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{{Infobox disease {{Infobox medical condition (new)
| Name = Chlorine gas poisoning | name = Chlorine poisoning
| Image = | synonyms = Chlorine gas toxicity
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'''Chlorine gas poisoning''', also known as '''bertholite poisoning''', is illness resulting from the toxic effect of ] in its gaseous states. It occurs after the inhalation of ] beyond the ]. Chlorine gas is a toxic gas and pulmonary irritant with intermediate water solubility that causes acute damage to the receptors in the epithelium of the ]. '''Chlorine gas poisoning''' is an illness resulting from the effects of exposure to ] beyond the ].


==Signs and symptoms==
The dose inhaled determines the ] on the respiratory tract. Occupational exposures constitute the highest risk of toxicity and common domestic exposure results from the mixing of ] with ] such as ], ] and ].
The signs of acute chlorine gas poisoning are primarily respiratory, and include ] and cough; listening to the lungs will generally reveal ]. There will generally be sneezing, nose irritation, burning sensations, and throat irritations. There may also be skin irritations or chemical burns and eye irritation or conjunctivitis. A person with chlorine gas poisoning may also have nausea, vomiting, or a headache.<ref name=Jones2010rev>Jones R, Wills B, Kang C. Chlorine gas: an evolving hazardous material threat and unconventional weapon. West J Emerg Med. 2010 May;11(2):151-6. {{PMID|20823965}} </ref><ref name=White2010rev>White CW, Martin JG. Chlorine gas inhalation: human clinical evidence of toxicity and experience in animal models. Proc Am Thorac Soc. 2010 Jul;7(4):257-63. Review. {{PMID|20601629}} </ref><ref name=medscapeOver>Gerald F O'Malley, GF et al. Medscape Drugs & Diseases, Ed. Dembek, ZF. Updated: Dec 11, 2015</ref>


Prolonged exposure to low concentration of chlorine gas may have lethal effects, as can short-term exposure to high concentrations. Chronic exposure to relatively low levels of chlorine gas may cause pulmonary problems like acute wheezing attacks, chronic cough with phlegm, and asthma.<ref name=White2010rev/>


==Causes==
Chlorine gas damages the respiratory tract using a ] involving the exchange of ] (HCO<sub>3</sub><sup>−</sup>) and ] (Cl<sup>−</sup>) across the membrane of ]s (RBCs).
Occupational exposures constitute the highest risk of toxicity and common domestic exposures result from the mixing of ] with ] such as ], ] or ]. They also occur as a result of the chlorination of table water. Other exposure risks occur during industrial or transportation accidents. Wartime exposure is rare.<ref name=White2010rev/><ref name=medscapeOver/>


===Dose toxicity===
The cell membranes of red blood cells are impermeable to hydrogen ions but exchange bicarbonate ions for chloride ions using the anion exchanger protein ] and a rise in intracellular bicarbonate causes chloride intake and bicarbonate export. As a result, blood chloride concentration is lower in systemic venous blood than in pulmonary circulation because the levels of CO<sub>2</sub> and therefore bicarbonate are higher in systemic venous blood, providing less of a driving force for exchange. Excess chlorine gas in the lung and bloodstream deregulate the affinity of ] for ] through the chloride ion acting as an ] inhibitor.
Humans can smell chlorine gas at ranges from 0.1–0.3 ppm. According to a review from 2010: "At 1–3 ppm, there is mild mucous membrane irritation that can usually be tolerated for about an hour. At 5–15 ppm, there is moderate mucous membrane irritation. At 30 ppm and beyond, there is immediate chest pain, shortness of breath, and cough. At approximately 40–60 ppm, a toxic pneumonitis and/or acute pulmonary edema can develop. Concentrations of about 400 ppm and beyond are generally fatal over 30 minutes, and at 1,000 ppm and above, fatality ensues within only a few minutes."<ref name=White2010rev/>


==Mechanism==
The concentration of the inhaled gas and duration of exposure and water contents of the tissues exposed are the key determinants of toxicity; moist tissues like the eyes, throat, and lungs are the most susceptible to damage.<ref name=CDCbasic>CDC Page last reviewed April 10, 2013. Page last updated April 10, 2013</ref>


