a) Transient mild inflammation and conjunctivitis have resulted from application of liquid Freon 11 to rabbit eyes (Grant & Schuman, 1993; Anon, 1968) .
b) Liquid Halon 2402 was not an eye irritant when instilled into the conjunctival sac of rabbits (Technical Information, 1987b).
c) 1,1-dichloro-1-fluoroethane is a mild eye irritant in rabbits (Brock et al, 1995).

a) CORNEAL EDEMA was described in 2 patients undergoing cataract extraction following application of liquid Freon-12 to freeze extruding vitreous (Miller & Perdriel, 1964).
b) ANIMAL EXPOSURE: Deliberate exposure to liquid Freon-12 from a refrigerator to forcibly open rabbit eyes produced effects related to the duration of exposure as follows (Grant & Schuman, 1993):

a) CASE REPORT: Frostbite of the lips, tongue, buccal mucosa, and hard palate developed in a man after deliberate inhalation of a propellant containing propane and dichlorodifluoromethane (Elliot, 1991).
b) CASE REPORT: A 16-year-old boy developed frostbite of the lips and tongue, and first-degree burns of the esophagus after deliberate inhalation of an airbrush propellant containing 1,1-difluoroethane (Kuspis & Krenzelok, 1999).
c) DYSESTHESIA OF THE TONGUE: Dysesthesia of the tongue occurred in 15 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) HIGH CONCENTRATIONS: Ventricular fibrillation and ventricular tachycardia have been reported with inhalation exposures to high concentrations, usually deliberate abuse or industrial use or spills in poorly ventilated areas (Brady et al, 1994; Fitzgerald et al, 1993; Lerman et al, 1991; McGee et al, 1990; Clark et al, 1985; May & Blotzer, 1984; Steadman et al, 1984) .
b) LOW CONCENTRATIONS: No clear connection with exposure and cardiac dysrhythmias was found in 6 refrigerator repairmen (Antti-Poika et al, 1990). Ambulatory electrocardiograms were performed for 24 hours on the day of exposure and on a control day. Peak concentration and average level of exposure reported in the breathing zone were 3200 cm(3)/m(3) and 170 cm(3)/m(3), respectively.
c) MECHANISM: Fluorinated hydrocarbons are believed to cause dysrhythmias by sensitizing the myocardium to endogenous catecholamines (Voge, 1989). Neuroreflexes from lung receptors may play a role (Aviado & Micozzi, 1981).
d) Once cardiac dysrhythmias develop, they are difficult to reverse. Ventricular fibrillation that develops following exposure to fluorinated hydrocarbons can be treated by cardioversion; however, not always successfully (Lown, 1977; Lerman et al, 1991).

a) CASE REPORT: Three men (aged 22 to 41 years) died after inhaling 1,1-difluoroethane (HFC-152a), a common formulation for electronic spray cleaners. No report of intentional suicide was found in all 3 cases. Two spent canisters (approximate volume 500 mL) were found in 1 case, and 1 canister of the same size along with barrier asphyxiants with attached tubes (eg, plastic bag and gas mask) were found with the other 2 cases. All patients were discovered in the early to late stages of rigor mortis. Similar findings on autopsy for each case included cyanosis of the lips and fingernails, alveolar edema, and pulmonary congestion. The man in the first case also had frostbite on the dorsa of the hand, most likely due to extensive exposure to the cold exterior of the canisters while inhaling the fumes(Sakai et al, 2011).
b) Patients are often described as inhaling fluorinated hydrocarbons, becoming "high," and then developing agitation, being frightened, or engaging in physical exertion (presumably associated with increased endogenous catecholamine levels) followed by sudden collapse (Smeeton, 1985; Kamm, 1975).
c) CASE REPORT: A 32-year-old man entered a battle tank that had been degreased with trifluorotrichloroethane and rapidly became diaphoretic and lost consciousness. He was pulled from the tank, vomited, and became pulseless and apneic. CPR was initiated. He was asystolic when paramedics arrived and could not be resuscitated (Kaufman et al, 1994).

a) CASE REPORT: Two healthy men became unconscious and developed atrial fibrillation with rapid ventricular response after working in battle tanks that had been degreased with trifluorotrichloroethane (Kaufman et al, 1994). One was treated with digoxin and quinidine and converted to sinus bradycardia with ventricular and atrial ectopy, which resolved over 6 days. The other spontaneously converted to sinus rhythm.

