1. MANAGEMENT OF EXPOSURE TO HYDROGEN FLOURIDE OR HF PRESENTED BY: Miguel Trevino, M.D. Occupational Medicine U.de M - U.C.S.C - FACOEM MRO

2. GENERAL INFORMATION ABOUT HF

3. USES OF HF ELECTRONICS.- Production of microchips, electronic circuit cleaners. ELECTRONICS.- Production of microchips, electronic circuit cleaners. METALURGY.- Metal pickling/Aluminum manufacture PETRO CHEMICALS.- As a catalyst in the alkalization of gasoline. GLASS INDUSTRY. Glass edging. REFRIGERENT GASES.- For automotive, air conditioning, refrigerator home/industry. FIRE EXTINGUISHERS.- Fluorocarbons. FIRE EXTINGUISHERS.- Fluorocarbons.

4. USES OF HF FLUOROCHEMICALS.- Fluorinated Salts Production. FLUOROCHEMICALS.- Fluorinated Salts Production. ANTIADHERENTS.- Production of Teflon. MEDICINE.- Propellants for medication, anesthetic gases, antibiotic production, production and finishes of surgical prosthesis. NUCLEAR INDUSTRY.- Purification of uranium ore. AGROCHEMICALS. Pesticides. CLEANING SOLUTIONS. Rust removers.

5. PHYSICAL CHEMICAL PROPERTIES FREEZING POINT - 118ºF -83ºC VAPOR DENSITY 3.0 AT 25ºC SPECIFIC GRAVITY (2514) 0.97 VAPOR PRESSURE AT 20ºC 775MM Hg ODOR PUNGENT & IRRITATING ODOR PUNGENT & IRRITATING PHYSICAL STATE GAS PHYSICAL STATE GAS DISSOCIATION K=3.5 x 10-4 DISSOCIATION K=3.5 x 10-4 BOILING POINT 67 ºF19ºC BOILING POINT 67 ºF19ºC VOLATILITY 100% VOLATILITY 100% SOLUBILITY IN WATER 100% SOLUBILITY IN WATER 100%

6. PHYSIOPATHOLOGY OF EXPOSURES & KNOWN TOXICOLOGY

7. HF  ////////////////// TISSUE + H - F

9. ENTRY ROUTES SKIN RESPIRATORY TRACT EYESGASTRO-INTESTINAL

10. TYPES OF EXPOSURE LIQUID EXPOSURE (SPLASH BURN). GAS EXPOSURE (INHALATION, SKIN & EYES). LIQUID & GAS (MIXED EXPOSURE). LOW CONCENTRATION HF SOLUTIONS.

11. Once ionized, the fluoride creates two types of salts: INSOLUBLE SALTS INSOLUBLE SALTS Fˉ + Ca (++ ) = Ca F (2) Calcium Fluoride Fˉ + Ca (++ ) = Ca F (2) Calcium Fluoride Fˉ + Mg (++ ) = Mg F Magnesium Fluoride Fˉ + Mg (++ ) = Mg F Magnesium Fluoride This can lead to Hypoglycemia that in turn This can lead to Hypoglycemia that in turn can lead to Cardio Respiratory Arrest, can lead to Cardio Respiratory Arrest, Hypomagnesaemia, Na (Sodium) and K Hypomagnesaemia, Na (Sodium) and K (Potassium) alterations. (Potassium) alterations.

12. SOLUBLE SALTS SOLUBLE SALTS Fˉ + Na (+) = Na FSodium Fluoride Fˉ + Na (+) = Na FSodium Fluoride Fˉ + K (+) = KFPotassium Fluoride Fˉ + K (+) = KFPotassium Fluoride Which target: Which target: The Kidneys – Nefro - Toxic The Liver – Liver - Toxic And are the cause of Acute Fluoride Intoxication if sufficient quantities are created. And are the cause of Acute Fluoride Intoxication if sufficient quantities are created.

13. SO, WHY IS HF A HAZARDOUS MATERIAL? It is a Corrosive. (Acid) It is a Corrosive. (Acid) It is a Poison. (Toxic) It is a Poison. (Toxic) It is an Inhalation Hazard. It is an Inhalation Hazard.

14. INTRINSIC PROCESS RISK FACTORS IN RELATION TO HF CHEMICAL FACTORS PHOSGENECYLINDERS200 HCN RAILROAD TANK 10 H2S PRESSURIZED TANK 10 C12 RAILROAD TANK 9 SO2 IN CYLINDER 8 AHC1 ROAD TANK 2.5 AHF IN A RAILROAD TANKER 1 Br2 PRESSURIZED TANK 0.80 SO3 0.60 NH3 NORMAL ATM CONDITIONS 0.30 OLEU PRESSURIZED TANK 0.20 NH3 AT 33 ºC 0.09 MMATANK0.05 Br2 NORMAL ATM CONDITIONS 0.05 POC13 PRESSURIZED TANK 0.04 RISK FACTORS IN RELATION TO HF WHEN HF = 1.0

15. KNOWN TOXICOLOGY  Acute Corrosive Effects (Burns) Acute Fluoride Intoxication Acute Fluoride Intoxication  Sub-AcuteImpaired Breathing (hours after) Delayed appearance of skin injury (hours after) Chronic or Long Term Injury to tissue due to corrosive and toxic effects. No other effects documented or reported. Possible Fluorosis after chronic exposure to low concentrations of HF.

