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Selected Topics: Toxicology| Volume 57, ISSUE 2, P177-180, August 2019

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Dose-Dependent Pulmonary Injury Following Nitrogen Dioxide Inhalation From Kinepak Detonation

      Abstract

      Background

      Nitrogen dioxide (NO2) is a pulmonary irritant produced as a byproduct of bacterial anaerobic metabolism of organic materials, and is also produced as a byproduct of explosive detonations. Significant NO2 exposure results in free-radical–induced pulmonary injury that may be delayed up to 3–30 h after exposure and can progress to acute respiratory distress syndrome (ARDS) and death. Here we present a case series of 3 patients with dose-dependent pulmonary injury consistent with NO2 inhalation following exposure to fumes from detonation of an ammonium nitrate/nitromethane (ANNM) explosive device.

      Case Reports

      Three individuals presented to the emergency department over the course of 16 h, beginning approximately 16 h after exposure to fumes from an ANNM explosive device. Patient 1, with the most significant exposure, developed ARDS necessitating intubation and mechanical ventilation. Patient 2 exhibited hypoxia and findings concerning for diffuse airway inflammation, but ultimately required only supplemental oxygen. Patient 3, with the least exposure, had imaging abnormalities but required no intervention.

      Why Should an Emergency Physician Be Aware of This?

      Respiratory distress is a common presenting complaint to the emergency department. Because of the delayed presentation and the potential for progressive worsening of symptoms associated with NO2 exposure, it is important that emergency physicians be aware of the multiple potential means of exposure and consider this diagnosis in the proper clinical context. Patients with suspicion of NO2-related lung injury should undergo more extended observation than their initial clinical presentation may suggest.

      Keywords

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      References

        • Green E.M.
        Explosives regulation in the USA.
        Ind Mater. 2006; 465: 78-79
        • KINEPAK
        KINEPAK Liquid Component A (Nitromethane).
        KINEPAK, Inc, Lewisville, TX1986
      1. U.S. v. McVeigh, 153 F.3d 1166 (10th Cir. 1998).

        • Lowry T.
        • Schuman L.
        “Silo-filler’s disease”—a syndrome cause by nitrogen dioxide.
        J Am Med Assoc. 1956; 162: 153-160
        • Gailitis J.
        • Burns L.
        • Nally J.
        Silo-fillers disease.
        N Engl J Med. 1958; 258: 543-544
        • Cornelius E.A.
        • Betlach E.H.
        Silo-filler’s disease.
        Radiology. 1960; 74: 232-238
        • Mainiero R.J.
        • Rowland III, J.H.
        • Harris M.L.
        • Sapko M.J.
        Behavior of nitrogen oxides in the product gases from explosive detonations.
        (Available at:) (Accessed: 27 March 2018)
        • Sapko M.
        • Rowland J.
        • Mainiero R.
        • Zlochower I.
        Chemical and physical factors that influence NOx production during blasting—exploratory study.
        Proc Annu Conf Explos Blasting Tech. 2002; 2 (Available at:) (Accessed: 27 March 2018): 317-330
        • Mainiero R.J.
        • Harris M.L.
        • Rowland J.H.
        Dangers of toxic fumes from blasting.
        Proc Annu Conf Explos Blasting Tech. 2007; 33: 73
        • Mainiero R.
        A technique for measuring toxic gases produced by blasting agents.
        Proc Annu Conf Explos. 1997; 23 (Available at:) (Accessed: 27 March 2018): 1-10
        • Department of Employment, Economic Development
        • Innovation (DEEDI)
        Queensland Guidance Note—Management of Oxides of Nitrogen in open Cut Blasting.
        DEEDI, Queensland, Australia2011: 95
        • Sullivan J.
        • Krieger G.
        Oxides of nitrogen and sulfur.
        Clinical Environmental Health and Toxic Exposures. 2nd ed. Lippincott Williams & Wilkins, 2001: 818-832
        • Mirowsky J.E.
        • Dailey L.A.
        • Devlin R.B.
        Differential expression of pro-inflammatory and oxidative stress mediators induced by nitrogen dioxide and ozone in primary human bronchial epithelial cells.
        Inhal Toxicol. 2016; 28: 374-382
        • Elsayed N.M.
        Toxicity of nitrogen dioxide: an introduction.
        Toxicology. 1994; 89: 161-174
        • Robinson D.M.
        • Yu M.L.
        • Prakash U.B.S.
        60-Year-old man with respiratory distress and confusion.
        Mayo Clin Proc. 1996; 71: 813-816
        • Murphy C.M.
        • Akbarnia H.
        • Rose S.R.
        Fatal pulmonary edema after acute occupational exposure to nitric acid.
        J Emerg Med. 2010; 39: 39-43
        • Ayyagari V.N.
        • Januszkiewicz A.
        • Nath J.
        Pro-inflammatory responses of human bronchial epithelial cells to acute nitrogen dioxide exposure.
        Toxicology. 2004; 197: 149-164
        • O’Donnell V.B.
        • Eiserich J.P.
        • Chumley P.H.
        • et al.
        Nitration of unsaturated fatty acids by nitric oxide-derived reactive nitrogen species peroxynitrite, nitrous acid, nitrogen dioxide, and nitronium ion.
        Chem Res Toxicol. 1999; 12: 83-92
        • Lee L.T.
        • Ho C.H.B.
        • Putti T.C.
        Bronchiolitis obliterans organizing pneumonia following nitric acid fume exposure.
        Occup Med (Lond). 2014; 64: 136-138