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LACRIMATORS

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Lacrimators are chemical agents used in riot control. This family of compounds has also been referred to as "tear gas" or "harassing agents". They are solid chemicals administered as a fine dust or aerosol spray, and not true gases.
    B) "Pepper sprays" containing oleoresin of capsicum are sometimes used in law enforcement and personal protection. For further information on these sprays, please refer to the CAPSAICIN management.

Specific Substances

    A) CHLOROACETONE
    1) Monochloroacetone
    CHLOROACETOPHENONE
    1) 1-chloroacetophenone
    2) 2-chloro-1-phenyl ethone
    3) 2-chloroacetophenone
    4) alpha-chloroacetophenone
    5) Chemical Mace (0.9 to 1.2% CN dissolved in a solvent mixture)
    6) Chloroacetophenone, liquid
    7) Chloroacetophenone, solid
    8) Chloromethyl phenyl ketone
    9) CN
    10) Mace
    11) Omega-chloroacetophenone
    12) Phenacyl chloride
    13) Phenylchloromethylketone
    14) Tear gas
    15) NIOSH/RTECS AM 6300000
    16) CAS 532-27-4
    DIBENZOXAZEPINE
    1) Agent CR
    2) CR
    3) Dibenz(b,f)(1,4)oxazepine
    4) EA 3547
    5) NIOSH/RTECS HQ 3950000
    6) UPDT 8109
    7) CAS 257-07-8
    ORTHO-CHLOROBENZYLIDENE MALONONITRILE
    1) Chlorobenzylidene malonitrile
    2) 2-chlorobenzalmalononitrile
    3) 2-chlorobenzylidene malononitrile
    4) 2-chlorobmn
    5) beta, beta-dicyano-ortho-chlorostyrene
    6) Chemshield
    7) CS
    8) Malononitrile, ortho-chlorobenzylidene
    9) (ortho-chlorobenzal) malononitrile
    10) Orthochlorobenzalmalononitrile
    11) NCI-c 55118
    12) Paralyzer(R)
    13) Propanedinitrile, ((2-chlorophenyl)-methylene)
    14) Super Tear Gas
    15) UPDT 8212
    16) USAF KF-11
    17) NIOSHI/RTECS OO 3675000
    18) CAS 2698-41-1
    BROMBENZYLCYANIDE
    1) CA
    General Terms
    1) LACHRYMATORS

Available Forms Sources

    A) FORMS
    1) DISPERSAL METHODS: These agents are available in various sizes ranging from fountain pen sized purse sprayers to grenades used by law enforcement personnel. They are dispersed as an aerosol or dust.
    2) CHLOROACETOPHENONE (CN) is available as powder or emulsion in aerosols with apple odor (Carron & Yersin, 2009).
    3) CHLOROBENZYLIDENE MALONONITRILE (CS) is available as microparticles with dispersing effect (grenades) and pepper odor (Carron & Yersin, 2009).
    4) DIBENZOXAZEPINE (CR) is an odorless chemical available in aerosols. The chemical persists for prolonged periods in the environment or on clothes (Carron & Yersin, 2009).
    5) DIPHENYLAMINOCHLOROARSINE is an emetic agent without odor or may have slightly bitter almond odor (Carron & Yersin, 2009).
    6) OLEORESIN CAPSICUM is a short distance spray with pepper odor. The chemical persists for prolonged periods in the environment or on clothes (Carron & Yersin, 2009). Please refer to CAPSAICIN management for more information.
    7) CS may be micronized and mixed with an antiagglomerant agent. This formulation is known as CS1, and remains active for up to 5 days when dusted on the ground. A similar formulation mixed with silicone is known as CS2, and is potent for up to 45 days (Hu et al, 1989).
    8) Although often sold as self-defense sprays, these agents are also used as harassing agents during robberies (Van Tittelboom & Mostin, 1992).
    B) USES
    1) SUMMARY: Lacrimators are chemical agents used in riot control. This family of compounds has also been referred to as "tear gas" or "harassing agents". They are solid chemicals administered as a fine dust or aerosol spray, and not true gases.
    2) The 3 agents used most frequently because of effectiveness and low risk are chloroacetophenone (CN), ortho-chlorobenzylidene malononitrile (CS), and dibenzoxazepine (CR) (Beswick, 1983). Agents containing capsaicin (pepper sprays-oleoresin capsicum [OC]) are discussed in a separate management (CAPSAICIN).
    3) MONOCHLORACETONE, introduced in 1914 as a war gas and presently used as a chemical intermediate, is a lacrimator and vesicant. It is recommended that direct contact with liquid and vapor be prevented through strict engineering controls and that air concentrations be kept below 1 ppm as a ceiling concentration (Sargent et al, 1986).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Lacrimators are various nonlethal chemical agents used for riot control. These agents temporarily incapacitate individuals through intense irritation of mucous membranes and skin. They are characteristically dispersed as aerosols, have rapid onset of effects, and a high safety ratio. The most commonly used agents are chloroacetophenone (CN) and ortho-chlorobenzylidene malononitrile (CS). Agents containing capsaicin (pepper sprays-oleoresin capsicum [OC]) are discussed in a separate management (CAPSAICIN).
    B) TOXICOLOGY: Lacrimators such as CN and CS gases are alkylating agents, which have activated halogen groups. They bind sulfhydryl groups and fix enzymes. This activity is transient because these enzymes are rapidly reactivated. Tissue injury is thought to be related to enzyme inactivation and pain is bradykinin mediated.
    C) EPIDEMIOLOGY: Exposure is common; however, symptoms are short-lived with rapid recovery and mortality is rare, usually linked to enclosed exposures and related to respiratory complications.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Intense irritation to mucous membranes resulting in conjunctival irritation/burning, lacrimation, metallic taste, photophobia, blepharospasm, corneal injury (high concentration), chest tightness, cough, sneeze, rhinorrhea, sore throat, shortness of breath, oropharyngeal burning, bronchospasm, and skin irritation including burning, erythema, and/or vesiculation may occur. Oral exposure may result in gastrointestinal upset (eg, nausea and vomiting), usually resolving within 24 hours.
    2) SEVERE TOXICITY: Mechanical injury to the cornea, sclera or conjunctiva may occur with close range fire, rarely resulting in perforation of ocular structures. Acute lung injury resulting in fatalities have been reported 24 hours after exposure, but this is uncommon and usually related to enclosed space high concentration exposures.
    0.2.20) REPRODUCTIVE
    A) Neither animal studies nor human exposure (as in rat control) have demonstrated embryotoxic actions.
    0.2.21) CARCINOGENICITY
    A) Based on animal findings, there is no evidence that CR represents a carcinogenicity risk (Blain , 2003).

