576924
research-article2015
WHSXXX10.1177/2165079915576924Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
July 2015
PROFESSIONAL PR ACTICE
Occupational-Related Chemical Injuries A Review of the Literature Ann Lurati, ARNP, MPH, ACNP-BC, DNP, COHN-S1
Abstract: Although few occupational chemical injuries are reported each year, the severity of these injuries increases their importance to occupational health nurses who intervene to prevent these injuries by understanding their nature and etiology. This article is a review of the literature detailing specific occupational chemical injuries as well as a review of common occupational chemical injuries in the United States focusing on pulmonary, ocular, and burn injuries. Keywords: chemicals, ocular, dermal, and pulmonary
A
ccording to the Occupational Safety and Health Administration (OSHA), approximately 14,024 fatal and nonfatal occupational chemical injuries were reported in 2012 (Centers for Disease Control and Prevention [CDC], 2013). The number of occupational chemical injuries may be relatively small, but these injuries can cause permanent disability. A chemical injury is due to an acute or chronic exposure to a chemical that alters bodily structures or functions. Chemical injuries may occur via multiple exposure routes: dermal, respiratory, or oral (CDC, 2013). Workers may be exposed to chemicals in various forms: liquids, gases, fumes, vapors, and solids (CDC, 2013). Most common chemicals are acids, alkalis, aromatic compounds, hydrocarbon derivatives, halogens and their derivatives, metallic dusts or powders, agricultural chemicals and pesticides, coal, and natural gas and petroleum fuels and their by-products (Agency for Toxic Substances and Disease Registry [ATSDR], 2013). Poisonings, toxic exposures, noxious exposures, and allergic reactions can occur (American Association of Poison Control Centers [AAPCC], 2014). Other injuries may be the result of exposures to venoms from bites and stings or medications, as in the pharmaceutical industry (CDC, 2013). This article is a review of literature detailing specific occupational chemical injury case studies and a general review of common injuries that have occurred in the United States. PubMed was selected as the database for this review because it includes all peer-reviewed research journal articles in
occupational health and safety. The inclusion criteria included studies of occupational chemical injuries that occurred in the United States, particularly pulmonary, ocular, and burn injuries. Only injuries that occurred in U.S. workplaces were included because occupational standards and regulations differ by country as does worker training. The literature review focused only on pulmonary, ocular, and burn injuries because these injuries were the most common. Keywords for the literature search included chemicals, toxin, exposure, work-related, occupational-related, ocular, pulmonary, burns, and injuries. A total of 10 articles were found but only 8 met the inclusion criteria. Finally, public health agencies, such as Poison Control Centers and the Agency for Toxic Substances and Disease Registry, were identified as assisting occupational health nurses in preventing and managing these injuries.
Occupational Pulmonary Injuries Pulmonary exposures in the workplace are considered most hazardous (Murphy, Akbarnia, & Rose, 2008). In 2008, a State of Virginia worker sustained a fatal injury via pulmonary exposure to nitric acid, a corrosive inorganic acid and strong oxidizing agent in woodworking and the production of fertilizers, explosives such as trinitrotoluene (TNT), rocket fuel, semiconductors, and cleaning agents (Murphy et al., 2008). This worker was not wearing personal protective equipment and, as a result, inhaled toxic fumes. An occupational physician examined the worker immediately following the exposure, and reported that the worker was asymptomatic and therefore did not require immediate care; however, the physician also did not monitor the injured worker’s condition. Within 24 hours, the worker developed delayed-onset pulmonary edema and died 53 hours after exposure. An investigation revealed that the worker had not learned about hazardous materials in the workplace, nor had he received appropriate personal protective equipment. In addition, the physician had inadequate knowledge of the chemicals used by this company. One of the recommendations of the investigation was that the occupational health team should have contacted the Regional Poison Control Center for an evidenced-based protocol.
