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Last updated December 2012

Table of Contents

1. 1. Introduction
2. 2. A Basic Approach to First-Aid for the Safety Data Sheet
3. 3. A Background Discussion of the Recommendations
   1. 3.1 Emergency Oxygen Administration
   2. 3.2 Neutralization Following Skin Contact
   3. 3.3 Duration of Rinsing/Washing and Rinsing/Washing Agent
   4. 3.4 Frostbite/Cryogenic Injuries
   5. 3.5 Inducing Vomiting
   6. 3.6 Syrup of Ipecac
   7. 3.7 Oral Dilution with Water or Milk
   8. 3.8 Activated Charcoal
4. 4. A Step-by-Step Guide to Making Recommendations
   1. 4.1 Information Needed to Make Recommendations
   2. 4.2 Decision Trees
      • Decision Tree Worksheet
      • Decision Tree For Inhalation Exposures
      • Decision Tree For Skin Exposures
      • Decision Tree For Skin Exposures cont'd
      • Decision Tree For Eye Exposures
      • Decision Tree For Ingestion Exposures
5. 5. Conclusion
6. References
7. Appendix 1 – Examples of Applications
8. Appendix 2 – Special Situations
9. Appendix 3 – Explanation of Specific Wording used in First-Aid Recommendations
10. Appendix 4 – Note to Physicians / Special Instructions

1. Introduction

First-aid is defined as "the assessments and interventions that can be performed by a bystander (or the victim) with minimal or no medical equipment." (Markenson, et al., 2010b) The purpose of first-aid is to minimize injury and disability. In serious cases, first-aid is necessary to sustain life. The First-Aid Measures section on a Safety Data Sheet provides recommendations on how to minimize the effects of an accidental exposure to a chemical product. The recommendations describe measures that trained first-aid providers are able to safely use at the scene of a chemical exposure.

Provision of first-aid information on a Safety Data Sheet is only one component of establishing an effective first-aid program for the workplace. The people responsible for this program must also ensure that:

This publication presents a system for preparing and/or evaluating first-aid recommendations for chemical exposures in the workplace. It is not intended to provide specific advice on how to respond to the effects of particular chemicals, nor is it a first-aid training manual. Rather, it is to be used by people who have a basic understanding of chemicals and their hazards and who write or evaluate first-aid recommendations for Safety Data Sheets.

Significant effort has been invested in identifying the scientific basis for first-aid procedures recommended in this document. However, it must be recognized that many first-aid practices rest on uncertain scientific foundations. Most of the evidence supporting the value of first-aid assessment and management is based on extrapolations from research and experience in other medical settings, animal studies, and case series (Jones, et al. 2001, Markenson, et al, 2010a). In an evidence-based review, these types of evidence are considered relatively weak, but it is the best evidence currently available.

This document first describes a basic approach to preparing the First-Aid Measures section of a Safety Data Sheet. Next, the logic and scientific evidence behind the specific recommendations are discussed. Finally, a step-by-step system for selecting the appropriate recommendations for each route of exposure is presented.

2. A Basic Approach to First-Aid for the Safety Data Sheet

This section examines assumptions that can be made and factors that must be considered when writing first-aid recommendations for a Safety Data Sheet. The principles stated in this section are used to develop the specific recommendations and the step-by-step system presented in Section 4.

The Safety Data Sheet writer can assume that the person who provides first-aid to the victim has basic first-aid training. Therefore, Safety Data Sheets do not need to recommend or explain how to execute procedures to be followed in every emergency. For example, trained first-aid providers will know how to assess the initial status of a victim.

Generally, the Safety Data Sheet writer can assume that medical assistance can be obtained within a reasonably short period of time (60 minutes or less). If medical assistance is not readily available, a doctor familiar with the product or specializing in occupational health and safety and familiar with the facilities available at the location should review the first-aid recommendations, and make changes appropriate to the circumstances, as required.

The Safety Data Sheet should provide instructions that direct the first-aid provider to respond to the specific health effects of the product. Any procedures recommended in the First-Aid Measures section must correspond to specific health effects and routes of exposure identified in the Hazard(s) Identification or Toxicological Information sections of the Safety Data Sheet. The Safety Data Sheet should not introduce any new health effects in the First-Aid Measures section. The Safety Data Sheet should not include first-aid procedures that are not applicable to the product.