16. KNOWN TOXICOLOGY  Reproductive & Developmental None described or found None described or found  Immuno-Toxicity None described or found None described or found  Cancer Forming No human reports or studies No human reports or studies  Cardiac & Muscular Toxicity Yes, due to Fluoride binding to Calcium, Yes, due to Fluoride binding to Calcium, and Magnesium. and Magnesium.

17. KNOWN TOXICOLOGY Hepatic & Nefro Toxicity Yes, due to creation of Sodium Yes, due to creation of Sodium Fluoride and Potassium Fluoride Fluoride and Potassium Fluoride after exposure (untreated). after exposure (untreated).

18. KNOWN TOXICOLOGY  TWA Time weighted average concentration for a normal 8 hour workday and a 40 hour work week to which nearly all workers may be repeatedly exposed, day after day, without adverse effects for all of their working life 3PPM (ACGIH). Time weighted average concentration for a normal 8 hour workday and a 40 hour work week to which nearly all workers may be repeatedly exposed, day after day, without adverse effects for all of their working life 3PPM (ACGIH).

19. KNOWN TOXICOLOGY  IDLH = 30 ppm Immediately dangerous to life and health Immediately dangerous to life and health (NIOSH). (NIOSH).

20. KNOWN TOXICOLOGY  ERPG 1 = 5 ppm The maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to 1 hour without experiencing other than mild, transient The maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to 1 hour without experiencing other than mild, transient adverse health effects or without perceiving a clearly defined objectionable odor. adverse health effects or without perceiving a clearly defined objectionable odor.

21. KNOWN TOXICOLOGY  ERPG 2 = 20 ppm The maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to 1 hour without experiencing or developing irreversible The maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to 1 hour without experiencing or developing irreversible or other serious health effects or symptoms which could impair an individual’s ability to take protective action. or other serious health effects or symptoms which could impair an individual’s ability to take protective action.

22. KNOWN TOXICOLOGY  ERPG 3 = 50 ppm The maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to an hour without experiencing or developing life- threatening health effects. The maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to an hour without experiencing or developing life- threatening health effects.

23. PRIMARY DECONTAMINATION PROCEDURES

24. DECONTAMINATION PROCEDURES  GO TO THE NEAREST FUNCTIONAL DECON UNIT.  OPEN THE WATER VALVE.  TAKE OFF ALL CLOTHING, SHOES & JEWELRY.  REMOVE GOGGLES LAST, FACE THE WATER FLOW, CLOSE YOUR EYES, PULL GOGGLES OVER YOUR HEAD.  REMEMBER, MAXIMUM TIME UNDER SHOWER IS 5 MINUTES. This is a Dilution Technique.

32. TRIAGE

33. PRIMARY TRIAGE 1 ST To Go Many Signs & Symptoms of Exposure 2 nd To Go Signs and Symptoms Present and Possible Systematic Effects in Near Possible Systematic Effects in Near Future Future 3rd To Go Minor or No Signs & Symptoms Do Not Go Fatalities

34. SUGGESTED TREATMENT THROUGH HISTORY WASH COPIOUSLY WITH WATER FOR 15 MINUTES. SODIUM BICARBONATE SOLUTIONS MAGNESIUM SULFATE PASTE. MAGNESIUM OXIDE PASTE. AMMONIA SOLUTIONS & INHALANT. HYAMINE SOLUTIONS 0.2% (2 gm BENZEHTONIUM CHLORIDE IN 1 LITER OF ICE WATER).

35. SUGGESTED TREATMENT THROUGH HISTORY ZEPHIRAN 0.13% (1.3 gm BENZALKONIUM CHLORIDE IN 1 LITER OF ICE WATER). CALCIUM GLUCONATE SOLUTIONS: 10%, 5%, 2.5%, 1% CALCIUM GLUCONATE GEL 2.5%. CALCIUM ACETATE SOLUTIONS. ORAL CALCIUM & MAGNESIUM BASED ANTACIDS AND SOLUTIONS.

36. SUGGESTED TREATMENT THROUGH HISTORY INTR-ARTERIAL CALCIUM TECHNIQUE (BOLUS AND SLOW INFUSION). INTRA-VENOUS CALCIUM TECHNIQUE (BIEAR BLOCK). HEXAFLUORINE RINSING SOLUTION. DMSO + CALCIUM GLUCONATE SOLUTION.

