MANAGEMENT OF EXPOSURE TO

HYDROGEN FLOURIDE OR HF

PRESENTED BY:PRESENTED BY:

Miguel Trevino, M.D.Miguel Trevino, M.D.

Occupational MedicineOccupational Medicine

U.de M - U.C.S.C - FACOEMU.de M - U.C.S.C - FACOEM

MROMRO

GENERAL INFORMATION ABOUT HF

USES OF HFUSES OF HF

ELECTRONICS.-ELECTRONICS.- Production of microchips, Production of microchips, electronic circuit cleaners.electronic circuit cleaners.

METALURGYMETALURGY.- .- Metal pickling/Aluminum Metal pickling/Aluminum manufacturemanufacture

PETRO CHEMICALS.-PETRO CHEMICALS.- As a catalyst in the As a catalyst in the alkalization of gasoline.alkalization of gasoline.

GLASS INDUSTRYGLASS INDUSTRY. . Glass edgingGlass edging..

REFRIGERENT GASES.-REFRIGERENT GASES.- For automotive, air For automotive, air conditioning, refrigerator home/industryconditioning, refrigerator home/industry..

FIRE EXTINGUISHERS.- FIRE EXTINGUISHERS.- Fluorocarbons.Fluorocarbons.

USES OF HFUSES OF HF FLUOROCHEMICALSFLUOROCHEMICALS.- .- Fluorinated Salts Fluorinated Salts

Production.Production.

ANTIADHERENTS.-ANTIADHERENTS.- Production of Teflon.Production of Teflon.

MEDICINEMEDICINE.- .- Propellants for medication, Propellants for medication, anesthetic gases, antibiotic production, production anesthetic gases, antibiotic production, production and finishes of surgical prosthesis.and finishes of surgical prosthesis.

NUCLEAR INDUSTRY.-NUCLEAR INDUSTRY.- Purification of uranium Purification of uranium ore.ore.

AGROCHEMICALS.AGROCHEMICALS. Pesticides. Pesticides.

CLEANING SOLUTIONS.CLEANING SOLUTIONS. Rust removers. Rust removers.

PHYSICAL CHEMICAL PHYSICAL CHEMICAL PROPERTIESPROPERTIES

FREEZING POINTFREEZING POINT - -118ºF118ºF -83ºC -83ºC

VAPOR DENSITYVAPOR DENSITY 3.0 AT3.0 AT 25ºC 25ºC

SPECIFIC GRAVITYSPECIFIC GRAVITY (2514) 0.97 (2514) 0.97

VAPOR PRESSUREVAPOR PRESSURE AT 20ºC 775MM Hg AT 20ºC 775MM Hg

ODORODOR PUNGENT & IRRITATING PUNGENT & IRRITATING

PHYSICAL STATE GASPHYSICAL STATE GAS

DISSOCIATION K=3.5 x 10-4DISSOCIATION K=3.5 x 10-4

• BOILING POINTBOILING POINT 67 67ºFºF 19ºC19ºC

• VOLATILITYVOLATILITY 100% 100%

• SOLUBILITY IN WATERSOLUBILITY IN WATER 100%100%

PHYSIOPATHOLOGY OF PHYSIOPATHOLOGY OF EXPOSURES EXPOSURES

&&KNOWN TOXICOLOGYKNOWN TOXICOLOGY

HFHF

////////////////////////////////////TISSUE

+H -F

ENTRY ROUTESENTRY ROUTES

SKINSKIN

RESPIRATORY TRACTRESPIRATORY TRACT

EYESEYES

GASTRO-INTESTINAL GASTRO-INTESTINAL

TYPES OF EXPOSURETYPES OF EXPOSURE

LIQUID EXPOSURE (SPLASH BURN).LIQUID EXPOSURE (SPLASH BURN).

GAS EXPOSURE (INHALATION, SKIN & GAS EXPOSURE (INHALATION, SKIN & EYES).EYES).

LIQUID & GAS (MIXED EXPOSURE).LIQUID & GAS (MIXED EXPOSURE).

LOW CONCENTRATION HF SOLUTIONS.LOW CONCENTRATION HF SOLUTIONS.

Once ionized, the fluoride createsOnce ionized, the fluoride creates two two types of salts:types of salts:

INSOLUBLE SALTSINSOLUBLE SALTS FFˉ + Ca ˉ + Ca (++ )(++ ) = Ca F = Ca F(2)(2) Calcium FluorideCalcium Fluoride

Fˉ + MgFˉ + Mg(++ )(++ ) = Mg F = Mg F Magnesium FluorideMagnesium Fluoride

This can lead to Hypoglycemia that in turn This can lead to Hypoglycemia that in turn

can lead to Cardio Respiratory Arrest,can lead to Cardio Respiratory Arrest,

Hypomagnesaemia, Na (Sodium)Hypomagnesaemia, Na (Sodium) and K and K

(Potassium) alterations.(Potassium) alterations.

SOLUBLE SALTSSOLUBLE SALTS

FFˉ + Naˉ + Na(+)(+) = Na F= Na F Sodium FluorideSodium Fluoride

Fˉ + KFˉ + K(+) (+) = KF= KF Potassium FluoridePotassium Fluoride

Which target:Which target:

The Kidneys – Nefro - ToxicThe Kidneys – Nefro - Toxic

The Liver – Liver - ToxicThe Liver – Liver - Toxic

And are the cause of Acute Fluoride Intoxication if And are the cause of Acute Fluoride Intoxication if sufficient quantities are created.sufficient quantities are created.

SO, WHY IS HF A HAZARDOUS SO, WHY IS HF A HAZARDOUS MATERIAL?MATERIAL?

It is a Corrosive. (Acid)It is a Corrosive. (Acid)

It is a Poison. (Toxic)It is a Poison. (Toxic)

It is an Inhalation Hazard.It is an Inhalation Hazard.

