Discussion

Chlorine gas is an irritant to the lungs, eyes, and throat causing burning sensation and watering from eyes, cough, and shortness of breath. It is a toxic inhalant and the victims showed a latency period from the time of exposure to the development of symptoms. ^{Reference Cone, MacMillan and Parwani8,Reference Neal9} Clinical signs and symptoms of chlorine gas reported in previous studies include eye irritation, shortness of breath, chest discomfort, sore throat, and dizziness. This study shows symptoms of cough and dyspnea, followed by sore throat and wheezing, as did the studies of Cevik, et al and Bosse, et al. ^{Reference Cevik, Onay, Akmaz and Sezigen10,Reference Bosse11} The important chlorine gas exposure scenarios include exposure to home cleaning products, chlorination reactions in swimming pool, chlorine, transportation accidents, industry-related accidents, and exposure to chemical warfare. ^{Reference Vajner and Lung2} Household cleaners including toilet cleaners, drain openers, and window cleaners contain chlorine and can be the source for accidental or intentional exposure. ^{Reference Vajner and Lung2} Chlorination of swimming pools is another source of chlorine gas exposure and several incidents were reported in the literature. ^{Reference Evans12-Reference Mohan, Kumar, Rao, Bollineni and Manohar14} Chlorine gas was first used as chemical warfare in World War I against allied forces in Ypres, Belgium. ^{Reference Szinicz15} Chlorine is used in a variety of industries, including pesticides, pharmaceutical, plastic, paper, rubber, cosmetic, disinfectant, and battery industry, hence producing the possibility of industrial chlorine exposure. ^{Reference Martinez and Long16-Reference Winder19} Transport-related accidents were also reported. ^{Reference Jones, Wills and Kang20,Reference Van Sickle, Wenck and Belflower21} In this study, the patients were exposed to chlorine gas in a metal melting factory. The total number of patients in this study was 15, and the majority of patients had cough (73.3%); while in another study by Joo-An Kim, et al, cough was found in only 29.6% of patients; and finally in another study by Mohan, et al, cough was found in 97.0% of patients. ^{Reference Mohan, Kumar, Rao, Bollineni and Manohar14,Reference Kim, Yoon and Cho22} The symptom of eye irritation is 66.6% in this study, whereas the Mohan, et al study showed eye irritation in 88.0% of victims. ^{Reference Mohan, Kumar, Rao, Bollineni and Manohar14} The rate of admission (40%) is higher in this study as compared to the study done by Mohan, et al (18.7%) and is almost similar to the study done by Lehavi, et al (50%). ^{Reference Mohan, Kumar, Rao, Bollineni and Manohar14,Reference Lhavi, Leiba and Dahan23} Scene safety is essential in cases of chlorine gas incidents. Level A or B PPE is advised in large-scale industrial or warfare incidents. ^{Reference Martinez and Long16} In swimming pool and residential exposure incidents, PPE is not required as gas dissipates in the air very quickly. ^{Reference Martinez and Long16} In most of the incidents except warfare, large transportation, or large industrial accidents, removal of patients from the site of accident with removal of clothes is enough scene decontamination measures. The main pathophysiology of chlorine toxic effects is due to its reaction with water contained in cells of the conjunctiva epithelium, oral, pharyngeal, nasal, and alveolar mucosa, resulting in cell edema and cell lysis. ^{Reference Barrow, Alarie, Warrick and Stock24-Reference Schraufstaetter, Browne and Harris26} Cough and dyspnea followed by sore throat and wheezing are the most common symptoms, as shown in this study. ^{Reference Cevik, Onay, Akmaz and Sezigen10,Reference Bosse11} Physical examination findings include tachycardia, tachypnea, rhonchi, wheeze, and use of accessory muscles for breathing. The Guloglu, et al study showed wheeze as the main pulmonary finding on physical examination. ^{Reference Güloğlu, Kara and Erten27} Restrictive, obstructive, or both features may be present in the pulmonary function tests. ^{Reference Barret and Faure28,Reference Moulick, Banavali and Abhyankar29} The Van Sickle, et al study showed that hydrogen ion derangement and hypoxia on arrival are associated with a prolonged length of hospital stay. ^{Reference Van Sickle, Wenck and Belflower21} Usually, oxygen saturation and clinical judgment are used to triage chlorine-affected patients. ^{Reference Kirk and Deaton30-Reference Eldridge, Richardson and Michels32} The Culley, et al study of the Graniteville (South Carolina USA) chlorine spill (2005) showed that oxygen saturation has a predictive value in determining the severity of lung injury in chlorine gas exposure patients. ^{Reference Culley, Svendsen, Craig and Tavakoli33} Different triage systems studied previously have not shown any efficacy helping prioritize chlorine-affected patients. ^{Reference Culley, Svendsen, Craig and Tavakoli33} Chlorine is one of the agents, along with ammonia and sulphur dioxide, producing Irritant Gas Syndrome Agent (IGSA); ^{Reference Kirk and Deaton30,34} IGSA clusters have at least one of the respiratory, chest, or ear, nose, throat (ENT) symptoms. The respiratory symptoms include shortness of breath, wheeze, cough, or choking. The ENT symptoms include irritation of the throat, pain, or burning sensation, whereas chest symptoms include chest tightness, chest pain, or burning sensation of chest. ^{Reference Culley, Richter, Donevant, Tavakoli, Craig and DiNardi35} The usual triage system tends to miss the diagnosis of IGSA, along with missing latent signs of chemical agent induced respiratory distress. ^{Reference Culley, Richter, Donevant, Tavakoli, Craig and DiNardi35} The different types of triage systems include: Simple Triage and Rapid Treatment (START), JumpSTART, Sort Assess Life-saving intervention Treatment/Transport (SALT), Chemical Biological Radiological Nuclear (CBRN) mass-casualty triage system, and Emergency Severity Index (ESI). ^{Reference Cone, MacMillan and Parwani8,36-Reference Gilboy, Tanabe and Travers39} The chlorine gas inhalation management mainly depends on the oxygen saturation and clinical presentation of the exposed patients, which includes decontamination measures followed by supportive treatment with humidified supplemental oxygen, beta 2 agonist nebulization, with or without nebulized or parenteral steroids. ^{Reference White and Martin40} Pulse oximetry, peak flow monitoring is also required. Chest x-ray, electrocardiogram, arterial blood gas, full blood count, and electrolytes are required in more sick patients who need admission. ^{Reference Hoffman, Nelson, Howland, Lewin, Goldfrank and Flomenbaum41} Nebulized sodium bicarbonate was used in chlorine gas exposure victims, but its efficacy is not yet confirmed. ^{Reference Güloğlu, Kara and Erten27,Reference Done42} Decline in lung function due to chronic pulmonary inflammation and fibrosis is the usual long-term sequel of chlorine gas exposure. ^{Reference Brooks, Weiss and Bernstein43,Reference Gautrin, Boulet and Boutet44} The main fundamentals of dealing with mass-toxicological events include involved staff protection, proper decontamination of victims, use of water for decontamination at the assigned areas near the emergency, proper triage, patients care at one location, and review by the toxicologist. ^{Reference Lhavi, Leiba and Dahan23} The toxicologist, nursing, allied specialist’s notes, and related hospital charts studied for overall handling of the incidence showed that this study met all above-mentioned fundamentals for dealing with toxicological events; however, there were some gaps found during the evaluation of the incidence handling. The main gaps are the contaminated fluid runoff facility is not available. All staff are prepared to handle a general disaster, but they are not fully prepared to handle a chemical disaster or incidence. There is a need to develop a chemical disaster or incident protocol with regular drills.