DOI: 10.1177/2165079915576924. From 1University of South Florida. Address correspondence to: Ann Lurati, ARNP, MPH, ACNP-BC, DNP, COHN-S, Occupational Health Nurse Practitioner, University of South Florida, 4505 West Brookwood Drive, Tampa, FL 33629, USA; email: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
284 Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
Workplace Health & Safety
vol. 63 ■ no. 7
Examples of Personal Protective Equipment Respiratory protection N95 Self-contained breathing apparatus Air purifying respirators Half-face particulate respirators Gloves Rubber gloves Vinyl gloves Neoprene gloves Silver shield laminate gloves Eye protection Goggles Face shields Safety glasses Clothing HAZMAT Suit Lab Coat Public Health Sources of Chemical Data Environmental Protection Agency Hazardous Substances Data Base Agency for Toxic Substances and Disease Registry NLM TOXLINE-Toxicology Bibliographic Registry National Poison Control Centers National Institute of Occupational Safety and Health Centers for Disease Control and Prevention Occupational Safety and Health Administration
Smith and Yalamanchili (2008) reported a death due to acute hydrogen sulfide toxicity from a sewer gas exposure. Hydrogen sulfide, a toxic gas, is a by-product of petroleum refineries, oil and natural gas production, mines, and dye-making plants. It is also commonly found in sewer lines and liquid manure lagoons because hydrogen sulfide is a by-product of organic sulfide compounds. Hydrogen sulfide inhibits the cytochrome oxidase system, halting aerobic cellular respiration causing cellular asphyxia resulting in death. A 34-year-old sewer worker was found unresponsive, 20 feet below street level in a sewer line. The worker later died of respiratory failure. In the final investigation, it was determined that the worker was not wearing protective respiratory equipment nor was he provided with hazardous materials training. Another fatal pulmonary exposure involving methylene chloride was reported to the CDC (2011). The Michigan Fatality Assessment and Control Evaluation program investigated the death of a bathroom refinisher exposed to methylene chloride vapors. Methylene chloride is a volatile liquid solvent and degreaser used in model building and painting. In its simplest form, it is a chlorohydrocarbon but is metabolized in the human body to carbon monoxide. In this case, the work environment did not have adequate ventilation and the worker was not wearing proper personal protective equipment, for example, a respirator. In a subsequent review of these work-related deaths from 2000 to 2011, it was discovered that three other workers
had died under similar circumstances. Their employers were not compliant with OSHA methylene chloride standards, the workers had not received hazardous materials training, nor were they provided with effective personal protective equipment. Finally, in 2010, Occupational Health and Safety Weekly Fatality/Catastrophe Reports reviewed the death of a worker exposed to high temperature chemical steam. The worker died of pulmonary edema. The exposure occurred while working with clinker material clearing process machinery, which involved exposure to water vapors, but due to reporting omissions, it is unknown if any chemicals were in the water vapors (U.S. Department of Labor, 2011).
Occupational Ocular Injuries Occupational eye injuries may also result from chemical exposures. In 2008, Spector and Fernandez reported that the majority of eye injuries treated in the emergency department at Boston Medical Center were occupationally related. Occupational ocular chemical injuries are the result of exposure to alkaline or acidic products commonly found in the workplace. Ocular injuries are dangerous because alkali products cause liquefactive necrosis of the surface of the eye, and damage to the eye is irreversible. Industries that use alkaline or acidic chemicals include those that produce lime, fertilizers and batteries, polish glass, remove rust, and process leather and food. Most occupational chemical eye injuries occur when workers are not wearing effective personal protective equipment, such as eye shields that protect against acid or alkaline splashes. Other types of eye injuries result from exposure to cyanacrylates that form a strong polymer bonding to the surface of the eye. Cyanacrylates have little toxicity; however, when cyanacrylates attach to the eye, surgical removal is required. Finally, ultraviolet (UV) radiation may cause irreversible burn injuries. Again, these injuries occur when workers are not wearing appropriate personal protective equipment mandated by OSHA.
Occupational Burn Injuries Chemical burns are a common injury in the workplace. Burns may result from an acid or alkaline exposure. Amshel, Fealk, Phillips, and Caruso (2000) published a case study of a 28-year-old male employee who sustained a 45% body surface area burn due to an anhydrous ammonia explosion. Anhydrous ammonia is a pungent gas used as a potent fertilizer and in the nylon and rayon industries. It was concluded by the authors that the injured worker had not received formal training about the hazardous nature of anhydrous ammonia and the company was unprepared to provide immediate first aid. Blodgett, Suruda, and Crouch (2001) reported a fatal occupational hydrofluoric acid incident; the worker died from pulmonary failure and third-degree burns. Hydrofluoric acid is a corrosive inorganic acid commonly used in glass etching, petroleum refining, and electronics and semiconductor manufacturing. Once hydrofluoric acid contacts the skin, the worker experiences severe burns and systemic poisoning. If 285
Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
Workplace Health & Safety
July 2015
inhaled, hydrofluoric acid causes massive pulmonary edema. OSHA reported nine deaths in the United States during an 11-year period from 1984 to 1994 (Blodgett et al., 2001). After an investigation, OSHA concluded that the deaths were due to inadequate emergency response; the employer should have contacted the Regional Poison Control Center to manage the injury (Blodgett et al., 2001).