37. FIRSTAIDPROCEDURES

38. FIRST AID SKIN EXPOSURE  MINOR BURNS  Burns smaller than 2 square inches of body surface, such as small droplets, or very small surface, such as small droplets, or very small skin burns, low concentration gas or solution skin burns, low concentration gas or solution exposures. exposures.  MAJOR BURNS  Burns larger than 2 square inches with A.H.F.

115. AFTER DECONTAMINATION Initiate calcium gluconate 2.5% gel inunction. Note the time you start this step. Obtain medical attention (call). If pain does not subside in 20-30 minutes, go to medical treatment.

116. FIRST AID: EYES ALL EXPOSURES ARE CONSIDERED SEVERE.  DECON: USE EYEWASH, A GLASS OR LOW PRESSURE WATER HOSE. MAXIMUM TIME IS 5 MINUTES. IRRIGATE: 500cc to 1000cc OF A 1% CALCIUM GLUCONATE SOLUTION IN NORMAL SALINE PER EYE.

117. FIRST AID: EYES  SEEK SPECIALIZED MEDICAL ATTENTION IMMEDIATELY. USE CALCIUM GLUCONATE AT 1% CONCENTRATION UNTIL MEDICAL HELP IS REACHED.  IF THERE IS SKIN EXPOSURE, ALSO FOLLOW SKIN DECONTAMINATION AND FIRST-AID PROCEDURES.

122. FIRST AID INHALATION  DECON  ADMINISTER OXYGEN AT 12 LTS. PER MINUTE.  START NEBULIZING A 2.5% SOLUTION OF CALCIUM GLUCONATE IN NORMAL SALINE, USING A STANDARD NEBULIZER OR ULTRA NEBULIZER. PREFERABLY NOSE AND MOUTH MASK AND ¾ IN. TUBING  OBTAIN MEDICAL ASSISTANCE.

124.  CONCIOUS PATIENT: GIVE ORALLY HIGH AMOUNTS OF ANY CALCIUM OR MAGNESIUM BASED ANTACID, EFFERVESCENT CALCIUM IN WATER, MILK OR WATER. DO NOT INDUCE VOMITING!  UNCONCIOUS PATIENT: OBTAIN MEDICAL ASSISTANCE IMMEDIATELY.  DO NOT FORGET TO DECONTAMINATE SKIN OR EYES IF THEY WERE EXPOSED. FIRST AID: INGESTION

125. SECONDARY DECONTAMINATION PROCEDURES

131. SECONDARY DECONTAMINATION  EXAMINE & DECONTAMINATE: -EAR CANALS -MOUTH-NOSE-ANUS-VAGINA  EXAMINE & DECONTAMINATE SKIN FOLDS: -NECK

132. SECONDARY DECONTAMINATION - AXILARY REGIONS -SUB-MAMMARIAN FOLDS -GROIN -GROIN -BEHIND THE KNEES -INTER-DIGITAL FOLDS -INTER-DIGITAL FOLDS  EXAMINE & DECONTAMINATE BELOW THE NAILS OF: -HANDS-FEET

133. SECONDARY DECONTAMINATION  EXAMINE & DECONTAMINATE AREAS COVERED WITH HAIR: -SCALP-PUBIS -OTHER AREAS AS NEEDED

134. ELECTROCARDIOGRAPHIC EFFECTS  PROLONGED Q-T INTERVAL (DUE TO HYPOCALCEMIA).  NORMAL SERUM CALCIUM LEVELS: 2.25 TO 2.6 mmol/lt 9 TO 10.5 mg/dl

135. MEDICAL TREATMENT PROCEDURES

136. FLUORIDE IN SERUM OR IN URINE CLINICALLY- THE BEST INDICATOR IS URINE FLUORIDES. EASY TO DO, RESULTS IN MINUTES AND DEPENDABLE. FLUORIDES IN SERUM ARE NOT RELIABLE INDICATORS BECAUSE IT DOES NOT PROVIDE A GOOD MEASURE OF EXPOSURE TO FLUORIDES, AND IS COMPLICATED TO PERFORM, MAY TAKE DAYS BEFORE REPORTED. FLUORIDES IN SERUM ARE NOT RELIABLE INDICATORS BECAUSE IT DOES NOT PROVIDE A GOOD MEASURE OF EXPOSURE TO FLUORIDES, AND IS COMPLICATED TO PERFORM, MAY TAKE DAYS BEFORE REPORTED.

137. LONG TERM EFFECTS  FIRST: SEQUELA NORMALLY ARE ESTABLISHED IN THE SUB-ACUTE TIME PERIOD AFTER EXPOSURE AND ARE NORMALLY STABLE, SUCH AS: *SKIN HYPO-PIGMENTATION *KELOID SCARING *DEEP SEATED SCARING *SURGICAL SCARS *NEUROLOGIC, LIVER AND KIDNEY *NEUROLOGIC, LIVER AND KIDNEY DISFUNCTION MAY PERSIST IF DAMAGE IS DISFUNCTION MAY PERSIST IF DAMAGE IS SEVERE. SEVERE.