The Safety Data Sheet should not exclusively describe first-aid recommendations written for the "worst case" exposure imaginable. Usually, first-aid is given for mild to moderate exposures. If the Safety Data Sheet places too much emphasis on extreme exposures, which rarely occur, the first-aid procedures will be overstated. Inappropriate first-aid could further harm the victim. The best approach is to write first-aid procedures for situations most likely to occur based upon knowledge of the product's use and properties and/or on actual case reports.

In general, the Safety Data Sheet should keep recommendations simple and advise the use of materials that are readily available in most workplaces. For example, first-aid providers will usually use potable water to remove a chemical from the eye as it is generally readily available.

The Safety Data Sheet should not recommend procedures that could cause additional harm or may complicate subsequent medical care. For example, the use of special creams or ointments must be carefully considered. The cream or ointment may have to be removed before a medical professional can assess the injury and begin treatment, and its removal could worsen the injury. Nevertheless, in some cases the benefits do outweigh any risks. For example, there is evidence that certain topical preparations are beneficial in the first-aid treatment of hydrofluoric acid burns.

The First-Aid Measures section of a Safety Data Sheet should not include procedures that fall outside the definition of first-aid. Typically, first-aid does not include procedures like the administration of oral medications. However, under certain circumstances, it may be appropriate to recommend more advanced procedures (e.g., the administration of an antidote for cyanide toxicity). Protocols for undertaking advanced procedures must be developed in consultation with a doctor and must be regularly reviewed. In these situations, advanced, specialized training is required for first-aid providers.

There are two criteria for including these procedures:

The first-aid measures sub-headings of the Safety Data Sheet (i.e. Inhalation, Skin Contact, Eye Contact, Ingestion) should not contain information directed toward medical professionals. Inclusion of this information could be confusing to the first-aid provider. The Safety Data Sheet should direct comments to medical professionals under the Safety Data Sheet Section 4 sub-heading Note to Physicians (American National Standards Institute (ANSI) Material Safety Data Sheet) or Special Instructions (Globally Harmonized System of Classification and Labelling of Chemicals (GHS) Safety Data Sheet). For a brief discussion regarding Note to Physicians/Special Instructions, refer to Appendix 4.

Writers and reviewers of first-aid recommendations may find the following basic outline useful. A Safety Data Sheet should:

3. A Background Discussion of the Recommendations

This section discusses issues that affect the selection of appropriate first-aid recommendations for a Safety Data Sheet. This background discussion addresses topics such as the use of oxygen and whether or not to induce vomiting for chemical exposures. Appendix 3 explains the reasons for the wording of recommendations where specific wording has particular significance and is not self-explanatory.

3.1 Emergency Oxygen Administration

In the past, the use of emergency oxygen was commonly recommended as a first-aid procedure for any inhalation exposure. This practice was adopted because oxygen was thought to be helpful in any case where the victim became short of breath or unconscious. Administering oxygen may have been perceived as giving the victim "fresh air" or a "boost" to help get over the effects of an exposure.

Subsequently, concern was expressed that the administration of oxygen itself may be harmful if carried out improperly or in the wrong circumstances.In particular, there was a concern that administering oxygen to victims with chronic obstructive lung diseases, such as chronic bronchitis or emphysema, could cause the victim to stop breathing. Recent reviews have concluded that, during an emergency situation, the lack of oxygen is the most critical issue and there should be little concern over worsening the condition of victims with chronic obstructive pulmonary disease (COPD). (British Thoracic Society, 2008, Murphy, et al., 2001a, Murphy, et al., 2001b, Nelson, et al., 2011)

The presence of oxygen cylinders in the workplace can introduce additional hazards. For example, since oxygen supports combustion, the presence of oxygen cylinders could contribute to a fire hazard in the workplace. Also, since oxygen is stored under high pressure, the cylinder can behave like a missile if the valve breaks or the tank is punctured.