Discussion Ruckart and Burgess (2007) noted that 3,506 chemical accidents had occurred in mining and manufacturing industries; 3,282 of these chemical accidents were the result of human error. Human error was also the most cited cause of all occupational injuries (Dekker, 2003). Ruckart and Burgess (2007) reviewed the data from 1996 to 2003 accessed from Hazardous Substances Emergency Events Surveillance System; human error included the improper use of personal protective equipment, inadequate emergency care, and inadequate knowledge of chemicals that were used in the workplace. However, Dekker (2003) pointed out that human error in these cases was actually due to an inadequate safety system. It is also noted that human error was cited during post-accident investigations but that the injuries may have occurred because of work practices that appeared reasonable before the accident occurred. OSHA recommends enhancing safety programs by focusing on organizational leadership, worker participation, hazard identification, and hazard prevention and control with program evaluation and improvement monitoring (Dekker, 2003). The occupational health nurse is responsible for the health and well-being of employees, as well as implementation and documentation of safety training in some settings. The issuance of proper personal protective equipment and training about its proper use is part of OSHA-mandated safety programs. If a chemical exposure does occur resulting in injury, the occupational health nurse may be asked to participate in an accident investigation to determine the root cause of the accident. In most published case studies about occupational chemical injuries, employees were not wearing personal protective equipment properly or they were wearing the wrong equipment. Migrant workers, for example, may find personal protective equipment uncomfortable because they often work in warm environments such as hot houses or fields during the summer (Hansen & Donohoe, 2003). When working with toxic substances such as mercury, neoprene gloves are not adequate protection; sliver-shielded laminate gloves are recommended and may only be worn for a set period of time per manufacturer’s recommendation. Each worker may require a health risk assessment to establish personal risk factors. For example, a worker with psoriasis has an increased risk of susceptibility to a chemical’s toxic effects due to increased dermal absorption (FiserovaBergerova, Pierce, & Droz, 2007). It is the responsibility of occupational health nurses to determine appropriate personal protective equipment for each employee based on identified workplace hazards and OSHA standards. Workplace
walk-throughs and first-aid refresher courses for off-shift workers are essential due to fewer supervisory personnel and line workers on those shifts. The selection of personal protective equipment is essential to the prevention of injuries as in the example of chlorine gas exposure. Respirator selection recommendations may be found in the National Institute of Occupational Safety and Health (NIOSH; CDC, 2013) Pocket Guide. If workers are exposed to vapors or fumes, the worker should be fitted with an airpurifying respirator with a chemical cartridge (CDC, 2013). For a specific chemical that is not included in the Pocket Guide, the NIOSH Respirator Selection Logic may be used (CDC, 2004). Prior to respirator fit testing, a health assessment on each worker should be completed to determine whether the worker has any underlying cardiac or respiratory pathology that may limit the use of a respirator (CDC, 2013). Workers may struggle with workplace training if their first language is not English. Employing videos in the workers’ first language and pictures can improve comprehension. Workers must also feel empowered to report occupational accidents and injuries without fear of reprisal from their employers. Finally, workers must understand that a new illness could be work-related; for example, a cholinergic response to organophosphate exposure should be evaluated by the occupational health team. Education about personal hygiene and work rules is essential to maintaining a safe and healthy workplace.