138. LONG TERM EFFECTS  SECOND THE FOLLOWING HAVE NOT BEEN OBSERVED: *HYPER-REACTIVE AIRWAYS *KIDNEY, LIVER OR CNS DYSFUNCTION *CANCER *REPRODUCTIVE PROBLEMS, ETC (SEE TOXICOLOGY) (SEE TOXICOLOGY)

139. CALCIUM GLUCONATE AS THE TREATMENT OF CHOICE

140. WHY ? * EASY TO USE. *CAN BE USED IN FIRST AID & MEDICAL TREATMENT. TREATMENT. *CAN BE USED TOPICALLY, INFILTRATED, INHALED, OPTHAMICALLY AND INHALED, OPTHAMICALLY AND INTRAVENOUSLY. INTRAVENOUSLY. *NO SOPHISTICATED MEDICAL EQUIPMENT REQUIRED, SUCH AS ARTERIAL CATHETERS, REQUIRED, SUCH AS ARTERIAL CATHETERS, IV INFUSERS, ETC. IV INFUSERS, ETC.

141. *EASY TO PREPARE IN GEL FORM OR SOLUTIONS. SOLUTIONS. TREATMENT IS FAST AND EFFECTIVE. *TREATMENT IS FAST AND EFFECTIVE. *THE RESULTING REACTION CHEMICAL IS PRIMARILY GLUCOSE AS COMPARED IS PRIMARILY GLUCOSE AS COMPARED TO AMMONIUM FLUORIDE & ACETIC TO AMMONIUM FLUORIDE & ACETIC ACID, IN THE CASE OD AMMONIA ACID, IN THE CASE OD AMMONIA COMPOUNDS OR CALCIUM ACETATE, COMPOUNDS OR CALCIUM ACETATE, RESPECTIVELY. RESPECTIVELY.

142. *CALCIUM IS MUCH MORE FAVORED TO BIND WITH FLUORIDE IN THE BODY. WITH FLUORIDE IN THE BODY. *NONE OR MINOR TISSUE IRRITATION AT DESCRIBED CONCENTRATIONS. DESCRIBED CONCENTRATIONS. *EXCELLENT RESULTS IN BOTH HIGH & LOW CONCENTRATION EXPOSURES OF HF. CONCENTRATION EXPOSURES OF HF. *NO SECONDARY EFFECTS AT THERAPEUTIC LEVELS. LEVELS. *NO NEED FOR SOAKING OR COOLING WITH RESULTING HYPOTHERMIC OR VASCULAR RESULTING HYPOTHERMIC OR VASCULAR RISKS. RISKS.

143. * IT IS AN EXCELLENT OUTSIDE SOURCE OF CALCIUM THAT WILL BIND THE FLUORIDE, AND IN DOING SO, WILL HELP AVOID HYPOCALCEMIA, AND THE CREATION OF TOXIC COMPOUND IN THE BODY. *CAN BE USED IN THE PRODUCTION FIELD, IN TRANSPORTATION INCIDENTS AND IN HOSPITALS.

144. ALGORITHMS FOR EMERGENCY MEDICAL PROCEDURES FOR HYDROFLUORIC ACID EXPOSURE

145. HF Exposure Decontamination = DECON = Procedures Recognize Exposure Rout (s)- Skin - Eyes - Inhalation - Ingestion Evaluate the severity of the Exposure Minor First aid Protocols Pain Subsides Pain Continues Major Systemic Effects Medical Treatment Protocols Systemic Effects Treatment Protocols and Go to

146. Skin Exposure Minor Exposure Major Exposure DECON SIGNS & SYMPTOMS FIRST-AID MEDICAL TREATMENT Signs & Symptoms. Low concentration of HF<30% < 3 sg.in. Of exposed skin. To AHF. Injury appears hours after exposure. Superficial injury. Conscious and Stable Signs & Symptoms. AHF or high concentration >30% > 3 sg.in of exposed skin to AHF. Injury appears immediately after exposure. Deep or extensive injury. Unconscious - or unstable. Face, Neck, Groin, genital exposure. Cardiac Arrithmia. (Irregular heart beats). First-Aid Procedures. Rub-in calcium-gluconate 2.5% gel for 20 to 30 minutes. Pain significantly decreases or subsides. Stop & observe. Never use local anesthetics. First-Aid Procedures. Rub-in calcium-gluconate 2.5% gel for 20 to 30 minutes. Pain does not decrease or subsides - within the first 20 to 30 Minutes. Medical Treatment Procedures.- = Injury Treatment = Inject into, around and under all injuries a solution of a 2.5% calcium gluconate solution in normal saline. = Systemic Toxicity Treatment = Start IV drip of 1000 cc in normal saline +20 cc of 10% calcium gluconate. The amount of solution administered will depend on the levels of Serum calcium (titer). Monitor ECG, Electrolytes with special interest on Ca, Mg, Na and K, Chest “x” Rays, Blood gases, Ph, Blood Chemistry, fluoride in urine and blood, liver & kidney function. Consider.- Intra Arterial slow infusion, of calcium gluconate and Consider Hemodialisis for the removal of serum Fluorides. Decontamination Procedure. Decontamination Procedures for HF Containing Oils & Tars. Go to the nearest water source or safety shower. Where the possibility of Exposure Exists.- and wearing acid resistant gloves. Open the valve. Remove all clothing, shoes, and jewerly. A) Remove the oil of Tor with baby-oil and Mechanical Remove eye protection last while facing the water flow. Means such as gauze,or tung depressors consider the materials used as a Hazardous waste and handle them adequately. Remember no more than five (5) minutes under the water flow. B) Remove baby-oil residue thoroughly by washing with soap and water. C) Follow basic decontamination procedure.