Once inhaled, chlorine gas diffuses into the epithelial lining fluid (ELF) of the ] and may directly interact with small molecules, proteins and lipids there and damage them, or may ] to ] and ] which in turn generate chloride ions and ]; the dominant theory is that most damage is via the acids.<ref name=White2010rev/><ref name=medscapeOver/><ref name=Mechanism2010rev>Squadrito GL, Postlethwait EM, Matalon S. Elucidating mechanisms of chlorine toxicity: reaction kinetics, thermodynamics, and physiological implications. Am J Physiol Lung Cell Mol Physiol. 2010 Sep;299(3):L289-300. Review. {{PMID|20525917}} </ref><ref name=ATSDRtreatment>Agency for Toxic Substances and Disease Registry via the CDC. Page last reviewed: October 21, 2014. Page last updated: October 21, 2014</ref>
Symptoms of mild ] include sneezing, tearing, nose irritation and throat irritation, while larger exposures can lead to significant toxicity of the respiratory tract and heart and sometimes death. Following acute poisoning, long-term sequelae often occur and chronic exposure to low levels of chlorine gas can lead to memory loss.


==Diagnosis==
==Signs and symptoms==
Tests performed to confirm chlorine gas poisoning and monitor patients for supportive care include pulse oximetry, testing serum electrolyte, blood urea nitrogen (BUN), and creatinine levels, measuring arterial blood gases, chest radiography, electrocardiogram (ECG), pulmonary function testing, and laryngoscopy or bronchoscopy.<ref name=medscapeOver/>
The signs of acute chlorine gas poisoning are primarily respiratory, and include ] and cough. There may also be skin irritation or chemical burns and eye irritation or conjunctivitis. A person with chlorine gas poisoning may also have nausea, vomiting, a runny nose, or a headache.<ref name=Jones2010>Jones R, Wills B, Kang C. Chlorine gas: an evolving hazardous material threat and unconventional weapon. West J Emerg Med. 2010 May;11(2):151-6. PMID 20823965 </ref>


==Treatment==
Holding <ref name=ATSDRtreatment>Agency for Toxic Substances and Disease Registry via the CDC. Page last reviewed: October 21, 2014. Page last updated: October 21, 2014</ref> Chlorine gas exposure may lead to a significantly shorter life span due to heart damage. Individual tolerance level for chlorine gas may be altered by several factors, such as ], hematological disorders and barometric pressure.<ref name=medscapeOver>Gerald F O'Malley, GF et al. Medscape Drugs & Diseases, Ed. Dembek, ZF. Updated: Dec 11, 2015</ref>
There is no antidote for chlorine poisoning; management is ] after evacuating people from the site of exposure and flushing exposed tissues. For lung damage caused by inhalation, oxygen and ] may be administered.<ref name=ATSDRtreatment/>


==Outcomes==
===Acute poisoning===
There is no way to predict outcomes. Most people with mild to moderate exposure generally recover fully in three to five days, but some develop chronic problems such as ]. Smoking or pre-existing lung conditions like asthma appear to increase the risk of long term complications.<ref name=Jones2010rev/>
The primary manifestations of chlorine gas poisoning develop in the organ systems most dependent on oxygen use: the central nervous system and the heart. The initial symptoms of acute chlorine gas poisoning include dyspnea, nausea and vomiting, violent cough, chest pains, lightheadedness, headache and muscle weakness.