a) An anesthetic state induced by 1,1-dichloro-1-fluoroethane has been associated with decreased blood pressure and a nodal cardiac rhythm (Johansson, 1998).

a) After a freezer exploded at a seafood factory, 43 of 80 workers exposed to chlorodifluoromethane (Freon-22) developed symptoms. Cardiovascular effects included palpitations (n=3) and chest pain (n=1). Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes (Kubota & Miyata, 2005).

a) DOGS: In dogs, inhalation of 1,1-dichloro-1-fluoroethane at 20,000 ppm caused myocardial sensitization to intravenous epinephrine (10 micrograms/kilogram), resulting in ventricular fibrillation (Brock et al, 1995).
b) DOGS: In dogs, dysrhythmias, including fibrillation, were seen on administration of epinephrine, which followed 5 minutes after exposure began; 7.5% was the lowest concentration of fluorocarbon that led to dysrhythmia (Mullin, 1979).

a) BRONCHIAL CONSTRICTION: Fluorinated hydrocarbons may cause bronchial constriction when inhaled. Inhalation of a fluorinated hydrocarbon aerosol produced a 20% or greater decrease in FEV1 in asthmatic patients (Sterling & Batten, 1976).
b) OCCUPATIONAL ASTHMA or RADS: Prolonged hyperreactivity of the airways has been reported in patients working with heated freon, although exposure to combustion products (hydrochloric acid, chlorine, phosgene) may have contributed to this effect (Malo et al, 1984; Field, 1985).
c) A 10 to 15 minute exposure to a BrF3C (Halon 1301) release without heat has led to a case of RADS with pulmonary hyperreactivity that has persisted for 7 years. The patient had no prior history of allergic or pulmonary disease (de la Hoz, 1999).
d) Among 39 patients exposed to a mixture of 'fluoroaliphatics' and n-heptane, isobutane, and diethyl acetate, 26 developed cough, 14 chest pain and shortness of breath. Symptoms persisted more than a month in 6 of the patients. Whether this was the fluorocarbon or a combination of 2 or more agents synergistically is not known (Burkhart et al, 1996).
e) REACTIVE UPPER AIRWAY SYNDROME: A man who developed RADS had symptoms of upper airway hyperreactivity to multiple triggers (de la Hoz, 1999).
f) CASE SERIES: Reactive airways dysfunction syndrome (RADS) was reported in four patients following exposure to high levels of bromochlorodifluoromethane due to release of contents from a defective fire extinguisher. Two of the 4 patients did not have any medical history of respiratory disease, 1 patient had a history of allergic rhinitis, and 1 patient had a history of childhood asthma, but he had not experienced an asthma attack in the past 10 years. All of the patients experienced cough, dyspnea, asthenia, and dizziness within days following exposure. One patient, who experienced the highest level of bromochlorodifluoromethane exposure, also developed malaise, wheezing, and limb paresthesia (Matrat et al, 2004).

a) IRRITATION: Fluorinated hydrocarbons may cause lung irritation, cough, and sore throat if inhaled (Holness & House, 1992). Respiratory arrest secondary to presumed asphyxia from displacement of ambient oxygen has been reported following severe inhalational exposure in a confined space (Johansson, 1998).

