic?

 

[usafmedic45]

Will create an exothermic rxn forming NaCl, water, and carbon dioxide?

That's a theoretical hazard but the concentrations of reagents are small enough and diluted enough, you probably do not get enough heat to do any damage. This is also particularly the case in that you're going to increase the amount of fluid down there (dilution effect) simply as a result of the initial chlorine exposure.

But, is there anything better?

I'm willing to put a small amount of cash on the fact that if you compared it point to point with bronchodilators (mostly saline after all) and plain old normal saline, you would probably get similar responses. That is the main problem with the articles cited. There is no comparison between bicarbonate and a "control" (those who did not receive bicarbonate).

is this delivered with oxygen or room air as the nebulizing force, or is it an ultrasonic?

You would give it through a standard small volume nebulizer driven by your choice of air or O2. There's no need to use an ultrasonic neb (in this or pretty much any other setting, IMHO). What made you think it might have to be given through an ultrasonic nebulizer?

Nebs need the solution defined as parts or totals of each component and total dose.

Most of the article abstracts I looked at discussed 3.5% bicarbonate solution. I don't think there is a defined dose (at least not that I have seen) since we don't seem to know if it actually does anything to begin with.

 

[mycrofft]

Oh, just rounding the bases with the ultrasonic gizmo.

Small cheap and portable nebulizers are becoming a marketing tool, so they may find their way into the field. A Piezo-driven neb could be cheap, battery-operated and might be adopted (if it isn't already...I AM ignorant) for prehospital use. It would be passive room air.

Thanks for the perspectives and info.

 

[usafmedic45]

I've never seen a handheld ultrasonic neb that really works as well as the gas driven ones. This is just my personal opinion as the father of an asthmatic and an RT. Given that you can carry around an MDI and get just as good, if not better, medication delivery in most patients (with proper education and use of a spacer), I see no reason for a pocket-sized ultrasonic neb.

 

[iamjeff171]

you can find the cogs here: http://www.atcomd.org/CMPMP100109 09.htm

click the link for "Toxic Exposure Patient Care Guidelines", its i think the third protocol down.

it reads:
FOR CHLORINE GAS EXPOSURE ONLY:
• Sodium Bicarbonate Nebulized:
Place 2 ml sodium bicarbonate 8.4% (standard
sodium bicarbonate) into 2 ml of sterile
water administered by hand-held
nebulizer. May be repeated every 20 minutes.
Max dose total of 2 times.

-Jeff

 

[mycrofft]

Second that USAF. I think nebs can be a fad.

Be interesting to see the outcome of this, including what other things occur when you do it (i.e., side effects like electrolytes and pH alterations).

 

[mycrofft]

Jeff see if they have references.

Nice specific order. 4 ml of 4.2 % Bicarb in sterile water USP once your bartending is done. The actual delivered dose is minus the residual caused by static cling in reservoir and lost mist due to absence of mist reservoir, I assume. Wonder how this would work with an unconscious or delerious/resistive pt?

 

[mycrofft]

I'be emailed the US Army medical continuing education section about this treatment.

They have many materials available for responses to chemical/toxic events.

The Austin protocols remind me of my days as DP officer for my unit. Ah, the chicken wire litters, the shuffle pits and showers....

 

[iamjeff171]

i couldnt find any references on the site. our schools medical director (Dr. Kimbrough) is an associate med dir for ATCEMS, i will be sure to ask him about it the next time i see him (im fairly confident he knows pretty much everything )

 

[mycrofft]

USAMRIID weighs in

[Thank you for considering us as your support system for Chemical Casualty Care management. BLUF: The administration of Sodium Bicarbonate to treat inhalation chlorine casualties does not improve patient outcome. It may have a placebo effect; however, nebulizer Terbutaline is the medication of choice if administered within 30 minutes of exposure.

Also, chlorine gas has a combination effect. It will cause damage to the pulmonary tree tissue (air conduction tubules) and cause life threatening laryngeal spasms and effect alveoli (pulmonary capillary bed) by causing latent pulmonary edema.


The current recommended treatment for chlorine casualties is humidified oxygen and Beta Agonist, such as Terbutaline. Aerosolized Terbutaline and corticosteroid budesonide administered 30 minutes post exposure reduces acute lung injury (Wang, et al., 2004). The premise of this therapy is Terbutaline will increase tight epithelial / endothelial junctions and reduce leakage of fluid into the airway tubules and alveolar sacks. Budesonide will reduce the inflammatory process and severity of tissue injury.

The use of Sodium Bicarbonate, so far, does improve mortality/morbidity of inhalation chlorine casualties (Sexton & Pronchik, 1998; Bosses, 1994).

The best recommendation for the lay public and EMT personnel is prevention. If this fails, then immediately remove casualties safely from the source of chlorine exposure, provide supplemental oxygen, and transport to definitive care (Thomas & Murray, 2008).

It will be beneficial if contaminated clothing is removed prior to placing casualties in a enclosed ambulance or admitting to the ED (Herringham, 1920). Chorine has a tendency to adhere to cloth fibers and off gas, which puts undue risk to health care providers.


References:

Bosses GM. Nebulized sodium bicarbonate in the treatment of chlorine gas inhalation. J Toxicol Clin Toxicol 1994;32(3):233-241.

Herringham, W. Gas poisoning. Lancet 1920;1:423-424.

Sexton JD & Pronchik. Chlorine inhalation: the big picture. J Toxicol Clin Toxicol 1998;36(1-2):87-93.

Wang J, Zhang L, Walther S. Administration of aerosolized terbutaline and budesonide reduces chlorine gas -- induced acute lung injury. J Trauma, 2004:56:850-862.

There is a citation which says bicarb helps, but the others say nope.
This is your tax dollars at work!!

 

[Laurenlee63]

I was recently treated with nebulizer sodium bicarbonate at the hospital because of chlorine exposure.