==Epidemiology==
These symptoms are synonymous to those of ] or other illnesses such as gastroenteritis or ]. Headache is the most common symptom of acute chlorine gas poisoning; it is often described as dull, frontal, and continuous. Increasing exposure produces cardiac abnormalities including fast heart rate, ], ] and ]. Less common symptoms of acute chlorine gas poisoning include ], ], muscle necrosis, ] and ].
In 2014, the ] reported about 6,000 exposures to chlorine gas in the US in 2013, compared with 13,600 exposures to ], which was the most common poison gas exposure;<ref>Mowry JB, et al 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol. 2015;53(10):962-1147. {{PMID|26624241}}. Page 1089</ref> the year before they reported about 5,500 cases of chlorine gas poisoning compared with around 14,300 cases of carbon monoxide poisoning.<ref>Mowry JB, et al. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol. 2014 Dec;52(10):1032-283. {{PMID|25559822}} Page 1225</ref>


===Chronic poisoning=== ==Mass poisoning incidents==
===Wartime===
Chronic exposure to relatively low levels of chlorine gas may cause persistent headaches, lightheadedness, nausea and vomiting. Like carbon monoxide poisoning, symptoms usually resolve themselves upon removal of exposure to the gas, unless there has been an episode of severe acute poisoning. Sea water is a large source of chlorine and a typical source of poisoning is exposure to the organic solvent dichloromethane, found in some paint strippers.
: {{Main|Chlorine#Use as a weapon}}
* In 1915, the German Army used chlorine against Allied soldiers in the 2nd ].
* In 2007 ] by insurgents in the ],<ref>David Cloud for the New York Times. May 21, 2007 </ref>
* In 2014 ] in ], ].<ref>{{cite news|url=http://www.ft.com/cms/s/0/5685e9c0-cdf3-11e3-9dfd-00144feabdc0.html#axzz30AxkhyIc|title=Syria fails to remove all chemical weapons as deadline passes|work=Financial Times|date=27 April 2014|access-date=12 September 2014}}</ref>


===Industrial accidents===
==Pathophysiology==
====United States====
Chlorine gas is non-combustible at room temperature and pressure. It is heavier than air in its pure state, causing it to remain near to the ground level, thereby increasing the exposure time. The odour threshold level for chlorine gas is approximately 0.3 - 0.5 ppm accounting for why the differentiation of toxic air levels from permissible air levels may seem difficult until irritative symptoms develop. The degree of exposure determines the lethality and severity of symptoms and rapidity of onset.
There have been many instances of mass chlorine gas poisonings in industrial accidents.
* In 2002 in ], a flex hose ruptured during unloading a ] at a chemical plant, releasing approximately {{convert|16900|lb}} of chlorine gas. 67 persons were injured.<ref name=Jones2010rev/>
* In 2004 in ], ], a ] accident released {{convert|9400|gal}} of chlorine gas and other toxic chemicals. At least 40 people were injured and three died, including two residents and the train conductor.<ref>{{Cite book|title=Collision of Union Pacific Railroad train MHOTU-23 with BNSF Railway Company train MEAP-TUL-126-D with subsequent derailment and hazardous materials release, Macdona, Texas, June 28, 2004|date=2006|publisher=United States National Transportation Safety Board|oclc=75276300|url=https://www.ntsb.gov/investigations/AccidentReports/Reports/RAR0603.pdf}}</ref>
* In 2005 in ] a freight train derailed, releasing an estimated {{convert|11500|USgal}} of chlorine. Nine people died, and at least 529 persons sought medical care.<ref>CDC </ref>