a) Dyspnea is an early symptom of severe exposures and is also reported with lower concentration exposures (Holness & House, 1992; Lerman et al, 1991). Chest tightness was reported in 39% of 31 workers exposed to a release of a Halon 1301 fire protection system designed to achieve a 7% concentration (Holness & House, 1992). Other studies found no pulmonary symptoms when the gas was administered at this concentration for 3 minutes (Call, 1973).
b) Shortness of breath occurred in 5 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) CASE REPORT: Adult respiratory distress syndrome was reported in a 60-year-old man after working with heated ski wax in an enclosed area for several hours. Severe respiratory failure developed over the next 24 hours. Endotracheal intubation was required. Severe hypoxemia (PO2=65 mmHg) persisted despite mechanical ventilation. Chest x-ray revealed bilateral reticulonodular infiltrates over both lung areas. The patient recovered over the next 6 days (Bracco & Favre, 1998).
b) CASE SERIES: Twelve factory workers presented to a local hospital with a dry cough after their shift. Exposure to an open-air discharge of fluorocarbons and pyrolysis products occurred from a neighboring factory approximately 35 meters away. Investigation of the workshop of the exposed factory workers, 22 hours after the discharge, detected perfluoroisobutylene, hydrogen fluoride, hexafluoropropylene, tetrafluoroethylene, and chlorotrifluoroethylene at levels of 0.06, 0.08, 0.7, 1.8, and 0.5 mg/m(3), respectively. One of the 12 patients died of respiratory failure within hours of presentation. The other 11 patients were transferred to another hospital due to increasing dyspnea. Urinalysis revealed a urinary fluoride concentration of greater than 1.72 mcg/mL in all patients, which was at the upper limit of the reference value. Initial chest radiographs in 5 patients demonstrated pulmonary edema, and those 5 patients also met the criteria for acute respiratory distress syndrome (ARDS). Chest radiographs in the other 6 patients showed increased lung markings and mild interstitial infiltrates. Treatment for the ARDS patients included non-invasive positive pressure ventilation (NIPPV) with IV methylprednisolone and inhaled budesonide. Two of the ARDS patients developed subcutaneous emphysema and pneumomediastinum which resolved with NIPPV treatment. CT scan of 4 ARDS patients demonstrated bilateral ground-glass opacities and interstitial pneumonia which gradually improved over a 3-month period. One patient died on day 11 due to ventilator-associated pneumonia (Tan et al, 2016).

a) CASE REPORT: A 40-year-old man presented to the emergency department with numbness and tingling of his lips and tongue 4 hours after deliberate inhalation ("huffing") of a canister containing 1,1-difluoroethane. At presentation, there was significant swelling of the patient's upper and lower lips and oropharynx, with blistering of his oral mucosa and oropharyngeal edema. He was having difficulty breathing and swallowing, necessitating intubation and mechanical ventilation. Following ventilation, the patient presented to the ICU with erythema and significant swelling on the right side of his neck with subsequent development of weeping blisters. A CT of the neck demonstrated extensive soft tissue swelling with evidence of edema on the right side of his upper neck. Laboratory data revealed a WBC of 16,800 cells/mcL with a normal differential and no bands. Improvement in the swelling and blistering occurred following administration of antihistamines, corticosteroids, and bacitracin, and the patient was eventually discharged in stable condition. Interview of the patient revealed that he had been "huffing" 1 canister per day for 3 to 4 years, and had "huffed" 3 canisters on the day of admission (Winston et al, 2015).

a) CROUP: An 11-year-old developed severe croup, requiring intubation, and pulmonary edema after inhaling a product containing capsaicin and fluorinated hydrocarbons (Winograd, 1977).
b) Pulmonary edema has been an autopsy finding in fatal cases (Phatak & Walterscheid, 2012; Lerman et al, 1991; McGee et al, 1990; Morita et al, 1977; Kamm, 1975) .
c) Pulmonary edema was reported in 5 patients with acute respiratory distress syndrome secondary to occupational exposure to fluorocarbons and pyrolysis products, including perfluoroisobutylene, hydrogen fluoride, hexafluoropropylene, tetrafluoroethylene, and chlorotrifluoroethylene (Tan et al, 2016).

a) CASE REPORT: A 16-year-old boy developed frostbite of the lips and tongue, first- and second-degree burns of the larynx and vocal cords, and first-degree burns of the trachea and mainstem bronchi after deliberate inhalation of an airbrush propellant containing 1,1-difluoroethane (Kuspis & Krenzelok, 1999).

a) CASE REPORT: A 15-year-old boy developed eosinophilic pneumonia and respiratory failure, which responded to steroids after repetitive inhalational abuse of a product containing trichloroethane and fluorocarbons (Kelly & Ruffing, 1993).
b) ALVEOLITIS has been reported following exposure to a complex mixture containing fluorocarbons. The syndrome was short-lived, responding to steroids (Wright & Lee, 1986).

a) Pharynx irritation occurred in 11 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) Headache is a common complaint, reported in 71% of 31 workers exposed to bromotrifluoromethane (Holness & House, 1992).
b) Headache occurred in 16 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) Dizziness was an early symptom noted by soldiers exposed to bromochlorodifluoromethane in a battle tank (Lerman et al, 1991) and following exposure from contents of defective fire extinguishers (Matrat et al, 2004). Lightheadedness was a common complaint (68%) among 31 workers exposed to bromotrifluoromethane (Holness & House, 1992). Dizziness, faintness, and drowsiness were reported at 4% and 7% exposure levels in 3 out of 4 subjects in a controlled exposure (Call, 1973). Prolonged tiredness has occurred (de la Hoz, 1999).
b) Dizziness occurred in 24 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) Disorientation was a common complaint (29%) among 31 workers exposed to bromotrifluoromethane (Holness & House, 1992).