147. Skin Exposure Minor Exposure Major Exposure Decontamination Procedure. Decontamination Procedures for HF Containing Oils & Tars. Go to the nearest water source or safety shower. Where the possibility of Exposure Exists.- and wearing acid resistant gloves. Open the valve. A) Remove the oil of Tar with baby-oil and Mechanical Means such as gauze, or tongue depressors (consider the Remove all clothing, shoes, and jewelry. Material used as a Hazardous waste and handle them adequately). Remove eye protection last while facing the water flow. Remember no more than five (5) minutes under the water flow. B) Remove baby-oil residue thoroughly by washing with soap and water. C) Follow basic decontamination procedure. Signs & Symptoms. Low concentration of HF<30% < 3 sg.in. Of exposed skin. To AHF. Injury appears hours after exposure. Superficial injury. Conscious and Stable Signs & Symptoms. AHF or high concentration >30% > 3 sg.in of exposed skin to AHF. Injury appears immediately after exposure. Deep or extensive injury. Unconscious - or unstable. Face, Neck, Groin, genital exposure. Cardiac Arrithmia. (Irregular heartbeats). DECON SIGNS & SYMPTOMS

148. First-Aid Procedures. Rub-in calcium-gluconate 2.5% gel for 20 to 30 minutes. Pain significantly decreases or subsides. Stop & observe. Never use local anesthetics. First-Aid Procedures. Rub-in calcium-gluconate 2.5% gel for 20 to 30 minutes. Pain does not decrease or subsides - within the first 20 to 30 Minutes. Medical Treatment Procedures.- = Injury Treatment = Inject into, around and under all injuries a solution of a 2.5% calcium gluconate solution in normal saline. = Systemic Toxicity Treatment = Start IV drip of 1000 cc in normal saline +20 cc of 10% calcium gluconate. The amount of solution administered will depend on the levels of Serum calcium (titer). Monitor ECG, Electrolytes with special interest on Ca, Mg, Na and K, Chest “x” Rays, Blood gases, Ph, Blood Chemistry, fluoride in urine and blood, liver & kidney function. Consider.- Intra Arterial slow infusion, of calcium gluconate and Consider Hemodialisis for the removal of serum Fluorides. FIRST-AID MEDICAL TREATMENT

149. Respiratory Exposure Minor Exposure Major Exposure Decontamination Procedures. Not Possible = If gaseous exposure occurs skin and eye decontamination is necessary. Signs & Symptoms. No signs & symptoms. Minor coughing. Minor swelling and Eritlema. Signs & Symptoms. Coughing Labored Breathing. Shortness of Breath Erithema Swelling Bleeding Upper Airway Edema. Pulmonary Edema. Cardiac Arrithmia. (Irregular heart beats). First-Aid Procedures. Administer O2 at a rate of 12 Lts./min. Nebulize calcium gluconate 2.5% in normal saline for 15 to 20 min. Obtain Medical Evaluation and observe. First-Aid Procedures. Administer O2 at a rate of 12 lts./min. Continuously nebulize calcium gluconate 2.5% in normal saline until medically evaluated. If respiratory assistance is needed - use indirect methods - (Bag-micro- shield).- Medical Treatment Procedures.- =Respiratory Track = & Systemic Toxicity. Air Way & Breathing must be secured. Evaluate ABC; and follow ACLS procedures. Positive Pressure Assistance and Positive end expiratory pressure (peep). Are necessary.- until edema has resolved. Evaluate and monitor.- Chest “x” Rays, Blood Gases, ECG, Electrolytes with special interest in Ca, Mg, Na, and K, Blood Chemistry, fluorides in urine and blood, liver & Kidney functions. Start IV drip of 1000 cc in normal seline. +20 cc of 10% Calcium Gluconate. The amount of the solution will depend on the levels of serum calcium. Consider Hemodialisis for the removal of serum Fluorides.- DECON SIGNS & SYMPTOMS FIRST-AID MEDICAL TREATMENT

150. Minor Exposure Major Exposure DECON SIGNS & SYMPTOMS Respiratory Exposure Decontamination Procedures. Not Possible If gaseous exposure occurs skin and eye decontamination is necessary. Signs & Symptoms. No signs & symptoms. Minor coughing. Minor swelling and Eritlema. Signs & Symptoms. Coughing Labored Breathing. Shortness of Breath Erithema Swelling Bleeding Upper Airway Edema. Pulmonary Edema. Cardiac Arrithmia. (Irregular heart beats).