INTRINSIC PROCESS RISK FACTORS IN INTRINSIC PROCESS RISK FACTORS IN RELATION TO HFRELATION TO HF

CHEMICAL FACTORSCHEMICAL FACTORS

PHOSGENEPHOSGENE CYLINDERSCYLINDERS 200200

HCNHCN RAILROAD TANKRAILROAD TANK 1010

H2SH2S PRESSURIZED TANKPRESSURIZED TANK 1010

C12C12 RAILROAD TANKRAILROAD TANK 99

SO2SO2 IN CYLINDERIN CYLINDER 88

AHC1AHC1 ROAD TANKROAD TANK 2.52.5

AHFAHF IN A RAILROAD TANKERIN A RAILROAD TANKER 11

Br2Br2 PRESSURIZED TANKPRESSURIZED TANK 0.800.80

SO3SO3 PRESSURIZED TANKPRESSURIZED TANK 0.600.60

NH3NH3 NORMAL ATM CONDITIONSNORMAL ATM CONDITIONS 0.300.30

OLEUOLEU PRESSURIZED TANKPRESSURIZED TANK 0.200.20

NH3NH3 AT 33AT 33ºCºC 0.090.09

MMAMMA TANKTANK 0.050.05

Br2Br2 NORMAL ATM CONDITIONSNORMAL ATM CONDITIONS 0.050.05

POC13POC13 PRESSURIZED TANKPRESSURIZED TANK 0.040.04

RISK FACTORS IN RELATION TO HF WHEN HF = 1.0RISK FACTORS IN RELATION TO HF WHEN HF = 1.0

KNOWN TOXICOLOGYKNOWN TOXICOLOGYAcute Acute Corrosive Effects (Burns)Corrosive Effects (Burns)

Acute Fluoride IntoxicationAcute Fluoride Intoxication

Sub-AcuteSub-Acute Impaired Breathing (hours after)Impaired Breathing (hours after)

Delayed appearance of skin injury (hours after)Delayed appearance of skin injury (hours after)

Chronic or Long TermChronic or Long Term

Injury to tissue due to corrosive and toxic effects. No Injury to tissue due to corrosive and toxic effects. No other effects documented or reported. Possible other effects documented or reported. Possible Fluorosis after chronic exposure to low Fluorosis after chronic exposure to low concentrations of HF.concentrations of HF.

KNOWN TOXICOLOGYKNOWN TOXICOLOGY

Reproductive & DevelopmentalReproductive & Developmental

None described or foundNone described or foundImmuno-ToxicityImmuno-Toxicity

None described or foundNone described or found

Cancer FormingCancer Forming

No human reports or studiesNo human reports or studiesCardiac & Muscular ToxicityCardiac & Muscular Toxicity

Yes, due to Fluoride binding to Calcium,Yes, due to Fluoride binding to Calcium,

and Magnesium.and Magnesium.

KNOWN TOXICOLOGYKNOWN TOXICOLOGY

Hepatic & Nefro ToxicityHepatic & Nefro Toxicity

Yes, due to creation of SodiumYes, due to creation of Sodium

Fluoride and Potassium FluorideFluoride and Potassium Fluoride

after exposure (untreated).after exposure (untreated).

KNOWN TOXICOLOGYKNOWN TOXICOLOGY

TWATWA Time weighted average concentration for Time weighted average concentration for a normal 8 hour workday and a 40 hour work a normal 8 hour workday and a 40 hour work week to which nearly all workers may be week to which nearly all workers may be repeatedly exposed, day after day, without repeatedly exposed, day after day, without adverse effects for all of adverse effects for all of their working life 3PPM (ACGIH).their working life 3PPM (ACGIH).

KNOWN TOXICOLOGYKNOWN TOXICOLOGY

IDLH = 30 ppmIDLH = 30 ppm Immediately dangerous to life and Immediately dangerous to life and

healthhealth

(NIOSH).(NIOSH).

KNOWN TOXICOLOGYKNOWN TOXICOLOGY

ERPG 1 = 5 ppmERPG 1 = 5 ppm The maximum airborne concentration The maximum airborne concentration below which it is believed that nearly all below which it is believed that nearly all individuals could be exposed for up to 1 hour individuals could be exposed for up to 1 hour without experiencing other than mild, transientwithout experiencing other than mild, transient

adverse health effects or without perceiving a adverse health effects or without perceiving a clearly defined objectionable odor. clearly defined objectionable odor.

KNOWN TOXICOLOGYKNOWN TOXICOLOGYERPG 2 = 20 ppmERPG 2 = 20 ppm

The maximum airborne concentration The maximum airborne concentration below which it is believed that nearly all below which it is believed that nearly all individuals could be exposed for up to 1 hour individuals could be exposed for up to 1 hour without experiencing or developing irreversiblewithout experiencing or developing irreversible

or other serious health effects or symptoms or other serious health effects or symptoms which could impair an individual’s ability to take which could impair an individual’s ability to take protective actionprotective action. .

KNOWN TOXICOLOGYKNOWN TOXICOLOGY

ERPG 3 = 50 ppmERPG 3 = 50 ppm

The maximum airborne concentration The maximum airborne concentration below which it is believed that nearly all below which it is believed that nearly all individuals could be exposed for up to an hour individuals could be exposed for up to an hour without experiencing or developing life- without experiencing or developing life- threatening health effects.threatening health effects.

PRIMARY PRIMARY DECONTAMINATION DECONTAMINATION

PROCEDURESPROCEDURES

DECONTAMINATION PROCEDURESDECONTAMINATION PROCEDURES GO TO THE NEAREST GO TO THE NEAREST FUNCTIONALFUNCTIONAL DECON UNIT. DECON UNIT.

OPEN THE WATER VALVE.OPEN THE WATER VALVE.

TAKE OFF ALL CLOTHING, SHOES & JEWELRY.TAKE OFF ALL CLOTHING, SHOES & JEWELRY.

REMOVE GOGGLES LAST, FACE THE WATER REMOVE GOGGLES LAST, FACE THE WATER FLOW, CLOSE YOUR EYES, PULL GOGGLES FLOW, CLOSE YOUR EYES, PULL GOGGLES OVER YOUR HEAD.OVER YOUR HEAD.

REMEMBER, MAXIMUM TIME UNDER SHOWER IS REMEMBER, MAXIMUM TIME UNDER SHOWER IS 5 MINUTES.5 MINUTES.

This is a Dilution Technique.This is a Dilution Technique.

TRIAGETRIAGE

PRIMARY TRIAGEPRIMARY TRIAGE

11STST To Go Many Signs & Symptoms of Exposure To Go Many Signs & Symptoms of Exposure

22ndnd To Go Signs and Symptoms Present and To Go Signs and Symptoms Present and

Possible Systematic Effects in NearPossible Systematic Effects in Near

FutureFuture

3rd To Go Minor or No Signs & Symptoms3rd To Go Minor or No Signs & Symptoms

Do Not Go FatalitiesDo Not Go Fatalities

SUGGESTED TREATMENT SUGGESTED TREATMENT THROUGH HISTORYTHROUGH HISTORY

WASH COPIOUSLY WITH WATER FOR 15 WASH COPIOUSLY WITH WATER FOR 15 MINUTES.MINUTES.