a) Cerebral edema may be found on autopsy after severe inhalation exposures (Lerman et al, 1991; Kamm, 1975).

a) PSYCHOORGANIC SYNDROME: Neuropsychological testing revealed a syndrome of impaired psychomotor speed, impaired learning and memory, and emotional lability in 7 of 21 workers chronically exposed to 1,1,2-trichloro-1,2,2-trifluoroethane (Rasmussen et al, 1988).

a) A short-term anxiety syndrome has been seen with lowered PCO2 (Gerhardt, 1996).

a) NEUROPSYCHIATRIC TEST EFFECTS: Reaction time and maze tracing errors, but not maze tracing time, were diminished to a small but statistically significant extent in 8 airmen exposed to 7% CBrF3 (Call, 1973).
b) CASE REPORT: A 19-year-old man who presented for psychiatric assessment following probation violation and subsequent incarceration, had a 3-year history of abusing inhalants, primarily with air conditioning fluid. When presenting for psychiatric evaluation, he appeared to be cognitively slower in conversation, although there appeared to be only minimal deficits in short-term memory when tested with the Mini-Mental State Exam (Caplan et al, 2012).

a) Seizures have been observed in experimental animals exposed to Freon-1301 and Freon-21 (Hathaway et al, 1996).

a) CASE REPORT: Peripheral neuropathy developed in 2 men anesthetized with 1.25 minimum alveolar concentration of sevoflurane (Goldberg et al, 1999).
b) After a freezer exploded at a seafood factory, 43 of 80 workers exposed to Freon-22 developed symptoms. Muscle weakness and numbness of legs occurred in 6 and 4 workers, respectively. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes (Kubota & Miyata, 2005).

a) CASE REPORT: A 28-year-old woman developed coma after exposure to Freon-22 when a freezer exploded at a seafood factory. Following supportive therapy, she recovered and was discharged 3 days later without any neurological deficits. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes (Kubota & Miyata, 2005).

a) CASE REPORT: An 18-year-old man was found dead following deliberate inhalation ("huffing") of difluorochloromethane air conditioner refrigerant. Microscopic examination of the brain during autopsy revealed evidence of cerebral leukoencephalopathy with ischemic or hypoxic neuronal changes. Other findings during the autopsy included pulmonary edema, diffuse visceral congestion, increased intramyocardial fibrosis, and centrilobular hepatic necrosis (Phatak & Walterscheid, 2012).

a) Nausea developed in 10% of 31 workers exposed to bromotrifluoromethane (Holness & House, 1992).
b) Nausea occurred in 18 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) CASE REPORT: Tissue necrosis and multiple perforation of the stomach developed in a 43-year-old man after ingesting an unknown amount of a mixture of Freon and water. The postoperative gastric fiberoptic endoscopy revealed 2 notable excavated ulcers with hemorrhagic fundi in the subcardial and back face of the gastric body. Following supportive care, the patient recovered gradually and was discharged on day 10. At a 3 month follow-up, complete healing of the gastric ulcers was observed (Gotelli et al, 2008).
b) CASE REPORT: Mucosal necrosis and perforation of the stomach developed in one patient after ingesting a small amount of trichlorofluoromethane (Haj et al, 1980).
c) CASE REPORT: A 16-year-old boy developed frostbite of the lips and tongue, and first-degree burns of the esophagus after deliberate inhalation of an airbrush propellant containing 1,1-difluoroethane (Kuspis & Krenzelok, 1999).

a) Jaundice and mild elevations of transaminases have been reported rarely after severe inhalation exposure and ingestion (Haj et al, 1980; Steadman et al, 1984).
b) CASE REPORT: Elevated liver enzymes (2-fold of normal limits) and gastric perforation developed in a 43-year-old man after ingesting an unknown amount of a mixture of Freon and water. Following supportive care, the patient recovered gradually and was discharged on day 10 (Gotelli et al, 2008).
c) CASE REPORT: After a freezer exploded in a seafood factory, 43 of 80 workers exposed to Freon-22 developed symptoms. Mildly elevated levels of alkaline phosphatase (max range 350-440 International Units/L) and lactic acid dehydrogenase (max range 258-262 International Units/L) were each reported in 3 workers. Levels returned to normal within 7 days. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes (Kubota & Miyata, 2005).