====Globally====
Chlorine gas dissolves in water to form chlorine water (HOCl) or ] and HCl. Chlorine reacts with ammonia gas to produce ], commonly used as a disinfectant. Chloramine decomposes in the presence of water to produce hydrochloric acid or hypochlorous acid. Due to the affinity of chloramine for water, chloramine exposures result in rapid symptom development.
* In 2015, In ], the explosion of a chlorine gas storage tank at a ] in ] killed eight people.<ref>Michael Olukayode for Bloomberg News. July 25, 2015 </ref>
The exact mechanisms by which the effects of chlorine gas poisoning are induced upon bodily systems are complex and poorly understood.
* In 2017, chlorine gas was released in ], ], Canada, after chemicals were mixed improperly at a water treatment plant. In 2020 the ] was fined $150,000 (CAD) for the incident.<ref>The Canadian Press. September 11, 2020 </ref>
* In 2017, in ], at least 475 people, including nine firemen, suffered respiratory and other symptoms after a chlorine gas leak in the southwestern Iranian province of ].{{cn|date=July 2021}}
*In 2020, on March 6, an incident occurred at EPCL (Engro Polymer and Chemicals Limited) Port Qasim, ], where over 50 people were hospitalized as a result of chlorine gas leakage. No fatalities were reported.<ref>{{Cite web|url=https://www.samaa.tv/news/pakistan/2020/03/port-qasim-chemical-leak-karachi/|title=Over 50 hospitalised after chemical leak at Karachi Engro factory {{!}} SAMAA|website=Samaa TV|date=6 March 2020 |language=en-US|access-date=2020-03-06}}</ref>
*In 2022, on June 27, a tank holding chlorine gas in the port of ], ], ]. 14 people were killed and more than 260 were injured.<ref>{{cite web | url=https://www.jordannews.jo/Section-109/News/Update-11-dead-over-250-injured-after-chlorine-gas-tank-ruptures-at-Aqaba-Port-18621 | title=Update: 13 dead, over 260 injured after chlorine gas tank ruptures at Aqaba Port - Jordan News &#124; Latest News from Jordan, MENA | date=27 June 2022 }}</ref>


==References==
The mechanisms of the biological activity of chlorine gas poisoning are not fully understood. The anatomic site of injury varies, depending on the produced chemical species. ] is more soluble in water than chlorine gas. Hydrochloric acid primarily target the upper respiratory mucous membranes and the epithelia of the ocular conjunctivae.
{{Reflist}}
Hypochlorous acid has a similar injury pattern to hydrochloric acid and is more soluble in water than hydrochloric acid.
The concentration of the inhaled gas, duration of exposure, water contents of the tissues exposed and individual susceptibility play a crucial role on the fatality of exposure.
Acute inflammation of the conjunctivae, pharynx, nose, trachea and bronchi are immediate effects of chlorine gas poisoning.
Chlorine gas poisoning poses severe pathological threats. The pathological effects of the poisoning includes pneumonia, pneumonitis, tracheobronchitis, pulmonary edema, multiple pulmonary thrombosis and ulcerative{{clarify|date=July 2015}} but the hallmark of the pathological effects is "pulmonary edema", clinically manifested as "dyspnea", hypoxia and adventitious lung sounds.