Community Resources Resources are available to assist occupational health nurses better understand the chemicals used in their work environments. Every worksite must have Material Safety Data Sheets (MSDS) available to all employees. Included in the MSDS are interventions to treat an exposure and an emergency number that physicians and nurses may use to learn more about treating employees exposed to occupational chemicals. Once an injury has occurred, the occupational health staff should contact the Regional Poison Control Center for immediate information about treatment after an acute exposure. OSHA, as well as the Environmental Protection Agency, is an additional resource that occupational health nurses may use to gather information regarding chemical hazards in the workplace. Occupational health nurses should also review pertinent literature about specific chemicals used by workers in the workplace. Finally, it is the responsibility of occupational health nurses to report all exposures to appropriate federal and state agencies to ensure that both workers and employers are in full compliance with regulations that ensure a safe workplace.
Conclusion The number of occupational chemical injuries is relatively small, however, according to published case studies, these injuries may lead to permanent disabilities or death. It can be difficult for occupational health nurses to access current information on occupational injuries; however, a review of the
286 Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
Workplace Health & Safety
vol. 63 ■ no. 7
literature and analysis of public health records provide examples of how occupational chemical injuries occur, and how to prevent them by providing worker training and selecting proper personal protective equipment to minimize exposures.
Conflict of Interest The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
Centers for Disease Control and Prevention. (2013). Chemical related injuries and illnesses in U.S. mining (Department of Health and Human Services). Retrieved from http://www.cdc.gov/niosh/mining/UserFiles/ works/pdfs/criai.pdf Dekker, S. (2003). Accidents are normal and human error does not exist: A new look at the creation of occupational safety. International Journal of Occupational Safety and Ergonomics, 9, 211-218. Hansen, E., & Donohoe, M. (2003). Health issues of migrant and seasonal farm workers. Journal of Health for Poor and Underserved, 14, 153-164. Fiserova-Bergerova, T., Pierce, T., & Droz, P. (2007). Dermal absorption potential of industrial chemicals: criteria for skin notation. American Journal of Industrial Medicine, 17, 617-635. doi:10.1002/ ajim.4700170507
The author received no financial support for the research, authorship, and/or publication of this article.
Murphy, C. M., Akbarnia, H., & Rose, S. R. (2010). Fatal pulmonary edema after acute occupational exposure to nitric acid. Journal of Emergency Medical, 39, 39-43. doi:10.1016/j.jemermed.2008.03.011
References
Ruckart, P., & Burgess, P. (2007). Human error and time of occurrence in hazardous material events in mining and manufacturing. Journal of Hazardous Material, 142, 747-753.
Amshel, C., Fealk, M., Phillips, B., & Caruso, D. (2000). Anhydrous ammonia burns care reports and review of the literature. Burns, 25, 493-497. Agency for Toxic Substances and Disease Registry. (2013). National Toxic Substance Incident report. Centers for Disease Control and Prevention. Retrieved from http://www.atsdr.cdc.gov/ntsip/docs/ATSDR_ Annual%20Report_121013_508%20compliant.pdf American Association of Poison Control Centers. (2014). National Poison Control Data System. Available from http://www.aapcc.org/ Blodgett, D., Suruda, A., & Crouch, B. (2001). Fatal unintentional occupational poisonings by hydrofluoric acid in the US. American Journal of Industrial Medicine, 40, 215-220. Centers for Disease Control and Prevention. (2011). Fatal exposure to methylene chloride among bathtub refinishers in the United States. Morbidity and Mortality Weekly Report, 24, 119-122. Centers for Disease Control and Prevention. (2004). NIOSH respirator selection logic (National Institute of Occupational Safety and Health). Retrieved from http://www.cdc.gov/niosh/docs/2005-100/
Smith, M., & Yalamanchili, C. (2008). Acute hydrogen sulfide toxicity due to sewer gas exposure. American Journal of Emergency Medicine, 26, 518e-518e7. doi:10.1016/j.jajem.2007.08.025 Spector, J., & Fernandez, W. (2008). Chemical, thermal, and biological ocular exposures. Emergency Medical Clinic North America, 26, 125136. doi:10.1016/j.emc.2007.11.002 U.S. Department of Labor. (2011). Injuries, illnesses, and fatalities. Bureau of Labor Statistics. Retrieved from http://www.bls.gov/iif/ oshsum.htm
Author Biography Ann Lurati, ARNP, MPH, ACNP-BC, DNP, COHN-S, is an occupational health nurse practitioner with a speciality in toxicology at the University of South Florida, Tampa, Florida.