a) CASE SERIES: Following repeated accidental exposures in 9 workers to a mixture of 1,1-dichloro-2,2,2-trifluoroethane and 1-chloro-1,2,2,2-tetrafluoroethane, various degrees of liver injuries resulted. Liver biopsy performed in one patient revealed hepatocellular coagulative necrosis. Other workers were diagnosed with hepatitis with elevated hepatic enzyme levels (Hoet et al, 1997).
b) CASE REPORT: Evidence of centrilobular hepatic necrosis was found during an autopsy of an 18-year-old man found dead following deliberate inhalation ("huffing") of difluorochloromethane air conditioner refrigerant (Phatak & Walterscheid, 2012).

a) A community in Taipei, Taiwan, was unintentionally exposed to fire extinguisher gases (mixture of Halon 1301, Halon 1211 and Freon 12), and 117 residents sought medical attention. Laboratory results demonstrated decreased hemoglobin and red blood cell counts. When compared to a nonexposed control group, there were significant differences for hemoglobin and red blood cell counts (p=0.011 and p=0.001, respectively), and a relationship between dose and response was also identified. Hematologic effects were transient; 91 of the residents who returned for a 9 month follow-up showed marked improvement in or resolution of hematologic abnormalities. The authors speculate the hematologic effects resulted from pyrolytic products of Halon-1211 and Freon-12 (Lo et al, 2006).

a) Fluorocarbons may produce contact dermatitis (Bircher et al, 1994; Valdivieso et al, 1987; Proctor & Hughes, 1978).

a) Freon solvents are degreasers. Defatting of the skin and erythema occur after contact.
b) Liquid Halon 2402 was not a skin irritant when applied to the intact or abraded skin of rabbits (Technical Information, 1987b).
c) Chemical burns were reported in 16 cases during a 7 year period following mishaps related to Freon-113 (Voge, 1989).

a) SUBCUTANEOUS INJECTION

a) Frostbite results from direct Freon exposure and is related to the high volatility of many of these compounds (Goldsmith, 1989).
b) CASE REPORT: Severe frostbite of the hand and shoulder developed after direct close range exposure to monochlorodifluoromethane for an unknown period of time.
c) CASE REPORT: A case of facial and oral exposure led to third degree burns of the lids and face and compromise of the airway (Kurbat & Pollack, 1998).
d) CASE REPORT: Intentional oral inhalation of airbrush propellant (1,1-difluoroethane) in a 16-year-old boy resulted in loss of consciousness and frozen lips and tongue. First- and second-degree burns of the larynx were noted as well as vocal cord involvement. His trachea, bronchi, and esophagus sustained first-degree burns, and the oral cavity had second- and third-degree burns requiring debridement (Kuspis & Krenzelok, 1999).
e) CASE REPORT: A 20-year-old man presented to the emergency department with pain, edema, and blistering, numbness, and tingling of the lips, cheeks, tongue, and fingers of the left hand. Initially, the patient indicated that he had possibly been bitten by a spider while camping, and he was subsequently treated with IV epinephrine, corticosteroids, and diphenhydramine for a suspected anaphylactic reaction. Over the next two days, the pain continued with development of large bullae on his face (right cheek, right nostril, lips) and on the fingers of his left hand, with the lesions on his face becoming honey-crusted and ulceration of his upper lip. After further questioning, the patient admitted that he had been inhaling an aerosolized computer cleaner containing a fluorinated hydrocarbon (HFC-134a) one hour prior to presentation until he lost consciousness. A diagnosis of an allergic reaction due to frostbite secondary to contact with HFC-134a was made. Following supportive care and continued observation, the patient gradually recovered without sequelae, although he required extensive outpatient occupational therapy to regain full use of his left hand (Koehler & Henninger, 2014).

a) Severe acne developed in a 50-year-old man exposed to dihydrotrifluoromethylphenyl benzothiopyranopyrazolone (Scerri et al, 1995).