Laboratory Monitoring

    A) Monitor vital signs and pules oximetry in symptomatic patients.
    B) Laboratory evaluation is rarely necessary for most exposures.
    C) Specific chemical concentrations are not clinically useful.
    D) Consider chest radiograph in patients with persistent pulmonary symptoms.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Although not often associated with oral toxicity, inadvertent ingestion of CS pellets has occurred. Symptoms are generally self-limited and may require antacids. Refer to INHALATION OVERVIEW for more treatment information.
    0.4.3) INHALATION EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Remove the patient from the exposure site. Remove all contaminated clothing (wash with soap and cold water/air non-washable items for a few days). Wash exposed areas of body with soap and cold water twice. Irrigate eyes with copious amounts of 0.9% normal saline or water for 15 minutes; if irritation persists perform ophthalmic exam. Symptoms usually resolve within 15 to 30 minutes of cessation of exposure. Minor chemical burns can be treated with soap and cold water along with a topical antibiotic cream. Consider tetanus prophylaxis.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Consider aggressive airway management for signs of respiratory compromise; treat severe respiratory irritation with bronchodilators and corticosteroids. For more severe dermal burns, contact your local burn center for guidance. Patients with corneal burn or penetration require emergent evaluation by an ophthalmologist.
    C) DECONTAMINATION
    1) PREHOSPITAL: If possible, onsite decontamination should be performed with soap and cold water. Place contaminated clothing in airtight bags to prevent secondary exposure. Irrigate exposed eyes.
    2) HOSPITAL: Onsite decontamination should be performed with soap and cold water if not performed in field. Place contaminated clothing in airtight bags to prevent secondary exposure. Irrigate exposed eyes.
    D) AIRWAY MANAGEMENT
    1) Practice usual airway management.
    E) ANTIDOTE
    1) Diphoterine(R) solution has been used for decontamination of eyes and skin following exposure to ortho-chlorobenzylidene malononitrile (CS), but there is limited availability and it is not clear if it is better than 0.9% saline in CS-exposed patients.
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients with mild irritant symptoms can be managed at home with soap and water decontamination of the skin and eye irrigation as needed.
    2) OBSERVATION CRITERIA: Most patients can be safely discharged home with minimal symptoms after appropriate decontamination. Observe patients with significant pulmonary, dermal or ocular complaints despite appropriate decontamination measures.
    3) ADMISSION CRITERIA: Consider admission of patients with significant pulmonary complaints, ocular injury, or severe burns.
    4) CONSULT CRITERIA: Medical toxicology, pulmonary medicine, burn surgery, or ophthalmology for significant injury.
    G) PITFALLS
    1) Failure to recognize severe injury.
    H) PHARMACOKINETICS
    1) Onset of toxic effects occurs rapidly. Duration of effects is generally brief (15 to 30 minutes).
    I) PREDISPOSING CONDITIONS
    1) Reactive airway disease, COPD, dermal disorders that might lead to more significant skin penetration, and underlying other ocular disorders or contact lens use.
    J) DIFFERENTIAL DIAGNOSIS
    1) Vesicants (sulfur mustard, lewisite, phosgene), pulmonary agents (chlorine, phosgene), other riot control agents (pepper spray, capsaicin), nerve agents and other incapacitating agents.
    0.4.4) EYE EXPOSURE
    A) ACTIVE BLOWN AIR: CS is highly soluble in water and the irrigation of eyes can intensify the irritation. One review article recommended to blow air directly into the patient's eyes using a fan. Then irrigate the exposed eyes with 2 L of cold water or normal saline if irritation persists (Svinos, 2011).
    B) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    2) Remove all contaminated clothing while avoiding self-contamination. Meticulously wash all exposed areas with copious amounts of soap and water. The patient's clothing may contain residual particles from the exposure and clothing should be removed and stored in a sealed polythene bag to prevent degassing. If clothing is to be washed, cold water should be used because hot water will cause residual O-chlorobenzylidene malononitrile (CS) gas to vaporize.

Range Of Toxicity

    A) TOXICITY: Minimum toxic or lethal doses are not well established in the literature. Most of these agents have a high safety ratio. The incapacitating doses (ICt 50) of CN and CS have ranged from 20 to 50 mg/min/m(3) and 4 to 20 mg/min/m(3), respectively.

Clinical Effects

Summary Of Exposure

    A) USES: Lacrimators are various nonlethal chemical agents used for riot control. These agents temporarily incapacitate individuals through intense irritation of mucous membranes and skin. They are characteristically dispersed as aerosols, have rapid onset of effects, and a high safety ratio. The most commonly used agents are chloroacetophenone (CN) and ortho-chlorobenzylidene malononitrile (CS). Agents containing capsaicin (pepper sprays-oleoresin capsicum [OC]) are discussed in a separate management (CAPSAICIN).
    B) TOXICOLOGY: Lacrimators such as CN and CS gases are alkylating agents, which have activated halogen groups. They bind sulfhydryl groups and fix enzymes. This activity is transient because these enzymes are rapidly reactivated. Tissue injury is thought to be related to enzyme inactivation and pain is bradykinin mediated.
    C) EPIDEMIOLOGY: Exposure is common; however, symptoms are short-lived with rapid recovery and mortality is rare, usually linked to enclosed exposures and related to respiratory complications.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Intense irritation to mucous membranes resulting in conjunctival irritation/burning, lacrimation, metallic taste, photophobia, blepharospasm, corneal injury (high concentration), chest tightness, cough, sneeze, rhinorrhea, sore throat, shortness of breath, oropharyngeal burning, bronchospasm, and skin irritation including burning, erythema, and/or vesiculation may occur. Oral exposure may result in gastrointestinal upset (eg, nausea and vomiting), usually resolving within 24 hours.
    2) SEVERE TOXICITY: Mechanical injury to the cornea, sclera or conjunctiva may occur with close range fire, rarely resulting in perforation of ocular structures. Acute lung injury resulting in fatalities have been reported 24 hours after exposure, but this is uncommon and usually related to enclosed space high concentration exposures.