SODIUM BICARBONATE SOLUTIONSSODIUM BICARBONATE SOLUTIONS

MAGNESIUM SULFATE PASTE.MAGNESIUM SULFATE PASTE.

MAGNESIUM OXIDE PASTE.MAGNESIUM OXIDE PASTE.

AMMONIA SOLUTIONS & INHALANT.AMMONIA SOLUTIONS & INHALANT.

HYAMINE SOLUTIONS 0.2% (2 gm HYAMINE SOLUTIONS 0.2% (2 gm BENZEHTONIUM CHLORIDE IN 1 LITER OF ICE BENZEHTONIUM CHLORIDE IN 1 LITER OF ICE WATER).WATER).

SUGGESTED TREATMENT SUGGESTED TREATMENT THROUGH HISTORYTHROUGH HISTORY

ZEPHIRAN 0.13% (1.3 gm BENZALKONIUM ZEPHIRAN 0.13% (1.3 gm BENZALKONIUM CHLORIDE IN 1 LITER OF ICE WATER).CHLORIDE IN 1 LITER OF ICE WATER).

CALCIUM GLUCONATE SOLUTIONS: 10%, 5%, CALCIUM GLUCONATE SOLUTIONS: 10%, 5%, 2.5%, 1%2.5%, 1%

CALCIUM GLUCONATE GEL 2.5%.CALCIUM GLUCONATE GEL 2.5%.

CALCIUM ACETATE SOLUTIONS.CALCIUM ACETATE SOLUTIONS.

ORAL CALCIUM & MAGNESIUM BASED ORAL CALCIUM & MAGNESIUM BASED ANTACIDS AND SOLUTIONSANTACIDS AND SOLUTIONS..

SUGGESTED TREATMENT SUGGESTED TREATMENT THROUGH HISTORYTHROUGH HISTORY

INTR-ARTERIAL CALCIUM TECHNIQUE (BOLUS INTR-ARTERIAL CALCIUM TECHNIQUE (BOLUS AND SLOW INFUSION).AND SLOW INFUSION).

INTRA-VENOUS CALCIUM TECHNIQUE (BIEAR INTRA-VENOUS CALCIUM TECHNIQUE (BIEAR BLOCK).BLOCK).

HEXAFLUORINE RINSING SOLUTION.HEXAFLUORINE RINSING SOLUTION.

DMSO + CALCIUM GLUCONATE SOLUTIONDMSO + CALCIUM GLUCONATE SOLUTION..

FIRST FIRST AIDAID

PROCEDURESPROCEDURES

FIRST AID SKIN EXPOSUREFIRST AID SKIN EXPOSURE

MINOR BURNSMINOR BURNSBurns smaller than 2 square inches of bodyBurns smaller than 2 square inches of body

surface, such as small droplets, or very smallsurface, such as small droplets, or very small

skin burns, low concentration gas or solutionskin burns, low concentration gas or solution

exposures.exposures.

MAJOR BURNSMAJOR BURNSBurns larger than 2 square inches with A.H.F.Burns larger than 2 square inches with A.H.F.

AFTER DECONTAMINATIONAFTER DECONTAMINATION

Initiate calcium gluconate 2.5% gel Initiate calcium gluconate 2.5% gel inunction. Note the time you start this step.inunction. Note the time you start this step.

Obtain medical attention (call).Obtain medical attention (call).

If pain does not subside in 20-30 minutes, If pain does not subside in 20-30 minutes, go to medical treatment.go to medical treatment.

FIRST AID: EYESFIRST AID: EYES

ALL EXPOSURES ARE CONSIDERED SEVERE.ALL EXPOSURES ARE CONSIDERED SEVERE.

DECON:DECON:

USE EYEWASH, A GLASS OR LOW PRESSURE USE EYEWASH, A GLASS OR LOW PRESSURE WATER HOSE. MAXIMUM TIME IS 5 MINUTES.WATER HOSE. MAXIMUM TIME IS 5 MINUTES.

IRRIGATE: 500cc to 1000cc OF A 1% CALCIUM IRRIGATE: 500cc to 1000cc OF A 1% CALCIUM GLUCONATE SOLUTION IN NORMAL SALINE PER GLUCONATE SOLUTION IN NORMAL SALINE PER EYE.EYE.

FIRST AID: EYESFIRST AID: EYES

SEEK SPECIALIZED MEDICAL ATTENTION SEEK SPECIALIZED MEDICAL ATTENTION IMMEDIATELY. USE CALCIUM GLUCONATE AT IMMEDIATELY. USE CALCIUM GLUCONATE AT 1% CONCENTRATION UNTIL MEDICAL HELP IS 1% CONCENTRATION UNTIL MEDICAL HELP IS REACHED.REACHED.

IF THERE IS SKIN EXPOSURE, ALSO FOLLOW IF THERE IS SKIN EXPOSURE, ALSO FOLLOW SKIN DECONTAMINATION AND FIRST-AID SKIN DECONTAMINATION AND FIRST-AID PROCEDURES.PROCEDURES.

FIRST AID INHALATIONFIRST AID INHALATION

DECONDECON

ADMINISTER OXYGEN AT 12 LTS. PER MINUTE.ADMINISTER OXYGEN AT 12 LTS. PER MINUTE.

START NEBULIZING A 2.5% SOLUTION OF START NEBULIZING A 2.5% SOLUTION OF CALCIUM GLUCONATE IN NORMAL SALINE, CALCIUM GLUCONATE IN NORMAL SALINE, USING A STANDARD NEBULIZER OR ULTRA USING A STANDARD NEBULIZER OR ULTRA NEBULIZER. PREFERABLY NOSE AND MOUTH NEBULIZER. PREFERABLY NOSE AND MOUTH MASK AND ¾ IN. TUBINGMASK AND ¾ IN. TUBING

OBTAIN MEDICAL ASSISTANCE.OBTAIN MEDICAL ASSISTANCE.

CONCIOUS PATIENT:CONCIOUS PATIENT:GIVE ORALLY HIGH AMOUNTS OF ANY CALCIUM GIVE ORALLY HIGH AMOUNTS OF ANY CALCIUM OR MAGNESIUM BASED ANTACID, OR MAGNESIUM BASED ANTACID, EFFERVESCENT CALCIUM IN WATER, MILK OR EFFERVESCENT CALCIUM IN WATER, MILK OR WATERWATER..