287 Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
research-article2015
WHSXXX10.1177/2165079915576924Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
July 2015
PROFESSIONAL PR ACTICE
Occupational-Related Chemical Injuries A Review of the Literature Ann Lurati, ARNP, MPH, ACNP-BC, DNP, COHN-S1
Abstract: Although few occupational chemical injuries are reported each year, the severity of these injuries increases their importance to occupational health nurses who intervene to prevent these injuries by understanding their nature and etiology. This article is a review of the literature detailing specific occupational chemical injuries as well as a review of common occupational chemical injuries in the United States focusing on pulmonary, ocular, and burn injuries. Keywords: chemicals, ocular, dermal, and pulmonary
A
ccording to the Occupational Safety and Health Administration (OSHA), approximately 14,024 fatal and nonfatal occupational chemical injuries were reported in 2012 (Centers for Disease Control and Prevention [CDC], 2013). The number of occupational chemical injuries may be relatively small, but these injuries can cause permanent disability. A chemical injury is due to an acute or chronic exposure to a chemical that alters bodily structures or functions. Chemical injuries may occur via multiple exposure routes: dermal, respiratory, or oral (CDC, 2013). Workers may be exposed to chemicals in various forms: liquids, gases, fumes, vapors, and solids (CDC, 2013). Most common chemicals are acids, alkalis, aromatic compounds, hydrocarbon derivatives, halogens and their derivatives, metallic dusts or powders, agricultural chemicals and pesticides, coal, and natural gas and petroleum fuels and their by-products (Agency for Toxic Substances and Disease Registry [ATSDR], 2013). Poisonings, toxic exposures, noxious exposures, and allergic reactions can occur (American Association of Poison Control Centers [AAPCC], 2014). Other injuries may be the result of exposures to venoms from bites and stings or medications, as in the pharmaceutical industry (CDC, 2013). This article is a review of literature detailing specific occupational chemical injury case studies and a general review of common injuries that have occurred in the United States. PubMed was selected as the database for this review because it includes all peer-reviewed research journal articles in
occupational health and safety. The inclusion criteria included studies of occupational chemical injuries that occurred in the United States, particularly pulmonary, ocular, and burn injuries. Only injuries that occurred in U.S. workplaces were included because occupational standards and regulations differ by country as does worker training. The literature review focused only on pulmonary, ocular, and burn injuries because these injuries were the most common. Keywords for the literature search included chemicals, toxin, exposure, work-related, occupational-related, ocular, pulmonary, burns, and injuries. A total of 10 articles were found but only 8 met the inclusion criteria. Finally, public health agencies, such as Poison Control Centers and the Agency for Toxic Substances and Disease Registry, were identified as assisting occupational health nurses in preventing and managing these injuries.
Occupational Pulmonary Injuries Pulmonary exposures in the workplace are considered most hazardous (Murphy, Akbarnia, & Rose, 2008). In 2008, a State of Virginia worker sustained a fatal injury via pulmonary exposure to nitric acid, a corrosive inorganic acid and strong oxidizing agent in woodworking and the production of fertilizers, explosives such as trinitrotoluene (TNT), rocket fuel, semiconductors, and cleaning agents (Murphy et al., 2008). This worker was not wearing personal protective equipment and, as a result, inhaled toxic fumes. An occupational physician examined the worker immediately following the exposure, and reported that the worker was asymptomatic and therefore did not require immediate care; however, the physician also did not monitor the injured worker’s condition. Within 24 hours, the worker developed delayed-onset pulmonary edema and died 53 hours after exposure. An investigation revealed that the worker had not learned about hazardous materials in the workplace, nor had he received appropriate personal protective equipment. In addition, the physician had inadequate knowledge of the chemicals used by this company. One of the recommendations of the investigation was that the occupational health team should have contacted the Regional Poison Control Center for an evidenced-based protocol.