Heent

    3.4.3) EYES
    A) LACRIMATION/PAIN: Lacrimation, ocular burning, photophobia, and pain are the most important clinical effects, and, depending upon the atmosphere, may last for up to 30 minutes following exposure (Carron & Yersin, 2009; Beswick, 1983). Lacrimation, blurred vision, and conjunctivitis have been reported after exposure to CS containing O-chlorobenzylidine malononitrile dissolved in methyl iso-butyl ketone (Euripidou et al, 2004).
    B) BLEPHAROSPASM: is a characteristic finding and causes lids to close tightly (Carron & Yersin, 2009; Blain , 2003; Grant, 1986).
    C) REDNESS/EDEMA: may last for up to 48 hours.
    D) DURATION: Symptoms generally subside within 30 minutes of CS or CR exposure, but may persist depending on the concentration and duration of exposure (Blain , 2003).
    E) CORNEAL EFFECTS: Corneal opacification may occur from short range contamination with CN (chloroacetophenone) from tear gas pistols (Grant, 1986). If sufficient CN particles penetrate the corneal stroma, severe scarring and ulceration with epithelial decompensation may ensue and corneal sensation may be permanently reduced (Blain , 2003; Scott, 1995).
    1) Corneal stromal edema and later deep vascularization may also occur with the development of other ocular complications including symblepharon, pseudopterygium, infective keratitis, trophic keratopathy, posterior synechia, secondary glaucoma, cataracts, hyphema, vitreous hemorrhage, and traumatic optic neuropathy (Hoffman, 1967).
    F) CONJUNCTIVAE: Conjunctival effects include sloughing, limbal ischemia, and the formation of symblepharon following exposure to CN (Scott, 1995).
    G) KERATITIS: Keratitis has been reported with exposure to chloroacetophenone (CN) (Carron & Yersin, 2009).
    H) ORAL EXPOSURE: Seven patients were inadvertently exposed to contaminated juice with CS pellets and complained of eye irritation, lacrimation, mild headache and gastrointestinal irritation. Most symptoms resolved within 24 hours of exposure (Solomon et al, 2003).
    I) NECROSIS: In ANIMAL studies, a 4% W/V CN product produced permanent corneal injury, but no such injury was seen in a 10% W/V CS product (Gaskins et al, 1972). High concentrations of CN (chloroacetophenone) have produced ocular necrosis in animals (Grant, 1986).
    3.4.5) NOSE
    A) RHINORRHEA/SNEEZING/PAIN: Rhinorrhea, sneezing, and burning pain occur within seconds and are characteristic of exposure (Beswick, 1983).
    3.4.6) THROAT
    A) SALIVATION/PAIN: Salivation, sore throat, and burning or stinging pain of the tongue may occur within seconds to minutes (Carron & Yersin, 2009; Beswick, 1983; Thorburn, 1982).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) TACHYCARDIA
    1) WITH POISONING/EXPOSURE
    a) Tachycardia may occur as a result of fear and pain (Beswick, 1983).
    B) HYPERTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Mild hypertension may occur as a result of fear and pain (Beswick, 1983).
    b) Hypertension has been reported with exposure to o-chlorobenzylidene malononitrile (CS) (Carron & Yersin, 2009).
    C) RIGHT HEART FAILURE
    1) WITH POISONING/EXPOSURE
    a) Heart failure has been reported as a potential complication of exposure to these agents (Carron & Yersin, 2009).
    b) Congestive heart failure has been reported in adults after exposure to high concentrations of O-chlorobenzylidene malononitrile (CS) (Hu et al, 1989).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) RESPIRATORY FINDING
    1) WITH POISONING/EXPOSURE
    a) Coughing, sneezing, severe rhinitis, dyspnea, pharyngitis, tracheal bronchitis, hypoxemia, and chest tightness immediately after exposure are characteristic; these symptoms may persist for weeks after exposure (Carron & Yersin, 2009; Blain , 2003; Beswick, 1983; Hu et al, 1989). In case studies, the most common respiratory effects following exposure to these agents were shortness of breath, sore throat, and chest pain. These effects usually resolve within 30 minutes (Carron & Yersin, 2009).
    B) LARYNGISMUS
    1) WITH POISONING/EXPOSURE
    a) Laryngospasm may occur immediately after exposure due to irritant effects (Carron & Yersin, 2009) or may be delayed for 1 to 2 days.
    C) ACUTE LUNG INJURY
    1) WITH POISONING/EXPOSURE
    a) Pulmonary edema may occur up to 24 (usually 12-24) hours post exposure. Fatalities have been reported (Stein & Kirwan, 1964).
    b) Delayed pulmonary edema has been reported with exposure to o-chlorobenzylidene (CS) (Carron & Yersin, 2009).
    c) CASE REPORT: Krapf & Thalmann (1981) reported a 43-year-old who developed pulmonary edema complicated by pneumonia, heart failure, and hepatocellular damage (Krapf & Thalmann, 1981).
    d) CASE REPORT: Vaca et al (1996) reported a 24-year-old woman with a history of rheumatic heart disease and mitral valve replacement who developed pulmonary edema and bronchospasm 18 hours after an exposure to what was thought to be a room deodorizer. The canister contained chloroacetaphenone (CN). The patient recovered without sequelae after mitral valve replacement. The authors speculate that the patient's symptoms could have been exacerbated by the CN exposure, but her underlying cardiac condition likely contributed to the development of the pulmonary edema (Vaca et al, 1996).
    e) Following a few exposures to field concentrations of CS, there is no evidence that CS will cause permanent lung damage (Blain , 2003).
    D) BRONCHOSPASM
    1) WITH POISONING/EXPOSURE
    a) Bronchospasm develops in most individuals exposed to an enclosed space (Carron & Yersin, 2009; Anon, 1971). This may be delayed up to 48 hours post-exposure and persist indefinitely. Occasionally bronchospasm is associated with bronchorrhea (Folb & Talmud, 1989).
    b) Delayed onset (1-2 days post-exposure) laryngotracheobronchitis, characterized by wheezing, dyspnea, tachypnea, hoarseness, fever, and purulent sputum, was reported in 3 of 8 patients severely exposed to CN (chloroacetophenone). Long-term bronchodilator therapy was required in one patient with pre-existing pulmonary disease (Thorburn, 1982).
    c) CASE REPORT: Bronchospasm was reported in a 21-year-old female with no previous pulmonary disease following exposure to CS in a closed space for 5-10 minutes. Immediate cough and dyspnea required treatment with inhaled beta agonists, theophylline, and steroids; symptoms persisted 2 years after exposure and were exacerbated by exercise, cold air or smoke exposure, despite continued bronchodilator and steroid treatment (Hu & Christiani, 1992).
    d) CASE REPORT: Vaca et al (1996) reported a 24-year-old woman with a history of rheumatic heart disease and mitral valve replacement who developed pulmonary edema and bronchospasm 18 hours after an exposure to what was thought to be a room deodorizer. The canister contained chloroacetaphenone (CN). The patient recovered without sequelae after mitral valve replacement. The authors speculate that the patient's symptoms could have been exacerbated by the CN exposure, but her underlying cardiac condition likely contributed to the development of the pulmonary edema (Vaca et al, 1996).
    e) Reactive airway dysfunction syndrome (RADS) has also been associated with high level exposure to CS and CR. Following acute symptoms (usually associated with the eyes, face, and throat), paroxysmal cough and feelings of tightness and burning in the chest can occur. Chronic changes may last up to several weeks (i.e., cough, shortness of breath) and can lead to RADS. With most CS exposures, the pulmonary effects usually resolve within 12 weeks (Blain , 2003).
    E) PNEUMONIA
    1) WITH POISONING/EXPOSURE
    a) Bronchopneumonia may occur from prolonged exposure to chlorbenzylidene malononitrile (CS) in an enclosed space. Onset may be delayed by about 24 hours or more (Beswick, 1983).
    F) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) Shortness of breath has been reported after exposure to CS spray containing O-chlorobenzylidine malononitrile dissolved in methyl iso-butyl ketone (Euripidou et al, 2004).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) PSYCHOMOTOR AGITATION
    1) WITH POISONING/EXPOSURE
    a) Agitation and panic may develop in individuals not previously exposed to tear gas (Carron & Yersin, 2009; Stein & Kirwan, 1964; Beswick, 1983).
    B) SYNCOPE
    1) WITH POISONING/EXPOSURE
    a) Syncope has been reported (Athanaselis et al, 1990).
    C) CEREBRAL HEMORRHAGE
    1) WITH POISONING/EXPOSURE
    a) Cerebral hemorrhage has been reported as a potential complication of exposure to these agents, although a cause and effect relationship is difficult to establish (Carron & Yersin, 2009).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) GASTROINTESTINAL TRACT FINDING
    1) WITH POISONING/EXPOSURE
    a) Following inhalation most riot control agents do not produce gastrointestinal effects, however, retching or vomiting may develop following prolonged exposure or high concentrations (Blain , 2003).
    b) Odynodysphagia, abdominal pain, diarrhea, nausea, and vomiting have been reported following exposure to these agents (Carron & Yersin, 2009).