151. FIRST-AID MEDICAL TREATMENT First-Aid Procedures. Administer O2 at a rate of 12 Lts./min. Nebulize calcium gluconate 2.5% in normal saline for 15 to 20 min. Obtain Medical Evaluation and observe. First-Aid Procedures. Administer O2 at a rate of 12 lts./min. Continuously nebulize calcium gluconate 2.5% in normal saline until medically evaluated. If respiratory assistance is needed - use indirect methods (Bag-microshield). Medical Treatment Procedures.- =Respiratory Track = & Systemic Toxicity. Air Way & Breathing must be secured. Evaluate ABC; and follow ACLS and ATLS procedures. Positive Pressure Assistance and Positive end expiratory pressure (peep). Are necessary.- until edema has resolved. Evaluate and monitor.- Chest “x” Rays, Blood Gases, ECG, Electrolytes with special interest in Ca, Mg, Na, and K, Blood Chemistry, fluorides in urine and blood, liver & Kidney functions. Start IV drip of 1000 cc in normal seline. +20 cc of 10% Calcium Gluconate. The amount of the solution will depend on the levels of serum calcium. Consider Hemodialisis for the removal of serum Fluorides.-

152. Eye Exposure Minor Exposure Major Exposure Decontamination Procedure. Go to the nearest water source or eye wash. Open the valve. Mechanically maintain eye lids open, or ask for help. Wash for five minutes (5) and no more. Signs & Symptoms. Irritation of conjunctiva layer and eye lid skin (minor). Conjuctival injection. No evidence of corneal injury. No vision loss Signs & Symptoms. Severe irritation of the conjunctival eye, and skin burn to eye lids.- Conjuctival injection and swelling. Corneal “Opacification” or Pitting. Vision loss. First-Aid Procedures. Irrigate eyes with a 1% Calcium gluconate solution in normal saline 1000 cc per eye (15 min. aprox.). The use of an irrigating system (Morgan Lens) after using a local eye anesthetic (one or two drops per eye) should be considered. Obtain specialized medical evaluation. First-Aid Procedures. Irrigate eyes with a 1% calcium gluconate solution in normal saline 1000 cc per eye (15 min. Aprox.).- The use of an irrigating system (Morgan Lens) after using a local eye anesthetic (one or two drops per eye) should be considered. Specialized Medical Evaluation should be done (Slit lamp, etc). Medical Treatment Procedures.- If necessary continue treatment with a 1% solution of calcium gluconate in normal saline.- Antibiotics and steroids can be used as indicated by eye specialist. Monitor ocular pressure. Evaluate corneal opacification regularly.- If skin, ingestion or inhalation exposure occurs do not forget to decontaminate, and follow systemic toxicity treatment protocols. Psychological support may be necessary. DECON SIGNS & SYMPTOMS FIRST-AID MEDICAL TREATMENT

153. Minor Exposure Major Exposure DECON SIGNS & SYMPTOMS Decontamination Procedure. Go to the nearest water source or eye wash. Open the valve. Mechanically maintain eye lids open, or ask for help. Wash for five minutes (5) and no more. Eye Exposure Signs & Symptoms. Irritation of conjunctiva layer and eye lid skin (minor). Conjuctival injection. No evidence of corneal injury. No vision loss. Signs & Symptoms. Severe irritation of the conjunctival eye, and skin burn to eye lids.- Conjuctival injection and swelling. Corneal “Opacification” or Pitting. Vision loss.

154. FIRST-AID MEDICAL TREATMENT First-Aid Procedures. Irrigate eyes with a 1% Calcium gluconate solution in normal saline 1000 cc per eye (15 min. aprox.). The use of an irrigating system (Morgan Lens) after using a local eye anesthetic (one or two drops per eye) should be considered. Obtain specialized medical evaluation. First-Aid Procedures. Irrigate eyes with a 1% calcium gluconate solution in normal saline 1000 cc per eye (15 min. Aprox.).- The use of an irrigating system (Morgan Lens) after using a local eye anesthetic (one or two drops per eye) should be considered. Specialized Medical Evaluation should be done (Slit lamp, etc). Medical Treatment Procedures.- If necessary continue treatment with a 1% solution of calcium gluconate in normal saline.- Antibiotics and steroids can be used as indicated by eye specialist. Monitor ocular pressure. Evaluate corneal opacification regularly.- If skin, ingestion or inhalation exposure occurs do not forget to decontaminate, and follow systemic toxicity treatment protocols. Psychological support may be necessary.