DOI: 10.1177/2165079915576924. From 1University of South Florida. Address correspondence to: Ann Lurati, ARNP, MPH, ACNP-BC, DNP, COHN-S, Occupational Health Nurse Practitioner, University of South Florida, 4505 West Brookwood Drive, Tampa, FL 33629, USA; email: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
284 Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
Workplace Health & Safety
vol. 63 ■ no. 7
Examples of Personal Protective Equipment Respiratory protection N95 Self-contained breathing apparatus Air purifying respirators Half-face particulate respirators Gloves Rubber gloves Vinyl gloves Neoprene gloves Silver shield laminate gloves Eye protection Goggles Face shields Safety glasses Clothing HAZMAT Suit Lab Coat Public Health Sources of Chemical Data Environmental Protection Agency Hazardous Substances Data Base Agency for Toxic Substances and Disease Registry NLM TOXLINE-Toxicology Bibliographic Registry National Poison Control Centers National Institute of Occupational Safety and Health Centers for Disease Control and Prevention Occupational Safety and Health Administration
Smith and Yalamanchili (2008) reported a death due to acute hydrogen sulfide toxicity from a sewer gas exposure. Hydrogen sulfide, a toxic gas, is a by-product of petroleum refineries, oil and natural gas production, mines, and dye-making plants. It is also commonly found in sewer lines and liquid manure lagoons because hydrogen sulfide is a by-product of organic sulfide compounds. Hydrogen sulfide inhibits the cytochrome oxidase system, halting aerobic cellular respiration causing cellular asphyxia resulting in death. A 34-year-old sewer worker was found unresponsive, 20 feet below street level in a sewer line. The worker later died of respiratory failure. In the final investigation, it was determined that the worker was not wearing protective respiratory equipment nor was he provided with hazardous materials training. Another fatal pulmonary exposure involving methylene chloride was reported to the CDC (2011). The Michigan Fatality Assessment and Control Evaluation program investigated the death of a bathroom refinisher exposed to methylene chloride vapors. Methylene chloride is a volatile liquid solvent and degreaser used in model building and painting. In its simplest form, it is a chlorohydrocarbon but is metabolized in the human body to carbon monoxide. In this case, the work environment did not have adequate ventilation and the worker was not wearing proper personal protective equipment, for example, a respirator. In a subsequent review of these work-related deaths from 2000 to 2011, it was discovered that three other workers
had died under similar circumstances. Their employers were not compliant with OSHA methylene chloride standards, the workers had not received hazardous materials training, nor were they provided with effective personal protective equipment. Finally, in 2010, Occupational Health and Safety Weekly Fatality/Catastrophe Reports reviewed the death of a worker exposed to high temperature chemical steam. The worker died of pulmonary edema. The exposure occurred while working with clinker material clearing process machinery, which involved exposure to water vapors, but due to reporting omissions, it is unknown if any chemicals were in the water vapors (U.S. Department of Labor, 2011).
Occupational Ocular Injuries Occupational eye injuries may also result from chemical exposures. In 2008, Spector and Fernandez reported that the majority of eye injuries treated in the emergency department at Boston Medical Center were occupationally related. Occupational ocular chemical injuries are the result of exposure to alkaline or acidic products commonly found in the workplace. Ocular injuries are dangerous because alkali products cause liquefactive necrosis of the surface of the eye, and damage to the eye is irreversible. Industries that use alkaline or acidic chemicals include those that produce lime, fertilizers and batteries, polish glass, remove rust, and process leather and food. Most occupational chemical eye injuries occur when workers are not wearing effective personal protective equipment, such as eye shields that protect against acid or alkaline splashes. Other types of eye injuries result from exposure to cyanacrylates that form a strong polymer bonding to the surface of the eye. Cyanacrylates have little toxicity; however, when cyanacrylates attach to the eye, surgical removal is required. Finally, ultraviolet (UV) radiation may cause irreversible burn injuries. Again, these injuries occur when workers are not wearing appropriate personal protective equipment mandated by OSHA.
Occupational Burn Injuries Chemical burns are a common injury in the workplace. Burns may result from an acid or alkaline exposure. Amshel, Fealk, Phillips, and Caruso (2000) published a case study of a 28-year-old male employee who sustained a 45% body surface area burn due to an anhydrous ammonia explosion. Anhydrous ammonia is a pungent gas used as a potent fertilizer and in the nylon and rayon industries. It was concluded by the authors that the injured worker had not received formal training about the hazardous nature of anhydrous ammonia and the company was unprepared to provide immediate first aid. Blodgett, Suruda, and Crouch (2001) reported a fatal occupational hydrofluoric acid incident; the worker died from pulmonary failure and third-degree burns. Hydrofluoric acid is a corrosive inorganic acid commonly used in glass etching, petroleum refining, and electronics and semiconductor manufacturing. Once hydrofluoric acid contacts the skin, the worker experiences severe burns and systemic poisoning. If 285
Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
Workplace Health & Safety
July 2015
inhaled, hydrofluoric acid causes massive pulmonary edema. OSHA reported nine deaths in the United States during an 11-year period from 1984 to 1994 (Blodgett et al., 2001). After an investigation, OSHA concluded that the deaths were due to inadequate emergency response; the employer should have contacted the Regional Poison Control Center to manage the injury (Blodgett et al., 2001).