    c) Ingestion of CS can produce episodes of nausea, vomiting, abdominal pain, and diarrhea (Blain , 2003; Solomon et al, 2003).
    B) TASTE SENSE ALTERED
    1) WITH POISONING/EXPOSURE
    a) A metallic taste with a burning sensation of the tongue is common (Folb & Talmud, 1989).
    C) HYPERESTHESIA
    1) WITH POISONING/EXPOSURE
    a) A burning sensation of the tongue with a metallic taste is common (Folb & Talmud, 1989).
    b) ORAL EXPOSURE: Gastrointestinal mucosal irritation and a burning sensation in the mouth and throat were reported in 7 patients inadvertently exposed to a juice contaminated with CS pellets (the pellets contained 90% O-chlorobenzylidene malononitrile and 10% dextrin) (Solomon et al, 2003).
    D) VOMITING
    1) WITH POISONING/EXPOSURE
    a) Nausea is common; vomiting occurs occasionally (Carron & Yersin, 2009; Athanaselis et al, 1990). Vomiting was reported in 2 of 8 patients with severe reactions to CN in an enclosed space. Vomiting lasted for 1 week in one patient (Thorburn, 1982).
    b) CASE REPORTS: Seven patients were inadvertently exposed to CS pellets in a contaminated drink. Besides gastrointestinal tract burning, abdominal pain, vomiting, and diarrhea were reported in 2 of 7 patients exposed. Dilution was recommended, and all patients were discharged with almost complete resolution of symptoms following a 24 hour observation period (Solomon et al, 2003).
    E) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) Epigastric discomfort is likely to occur if tear gas is swallowed and was reported following inadvertent oral exposure to CS pellets (Beswick, 1983; Solomon et al, 2003). Patients have described the pain as cramping abdominal pain following oral exposure to CS pellets (Blain , 2003).
    3.8.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) GASTROENTERITIS
    a) Animals given CN & CS on an empty stomach developed gastroenteritis (Gaskins et al, 1972).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) LIVER DAMAGE
    1) WITH POISONING/EXPOSURE
    a) Liver toxicity has been reported as a potential complication of exposure to CS (Carron & Yersin, 2009).
    b) Hepatocellular injury has been reported in one case of serious CS gas intoxication (Krapf & Thalmann, 1981).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) NEPHRITIS
    1) WITH POISONING/EXPOSURE
    a) There is an anecdotal report of renal tubular injury in a worker killed in an explosion in a lacrimator manufacturing plant (Cookson & Nottingham, 1969).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) All body surfaces exposed for a prolonged period will be irritated. Dibenzoxazepine (CR) exposed areas of skin may become painful again when exposed, even to water, up to about 24 hours after exposure (Pinkus, 1978).
    b) Erythematous dermatitis and blisters have been reported after exposure to CS spray containing o-chlorobenzylidine malononitrile, dissolved in methyl iso-butyl ketone (Carron & Yersin, 2009; Euripidou et al, 2004).
    c) CASE REPORT: A 31-year-old man developed a large erythematous-papular lesion on the scapular region after being accidentally hit by a teargas canister thrown by the police during a scuffle following a sports event. Physical examination revealed a large erythematous plaque, with an indistinct margin and vesico-bullous lesions containing serous liquid in the center in a semicircular pattern. His skin was hot to the touch and he experienced an intense burning sensation and pruritus. Following supportive care, he recovered completely, with an exception of a small semilunar scar. The authors suggested that these lesions may be caused by the flame generated by the gas explosion, by direct contact between the hot metal canister and the skin, or by the powder inside the canister that, by sublimation, releases hydrochloride acid (Morrone et al, 2005).
    B) ERYTHEMA
    1) WITH POISONING/EXPOSURE
    a) Erythema is a common effect, which generally resolves within 48 hours (Carron & Yersin, 2009; Blain , 2003).
    C) ERUPTION
    1) WITH POISONING/EXPOSURE
    a) Rash and edema have been reported following exposure to these agents (Carron & Yersin, 2009).
    D) CONTACT DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) Allergic contact dermatitis has been reported (Bhargava et al, 2012; Treudler et al, 1999; Pennys, 1971; Madden, 1951). Sensitization is more likely to occur after dermal exposure to high concentrations under occlusion (Holland & White, 1972; Pennys et al, 1969; Leenutaphong & Goerz, 1989).
    b) Reactions can persist for up to 4 weeks (Leenutaphong & Goerz, 1989). This hypersensitivity has been shown to chloroacetophenone (Kissen & Mazer, 1944; Ingram, 1942), to Mace (chloroacetophenone, 5% chloroethane, 4% hydrocarbons) (Steffen, 1968; Frazier, 1976), and to CS (O-chlorobenzylidene malononitrile) (Bhargava et al, 2012; Ro & Lee, 1991).
    1) Three police officers developed localized dermatitis (erythema and swelling) at the site of contact to 2-chloroacetophenone (CN). Disseminated erythematous and papulovesicular lesions developed 4 days after exposure in one patient. Patch tests indicated an allergic reaction in two patients and an irritative reaction in the third (Treudler et al, 1999).
    E) CHEMICAL BURN
    1) WITH POISONING/EXPOSURE
    a) Burning and erythema are possible following dermal exposure. Contact can produce skin tingling or a burning sensation, which usually begins within minutes of exposure and lasts approximately an hour after exposure has terminated (Blain , 2003).
    1) CR: the development of skin effects depends on the thickness of the stratum corneum, and the extent of exposure. Contact with water up to 24 to 48 hours after exposure can be painful; erythema usually resolves within 3 hours (Blain , 2003).
    2) CN: is a skin sensitizer that can produce an allergic contact dermatitis (pruritus, weeping and papulovesicular rash) within 72 hours of exposure (Blain , 2003).
    b) MECHANISMS OF BURN INJURY: Burns from CS gas may be due to either chemical burns from CS, or contact burns by direct contact with the hot canisters, or flame burns caused by explosion of the tear gas grenades near victims (Agrawal et al, 2009).
    c) CASE REPORT: A 39-year-old man was sprayed in the face with a CS gas and presented the next day with pain, blistering and redness over the left side of his face, neck and upper chest, reduced vision in the left eye, and reduced hearing in the left ear. The day after presentation, painful superficial burns with erythema and blistering over 4% total body surface area were observed during examination. Following supportive treatment, including chloramphenicol ointment applied to his eye, his symptoms gradually resolved over the next 4 weeks (Agrawal et al, 2009).
    d) High concentrations may produce first and second degree burns of the skin (Stein & Kirwan, 1964; Hu et al, 1989). A high incidence of burns in one series of prisoners exposed to CN was attributed to showering without removal of clothing and contact with flooded floors (Thorburn, 1982).
    e) CASE REPORT: One day after being sprayed with a mace containing CN, a patient presented with erythema, multiple vesicles, and denuded areas revealing a weepy, tender, erythematous base developed over the exposed areas. The patient was treated with intravenous methylprednisolone and topical antibiotics with rapid improvement (King et al, 1993).
    f) CASE REPORTS: Within 72 hours after exposure to CS, patients presented with bullous dermatitis, most of the involved areas were covered with vesicles, blisters, and crusts. The patients rapidly improved following treatment with topical applications of antiseptic solutions (Parneix-Spake et al, 1993).
    F) EXANTHEMATOUS DISORDER
    1) WITH POISONING/EXPOSURE
    a) ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS: A 37-year-old man was sprayed with 2-chlorobenzylidene malononitrile (CS) gas and developed a severe blistering rash. Following supportive care, including treatment with topical therapy (silver sulfadiazine cream, liquid soft paraffin, mupirocin ointment, acetaminophen, codeine, morphine sulfate, and hydroxyzine), his symptoms improved and was discharged 10 days postexposure. He presented 2 days later with a tender, pustular rash affecting the face, chest, arms, and anterior thighs. He also had a low-grade fever. Laboratory results revealed elevated white cell count (17.4 x 10(9)/L) with a neutrophilia (12.6 x 10(9)/L), and a C-reactive protein of 42 mg/L. A diagnosis of acute generalized exanthematous pustulosis (AGEP) was made after a skin swab identified Staphylococcus aureus and a skin biopsy result revealed a florid, intra-epidermal neutrophilic pustulosis with an associated acute inflammatory infiltrate, a mild perivascular lymphocytic infiltrate in the dermis, and papillary dermal edema. Following treatment with emollients and clobetasol propionate 0.05%, his symptoms gradually resolved and he was discharged 5 days later (Wu et al, 2011).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ACUTE ALLERGIC REACTION
    1) WITH POISONING/EXPOSURE
    a) Allergic dermatitis confirmed by patch test have been reported (Bhargava et al, 2012).