==Etiology== ==Further reading==
* {{cite journal | last1=Beach | first1=F. X. M. | last2=Jones | first2=E. S. | last3=Scarrow | first3=G. D. | title=Respiratory effects of chlorine gas | journal=Occupational and Environmental Medicine | publisher=BMJ | volume=26 | issue=3 | date=1 July 1969 | issn=1351-0711 | doi=10.1136/oem.26.3.231 | pages=231–236| pmid=5794948 | pmc=1008943 | s2cid=36220465 }}
Occupational exposures constitute the highest risk of toxicity and common domestic exposures result from the mixing of ] with ] such as ], ] and ]. They also occur as a result of the chlorination of table water.<ref>{{cite web|url=http://www.cdc.gov/healthywater/swimming/data/mmwr-pool-chemicals.html|title=CDC - Swimming Pool Chemicals - Healthy Swimming & Recreational Water - Healthy Water|work=cdc.gov}}</ref> Other exposure risks occur during industrial or transportation accidents. Wartime exposure is rare.<ref>{{cite web|url=http://www.ncbi.nlm.nih.gov/pubmed/17851445|title=Ocular and respiratory illness associated with an indoor swimming pool--Nebraska, 2006.|author=Centers for Disease Control and Prevention (CDC)|work=nih.gov}}</ref>
* {{cite journal | last1=Black | first1=J. E. | last2=Glenny | first2=E. T. | last3=McNee | first3=J. W. | title=Observations on 685 Cases of Poisoning by Noxious Gases Used by the Enemy | journal=BMJ | volume=2 | issue=2848 | date=31 July 1915 | issn=0959-8138 | doi=10.1136/bmj.2.2848.165 | pages=165–167| pmid=20767740 | pmc=2302752 }}
* {{cite journal | last1=Das | first1=Rupali | last2=Blanc | first2=Paul D. | title=Chlorine Gas Exposure and the Lung: A Review | journal=Toxicology and Industrial Health | publisher=SAGE Publications | volume=9 | issue=3 | year=1993 | issn=0748-2337 | doi=10.1177/074823379300900304 | pages=439–455| pmid=8367885 | bibcode=1993ToxIH...9..439D | s2cid=41284283 }}
* {{cite journal | last1=Chen | first1=Jing | last2=Mo | first2=Yiqun | last3=Schlueter | first3=Connie F. | last4=Hoyle | first4=Gary W. | title=Inhibition of chlorine-induced pulmonary inflammation and edema by mometasone and budesonide | journal=Toxicology and Applied Pharmacology | publisher=Elsevier BV | volume=272 | issue=2 | year=2013 | issn=0041-008X | doi=10.1016/j.taap.2013.06.009 | pages=408–413| pmid=23800689 | pmc=4005342 | bibcode=2013ToxAP.272..408C }}
* {{citation | last1=Fang | first1=Boliang | last2=Qian | first2=Suyun | last3=Li | first3=Zheng | last4=Gao | first4=Hengmiao | last5=Xu | first5=Wenmiao | last6=Ding | first6=Nan | title=Case report: Acute respiratory distress syndrome and shock caused by severe chlorine gas poisoning was successfully cured by venous-arterial extracorporeal membrane oxygenation | publisher=Authorea, Inc. | date=10 September 2020 | doi=10.22541/au.159969877.77536109| s2cid=242964247 }}
* {{cite journal | last1=Govier | first1=P. | last2=Coulson | first2=J.M. | title=Civilian exposure to chlorine gas: A systematic review | journal=Toxicology Letters | publisher=Elsevier BV | volume=293 | year=2018 | issn=0378-4274 | doi=10.1016/j.toxlet.2018.01.014 | pages=249–252| pmid=29355691 | s2cid=38779390 }}
* {{cite journal | last1=Zellner | first1=Tobias | last2=Eyer | first2=Florian | title=Choking agents and chlorine gas – History, pathophysiology, clinical effects and treatment | journal=Toxicology Letters | publisher=Elsevier BV | volume=320 | year=2020 | issn=0378-4274 | doi=10.1016/j.toxlet.2019.12.005 | pages=73–79| pmid=31811912 | s2cid=208870299 }}


{{CDC|article=Public Health Consequences from Hazardous Substances Acutely Released During Rail Transit --- South Carolina, 2005; Selected States, 1999--2004|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a2.htm}}
==Epidemology==
In 2011, the annual report of the ]' National Poison Data System (NPDS) confirmed that the United States has the highest exposure to chlorine gas. It reported that "3,988 exposures to chlorine gas, 1,524 single exposures to chlorine gas when household acid is mixed with hypochlorite, and 701 single exposures to chloramine gas".<ref>{{cite web|url=http://www.ncbi.nlm.nih.gov/pubmed/23272763|title=2011 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 29th Annual Report. |vauthors=Bronstein AC, etal |work=nih.gov}}</ref>
On July 26, 2015, it was reported that 14 people died and several others were injured from a chlorine gas explosion in ].
Globally, it constitutes a major cause of toxic release incidents.<ref>{{cite web|url=http://www.thisdaylive.com/articles/14-dead-scores-injured-as-chlorine-gas-explodes-in-jos/215656/|title=14 Dead, Scores Injured as Chlorine Gas Explodes in Jos, Articles - THISDAY LIVE|work=thisdaylive.com}}</ref>


== External links ==
==References==
{{Medical resources
{{Research help|Med}}
| DiseasesDB =
{{Reflist|2}}
| ICD10 = {{ICD10|T|59.4}}
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{{Poisoning and toxicity}} {{Poisoning and toxicity}}


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Latest revision as of 20:31, 27 October 2024

This article's lead section may be too short to adequately summarize the key points. Please consider expanding the lead to provide an accessible overview of all important aspects of the article. (October 2024)
Medical condition
Chlorine poisoning
Other namesChlorine gas toxicity
SpecialtyEmergency medicine

Chlorine gas poisoning is an illness resulting from the effects of exposure to chlorine beyond the threshold limit value.

