Phosgene emergengy protocols

BASF Chemical Emergency Medical Guidelines

Dimethyl sulfate (C2H6O4S)
Information and recommendations for doctors at hospitals/emergency departments
• Patients exposed only to dimethyl sulfate vapor do not pose a significant risk of secondary
contamination. Patients whose clothing or skin is contaminated with liquid dimethyl sulfate can
secondarily contaminate rescue and medical personnel by direct contact or through evaporation of
dimethyl sulfate.
• Dimethyl sulfate can produce eye, skin, and respiratory tract irritation. Signs of pulmonary edema
(shortness of breath, cyanosis, expectoration, cough) may evolve 12 hours or more after exposure.
Skin reactions may be delayed and may heal very slowly.
• Inhalation and skin contact may result in systemic absorption resulting in headache, nausea,
vomiting, abdominal pain, lung, liver, and kidney damage.
• There is no antidote to be administered to counteract the effects of dimethyl sulfate. Treatment
consists of supportive measures.

1. Substance information
Dimethyl sulfate (C2H6O4S), CAS 77-78-1 Synonyms: DMS, methyl sulphate, sulfuric acid dimethyl ester. Dimethyl sulfate is a color- and odorless (to faint onion odor) oily liquid with a melting point of about -32°C and a boiling point of 188 (-25,6°F, 370 °F respectively) . It is not flammable and not explosive, the flash point is 83 oC 181 oF)and the vapor pressure is low with 65 Pa at 20 oC ( 68 oF). It is slightly soluble in water; soluble in alcohols, ether, and aromatic hydrocarbons. It rapidly hydrolyzes in the presence of water to produce sulfuric acid and methanol. Dimethyl sulfate is mainly used as a chemical intermediate. Its major applications are as a methylating agent of many organic chemicals (e.g. amines, carbon acids, thiols and phenols) both in industry and in laboratories. DMS is used, for example, in the manufacturing of dyes, perfumes, pharmaceuticals, for the separation of mineral oils and for the analysis of automobile fluids. The substance has also sulphating properties. 2. Routes of exposure
Inhalation is a major route of dimethyl sulfate exposure. Dimethyl
sulfate is odorless (to faint onion odor) and is considered to have poor
warning properties of hazardous exposure.
Dimethyl sulfate vapor or liquids may be absorbed through the skin and eyes; however, direct contact with dimethyl sulfate vapor or concentrated solutions may cause severe chemical burns. Involuntary ingestion of dimethyl sulfate is unlikely. 3. Acute health effects
Exposure to dimethyl sulfate concentrations of more than 1 ppm
may produce irritation of the eyes, nose, and throat. Higher
concentrations may cause pulmonary edema up to 12 hours or more
after exposure.
Skin contact with dimethyl sulfate vapor or liquid may cause irritation with
redness of the skin, blistering, itching, and pain. Skin reactions may have
a 1 to 2 hour delay before onset of symptoms, and the full effects
may be delayed up to 12 hours or more after exposure and may heal
very slowly.
Dimethyl sulfate is a skin sensitizer.
High vapor concentrations or splashes of concentrated solutions can
cause tearing and redness of the eye, and corneal injury.

Both inhalation and skin contact may lead to systemic absorption
causing severe headache, nausea, vomiting, abdominal pain, and lung,
liver and kidney injury.
Dose-effect relationships are as follows: Burning of eyes, nose, and throat, dyspnea, coughing Survivors of severe inhalation injury may suffer residual chronic lung disease or recurrent respiratory tract infections. Permanent liver or kidney damage may result from high systemic exposure. Dimethyl sulfate is classified as a carcinogen on the basis of animal evidence as follows: - EC directive 1272/2008, Carc. 1B (known or presumed human carcinogen); - IARC Group 2A (probably carcinogenic to humans). 4. Actions
Patients exposed only to dimethyl sulfate vapor do not pose a significant
risk of secondary contamination. Patients whose clothing or skin is
contaminated with liquid dimethyl sulfate can secondarily contaminate
other people by direct contact or through evaporation of dimethyl sulfate.
Patients who are able and cooperative may assist with their own
decontamination. If the exposure involved liquid dimethyl sulfate and if
clothing is contaminated, remove and double-bag the clothing.
Assure that skin and hair exposed to liquid containing dimethyl
sulfate have been flushed with plain water for at least 15 minutes. If
not, continue flushing during other basic care. Protect eyes during flushing
of skin and hair.
Assure that exposed or irritated eyes have been irrigated with plain
water or saline for at least 15 minutes. If not, continue eye irrigation
during other basic care.
Remove contact lenses if present and easily removable without additional
trauma to the eye.
Therapy will be empiric; there is no antidote to be administered to
counteract the effects of dimethyl sulfate.
All asymptomatic patients potentially exposed to an airborne
dimethyl sulfate concentration of 1 ppm or more should take 8 puffs
of beclomethasone (800 µg beclomethasone dipropionate) from a
metered dose inhaler, if not already done. Thereafter, 4 puffs every 2
hours for 24 hours.
The following measures are recommended if the airborne exposure
concentration is 1 ppm or more and/or if patients have respiratory
complaints or evidence of systemic toxic effects after inhalation of
dimethyl sulfate:
If not already done, initially, administration of 8 puffs of beclo-
methasone (800 µg beclomethasone dipropionate) from a metered
dose inhaler.
Administration of 4 puffs every 2 hours for 24 hours.