a) CASE REPORT: A 43-year-old man was reported to be susceptible to malignant hyperthermia by in vitro testing of muscle, developed malaise, stiffness, and weakness in his forearms after taking a job that involved discharging bromochlorodifluoromethane fire extinguishers. Clinical manifestations included CPK levels of 1056 International Units/L (Denborough & Hopkkinson, 1988).
b) Brady et al (1994) report a case of cardiac arrest from intentional Freon inhalation resulting in rhabdomyolysis with an increase in CPK originating entirely from skeletal muscle (Brady et al, 1994a).
c) An anesthetic state induced by 1,1-dichloro-1-fluoroethane has been associated with hyperactivity of the skeletal muscles (Johansson, 1998).
d) Elevated creatine phosphokinase (max range 360-2023) occurred in 2 of 80 workers exposed to Freon-22 after a freezer exploded at a seafood factory; levels returned to normal within 7 days. Approximately 43 kg of Freon-22 escaped into the factory over 10 minutes, and 43 of 80 exposed workers developed symptoms (Kubota & Miyata, 2005).

a) Compartment syndrome is a rare complication of direct Freon exposure.
b) CASE REPORT: Severe frostbite of the hand and shoulder developed after direct close-range exposure to monochlorodifluoromethane for an unknown period of time.

a) A 31-year-old woman with a history of asthma and anaphylactoid reactions to foods developed pruritus, bronchospasm, abdominal cramps, vomiting, flushing, and facial edema, which resolved with epinephrine after using a leather protector containing a fluorocarbon (FX-3532) with ethyl acetate as a carrier in an enclosed space (McHugh, 1995).

a) Treatment is primarily supportive with removal from source, appropriate decontamination and oxygen administration.

a) Remove patient from exposure, decontaminate, and administer oxygen. Aggressive airway management for patients with respiratory or mental status depression should be instated along with supportive measures for hypotension. Administer nebulized bronchodilators (eg, albuterol) for respiratory irritation or bronchospasm. Consider surfactant administration (80ml/m(2) divided into 4 aliquots given every 12 hours through the endotracheal tube using four positions-left decubitus, head-up then down, right decubitus, head-up then down) for patients with a severe pneumonitis requiring intubation. Treat tachydysrhythmias with esmolol 0.025 to 0.1mg/kg/min IV. Cardiovert unstable ventricular dysrhythmias. Consider early ECMO for pediatric patients with severe pneumonitis. Consider N-acetylcysteine for severe liver injury.

a) Treatment is primarily supportive with removal from source, appropriate decontamination and oxygen administration.

a) Remove patient from exposure, decontaminate, and administer oxygen. Aggressive airway management for patients with respiratory or mental status depression should be instated along with supportive measures for hypotension. Administer nebulized bronchodilators (eg, albuterol) for respiratory irritation or bronchospasm. Consider surfactant administration (80ml/m(2) divided into 4 aliquots given every 12 hours through the endotracheal tube using four positions-left decubitus, head-up then down, right decubitus, head-up then down) for patients with a severe pneumonitis requiring intubation. Treat tachydysrhythmias with esmolol 0.025 to 0.1mg/kg/min IV. Cardiovert unstable ventricular dysrhythmias. Consider early ECMO for pediatric patients with severe pneumonitis. Consider N-acetylcysteine for severe liver injury.

a) To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Use of smaller tidal volumes (6 mL/kg) and lower plateau pressures (30 cm water or less) has been associated with decreased mortality and more rapid weaning from mechanical ventilation in patients with ARDS (Brower et al, 2000). More treatment information may be obtained from ARDS Clinical Network website, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary, http://www.ardsnet.org/node/77791 (NHLBI ARDS Network, 2008)

a) Rewarming of a localized area should only be considered if the risk of refreezing is unlikely. Avoid rubbing the frozen area which may cause further damage to the area (Grieve et al, 2011; Hallam et al, 2010).