Discussion Ruckart and Burgess (2007) noted that 3,506 chemical accidents had occurred in mining and manufacturing industries; 3,282 of these chemical accidents were the result of human error. Human error was also the most cited cause of all occupational injuries (Dekker, 2003). Ruckart and Burgess (2007) reviewed the data from 1996 to 2003 accessed from Hazardous Substances Emergency Events Surveillance System; human error included the improper use of personal protective equipment, inadequate emergency care, and inadequate knowledge of chemicals that were used in the workplace. However, Dekker (2003) pointed out that human error in these cases was actually due to an inadequate safety system. It is also noted that human error was cited during post-accident investigations but that the injuries may have occurred because of work practices that appeared reasonable before the accident occurred. OSHA recommends enhancing safety programs by focusing on organizational leadership, worker participation, hazard identification, and hazard prevention and control with program evaluation and improvement monitoring (Dekker, 2003). The occupational health nurse is responsible for the health and well-being of employees, as well as implementation and documentation of safety training in some settings. The issuance of proper personal protective equipment and training about its proper use is part of OSHA-mandated safety programs. If a chemical exposure does occur resulting in injury, the occupational health nurse may be asked to participate in an accident investigation to determine the root cause of the accident. In most published case studies about occupational chemical injuries, employees were not wearing personal protective equipment properly or they were wearing the wrong equipment. Migrant workers, for example, may find personal protective equipment uncomfortable because they often work in warm environments such as hot houses or fields during the summer (Hansen & Donohoe, 2003). When working with toxic substances such as mercury, neoprene gloves are not adequate protection; sliver-shielded laminate gloves are recommended and may only be worn for a set period of time per manufacturer’s recommendation. Each worker may require a health risk assessment to establish personal risk factors. For example, a worker with psoriasis has an increased risk of susceptibility to a chemical’s toxic effects due to increased dermal absorption (FiserovaBergerova, Pierce, & Droz, 2007). It is the responsibility of occupational health nurses to determine appropriate personal protective equipment for each employee based on identified workplace hazards and OSHA standards. Workplace
walk-throughs and first-aid refresher courses for off-shift workers are essential due to fewer supervisory personnel and line workers on those shifts. The selection of personal protective equipment is essential to the prevention of injuries as in the example of chlorine gas exposure. Respirator selection recommendations may be found in the National Institute of Occupational Safety and Health (NIOSH; CDC, 2013) Pocket Guide. If workers are exposed to vapors or fumes, the worker should be fitted with an airpurifying respirator with a chemical cartridge (CDC, 2013). For a specific chemical that is not included in the Pocket Guide, the NIOSH Respirator Selection Logic may be used (CDC, 2004). Prior to respirator fit testing, a health assessment on each worker should be completed to determine whether the worker has any underlying cardiac or respiratory pathology that may limit the use of a respirator (CDC, 2013). Workers may struggle with workplace training if their first language is not English. Employing videos in the workers’ first language and pictures can improve comprehension. Workers must also feel empowered to report occupational accidents and injuries without fear of reprisal from their employers. Finally, workers must understand that a new illness could be work-related; for example, a cholinergic response to organophosphate exposure should be evaluated by the occupational health team. Education about personal hygiene and work rules is essential to maintaining a safe and healthy workplace.