Reproductive

    3.20.1) SUMMARY
    A) Neither animal studies nor human exposure (as in rat control) have demonstrated embryotoxic actions.
    3.20.2) TERATOGENICITY
    A) LACK OF EFFECT
    1) Neither animal studies nor human exposure (as in rat control) have demonstrated teratogenic actions (Himsworth et al, 1971) Folb & Talmund, 1989; (Upshall, 1973).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS532-27-4 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    B) IARC Carcinogenicity Ratings for CAS76-06-2 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    C) IARC Carcinogenicity Ratings for CAS257-07-8 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    D) IARC Carcinogenicity Ratings for CAS2698-41-1 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    3.21.2) SUMMARY/HUMAN
    A) Based on animal findings, there is no evidence that CR represents a carcinogenicity risk (Blain , 2003).
    3.21.4) ANIMAL STUDIES
    A) LACK OF EFFECT
    1) Based on bacterial and mammalian cell mutagenicity studies, no carcinogenic potential was observed in mice or hamsters following CR exposure (Blain , 2003).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor vital signs and pules oximetry in symptomatic patients.
    B) Laboratory evaluation is rarely necessary for most exposures.
    C) Specific chemical concentrations are not clinically useful.
    D) Consider chest radiograph in patients with persistent pulmonary symptoms.
    4.1.2) SERUM/BLOOD
    A) ACID/BASE
    1) Pulse oximetry and (if indicated) arterial blood gases should be obtained and followed in symptomatic patients or patients with respiratory complaints. Tear gas itself is generally nondetectable.
    B) HEMATOLOGIC
    1) Leukocytosis has been described after significant CN exposure (Thorburn, 1982; Park & Giammona, 1972).
    4.1.4) OTHER
    A) OTHER
    1) PULMONARY FUNCTION TESTS
    a) Pulmonary function tests should be considered in patients with persistent pulmonary symptoms, and followed until stable. Pulmonary effects can be delayed in onset for 1 to 2 days, and persist for several weeks.

Radiographic Studies

    A) CHEST RADIOGRAPH
    1) A chest x-ray should be obtained in symptomatic patients or patients with respiratory complaints. Pulmonary edema may be delayed for 12 to 24 hours after exposure (Stein & Kirwan, 1964). Follow up x-rays may be indicated.