Therefore, the risks and benefits of storing and maintaining an emergency oxygen supply in the workplace must be weighed.

There are some situations where the benefits of emergency oxygen outweigh the potential risks associated with maintaining and storing oxygen cylinders in the workplace. Emergency oxygen may be beneficial for exposure to chemicals that interfere with the body getting the necessary levels of oxygen to sustain life and health including chemicals that can:

Since basic first-aid training courses do not include oxygen administration, additional training is required. First-aid providers who have been properly instructed in the use of oxygen can use supplemental oxygen for victims of serious illness or injury. First-aid providers must be familiar with laws that govern the use of oxygen equipment in their jurisdiction.

3.2 Neutralization Following Skin Contact

It seems logical to neutralize exposure to an acid with a base or vice versa. However, there are concerns that attempts to neutralize chemical contamination of the skin or eyes could increase injury by causing:

Research has examined the science behind these concerns.

In two studies (Yano, et al., 1993, Yano, et al. 1994), rat skin was damaged by a 1-minute exposure to a strong alkali (2N (8%) sodium hydroxide). Treatment consisted of continuous irrigation with water or a neutralizing agent (0.35M (9%) sodium citrate solution; pH 5.90) starting at 1, 10 or 30 minutes after injury. The first study demonstrated that water flushing must begin as soon as possible after the injury occurs (ideally within 1 minute) and should continue until the pH returns to normal (60 minutes, if flushing begins within 1 minute). In the experiment using sodium citrate, the tissue damage was deeper following citrate treatment when compared to water treatment. The authors believed that thermal injury occurred when the concentrated alkali was neutralized with the weakly acidic sodium citrate.

In another study (Andrews, et al., 2003), rat skin was damaged by a 1-minute exposure to a strong alkali (2N (8%) sodium hydroxide). Irrigation with tap water (pH 7.8) or 5% acetic acid (pH approximately 3) was started at 1 minute following exposure and continued until a near normal subcutaneous pH of 7.8 was reached. There were no significant differences between peak skin temperature or peak pH between the two groups. Flushing with 5% acetic acid was associated with a shorter flushing time (15 vs 32 minutes), less severe tissue injury at 24 hours and somewhat improved wound healing (as measured by one aspect) at 14 days. Overall, both treatments led to complete healing at 14 days.

In an early, less well-conducted study, alkali or acid burns were induced in rats. Animals that were vigorously washed with water survived longer and showed less evidence of injury than animals treated with chemical neutralizers.(Davidson, 1927)

It is critical that flushing a chemical burn commence as quickly as possible. Water is readily available in almost all circumstances.

3.3 Duration of Rinsing/Washing and Rinsing/Washing Agent

Most standard first-aid resources recommend that rinsing with water following skin or eye contact with a chemical product should continue for 15 or 20 minutes. The following section discusses some of the research behind this recommendation.

Skin Contact

In Yano et al., 1993, the subcutaneous pH returned to normal after 60 minutes of water flushing following a 1-minute skin contact with 8% sodium hydroxide, even when flushing started 1 minute after the injury. When flushing was delayed 10 minutes, the pH did not return to normal, even with 90 minutes of flushing. In Andrews , et al. (2003), the subcutaneous pH returned to normal after 32 minutes of water flushing following a 1-minute exposure to 8% sodium hydroxide.

In a related study (Yano, et al., 1995), rat skin was damaged by application of 0.05 mL of 1N (3.65%) hydrochloric acid. When flushing started at 1 minute after exposure, the pH returned to normal at 10 minutes. When flushing was delayed 3 or 10 minutes, the pH did not rise above 7.52 (return to normal), even with 60 minutes of flushing, but a statistically significant difference in pH (compared to the untreated group) was observed from 8-25 minutes.

Earlier studies (Bromberg, et al., 1965, Gruber, et al., 1975) show that the severity of skin injury increases with a longer delay between chemical exposure and the start of water flushing. Bromberg et al. (1965) exposed mice to 50% sodium hydroxide or 36% hydrochloric acid. The skin pH did not approach pre-burn levels until well after 1 hour of continuous irrigation. Gruber et al. (1975) exposed mice to 50% sodium hydroxide. Water treatment comprised of a 10-15 second wash, with some receiving an additional 8-hour wash. Treatment started at one minute, two minutes, or three minutes post-injury. Mice with an 8-hour wash had better outcomes than those with the brief washing alone. Mice with earlier washing had better outcomes than mice with delayed washing.