a) Do not institute rewarming unless complete rewarming can be assured; refreezing thawed tissue increases tissue damage. Place affected area in a water bath with a temperature of 40 to 42 degrees Celsius for 15 to 30 minutes until thawing is complete. The bath should be large enough to permit complete immersion of the injured part, avoiding contact with the sides of the bath. A whirlpool bath would be ideal. Some authors suggest a mild antibacterial (ie, chlorhexidine, hexachlorophene or povidone-iodine) be added to the bath water. Tissues should be thoroughly rewarmed and pliable; the skin will appear a red-purple color (Grieve et al, 2011; Hallam et al, 2010; Murphy et al, 2000).
b) Correct systemic hypothermia which can cause cold diuresis due to suppression of antidiuretic hormone; consider IV fluids (Grieve et al, 2011).
c) Rewarming may be associated with increasing acute pain, requiring narcotic analgesics.
d) For severe frostbite, clinical trials have shown that pentoxifylline, a phosphodiesterase inhibitor, can enhance tissue viability by increasing blood flow and reducing platelet activity (Hallam et al, 2010).

a) Digits should be separated by sterile absorbent cotton; no constrictive dressings should be used. Protective dressings should be changed twice per day.
b) Perform twice daily hydrotherapy for 30 to 45 minutes in warm water at 40 degrees Celsius. This helps debride devitalized tissue and maintain range of motion. Keep the area warm and dry between treatments (Hallam et al, 2010; Murphy et al, 2000).
c) The injured extremities should be elevated and should not be allowed to bear weight.
d) In patients at risk for infection of necrotic tissue, prophylactic antibiotics and tetanus toxoid have been recommended by some authors (Hallam et al, 2010; Murphy et al, 2000).
e) Non-tense clear blisters should be left intact due to the risk of infection; tense or hemorrhagic blisters may be carefully aspirated in a setting where aseptic technique is provided (Hallam et al, 2010).
f) Further surgical debridement should be delayed until mummification demarcation has occurred (60 to 90 days). Spontaneous amputation may occur.
g) Analgesics may be required during the rewarming phase; however, patients with severe pain should be evaluated for vasospasm.
h) IMAGING: Arteriography and noninvasive vascular techniques (e.g., plain radiography, laser Doppler studies, digital plethysmography, infrared thermography, isotope scanning), have been useful in evaluating the extent of vasospasm after thawing and assessing whether debridement is needed (Hallam et al, 2010). In cases of severe frostbite, Technetium 99 (triple phase scanning) and MRI angiography have been shown to be the most useful to assess injury and determine the extent or need for surgical debridement (Hallam et al, 2010).
i) TOPICAL THERAPY: Topical aloe vera may decrease tissue destruction and should be applied every 6 hours (Murphy et al, 2000).
j) IBUPROFEN THERAPY: Ibuprofen, a thromboxane inhibitor, may help limit inflammatory damage and reduce tissue loss (Grieve et al, 2011; Murphy et al, 2000). DOSE: 400 mg orally every 12 hours is recommended (Hallam et al, 2010).
k) THROMBOLYTIC THERAPY: Thrombolysis (intra-arterial or intravenous thrombolytic agents) may be beneficial in those patients at risk to lose a digit or a limb, if done within the first 24 hours of exposure. The use of tissue plasminogen activator (t-PA) to clear microvascular thromboses can restore arterial blood flow, but should be accompanied by close monitoring including angiography or technetium scanning to evaluate the injury and to evaluate the effects of t-PA administration. Potential risk of the procedure includes significant tissue edema that can lead to a rise in interstitial pressures resulting in compartment syndrome (Grieve et al, 2011).
l) CONTROVERSIAL: Adjunct pharmacological agents (ie, heparin, vasodilators, prostacyclins, prostaglandin synthetase inhibitors, dextran) are controversial and not routinely recommended. The role of hyperbaric oxygen therapy, sympathectomy remains unclear (Grieve et al, 2011).
m) CHRONIC PAIN: Vasomotor dysfunction can produce chronic pain. Amitriptyline has been used in some patients; some patients may need a referral for pain management. Inability to tolerate the cold (in the affected area) has been observed following a single episode of frostbite (Hallam et al, 2010).
n) MORBIDITIES: Frostbite can produce localized osteoporosis and possible bone loss following a severe case. These events may take a year or more to develop. Children may be at greater risk to develop more severe events (ie, early arthritis) (Hallam et al, 2010).

a) The peak blood level occurs immediately after inhalation. Within 15 minutes the level is down almost completely. Significance of blood levels in relationship to catecholamine-induced dysrhythmias is unknown.
b) FREON 11
c) CHLORODIFLUOROMETHANE & CHLOROPENTAFLUOROETHANE
d) DIFLUOROETHANE