Methods

    A) CHROMATOGRAPHY
    1) GC/MS has been used with and without mass spectometry to detect chloropicrin, CN, and CS (Gonmori et al, 1987; Ferslew et al, 1986).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Monitor vital signs and pules oximetry in symptomatic patients.
    B) Laboratory evaluation is rarely necessary for most exposures.
    C) Specific chemical concentrations are not clinically useful.
    D) Consider chest radiograph in patients with persistent pulmonary symptoms.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) PREHOSPITAL: If possible, onsite decontamination should be performed with soap and cold water. Place contaminated clothing in airtight bags to prevent secondary exposure. Irrigate exposed eyes.
    6.5.3) TREATMENT
    A) SUPPORT
    1) Although not often associated with oral toxicity, inadvertent ingestion of CS pellets has been reported. Based on limited case reports, signs and symptoms were generally mild and self-limited. Treatment is symptomatic and supportive (Solomon et al, 2003; Blain , 2003).
    B) MONITORING OF PATIENT
    1) Monitor vital signs and pulse oximetry in symptomatic patients.
    2) Laboratory evaluation is rarely necessary for most exposures.
    3) Specific chemical concentrations are not clinically useful.
    4) Consider chest radiograph in patients with persistent pulmonary symptoms.

Inhalation Exposure

    6.7.1) DECONTAMINATION
    A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
    B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.
    6.7.2) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF MILD TO MODERATE TOXICITY
    a) Remove the patient from the exposure site. Remove all contaminated clothing (wash with soap and cold water/air non-washable items for a few days). Wash exposed areas of body with soap and cold water twice. Irrigate eyes with copious amounts of 0.9% normal saline or water for 15 minutes; if irritation persists perform ophthalmic exam. Symptoms usually resolve within 15 to 30 minutes of cessation of exposure. Minor chemical burns can be treated with soap and cold water along with a topical antibiotic cream. Consider tetanus prophylaxis.
    2) MANAGEMENT OF SEVERE TOXICITY
    a) Consider aggressive airway management for signs of respiratory compromise; treat severe respiratory irritation with bronchodilators and corticosteroids. For more severe dermal burns, contact your local burn center for guidance. Patients with corneal burn or penetration require emergent evaluation by an ophthalmologist.
    B) MONITORING OF PATIENT
    1) Monitor vital signs and pulse oximetry in symptomatic patients.
    2) Laboratory evaluation is rarely necessary for most exposures.
    3) Specific chemical concentrations are not clinically useful.
    4) Consider chest radiograph in patients with persistent pulmonary symptoms.
    C) BRONCHOSPASM
    1) BRONCHOSPASM: May require the use of inhaled beta-2 agonists (e.g. albuterol, salbutamol), steroids (e.g. methylprednisolone), in symptomatic patients (Folb & Talmud, 1989; Ballantyne & Swanston, 1978).
    D) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    B) DIPHOTERINE: Diphoterine(R) solution has been used for decontamination of eyes and skin following exposure to ortho-chlorobenzylidene malononitrile (CS) " tear gas". Four French Gendarmes were exposed to CS in a standard training CS chamber for 2 minutes. They experienced excessive lacrimation, conjunctival irritation, reflex blepharospasm, reflex palpebral occlusion, and intense photophobia. All ocular signs and symptoms resolved approximately 3 to 7 minutes after decontamination with 250 mL of Diphoterine(R). In addition, in a pre-exposure prophylaxis test, a Gendarme was treated with 250 mL of Diphoterine(R) before entering the CS exposure chamber for 2 minutes. He did not experience any ocular or facial skin irritation, but he had mild coughing (Viala et al, 2005).
    1) The above study's limitations should be noted: small number of subjects, no blinding, placebo or control, and funding was provided by the company which produces Diphoterine(R). More studies need to be done to confirm if Diphoterine(R) solution is more efficacious than 0.9% saline in CS exposure.
    C) ACTIVE BLOWN AIR: CS is highly soluble in water and the irrigation of eyes can intensify the irritation. One review article recommended to blow air directly into the patient's eyes using a fan. Then irrigate the exposed eyes with 2 L of cold water or normal saline if irritation persists (Svinos, 2011).
    6.8.2) TREATMENT
    A) SUPPORT
    1) Treatment should include recommendations listed in the INHALATION EXPOSURE section when appropriate.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) Remove all contaminated clothing, wash them with soap in cold water and allow non-washable items to air for a few days.
    B) Exposed areas of the body should be washed with soap and water twice. Copious irrigation with at least 2 liters of cold water has been recommended for CS exposure, since small amounts of water can increase irritation (Lee et al, 1984). Contaminated hair may lead to re-exposure of the patient on showering or bathing (Beswick, 1983).
    C) Patients arriving at a hospital will most likely have contaminated the vehicle, it will need to be decontaminated with a soap and cold water wash to avoid discomfort to other passengers.
    D) To avoid discomforting vapors and contamination of emergency room personnel, patient's clothing should be placed in large plastic bags and sealed (Horton et al, 2005). The victims skin should be washed thoroughly with water, and eyes should be irrigated with saline.
    E) Emergency room personnel should be notified of possible exposure to lacrimators (Van Tittelboom & Mostin, 1992).
    F) DIPHOTERINE: Diphoterine(R) solution has been used for decontamination of eyes and skin following exposure to ortho-chlorobenzylidene malononitrile (CS) " tear gas". Four French Gendarmes were exposed to CS in a standard training CS chamber for 2 minutes. They experienced excessive lacrimation, conjunctival irritation, reflex blepharospasm, reflex palpebral occlusion, and intense photophobia. All ocular signs and symptoms resolved approximately 3 to 7 minutes after decontamination with 250 mL of Diphoterine(R). In addition, in a pre-exposure prophylaxis test, a Gendarme was treated with 250 mL of Diphoterine(R) before entering the CS exposure chamber for 2 minutes. He did not experience any ocular or facial skin irritation, but he had mild coughing (Viala et al, 2005).
    1) The above study's limitations should be noted: small number of subjects, no blinding, placebo or control, and funding was provided by the company which produces Diphoterine(R). More studies need to be done to confirm if Diphoterine(R) solution is more efficacious than 0.9% saline in CS exposure.
    6.9.2) TREATMENT
    A) CHEMICAL BURN
    1) APPLICATION
    a) These recommendations apply to patients with MINOR chemical burns (FIRST DEGREE; SECOND DEGREE: less than 15% body surface area in adults; less than 10% body surface area in children; THIRD DEGREE: less than 2% body surface area). Consultation with a clinician experienced in burn therapy or a burn unit should be obtained if larger area or more severe burns are present. Neutralizing agents should NOT be used.
    2) DEBRIDEMENT
    a) After initial flushing with large volumes of water to remove any residual chemical material, clean wounds with a mild disinfectant soap and water.
    b) DEVITALIZED SKIN: Loose, nonviable tissue should be removed by gentle cleansing with surgical soap or formal skin debridement (Moylan, 1980; Haynes, 1981). Intravenous analgesia may be required (Roberts, 1988).
    c) BLISTERS: Removal and debridement of closed blisters is controversial. Current consensus is that intact blisters prevent pain and dehydration, promote healing, and allow motion; therefore, blisters should be left intact until they rupture spontaneously or healing is well underway, unless they are extremely large or inhibit motion (Roberts, 1988; Carvajal & Stewart, 1987).
    3) TREATMENT
    a) TOPICAL ANTIBIOTICS: Prophylactic topical antibiotic therapy with silver sulfadiazine is recommended for all burns except superficial partial thickness (first-degree) burns (Roberts, 1988). For first-degree burns bacitracin may be used, but effectiveness is not documented (Roberts, 1988).
    b) SYSTEMIC ANTIBIOTICS: Systemic antibiotics are generally not indicated unless infection is present or the burn involves the hands, feet, or perineum.
    c) WOUND DRESSING:
    1) Depending on the site and area, the burn may be treated open (face, ears, or perineum) or covered with sterile nonstick porous gauze. The gauze dressing should be fluffy and thick enough to absorb all drainage.
    2) Alternatively, a petrolatum fine-mesh gauze dressing may be used alone on partial-thickness burns.
    d) DRESSING CHANGES:
    1) Daily dressing changes are indicated if a burn cream is used; changes every 3 to 4 days are adequate with a dry dressing.
    2) If dressing changes are to be done at home, the patient or caregiver should be instructed in proper techniques and given sufficient dressings and other necessary supplies.
    e) Analgesics such as acetaminophen with codeine may be used for pain relief if needed.
    4) TETANUS PROPHYLAXIS
    a) The patient's tetanus immunization status should be determined. Tetanus toxoid 0.5 milliliter intramuscularly or other indicated tetanus prophylaxis should be administered if required.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Abstracts