DO NOT INDUCE VOMITING!DO NOT INDUCE VOMITING! UNCONCIOUS PATIENT:UNCONCIOUS PATIENT:

OBTAIN MEDICAL ASSISTANCE IMMEDIATELY.OBTAIN MEDICAL ASSISTANCE IMMEDIATELY.

DO NOT FORGET TO DECONTAMINATE SKIN OR DO NOT FORGET TO DECONTAMINATE SKIN OR EYES IF THEY WERE EXPOSED.EYES IF THEY WERE EXPOSED.

FIRST AID: INGESTIONFIRST AID: INGESTION

SECONDARY SECONDARY DECONTAMINATION DECONTAMINATION

PROCEDURESPROCEDURES

SECONDARY SECONDARY DECONTAMINATIONDECONTAMINATION

EXAMINE & DECONTAMINATE:EXAMINE & DECONTAMINATE:

-EAR CANALS-EAR CANALS

-MOUTH-MOUTH

-NOSE-NOSE

-ANUS-ANUS

-VAGINA-VAGINA

EXAMINE & DECONTAMINATE SKIN FOLDS:EXAMINE & DECONTAMINATE SKIN FOLDS:

-NECK-NECK

SECONDARY SECONDARY DECONTAMINATIONDECONTAMINATION

--AXILARY REGIONSAXILARY REGIONS

-SUB-MAMMARIAN FOLDS-SUB-MAMMARIAN FOLDS

-GROIN-GROIN

-BEHIND THE KNEES-BEHIND THE KNEES

-INTER-DIGITAL FOLDS-INTER-DIGITAL FOLDS

EXAMINE & DECONTAMINATE BELOW THE NAILS EXAMINE & DECONTAMINATE BELOW THE NAILS OF:OF:

-HANDS-HANDS

-FEET-FEET

SECONDARY SECONDARY DECONTAMINATIONDECONTAMINATION

EXAMINE & DECONTAMINATE AREAS COVERED EXAMINE & DECONTAMINATE AREAS COVERED WITH HAIR:WITH HAIR:

-SCALP-SCALP-PUBIS-PUBIS-OTHER AREAS AS NEEDED-OTHER AREAS AS NEEDED

ELECTROCARDIOGRAPHIC ELECTROCARDIOGRAPHIC EFFECTSEFFECTS

PROLONGED Q-T INTERVAL PROLONGED Q-T INTERVAL

(DUE TO HYPOCALCEMIA).(DUE TO HYPOCALCEMIA).

NORMAL SERUM CALCIUM LEVELS:NORMAL SERUM CALCIUM LEVELS:

2.25 TO 2.6 mmol/lt2.25 TO 2.6 mmol/lt

9 TO 10.5 mg/dl9 TO 10.5 mg/dl

MEDICALTREATMENTPROCEDURES

FLUORIDE IN SERUM OR IN FLUORIDE IN SERUM OR IN URINEURINE

CLINICALLYCLINICALLY- THE BEST INDICATOR IS URINE - THE BEST INDICATOR IS URINE FLUORIDES. EASY TO DO, RESULTS IN MINUTES FLUORIDES. EASY TO DO, RESULTS IN MINUTES AND DEPENDABLE . AND DEPENDABLE .

FLUORIDES IN SERUM ARE NOT RELIABLE FLUORIDES IN SERUM ARE NOT RELIABLE INDICATORS BECAUSE IT DOES NOT PROVIDE A INDICATORS BECAUSE IT DOES NOT PROVIDE A GOOD MEASURE OF EXPOSURE TO FLUORIDES, GOOD MEASURE OF EXPOSURE TO FLUORIDES, AND IS COMPLICATED TO PERFORM, MAY TAKE AND IS COMPLICATED TO PERFORM, MAY TAKE DAYS BEFORE REPORTED.DAYS BEFORE REPORTED.

LONG TERM EFFECTSLONG TERM EFFECTS FIRSTFIRST::

SEQUELA NORMALLY ARE ESTABLISHED IN THE SEQUELA NORMALLY ARE ESTABLISHED IN THE SUB-ACUTE TIME PERIOD AFTER EXPOSURE AND SUB-ACUTE TIME PERIOD AFTER EXPOSURE AND ARE NORMALLY STABLE, SUCH AS:ARE NORMALLY STABLE, SUCH AS:

**SKIN HYPO-PIGMENTATIONSKIN HYPO-PIGMENTATION

**KELOID SCARINGKELOID SCARING

**DEEP SEATED SCARINGDEEP SEATED SCARING

**SURGICAL SCARSSURGICAL SCARS

**NEUROLOGIC, LIVER AND KIDNEYNEUROLOGIC, LIVER AND KIDNEY

DISFUNCTION MAY PERSIST IF DAMAGE ISDISFUNCTION MAY PERSIST IF DAMAGE IS

SEVERE.SEVERE.

LONG TERM EFFECTSLONG TERM EFFECTS

SECONDSECOND

THE FOLLOWING HAVE NOT BEEN OBSERVED:THE FOLLOWING HAVE NOT BEEN OBSERVED:

**HYPER-REACTIVE AIRWAYSHYPER-REACTIVE AIRWAYS

**KIDNEY, LIVER OR CNS KIDNEY, LIVER OR CNS DYSFUNCTIONDYSFUNCTION

**CANCERCANCER

**REPRODUCTIVE PROBLEMS, ETCREPRODUCTIVE PROBLEMS, ETC

(SEE TOXICOLOGY)(SEE TOXICOLOGY)

CALCIUM GLUCONATE AS CALCIUM GLUCONATE AS THE TREATMENT OFTHE TREATMENT OF

CHOICE CHOICE

WHY ?WHY ?

**EASY TO USE.EASY TO USE.

**CAN BE USED IN FIRST AID & MEDICAL CAN BE USED IN FIRST AID & MEDICAL

TREATMENT.TREATMENT.

**CAN BE USED TOPICALLY, INFILTRATED, CAN BE USED TOPICALLY, INFILTRATED,

INHALED, OPTHAMICALLY ANDINHALED, OPTHAMICALLY AND

INTRAVENOUSLY.INTRAVENOUSLY.

**NO SOPHISTICATED MEDICAL EQUIPMENTNO SOPHISTICATED MEDICAL EQUIPMENT

REQUIRED, SUCH AS ARTERIAL CATHETERS,REQUIRED, SUCH AS ARTERIAL CATHETERS,

IV INFUSERS, ETCIV INFUSERS, ETC..

**EASY TO PREPARE IN GEL FORM OR EASY TO PREPARE IN GEL FORM OR

SOLUTIONS.SOLUTIONS.