155. Ingestion Minor Exposure Major Exposure Decontamination Procedures. Not Possible If skin or eyes have been exposed decontamination procedures should be followed. ALL EXPOSURES ARE CONSIDERED MAJOR. Signs & Symptoms. Erithema of oral mucousa. Oral injury. Bleeding of the oral cavity. Systemic Toxicity. Possible bronchial or pulmonary problems if the patient vomited. First-Aid Procedures. Do Not induce Vomiting. If patient is able to swallow give oral calcium solutions - or - calcium based antacids - milk or water. If unconscious obtain Medical Attention Immediately Medical Treatment Procedures.- HF destroys fiber optics - consider before using endoscopic techniques. Establish IV drip 1000 cc Normal Saline + 20cc - 10% calcium gluconate. If possible install a naso-gastric or oral-gastric tube. Gastric Lavage with calcium solutions, calcium or magnesium based antacids. Systemic Toxicity Control. The amount of calcium or magnesium to be administed will depend on the serum levels. Monitor ECG, Electrolytes, with special interest on Ca, Mg, K, and Na, Chest X Rays may be necessary, blood gases, blood Chemistry, Kidney and Liver functions. Follow ACLS ATLS procedures. Consider Hemodialisis for the removal of fluorides in Blood. DECON SIGNS & SYMPTOMS FIRST-AID MEDICAL TREATMENT

156. Minor Exposure Major Exposure DECON SIGNS & SYMPTOMS Decontamination Procedures. Not Possible If skin or eyes have been exposed decontamination procedures should be followed. Ingestion ALL EXPOSURES ARE CONSIDERED MAJOR. Signs & Symptoms. Erithema of oral mucousa. Oral injury. Bleeding of the oral cavity. Systemic Toxicity. Possible bronchial or pulmonary problems if the patient vomited.

157. FIRST-AID MEDICAL TREATMENT First-Aid Procedures. Do Not induce Vomiting. If patient is able to swallow give oral calcium solutions - or - calcium based antacids - milk or water. If unconscious obtain Medical Attention Immediately Medical Treatment Procedures.- HF destroys fiber optics - consider before using endoscopic techniques. Establish IV drip 1000 cc Normal Saline + 20cc - 10% calcium gluconate. If possible install a naso-gastric or oral-gastric tube. Gastric Lavage with calcium solutions, calcium or magnesium based antacids. Systemic Toxicity Control. The amount of calcium or magnesium to be administed will depend on the serum levels. Monitor ECG, Electrolytes, with special interest on Ca, Mg, K, and Na, Chest X Rays may be necessary, blood gases, blood Chemistry, Kidney and Liver functions. Follow ACLS ATLS procedures. Consider Hemodialisis for the removal of fluorides in Blood.

158. PATIENT’S PROGNOSIS & LONG-TERM EFFECTS WILL DEPEND UPON:  EXPOSURE TIME.  DECONTAMINATION  ROUTE OF ENTRY  CONCENTRATION OF HF.  TYPE OF TREATMENT GIVEN  HOW FAST TREATMENT WAS GIVEN.  GENERAL STATE OF THE PATIENT. IF THE TREATMENT IS OPPORTUNE AND ADEQUATE, PROGNOSIS WILL BE GOOD IN MOST CASES.

159. MEDICATION & DRESSING MATERIALS THAT SHOULD EXIST WHEREVER HF IS HANDLED

160. 1. I I I IN THE FIELD

161.  DECONTAMINATION UNITS CONSIST OF : √ SAFETY SHOWER √ EYEWASH √ SEALED BOX WITH: *PAIRS OF GLOVES *PAIRS OF GLOVES *2 TUBES OF HF GEL 30 GRAMS EACH *2 TUBES OF HF GEL 30 GRAMS EACH *1 ALUMINIZED PLASTIC SHEET *1 ALUMINIZED PLASTIC SHEET

162. 2. IN AN AMBULANCE, MEDICAL AREAS, OR ANY WHERE MEDICALLY TRAINED PROFESSIONALS ARE AVAILABLE

163. ALUMINIZED PLASTIC SHEETS ALUMINIZED PLASTIC SHEETS HF GEL 2.5% HF GEL 2.5% EYE IRRIGATION SOLUTION 1% EYE IRRIGATION SOLUTION 1% NEBULIZING SOLUTION 2.5% NEBULIZING SOLUTION 2.5% 5 CALCIUM GLUCONATE AMPS 5 CALCIUM GLUCONATE AMPS NORMAL SALINE IV SOLUTION NORMAL SALINE IV SOLUTION WATER SOLUBLE LUBRICANT GEL WATER SOLUBLE LUBRICANT GEL LOCAL OPTHAMALIC ANESTHETIC LOCAL OPTHAMALIC ANESTHETIC GLOVES – LATEX, PVC OR NEOPRENE GLOVES – LATEX, PVC OR NEOPRENE HYPODERMICS, SEVERAL SIZES & CALIBERS, STAINLESS STEEL NEEDLES HYPODERMICS, SEVERAL SIZES & CALIBERS, STAINLESS STEEL NEEDLES MORGAN LENS MORGAN LENS