Signs and symptoms

The signs of acute chlorine gas poisoning are primarily respiratory, and include difficulty breathing and cough; listening to the lungs will generally reveal crackles. There will generally be sneezing, nose irritation, burning sensations, and throat irritations. There may also be skin irritations or chemical burns and eye irritation or conjunctivitis. A person with chlorine gas poisoning may also have nausea, vomiting, or a headache.

Chronic exposure to relatively low levels of chlorine gas may cause pulmonary problems like acute wheezing attacks, chronic cough with phlegm, and asthma.

Causes

Occupational exposures constitute the highest risk of toxicity and common domestic exposures result from the mixing of chlorine bleach with acidic washing agents such as acetic, nitric or phosphoric acid. They also occur as a result of the chlorination of table water. Other exposure risks occur during industrial or transportation accidents. Wartime exposure is rare.

Dose toxicity

Humans can smell chlorine gas at ranges from 0.1–0.3 ppm. According to a review from 2010: "At 1–3 ppm, there is mild mucous membrane irritation that can usually be tolerated for about an hour. At 5–15 ppm, there is moderate mucous membrane irritation. At 30 ppm and beyond, there is immediate chest pain, shortness of breath, and cough. At approximately 40–60 ppm, a toxic pneumonitis and/or acute pulmonary edema can develop. Concentrations of about 400 ppm and beyond are generally fatal over 30 minutes, and at 1,000 ppm and above, fatality ensues within only a few minutes."

Mechanism

The concentration of the inhaled gas and duration of exposure and water contents of the tissues exposed are the key determinants of toxicity; moist tissues like the eyes, throat, and lungs are the most susceptible to damage.

Once inhaled, chlorine gas diffuses into the epithelial lining fluid (ELF) of the respiratory epithelium and may directly interact with small molecules, proteins and lipids there and damage them, or may hydrolyze to hypochlorous acid and hydrochloric acid which in turn generate chloride ions and reactive oxygen species; the dominant theory is that most damage is via the acids.

Diagnosis

Tests performed to confirm chlorine gas poisoning and monitor patients for supportive care include pulse oximetry, testing serum electrolyte, blood urea nitrogen (BUN), and creatinine levels, measuring arterial blood gases, chest radiography, electrocardiogram (ECG), pulmonary function testing, and laryngoscopy or bronchoscopy.

Treatment

There is no antidote for chlorine poisoning; management is supportive after evacuating people from the site of exposure and flushing exposed tissues. For lung damage caused by inhalation, oxygen and bronchodilators may be administered.

Outcomes

There is no way to predict outcomes. Most people with mild to moderate exposure generally recover fully in three to five days, but some develop chronic problems such as reactive airway disease. Smoking or pre-existing lung conditions like asthma appear to increase the risk of long term complications.

Epidemiology

In 2014, the American Association of Poison Control Centers reported about 6,000 exposures to chlorine gas in the US in 2013, compared with 13,600 exposures to carbon monoxide, which was the most common poison gas exposure; the year before they reported about 5,500 cases of chlorine gas poisoning compared with around 14,300 cases of carbon monoxide poisoning.

Mass poisoning incidents

Wartime

Main article: Chlorine § Use as a weapon

Industrial accidents

United States

There have been many instances of mass chlorine gas poisonings in industrial accidents.

  • In 2002 in Missouri, a flex hose ruptured during unloading a train car at a chemical plant, releasing approximately 16,900 pounds (7,700 kg) of chlorine gas. 67 persons were injured.
  • In 2004 in Macdona, Texas, a freight train accident released 9,400 US gallons (36,000 L; 7,800 imp gal) of chlorine gas and other toxic chemicals. At least 40 people were injured and three died, including two residents and the train conductor.
  • In 2005 in South Carolina a freight train derailed, releasing an estimated 11,500 US gallons (44,000 L; 9,600 imp gal) of chlorine. Nine people died, and at least 529 persons sought medical care.