*TREATMENT IS FAST AND EFFECTIVE.TREATMENT IS FAST AND EFFECTIVE.

**THE RESULTING REACTION CHEMICAL THE RESULTING REACTION CHEMICAL

IS PRIMARILY GLUCOSE AS COMPAREDIS PRIMARILY GLUCOSE AS COMPARED

TO AMMONIUM FLUORIDE & ACETIC TO AMMONIUM FLUORIDE & ACETIC

ACID, IN THE CASE OD AMMONIA ACID, IN THE CASE OD AMMONIA

COMPOUNDS OR CALCIUM ACETATE, COMPOUNDS OR CALCIUM ACETATE,

RESPECTIVELY.RESPECTIVELY.

**CALCIUM IS MUCH MORE FAVORED TO BIND CALCIUM IS MUCH MORE FAVORED TO BIND WITH FLUORIDE IN THE BODY.WITH FLUORIDE IN THE BODY.

**NONE OR MINOR TISSUE IRRITATION ATNONE OR MINOR TISSUE IRRITATION AT DESCRIBED CONCENTRATIONS.DESCRIBED CONCENTRATIONS.

**EXCELLENT RESULTS IN BOTH HIGH & LOWEXCELLENT RESULTS IN BOTH HIGH & LOW CONCENTRATION EXPOSURES OF HF.CONCENTRATION EXPOSURES OF HF.

**NO SECONDARY EFFECTS AT THERAPEUTICNO SECONDARY EFFECTS AT THERAPEUTIC LEVELS.LEVELS.

**NO NEED FOR SOAKING OR COOLING WITHNO NEED FOR SOAKING OR COOLING WITH RESULTING HYPOTHERMIC OR VASCULARRESULTING HYPOTHERMIC OR VASCULAR RISKS.RISKS.

** IT IS AN EXCELLENT OUTSIDE SOURCE OF IT IS AN EXCELLENT OUTSIDE SOURCE OF CALCIUM THAT WILL BIND THE FLUORIDE, CALCIUM THAT WILL BIND THE FLUORIDE, AND IN DOING SO, WILL HELP AVOID AND IN DOING SO, WILL HELP AVOID HYPOCALCEMIA, AND THE CREATION OF HYPOCALCEMIA, AND THE CREATION OF TOXIC COMPOUND IN THE BODY. TOXIC COMPOUND IN THE BODY.

**CAN BE USED IN THE PRODUCTION FIELD,CAN BE USED IN THE PRODUCTION FIELD, IN TRANSPORTATION INCIDENTS AND IN IN TRANSPORTATION INCIDENTS AND IN HOSPITALS. HOSPITALS.

ALGORITHMS FOR ALGORITHMS FOR EMERGENCY MEDICAL EMERGENCY MEDICAL

PROCEDURES FOR PROCEDURES FOR HYDROFLUORIC ACID HYDROFLUORIC ACID

EXPOSUREEXPOSURE

HF Exposure

Decontamination= DECON =Procedures

Recognize Exposure Rout (s)-Skin - Eyes - Inhalation - Ingestion

Evaluate theseverity

of the Exposure

Minor

First aidProtocols

Pain Subsides

Pain Continues

Major

SystemicEffects

MedicalTreatmentProtocols

SystemicEffects

TreatmentProtocols

andGo to

Skin Exposure

MinorExposure

MajorExposure

DE

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SY

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FIR

ST

-AID

ME

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Signs & Symptoms.

•Low concentration of HF<30%•< 3 sg.in. Of exposed skin. To AHF.•Injury appears hours after exposure.•Superficial injury.•Conscious and Stable

Signs & Symptoms.•AHF or high concentration >30%•> 3 sg.in of exposed skin to AHF.•Injury appears immediately after exposure.•Deep or extensive injury.•Unconscious - or unstable.•Face, Neck, Groin, genital exposure.•Cardiac Arrithmia. (Irregular heart beats).

First-Aid Procedures.

•Rub-in calcium-gluconate 2.5% gelfor 20 to 30 minutes.•Pain significantly decreases orsubsides. Stop & observe.•Never use local anesthetics.

First-Aid Procedures.

•Rub-in calcium-gluconate 2.5% gel for 20 to 30 minutes.•Pain does not decrease or subsides - within the first 20 to 30 Minutes.

Medical Treatment Procedures.-= Injury Treatment =

•Inject into, around and under all injuries a solution of a 2.5% calcium gluconate solution in normal saline.

= Systemic Toxicity Treatment =

•Start IV drip of 1000 cc in normal saline +20 cc of 10% calcium gluconate.•The amount of solution administered will depend on the levels of Serum calcium (titer).•Monitor ECG, Electrolytes with special interest on Ca, Mg, Na and K, Chest “x” Rays, Blood gases, Ph, Blood Chemistry, fluoride in urine and blood, liver & kidney function.•Consider.- Intra Arterial slow infusion, of calcium gluconate and•Consider Hemodialisis for the removal of serum Fluorides.

Decontamination Procedure. Decontamination Procedures for HF Containing Oils & Tars.

•Go to the nearest water source or safety shower. Where the possibility of Exposure Exists.- and wearing acid resistant gloves.•Open the valve.•Remove all clothing, shoes, and jewerly. A) Remove the oil of Tor with baby-oil and Mechanical •Remove eye protection last while facing the water flow. Means such as gauze,or tung depressors consider the materials used as a Hazardous waste and handle them adequately.•Remember no more than five (5) minutes under the water flow. B) Remove baby-oil residue thoroughly by washing with soap and water.

C) Follow basic decontamination procedure.

Skin Exposure

MinorExposure

MajorExposure

Decontamination Procedure. Decontamination Procedures for HF Containing Oils & Tars.

•Go to the nearest water source or safety shower. Where the possibility of Exposure Exists.- and wearing acid resistant gloves.•Open the valve. A) Remove the oil of Tar with baby-oil and Mechanical

Means such as gauze, or tongue depressors (consider the •Remove all clothing, shoes, and jewelry. Material used as a Hazardous waste and handle them

adequately).•Remove eye protection last while facing the water flow. •Remember no more than five (5) minutes under the water flow. B) Remove baby-oil residue thoroughly by washing

with soap and water.

C) Follow basic decontamination procedure.

Signs & Symptoms.