Community Resources Resources are available to assist occupational health nurses better understand the chemicals used in their work environments. Every worksite must have Material Safety Data Sheets (MSDS) available to all employees. Included in the MSDS are interventions to treat an exposure and an emergency number that physicians and nurses may use to learn more about treating employees exposed to occupational chemicals. Once an injury has occurred, the occupational health staff should contact the Regional Poison Control Center for immediate information about treatment after an acute exposure. OSHA, as well as the Environmental Protection Agency, is an additional resource that occupational health nurses may use to gather information regarding chemical hazards in the workplace. Occupational health nurses should also review pertinent literature about specific chemicals used by workers in the workplace. Finally, it is the responsibility of occupational health nurses to report all exposures to appropriate federal and state agencies to ensure that both workers and employers are in full compliance with regulations that ensure a safe workplace.
Conclusion The number of occupational chemical injuries is relatively small, however, according to published case studies, these injuries may lead to permanent disabilities or death. It can be difficult for occupational health nurses to access current information on occupational injuries; however, a review of the
286 Downloaded from whs.sagepub.com at Middle East Technical Univ on March 6, 2016
Workplace Health & Safety
vol. 63 ■ no. 7
literature and analysis of public health records provide examples of how occupational chemical injuries occur, and how to prevent them by providing worker training and selecting proper personal protective equipment to minimize exposures.
Conflict of Interest The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
Centers for Disease Control and Prevention. (2013). Chemical related injuries and illnesses in U.S. mining (Department of Health and Human Services). Retrieved from http://www.cdc.gov/niosh/mining/UserFiles/ works/pdfs/criai.pdf Dekker, S. (2003). Accidents are normal and human error does not exist: A new look at the creation of occupational safety. International Journal of Occupational Safety and Ergonomics, 9, 211-218. Hansen, E., & Donohoe, M. (2003). Health issues of migrant and seasonal farm workers. Journal of Health for Poor and Underserved, 14, 153-164. Fiserova-Bergerova, T., Pierce, T., & Droz, P. (2007). Dermal absorption potential of industrial chemicals: criteria for skin notation. American Journal of Industrial Medicine, 17, 617-635. doi:10.1002/ ajim.4700170507
The author received no financial support for the research, authorship, and/or publication of this article.
Murphy, C. M., Akbarnia, H., & Rose, S. R. (2010). Fatal pulmonary edema after acute occupational exposure to nitric acid. Journal of Emergency Medical, 39, 39-43. doi:10.1016/j.jemermed.2008.03.011
References
Ruckart, P., & Burgess, P. (2007). Human error and time of occurrence in hazardous material events in mining and manufacturing. Journal of Hazardous Material, 142, 747-753.
Amshel, C., Fealk, M., Phillips, B., & Caruso, D. (2000). Anhydrous ammonia burns care reports and review of the literature. Burns, 25, 493-497. Agency for Toxic Substances and Disease Registry. (2013). National Toxic Substance Incident report. Centers for Disease Control and Prevention. Retrieved from http://www.atsdr.cdc.gov/ntsip/docs/ATSDR_ Annual%20Report_121013_508%20compliant.pdf American Association of Poison Control Centers. (2014). National Poison Control Data System. Available from http://www.aapcc.org/ Blodgett, D., Suruda, A., & Crouch, B. (2001). Fatal unintentional occupational poisonings by hydrofluoric acid in the US. American Journal of Industrial Medicine, 40, 215-220. Centers for Disease Control and Prevention. (2011). Fatal exposure to methylene chloride among bathtub refinishers in the United States. Morbidity and Mortality Weekly Report, 24, 119-122. Centers for Disease Control and Prevention. (2004). NIOSH respirator selection logic (National Institute of Occupational Safety and Health). Retrieved from http://www.cdc.gov/niosh/docs/2005-100/
Smith, M., & Yalamanchili, C. (2008). Acute hydrogen sulfide toxicity due to sewer gas exposure. American Journal of Emergency Medicine, 26, 518e-518e7. doi:10.1016/j.jajem.2007.08.025 Spector, J., & Fernandez, W. (2008). Chemical, thermal, and biological ocular exposures. Emergency Medical Clinic North America, 26, 125136. doi:10.1016/j.emc.2007.11.002 U.S. Department of Labor. (2011). Injuries, illnesses, and fatalities. Bureau of Labor Statistics. Retrieved from http://www.bls.gov/iif/ oshsum.htm
Author Biography Ann Lurati, ARNP, MPH, ACNP-BC, DNP, COHN-S, is an occupational health nurse practitioner with a speciality in toxicology at the University of South Florida, Tampa, Florida.
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