Globally

  • In 2015, In Nigeria, the explosion of a chlorine gas storage tank at a water treatment plant in Jos killed eight people.
  • In 2017, chlorine gas was released in Fort McMurray, Alberta, Canada, after chemicals were mixed improperly at a water treatment plant. In 2020 the Regional Municipality of Wood Buffalo was fined $150,000 (CAD) for the incident.
  • In 2017, in Iran, at least 475 people, including nine firemen, suffered respiratory and other symptoms after a chlorine gas leak in the southwestern Iranian province of Khuzestan.
  • In 2020, on March 6, an incident occurred at EPCL (Engro Polymer and Chemicals Limited) Port Qasim, Karachi, where over 50 people were hospitalized as a result of chlorine gas leakage. No fatalities were reported.
  • In 2022, on June 27, a tank holding chlorine gas in the port of Aqaba, Jordan, fell and ruptured. 14 people were killed and more than 260 were injured.

References

  1. ^ Jones R, Wills B, Kang C. Chlorine gas: an evolving hazardous material threat and unconventional weapon. West J Emerg Med. 2010 May;11(2):151-6. PMID 20823965 PMC 2908650
  2. ^ White CW, Martin JG. Chlorine gas inhalation: human clinical evidence of toxicity and experience in animal models. Proc Am Thorac Soc. 2010 Jul;7(4):257-63. Review. PMID 20601629 PMC 3136961
  3. ^ Gerald F O'Malley, GF et al. Chlorine Toxicity Medscape Drugs & Diseases, Ed. Dembek, ZF. Updated: Dec 11, 2015
  4. CDC Basic Facts Page last reviewed April 10, 2013. Page last updated April 10, 2013
  5. Squadrito GL, Postlethwait EM, Matalon S. Elucidating mechanisms of chlorine toxicity: reaction kinetics, thermodynamics, and physiological implications. Am J Physiol Lung Cell Mol Physiol. 2010 Sep;299(3):L289-300. Review. PMID 20525917 PMC 2951076
  6. ^ Agency for Toxic Substances and Disease Registry via the CDC. Medical Management Guidelines: Chlorine Page last reviewed: October 21, 2014. Page last updated: October 21, 2014
  7. Mowry JB, et al 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol. 2015;53(10):962-1147. PMID 26624241. Page 1089
  8. Mowry JB, et al. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol. 2014 Dec;52(10):1032-283. PMID 25559822 PMC 4782684 Page 1225
  9. David Cloud for the New York Times. May 21, 2007 7 U.S. Soldiers Die in Iraq, 6 in Sweep of Baghdad
  10. "Syria fails to remove all chemical weapons as deadline passes". Financial Times. 27 April 2014. Retrieved 12 September 2014.
  11. Collision of Union Pacific Railroad train MHOTU-23 with BNSF Railway Company train MEAP-TUL-126-D with subsequent derailment and hazardous materials release, Macdona, Texas, June 28, 2004 (PDF). United States National Transportation Safety Board. 2006. OCLC 75276300.
  12. CDC Public Health Consequences from Hazardous Substances Acutely Released During Rail Transit --- South Carolina, 2005; Selected States, 1999--2004
  13. Michael Olukayode for Bloomberg News. July 25, 2015 Nigeria Says 8 People Dead After Inhaling Chlorine Gas in Jos
  14. The Canadian Press. September 11, 2020 Regional Municipality in Northern Alberta Fined for Releasing Chlorine Gas
  15. "Over 50 hospitalised after chemical leak at Karachi Engro factory | SAMAA". Samaa TV. 6 March 2020. Retrieved 2020-03-06.
  16. "Update: 13 dead, over 260 injured after chlorine gas tank ruptures at Aqaba Port - Jordan News | Latest News from Jordan, MENA". 27 June 2022.

Further reading

Public Domain This article incorporates public domain material from Public Health Consequences from Hazardous Substances Acutely Released During Rail Transit --- South Carolina, 2005; Selected States, 1999--2004. Centers for Disease Control and Prevention.

External links

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