•Low concentration of HF<30%•< 3 sg.in. Of exposed skin. To AHF.•Injury appears hours after exposure.•Superficial injury.•Conscious and Stable

Signs & Symptoms.•AHF or high concentration >30%•> 3 sg.in of exposed skin to AHF.•Injury appears immediately after exposure.•Deep or extensive injury.•Unconscious - or unstable.•Face, Neck, Groin, genital exposure.•Cardiac Arrithmia. (Irregular heartbeats).

DE

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& S

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First-Aid Procedures.

•Rub-in calcium-gluconate 2.5% gelfor 20 to 30 minutes.•Pain significantly decreases orsubsides. Stop & observe.•Never use local anesthetics.

First-Aid Procedures.

•Rub-in calcium-gluconate 2.5% gel for 20 to 30 minutes.•Pain does not decrease or subsides - within the first 20 to 30 Minutes.

Medical Treatment Procedures.-= Injury Treatment =

•Inject into, around and under all injuries a solution of a 2.5% calcium gluconate solution in normal saline.

= Systemic Toxicity Treatment =

•Start IV drip of 1000 cc in normal saline +20 cc of 10% calcium gluconate.•The amount of solution administered will depend on the levels of Serum calcium (titer).•Monitor ECG, Electrolytes with special interest on Ca, Mg, Na and K, Chest “x” Rays, Blood gases, Ph, Blood Chemistry, fluoride in urine and blood, liver & kidney function.•Consider.- Intra Arterial slow infusion, of calcium gluconate and•Consider Hemodialisis for the removal of serum Fluorides.

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Respiratory Exposure

MinorExposure

MajorExposure

Decontamination Procedures.•Not Possible =

•If gaseous exposure occurs skin and eye decontamination is necessary.

Signs & Symptoms.

•No signs & symptoms.•Minor coughing.•Minor swelling and Eritlema.

Signs & Symptoms.•Coughing•Labored Breathing.•Shortness of Breath•Erithema•Swelling•Bleeding•Upper Airway Edema.•Pulmonary Edema.•Cardiac Arrithmia. (Irregular heart beats).

First-Aid Procedures.

•Administer O2 at a rate of 12 Lts./min.•Nebulize calcium gluconate 2.5% in normal saline for 15 to 20 min.•Obtain Medical Evaluation and observe.

First-Aid Procedures.•Administer O2 at a rate of 12 lts./min.•Continuously nebulize calcium gluconate 2.5% in normal saline untilmedically evaluated.•If respiratory assistance is needed - use indirect methods - (Bag-micro-shield).-

Medical Treatment Procedures.-=Respiratory Track = & Systemic Toxicity.

•Air Way & Breathing must be secured. Evaluate ABC; andfollow ACLS procedures.•Positive Pressure Assistance and Positive end expiratorypressure (peep). Are necessary.- until edema has resolved.•Evaluate and monitor.- Chest “x” Rays, Blood Gases, ECG,Electrolytes with special interest in Ca, Mg, Na, and K, BloodChemistry, fluorides in urine and blood, liver & Kidney functions.•Start IV drip of 1000 cc in normal seline. +20 cc of 10% CalciumGluconate.•The amount of the solution will depend on the levels of serum calcium.•Consider Hemodialisis for the removal of serum Fluorides.-

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Respiratory Exposure

Decontamination Procedures.

•Not Possible

•If gaseous exposure occurs skin and eye decontamination is necessary.

Signs & Symptoms.

•No signs & symptoms.•Minor coughing.•Minor swelling and Eritlema.

Signs & Symptoms.•Coughing•Labored Breathing.•Shortness of Breath•Erithema•Swelling•Bleeding•Upper Airway Edema.•Pulmonary Edema.•Cardiac Arrithmia. (Irregular heart beats).

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First-Aid Procedures.

•Administer O2 at a rate of 12 Lts./min.

•Nebulize calcium gluconate 2.5% in normal saline for 15 to 20 min.

•Obtain Medical Evaluation and observe.

First-Aid Procedures.•Administer O2 at a rate of 12 lts./min.

•Continuously nebulize calcium gluconate 2.5% in normal saline until medically evaluated.

•If respiratory assistance is needed - use indirect methods (Bag-microshield).

Medical Treatment Procedures.-=Respiratory Track = & Systemic Toxicity.

•Air Way & Breathing must be secured. Evaluate ABC; and follow ACLS and ATLS procedures.•Positive Pressure Assistance and Positive end expiratory pressure (peep). Are necessary.- until edema has resolved.•Evaluate and monitor.- Chest “x” Rays, Blood Gases, ECG, Electrolytes with special interest in Ca, Mg, Na, and K, Blood Chemistry, fluorides in urine and blood, liver & Kidney functions.•Start IV drip of 1000 cc in normal seline. +20 cc of 10% Calcium Gluconate.•The amount of the solution will depend on the levels of serum calcium.•Consider Hemodialisis for the removal of serum Fluorides.-

Eye Exposure

MinorExposure

MajorExposure

Decontamination Procedure.•Go to the nearest water source or eye wash.•Open the valve.•Mechanically maintain eye lids open, or ask for help.•Wash for five minutes (5) and no more.

Signs & Symptoms.

•Irritation of conjunctiva layer and eye lid skin (minor).•Conjuctival injection.•No evidence of corneal injury.•No vision loss

Signs & Symptoms.•Severe irritation of the conjunctival eye, and skin burn to eye lids.-•Conjuctival injection and swelling.•Corneal “Opacification” or Pitting.•Vision loss.

First-Aid Procedures.•Irrigate eyes with a 1% Calciumgluconate solution in normal saline1000 cc per eye (15 min. aprox.).•The use of an irrigating system(Morgan Lens) after using a local eyeanesthetic (one or two drops per eye)should be considered.•Obtain specialized medical evaluation.

First-Aid Procedures.•Irrigate eyes with a 1% calcium gluconate solution in normal saline1000 cc per eye (15 min. Aprox.).-•The use of an irrigating system(Morgan Lens) after using a local eyeanesthetic (one or two drops per eye)should be considered.•Specialized Medical Evaluation shouldbe done (Slit lamp, etc).

Medical Treatment Procedures.-

•If necessary continue treatment with a 1% solution of calciumgluconate in normal saline.-•Antibiotics and steroids can be used as indicated by eye specialist.•Monitor ocular pressure.•Evaluate corneal opacification regularly.-•If skin, ingestion or inhalation exposure occurs do not forget todecontaminate, and follow systemic toxicity treatment protocols.•Psychological support may be necessary.

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Decontamination Procedure.•Go to the nearest water source or eye wash.•Open the valve.•Mechanically maintain eye lids open, or ask for help.•Wash for five minutes (5) and no more.