Case Reports

    A) CHRONIC EFFECTS
    1) A previously well 21-year-old woman had continuous coughing, wheezing, and shortness of breath for two years after short-term exposure to CS gas (Beare et al, 1988).
    B) ADULT
    1) On a calm day, a 29-year-old man, barricaded in a small room (9'x9'x8.5') with a single door and a small high window, was exposed for approximately 30 minutes to a single 112 tear gas grenade containing 128 grams of chloracetophenone. He presented to the emergency department agitated and under restraints. Vital signs were temperature 99 degrees Fahrenheit, pulse 80, respirations 24/minute, and blood pressure 130/80. The conjunctivae were suffused, and the pupils were small and unreactive. The chest was clear by auscultation, but there was abundant mucoid discharge from the nose and the mouth. The ECG was within normal limits with occasional premature ventricular contraction. He remained semicomatose, and then suddenly developed pulmonary edema and died 12 hours after admission (Stein & Kirwan, 1964).

Range Of Toxicity

Summary

    A) TOXICITY: Minimum toxic or lethal doses are not well established in the literature. Most of these agents have a high safety ratio. The incapacitating doses (ICt 50) of CN and CS have ranged from 20 to 50 mg/min/m(3) and 4 to 20 mg/min/m(3), respectively.

Minimum Lethal Exposure

    A) LETHAL DOSE
    1) Lethal dose (LCt 50): the concentration (C) that causes death (L) in 50% of individuals after one minute (t=time) (Carron & Yersin, 2009).
    2) CHLOROACETOPHENONE (CN): 8500 to 25,000 mg/min/m(3) (Carron & Yersin, 2009).
    3) CHLOROBENZYLIDENE MALONONITRILE (CS): 25,000 to 100,000 mg/min/m(3) (Carron & Yersin, 2009), or 60 x 10(3) mg/min/m(-3) (Beswick, 1983).
    4) DIBENZOXAZEPINE (CR): Greater than 100,000 mg/min/m(3) (Carron & Yersin, 2009; Beswick, 1983) .
    5) DIPHENYLAMINOCHLOROARSINE (DM): 10,000 to 35,000 mg/min/m(3) (Carron & Yersin, 2009).

Maximum Tolerated Exposure

    A) INCAPACITATING DOSE
    1) The toxicity of these agents is concentration, particle size, and time dependent. Incapacitating dose (ICt 50) is the concentration (C) that causes incapacitation (I) in 50% of individuals after one minute (t=time) (Carron & Yersin, 2009).
    2) CHLOROACETOPHENONE (CN): 20 to 50 mg/min/m(3) (Carron & Yersin, 2009).
    3) CHLOROBENZYLIDENE MALONONITRILE (CS): 4 to 20 mg/min/m(3) (Carron & Yersin, 2009).
    4) DIBENZOXAZEPINE (CR): 0.2 to 1 mg/min/m(3) (Carron & Yersin, 2009).
    5) DIPHENYLAMINOCHLOROARSINE (DM): 50 to 100 mg/min/m(3) (Carron & Yersin, 2009).
    B) EYE IRRITATION THRESHOLD
    1) Approximate threshold for eye irritation (aerosol) in mg/m(3) (Beswick, 1983).
    a) CHLOROACETOPHENONE (CN): 0.3 mg/m(3).
    b) CHLOROBENZYLIDENE MALONONITRILE (CS): 0.004 mg/m(3).
    c) CHLOROBENZYLIDENE MALONONITRILE (CS): 0.002 mg/m(3).

Workplace Standards

    A) ACGIH TLV Values for CAS532-27-4 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.
    a) Adopted Value
    1) 2-Chloroacetophenone
    a) TLV:
    1) TLV-TWA: 0.05 ppm
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: A4
    2) Codes: Not Listed
    3) Definitions:
    a) A4: Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    c) TLV Basis - Critical Effect(s): Eye, URT, and skin irr
    d) Molecular Weight: 154.59
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:

    B) ACGIH TLV Values for CAS76-06-2 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.
    a) Adopted Value
    1) Chloropicrin
    a) TLV:
    1) TLV-TWA: 0.1 ppm
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: A4
    2) Codes: Not Listed
    3) Definitions:
    a) A4: Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    c) TLV Basis - Critical Effect(s): Eye irr; pulm edema
    d) Molecular Weight: 164.39
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:

    C) ACGIH TLV Values for CAS257-07-8 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    D) ACGIH TLV Values for CAS2698-41-1 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.
    a) Adopted Value
    1) o-Chlorobenzylidene malononitrile
    a) TLV:
    1) TLV-TWA:
    2) TLV-STEL:
    3) TLV-Ceiling: 0.05 ppm
    b) Notations and Endnotes:
    1) Carcinogenicity Category: A4
    2) Codes: Skin
    3) Definitions:
    a) A4: Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    b) Skin: This refers to the potential significant contribution to the overall exposure by the cutaneous route, including mucous membranes and the eyes, either by contact with vapors or, of likely greater significance, by direct skin contact with the substance. It should be noted that although some materials are capable of causing irritation, dermatitis, and sensitization in workers, these properties are not considered relevant when assigning a skin notation. Rather, data from acute dermal studies and repeated dose dermal studies in animals or humans, along with the ability of the chemical to be absorbed, are integrated in the decision-making toward assignment of the skin designation. Use of the skin designation provides an alert that air sampling would not be sufficient by itself in quantifying exposure from the substance and that measures to prevent significant cutaneous absorption may be warranted. Please see "Definitions and Notations" (in TLV booklet) for full definition.
    c) TLV Basis - Critical Effect(s): URT irr; skin sens
    d) Molecular Weight: 188.61
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:

    E) NIOSH REL and IDLH Values for CAS532-27-4 (National Institute for Occupational Safety and Health, 2007):
    1) Listed as: alpha-Chloroacetophenone
    2) REL:
    a) TWA: 0.3 mg/m(3) (0.05 ppm)
    b) STEL:
    c) Ceiling:
    d) Carcinogen Listing: (Not Listed) Not Listed
    e) Skin Designation: Not Listed
    f) Note(s):
    3) IDLH:
    a) IDLH: 15 mg/m3
    b) Note(s): Not Listed

    F) NIOSH REL and IDLH Values for CAS76-06-2 (National Institute for Occupational Safety and Health, 2007):
    1) Listed as: Chloropicrin
    2) REL:
    a) TWA: 0.1 ppm (0.7 mg/m(3))
    b) STEL:
    c) Ceiling:
    d) Carcinogen Listing: (Not Listed) Not Listed
    e) Skin Designation: Not Listed
    f) Note(s):
    3) IDLH:
    a) IDLH: 2 ppm
    b) Note(s): Not Listed

    G) NIOSH REL and IDLH Values for CAS257-07-8 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    H) NIOSH REL and IDLH Values for CAS2698-41-1 (National Institute for Occupational Safety and Health, 2007):
    1) Listed as: o-Chlorobenzylidene malononitrile
    2) REL:
    a) TWA:
    b) STEL:
    c) Ceiling: 0.05 ppm (0.4 mg/m(3))
    d) Carcinogen Listing: (Not Listed) Not Listed
    e) Skin Designation: [skin]
    1) Indicates the potential for dermal absorption; skin exposure should be prevented as necessary through the use of good work practices and gloves, coveralls, goggles, and other appropriate equipment.
    f) Note(s):
    3) IDLH:
    a) IDLH: 2 mg/m3
    b) Note(s): Not Listed

    I) Carcinogenicity Ratings for CAS532-27-4 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): A4 ; Listed as: 2-Chloroacetophenone
    a) A4 :Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Assessed under the IRIS program. ; Listed as: 2-Chloroacetophenone
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: alpha-Chloroacetophenone
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    J) Carcinogenicity Ratings for CAS76-06-2 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): A4 ; Listed as: Chloropicrin
    a) A4 :Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: Chloropicrin
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    K) Carcinogenicity Ratings for CAS257-07-8 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    L) Carcinogenicity Ratings for CAS2698-41-1 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): A4 ; Listed as: o-Chlorobenzylidene malononitrile
    a) A4 :Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: o-Chlorobenzylidene malononitrile
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    M) OSHA PEL Values for CAS532-27-4 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Listed as: a-Chloroacetophenone (Phenacyl chloride)
    2) Table Z-1 for a-Chloroacetophenone (Phenacyl chloride):
    a) 8-hour TWA:
    1) ppm: 0.05
    a) Parts of vapor or gas per million parts of contaminated air by volume at 25 degrees C and 760 torr.
    2) mg/m3: 0.3
    a) Milligrams of substances per cubic meter of air. When entry is in this column only, the value is exact; when listed with a ppm entry, it is approximate.
    3) Ceiling Value:
    4) Skin Designation: No
    5) Notation(s): Not Listed

    N) OSHA PEL Values for CAS76-06-2 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Listed as: Chloropicrin
    2) Table Z-1 for Chloropicrin:
    a) 8-hour TWA:
    1) ppm: 0.1
    a) Parts of vapor or gas per million parts of contaminated air by volume at 25 degrees C and 760 torr.
    2) mg/m3: 0.7
    a) Milligrams of substances per cubic meter of air. When entry is in this column only, the value is exact; when listed with a ppm entry, it is approximate.
    3) Ceiling Value:
    4) Skin Designation: No
    5) Notation(s): Not Listed

    O) OSHA PEL Values for CAS257-07-8 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

    P) OSHA PEL Values for CAS2698-41-1 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Listed as: o-Chlorobenzylidene malononitrile
    2) Table Z-1 for o-Chlorobenzylidene malononitrile:
    a) 8-hour TWA:
    1) ppm: 0.05
    a) Parts of vapor or gas per million parts of contaminated air by volume at 25 degrees C and 760 torr.
    2) mg/m3: 0.4
    a) Milligrams of substances per cubic meter of air. When entry is in this column only, the value is exact; when listed with a ppm entry, it is approximate.
    3) Ceiling Value:
    4) Skin Designation: No
    5) Notation(s): Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) CHLOROACETOPHENONE
    1) LD50- (ORAL)RAT:
    a) 126 mg/kg (Beswick, 1983)
    B) DIBENZOXAZEPINE
    1) LD50- (ORAL)RAT:
    a) 7500 mg/kg (Beswick, 1983)
    C) ORTHO-CHLOROBENZYLIDENE MALONONITRILE
    1) LD50- (ORAL)RAT:
    a) 1366 mg/kg (Beswick, 1983)

Pharmacology Toxicology

Toxicologic Mechanism

    A) Lacrimators such as CN gas (1-chloroacetophenone) and CS gas (2-chlorobenzylidene malononitrile) are SN2 alkylating agents, which have activated halogen groups. They bind sulfhydryl groups and fix enzymes. This activity is transient because these enzymes are rapidly reactivated. Tissue injury is thought to be related to enzyme inactivation and pain is bradykinin mediated (Suchard, 2011).

Physicochemical

Physical Characteristics

    A) ALPHA-CHLOROACETOPHENONE (CN)
    1) Exists as colorless crystals. A low concentration of vapor resembles an odor of apple blossoms (Stein & Kirwan, 1964).
    B) BROMBENZYLCYANIDE (CA): Odor of sour fruit
    C) ORTHO-CHLOROBENZYLIDENE MALONONITRILE (CS): white crystalline solid
    D) ORTHO-CHLOROBENZAMALONITRILE (CS): pepper-like odor

Molecular Weight

    A) alpha-Chloroacetophenone (CN): 154.59
    B) ortho-Chlorobenzylidene Malononitrile (CS): 188.62
    C) Dibenzoxazepine (CR): 195.23

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