1. Health Hazards of Solvents Case Study #2 James E. Cone MD, MPH and Karen Packard, RDH, MS This presentation is made possible by a grant from the Association of Occupational and Environmental Clinics and the National Institute for Occupational Safety & Health.

2. Case 2 n 24 year old male electrical parts manufacturing plant worker entered a vapor degreasing tank to clean, noted dizziness and fell unconscious to bottom of tank. n Co-worker tried to lift him out of tank. He also began feeling dizzy and climbed out of the tank.

3. Case 2 n 5-8 minutes delay until paramedics arrived n Paramedics in SCBA and protective clothing lifted patient out of tank. n Initial examination at scene of index case: cyanotic, pulseless, no spontaneous respirations n MSDS revealed 1,1,1-trichloroethane n 1,1,1-trichloroethane levels measured in the bottom of tank = 20,000 ppm. n Measured oxygen levels in tank were low due to displacement by solvent vapor.

4. Case 2 n Intubated, and CPR initiated. n Initial electrocardiogram is shown next: Laboratory: O2 Saturation reduced AST 36 (0-35), ALT 44 (0-35) CPK, CPK-MB and troponin all normal

5. Case 2 n Ongoing symptoms reported in follow-up clinic visit: –lightheadedness –trouble with speech, memory and sleep disturbance. –Shortness of breath on exertion, wheezing. Nightmares about the incident. n Physical Examination: - Normal except wheezing on forced expiration, abnormal mental status (Digit span forward = 6, reverse=4).

6. Case 2  Neuropsychological testing. Decreased grip strength on left. Otherwise normal.  PFTs : FVC 5.48 (116% of predicted), FEV1 4.48 (114%), FEV1/FVC 84%.  Methacholine challenge: Increased responsiveness to methacholine.  Psychiatric evaluation: Fear, tension, anxiety, recurrent ruminations and dreams about incident, with anger and depression.

7. Case 2 n What diagnoses does this suggest? n Is the patient disabled? n His vocation rehabilitation counselor asks whether he would be a good candidate to be a floor refinisher? What do you say? n What recommendations would you give to the employer?

8. Case 2  His diagnosis includes: (1) s/p cardiopulmonary arrest due to solvent intoxication and likely acute asphyxiation in degreasing tank (2) reactive airways disease most likely due to acute solvent overexposure (3) post-traumatic stress disorder (PTSD)  He is unlikely to be able to return to his prior employment as a vapor degreaser. He should avoid future exposures to respiratory irritants or solvents. Thus, he would not be a good candidate to be a floor refinisher.  Recommendations to employer: Confined space program.