Eye Exposure

Signs & Symptoms.

•Irritation of conjunctiva layer and eye lid skin (minor).•Conjuctival injection.•No evidence of corneal injury.•No vision loss.

Signs & Symptoms.

•Severe irritation of the conjunctival eye, and skin burn to eye lids.-•Conjuctival injection and swelling.•Corneal “Opacification” or Pitting.•Vision loss.

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First-Aid Procedures.

•Irrigate eyes with a 1% Calcium gluconate solution in normal saline 1000 cc per eye (15 min. aprox.).•The use of an irrigating system (Morgan Lens) after using a local eye anesthetic (one or two drops per eye) should be considered.•Obtain specialized medical evaluation.

First-Aid Procedures.•Irrigate eyes with a 1% calcium gluconate solution in normal saline 1000 cc per eye (15 min. Aprox.).-•The use of an irrigating system(Morgan Lens) after using a localeye anesthetic (one or two drops per eye)should be considered.•Specialized Medical Evaluation should be done (Slit lamp, etc).

Medical Treatment Procedures.-

•If necessary continue treatment with a 1% solution of calciumgluconate in normal saline.-•Antibiotics and steroids can be used as indicated by eye specialist.•Monitor ocular pressure.•Evaluate corneal opacification regularly.-•If skin, ingestion or inhalation exposure occurs do not forget todecontaminate, and follow systemic toxicity treatment protocols.•Psychological support may be necessary.

Ingestion

MinorExposure

MajorExposure

Decontamination Procedures.

•Not Possible•If skin or eyes have been exposed decontamination procedures should be followed.

ALL EXPOSURES ARE CONSIDERED MAJOR.

Signs & Symptoms.

•Erithema of oral mucousa.•Oral injury.•Bleeding of the oral cavity.•Systemic Toxicity.•Possible bronchial or pulmonaryproblems if the patient vomited.

First-Aid Procedures.

•Do Not induce Vomiting.•If patient is able to swallow give oralcalcium solutions - or - calcium basedantacids - milk or water.•If unconscious obtain Medical Attention Immediately

Medical Treatment Procedures.-

•HF destroys fiber optics - consider before using endoscopictechniques.•Establish IV drip 1000 cc Normal Saline + 20cc - 10% calciumgluconate.•If possible install a naso-gastric or oral-gastric tube.•Gastric Lavage with calcium solutions, calcium or magnesium based antacids. Systemic Toxicity Control.•The amount of calcium or magnesium to be administed willdepend on the serum levels.•Monitor ECG, Electrolytes, with special interest on Ca, Mg, K,and Na, Chest X Rays may be necessary, blood gases, bloodChemistry, Kidney and Liver functions.•Follow ACLS ATLS procedures.•Consider Hemodialisis for the removal of fluorides in Blood.

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Decontamination Procedures.

•Not Possible•If skin or eyes have been exposed decontamination procedures should be followed.

Ingestion

ALL EXPOSURES ARE CONSIDERED MAJOR.

Signs & Symptoms.

•Erithema of oral mucousa.•Oral injury.•Bleeding of the oral cavity.•Systemic Toxicity.•Possible bronchial or pulmonaryproblems if the patient vomited.

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First-Aid Procedures.

•Do Not induce Vomiting.•If patient is able to swallow give oralcalcium solutions - or - calcium basedantacids - milk or water.•If unconscious obtain Medical Attention Immediately

Medical Treatment Procedures.-

•HF destroys fiber optics - consider before using endoscopic techniques.•Establish IV drip 1000 cc Normal Saline + 20cc - 10% calcium gluconate.•If possible install a naso-gastric or oral-gastric tube.•Gastric Lavage with calcium solutions, calcium or magnesium based antacids. Systemic Toxicity Control.•The amount of calcium or magnesium to be administed will depend on the serum levels.•Monitor ECG, Electrolytes, with special interest on Ca, Mg, K, and Na, Chest X Rays may be necessary, blood gases, blood Chemistry, Kidney and Liver functions.•Follow ACLS ATLS procedures.•Consider Hemodialisis for the removal of fluorides in Blood.

PATIENT’S PROGNOSIS & PATIENT’S PROGNOSIS & LONG-TERM EFFECTS WILL LONG-TERM EFFECTS WILL

DEPEND UPON:DEPEND UPON: EXPOSURE TIME.EXPOSURE TIME. DECONTAMINATIONDECONTAMINATION ROUTE OF ENTRYROUTE OF ENTRY CONCENTRATION OF HF.CONCENTRATION OF HF. TYPE OF TREATMENT GIVENTYPE OF TREATMENT GIVEN HOW FAST TREATMENT WAS GIVEN.HOW FAST TREATMENT WAS GIVEN. GENERAL STATE OF THE PATIENT.GENERAL STATE OF THE PATIENT.

IF THE TREATMENT IS OPPORTUNE AND IF THE TREATMENT IS OPPORTUNE AND

ADEQUATE, PROGNOSIS WILL BE GOOD IN ADEQUATE, PROGNOSIS WILL BE GOOD IN

MOST CASES.MOST CASES.

MEDICATION & DRESSING MEDICATION & DRESSING MATERIALS THAT MATERIALS THAT

SHOULD EXIST SHOULD EXIST WHEREVER HF IS WHEREVER HF IS

HANDLEDHANDLED

1. 1. IN THE FIELD IN THE FIELD

DECONTAMINATION UNITS CONSIST DECONTAMINATION UNITS CONSIST OFOF::

√√SAFETY SHOWERSAFETY SHOWER

√√EYEWASHEYEWASH

√√SEALED BOX WITHSEALED BOX WITH::

**PAIRS OF GLOVESPAIRS OF GLOVES

**2 TUBES OF HF GEL 30 GRAMS EACH2 TUBES OF HF GEL 30 GRAMS EACH

**1 ALUMINIZED PLASTIC SHEET1 ALUMINIZED PLASTIC SHEET

2. 2. IN AN AMBULANCE, IN AN AMBULANCE, MEDICAL AREAS, OR ANY MEDICAL AREAS, OR ANY

WHERE MEDICALLY TRAINED WHERE MEDICALLY TRAINED PROFESSIONALS ARE PROFESSIONALS ARE

AVAILABLEAVAILABLE

ALUMINIZED PLASTIC SHEETSALUMINIZED PLASTIC SHEETS HF GEL 2.5%HF GEL 2.5% EYE IRRIGATION SOLUTION 1%EYE IRRIGATION SOLUTION 1% NEBULIZING SOLUTION 2.5%NEBULIZING SOLUTION 2.5% 5 CALCIUM GLUCONATE AMPS5 CALCIUM GLUCONATE AMPS NORMAL SALINE IV SOLUTIONNORMAL SALINE IV SOLUTION WATER SOLUBLE LUBRICANT GELWATER SOLUBLE LUBRICANT GEL LOCAL OPTHAMALIC ANESTHETICLOCAL OPTHAMALIC ANESTHETIC GLOVES – LATEX, PVC OR NEOPRENEGLOVES – LATEX, PVC OR NEOPRENE HYPODERMICS, SEVERAL SIZES & CALIBERS, HYPODERMICS, SEVERAL SIZES & CALIBERS,