If not already done, establishment of intravenous access and
intravenous administration of 1.0 g methylprednisolone (or an
equivalent steroid dose).
Note: Efficacy of corticosteroid administration has not yet been proven in
controlled clinical studies.
If inhalation exposure has occurred, humidified air or oxygen should be
provided. If signs of hypoxemia are present, humidified supplemental
oxygen should be administered.
Intubation of the trachea or an alternative airway management should be
considered in cases of respiratory compromise. When the patient’s
condition precludes this, consider cricothyrotomy if equipped and trained
to do so.
If dimethyl sulfate was in contact with the skin, chemical burns may result;
treat as thermal burns: adequate fluid resuscitation and administration of
analgesics, maintenance of the body temperature, covering of the burn
with a sterile pad or clean sheet.
After eye exposure chemical burns may result; treat as thermal
burns. Immediately consult an ophthalmologist.
To the standard intake history, physical examination, and vital
signs add pulse oximetry monitoring and a PA chest X-ray.
Spirometry should be performed.
Routine laboratory studies should include a complete blood count,
hepatic and renal function parameters, glucose and electrolyte
determinations.
Consider hospitalization of patients who have evidence of systemic toxicity
from any route of exposure.
Evidence of pulmonary edema - hilar enlargement, and ill-defined,
central-patch infiltrates on chest radiography - is a late finding that may
occur 12 hours or later after exposure. The chest X-ray is typically
normal on first presentation to the emergency department even with
severe exposures.
If oxygen saturation is less than 90 % or if it appears to drop, immediately
check arterial blood gasses and repeat the chest X-ray.
If blood gasses begin to show deterioration and/or if the chest X-ray begins
to show pulmonary edema start oxygen supplementation.
Should it become clear that pulmonary edema is worsening, positive
end-expiratory pressure (PEEP) therapy should be started within the first
24 hours after exposure, even if oxygenation can be maintained by mask.
Early indication for PEEP therapy is tachypnea (>30/min) with a
simultaneous decrease of the partial pressure of carbon dioxide.
An inadequate increase or a relative decrease of the partial pressure of
oxygen despite hyperventilation indicates the development of pulmonary
edema. Fluid intake/output and electrolytes should be monitored closely.
Avoid net positive fluid balance. Central line or Swan-Ganz catheterization
might be considered, to optimize fluid management.
As long as signs of pulmonary edema are present, intravenous
administration of 1 g methylprednisolone (or an equivalent steroid dose)
should be continued in intervals of 8-12 hours.
Patients with bronchospasms should be treated as follows:
a) Aerolized ß2-selective adrenergic agonist, e.g. 4 puffs of terbutaline, or
salbutamol, or fenoterol from a metered dose inhaler (1 puff usually
contains 0.25 mg terbutaline sulfate, or 0.1 mg salbutamol, or 0.2 mg
fenoterol, respectively); may be repeated once after 10 min.
If inhalation is not possible, terbutaline sulfate (0.25-0.5 mg)
subcutaneously or salbutamol (0.2-0.4 mg over 15 min) intravenously.
b) If a) is not effective or insufficient: theophylline (5 mg/kg body weight
intravenously over 20-30 min).

c) If a) and b) are not effective or insufficient: 2 puffs of epinephrine (0.4
mg per puff) from a metered dose inhaler; may be repeated after 5 min.
Prophylactic antibiotics are not routinely recommended, but may be used
based on the results of sputum cultures. Pneumonia can complicate
severe pulmonary edema.
Consider hemodialysis in case of significant systemic absorption of
dimethyl sulfate with impairment of liver and/or kidney function.
Patients who have a normal examination and no signs or symptoms
of toxicity after observation for 12 hours or who have been exposed
to an airborne concentration less than 1 ppm may be discharged in the
following circumstances:
a) The evaluating physician is experienced in the evaluation of individuals
with dimethyl sulfate exposure.
b) Information and recommendations for patients with follow-up
instructions are provided verbally and in writing. Patients are advised to
seek medical care promptly if symptoms develop or recur.
c) The physician is comfortable that the patient understands the health
effects of dimethyl sulfate.
d) Site medical is notified, so that the patient may be contacted at regular
intervals in the 24-hour period following release from the emergency
department.
e) Heavy physical work should be precluded for up to 24 hours.
f) Exposure to cigarette smoke should be avoided for 72 hours; the smoke
may worsen the condition of the lungs.
Patients who have eye exposures should be reexamined after 24 hours. For those patients with inhalation injury, post discharge spirometry should be repeated until values return to the patient’s baseline values. In this document BASF has made a diligent effort to ensure the accuracy and currency of the information presented but makes no claim that the document comprehensively addresses all possible situations related to this topic. This document is intended as an additional resource for doctors at hospitals/emergency departments in assessing the condition and managing the treatment of patients exposed to dimethyl sulfate. It is not, however, a substitute for the professional judgement of a doctor and must be interpreted in the light of specific information regarding the patient available to such a doctor and in conjunction with other sources of authority. BASF Corporation

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