164. MORGAN LENS DELIVERY SYSTEM (Y) MORGAN LENS DELIVERY SYSTEM (Y) IV DELIVERY SYSTEMS IV DELIVERY SYSTEMS COLD PACKS COLD PACKS TRACHEOSTOMY KIT TRACHEOSTOMY KIT WELL STOCKED EMERGENCY CART WELL STOCKED EMERGENCY CART DEFIB / MONITOR UNIT DEFIB / MONITOR UNIT INHALATION THERAPY EQUIPMENT INHALATION THERAPY EQUIPMENT NEBULIZERS NEBULIZERS MINOR SURGICAL KIT MINOR SURGICAL KIT CALCIUM EFFERVESCENT TABLETS CALCIUM EFFERVESCENT TABLETS DRESSING MATERIALS DRESSING MATERIALS

165. 3. HYDROFLUORIC ACID KIT

166.  SHOULD BE IN CONTROL ROOMS OR WELL CONTROLLED AREAS. THEY ARE COMPOSED OF TWO MAIN PARTS: A. INHALATION THERAPY UNIT O(2) CYLINDER VALVE, FLOWMETER PRESSURE METER NEBULIZER, TUBING & MASK. B. ONE PORTABLE CONTAINER THAT CONTAINS: *4 PAIRSOF GLOVES – LATEX, PVC, NEOPRENE *1 FLASHLIGHT *1 LITER OF 1% CALCIUM SOLUTION IN NORMAL SALINE NORMAL SALINE

167. *1 LITER OF 2.5% CALCIUM SOLUTION IN NORMAL SALINE NORMAL SALINE *8 TUBES OF HF GEL, 2.5% *8 TUBES OF HF GEL, 2.5% *5 AMP OF CALCIUM GLUCONATE, 10% SOL *5 AMP OF CALCIUM GLUCONATE, 10% SOL *5 NEEDLES, 25 CAL 1 ½” LONG, STAINLESS *5 NEEDLES, 25 CAL 1 ½” LONG, STAINLESS STEEL STEEL *20 STERILE GAUZE *20 STERILE GAUZE *2 TOURNIQUETS *2 TOURNIQUETS *2 IV TUBING SETS *2 IV TUBING SETS *4 BOTTLES OF ANTACID (CALCIUM OR *4 BOTTLES OF ANTACID (CALCIUM OR MAGNESIUM BASED) MAGNESIUM BASED)

168. *2 IV TUBING SETS *2 IV TUBING SETS *4 BOTTLES OF ANTACID (CALCIUM OR *4 BOTTLES OF ANTACID (CALCIUM OR MAGNESIUM BASED) MAGNESIUM BASED) *1 BOTTLE OF EFFERVESCENT CALCIUM *1 BOTTLE OF EFFERVESCENT CALCIUM TABLETS TABLETS *1 BOTTLE OF LOCAL EYE ANESTHETIC *1 BOTTLE OF LOCAL EYE ANESTHETIC *2 COLD PACKS *2 COLD PACKS *2 MAYO CANULAS *2 MAYO CANULAS *2 ALUMINIZED PLATIC SHEETS *2 ALUMINIZED PLATIC SHEETS *1 TUBE OF LUBRICATING GEL *1 TUBE OF LUBRICATING GEL *2 STERILE CONTAINERS *2 STERILE CONTAINERS *1 IV INFUSOR *1 IV INFUSOR *4 MORGAN LENSES *4 MORGAN LENSES

169. KEYS TO GOOD CONTROL WITH HF AVOID EXPOSURES THROUGH : * CONTINUOUS EDUCATION. * GOOD INDUSTRIAL HYGIENE PRACTICES. * MAXIMUM SAFETY IN HANDLING HF ON & OFF-SITE. *CONTINOUS MEDICAL TRAINING ON & OFF-SITE. *PARTICIPATE IN NEIGHBORING COMMUNITY HOSPITALS, EMS, AND OTHER AGENCIES, SO THAT YOU MAY BE PREPARED FOR ANY CONTIGENCY.

173. SO, PRODUCE, STORE, HANDLE AND DISPOUSE ALL HAZARDOUS CHEMICALS DISPOUSE ALL HAZARDOUS CHEMICALS WITH RESPECT AND KNOWLEDGE

174. FOR YOUR ATTENTION AND PATIENCE THANK YOU VERY MUCH !!!