STAINLESS STEEL NEEDLESSTAINLESS STEEL NEEDLES MORGAN LENSMORGAN LENS

MORGAN LENS DELIVERY SYSTEM (Y)MORGAN LENS DELIVERY SYSTEM (Y) IV DELIVERY SYSTEMSIV DELIVERY SYSTEMS COLD PACKSCOLD PACKS TRACHEOSTOMY KITTRACHEOSTOMY KIT WELL STOCKED EMERGENCY CARTWELL STOCKED EMERGENCY CART DEFIB / MONITOR UNITDEFIB / MONITOR UNIT INHALATION THERAPY EQUIPMENTINHALATION THERAPY EQUIPMENT NEBULIZERSNEBULIZERS MINOR SURGICAL KITMINOR SURGICAL KIT CALCIUM EFFERVESCENT TABLETSCALCIUM EFFERVESCENT TABLETS DRESSING MATERIALSDRESSING MATERIALS

3. 3. HYDROFLUORIC HYDROFLUORIC ACID KITACID KIT

SHOULD BE IN CONTROL ROOMS OR WELLSHOULD BE IN CONTROL ROOMS OR WELL

CONTROLLED AREAS. THEY ARECONTROLLED AREAS. THEY ARE COMPOSED OF COMPOSED OF

TWO MAIN PARTS:TWO MAIN PARTS:

A.A. INHALATION THERAPY UNIT OINHALATION THERAPY UNIT O(2) (2) CYLINDER CYLINDER

VALVE, FLOWMETER PRESSURE METER VALVE, FLOWMETER PRESSURE METER

NEBULIZER, TUBING & MASK.NEBULIZER, TUBING & MASK.

B.B. ONE PORTABLE CONTAINER THAT CONTAINS:ONE PORTABLE CONTAINER THAT CONTAINS:

**4 PAIRSOF GLOVES – LATEX, PVC, NEOPRENE4 PAIRSOF GLOVES – LATEX, PVC, NEOPRENE

**1 FLASHLIGHT1 FLASHLIGHT

**1 LITER OF 1% CALCIUM SOLUTION IN1 LITER OF 1% CALCIUM SOLUTION IN

NORMAL SALINENORMAL SALINE

*1 LITER OF 2.5% CALCIUM SOLUTION IN *1 LITER OF 2.5% CALCIUM SOLUTION IN

NORMAL SALINENORMAL SALINE

**8 TUBES OF HF GEL, 2.5%8 TUBES OF HF GEL, 2.5%

**5 AMP OF CALCIUM GLUCONATE, 10% SOL5 AMP OF CALCIUM GLUCONATE, 10% SOL

**5 NEEDLES, 25 CAL 1 ½” LONG, STAINLESS5 NEEDLES, 25 CAL 1 ½” LONG, STAINLESS

STEELSTEEL

**20 STERILE GAUZE20 STERILE GAUZE

**2 TOURNIQUETS 2 TOURNIQUETS

**2 IV TUBING SETS2 IV TUBING SETS

**4 BOTTLES OF ANTACID (CALCIUM OR4 BOTTLES OF ANTACID (CALCIUM OR

MAGNESIUM BASED)MAGNESIUM BASED)

**2 IV TUBING SETS2 IV TUBING SETS **4 BOTTLES OF ANTACID (CALCIUM OR4 BOTTLES OF ANTACID (CALCIUM OR MAGNESIUM BASED)MAGNESIUM BASED) **1 BOTTLE OF EFFERVESCENT CALCIUM 1 BOTTLE OF EFFERVESCENT CALCIUM TABLETSTABLETS **1 BOTTLE OF LOCAL EYE ANESTHETIC1 BOTTLE OF LOCAL EYE ANESTHETIC **2 COLD PACKS2 COLD PACKS **2 MAYO CANULAS2 MAYO CANULAS **2 ALUMINIZED PLATIC SHEETS2 ALUMINIZED PLATIC SHEETS **1 TUBE OF LUBRICATING GEL1 TUBE OF LUBRICATING GEL **2 STERILE CONTAINERS2 STERILE CONTAINERS **1 IV INFUSOR1 IV INFUSOR **4 MORGAN LENSES4 MORGAN LENSES

KEYS TO GOOD CONTROL KEYS TO GOOD CONTROL WITH HFWITH HF

AVOID EXPOSURES THROUGHAVOID EXPOSURES THROUGH::

** CONTINUOUS EDUCATION.CONTINUOUS EDUCATION.

** GOOD INDUSTRIAL HYGIENE PRACTICES. GOOD INDUSTRIAL HYGIENE PRACTICES.

** MAXIMUM SAFETY IN HANDLING HF ON & OFF-SITE. MAXIMUM SAFETY IN HANDLING HF ON & OFF-SITE.

**CONTINOUS MEDICAL TRAINING ON & OFF-SITE.CONTINOUS MEDICAL TRAINING ON & OFF-SITE.

**PARTICIPATE IN NEIGHBORING COMMUNITY PARTICIPATE IN NEIGHBORING COMMUNITY HOSPITALS, EMS, AND OTHER AGENCIES, SO THAT YOU HOSPITALS, EMS, AND OTHER AGENCIES, SO THAT YOU MAY BE PREPARED FOR ANY CONTIGENCY.MAY BE PREPARED FOR ANY CONTIGENCY.

SO , PRODUCE, STORE, HANDLE ANDSO , PRODUCE, STORE, HANDLE AND DISPOUSE ALL HAZARDOUS CHEMICALSDISPOUSE ALL HAZARDOUS CHEMICALS

WITH RESPECT AND KNOWLEDGEWITH RESPECT AND KNOWLEDGE

FOR YOUR ATTENTION AND PATIENCE

THANK YOU

VERY MUCH !!!