A Regional Burn Center followed up on 35 cases of skin burns, half of which were work-related. Appropriate first-aid was defined as starting water flushing within 10 minutes, using a large volume of water and continuing treatment for at least 15 minutes. Appropriate first-aid led to a 5-times decrease in third degree burns and an almost 3-times shorter hospital stay.(Leonard, et al., 1982) A report on ten years experience with 83 chemical burns showed that effective first-aid (defined as copious water lavage within 3 minutes of injury) statistically reduced the incidence of third degree burns, length of hospital stay and delayed complications.(Moran, 1987)

Eye Contact

A recent systematic review examined the methods of eye irrigation for chemical eye burns. The literature search led to the identification of four relevant studies involving 302 patients. The studies examined time to commence first eye irrigation, type of irrigating fluid, and duration of eye irrigation. The studies had a number of methodological weaknesses that could have biased results. However, the authors observed that it is important to commence eye irrigation with tap water immediately after burns are sustained based on evidence of better outcomes following alkali burns. The authors concluded that there is insufficient evidence on the different types of eye irrigating fluids on outcome. Irrigating fluids including normal saline, lactated Ringer's, normal saline with sodium bicarbonate added, BSS Plus, and Diphoterine® all yielded positive outcomes suggesting that their use may be appropriate in hospital settings. There was insufficient evidence to draw conclusions on the optimal duration of irrigation. (Chau, et al., 2011)

Kuckelkorn, et al. (1995) reviewed the histories of 101 patients with eyes severely injured by a chemical exposure. In patients receiving immediate rinsing, fewer operations were required, there was a significantly shorter length of hospital stay and there was significantly better visual outcome. However, even eyes with immediate first-aid showed severe damage. Kuckelkorn states that this may have been due to inappropriate first-aid, because even though initial irrigation was carried out, it was not continued for at least 30 minutes in any of the cases.

Summary

In their review of the science behind first-aid practices, the American Heart Association and American Red Cross recommend the following for chemical burns of the skin:

and for eyes:

In Goldfrank's Toxicologic Emergencies, Nelson, et al., 2011 recommend the following for skin:

and for eyes:

For skin contact hazards (irritation and absorption), the GHS advises that the:

and for eyes:

The ANSI standard for emergency eyewash and shower equipment defines "flushing fluid" as any of potable (drinking) water, preserved water, preserved buffered saline solution or other medically acceptable solutions. (ANSI Z358.1-2009) Houston and Hendrickson (2005) state:

At the present time, there is insufficient evidence available to properly address the question of how long rinsing/washing should continue. However, based on what is known it makes sense to tailor the duration of rinsing/washing to the known effects of the chemical or product.

It is preferable that complete decontamination of the skin or eyes occur on-site. (Bronstein, et al., 1994, ATSDR, 2001) With a severe corrosive injury, it may be necessary to delay transport to an emergency care facility to ensure a complete, uninterrupted 30 or 60 minute of rinsing/washing. However, transporting the victim earlier may be necessary depending on the condition of the victim or the availability of the rinsing/washing fluid supply. If necessary, rinsing/washing the affected area should continue during emergency transport, taking proper precautions to protect emergency services personnel. (Edlich, et al. 2005)

Note: Refer to ("lukewarm water") for information regarding water temperature.

3.4 Frostbite/Cryogenic Injuries

Direct contact with a liquefied compressed gas or gas under pressure can cause serious tissue damage. Brief contact with a small amount of the liquid may not pose as great a danger because a protective vapour film may form. Danger of freezing occurs when large amounts are spilled and exposure is extensive. (H2 Safety Best Practices, 2011)

Medical assistance for a cryogenic-induced injury should be obtained as soon as possible. Treatment of frozen tissue requires medical supervision because incorrect first-aid practices will aggravate the injury. The speed of re-warming must be carefully controlled, as should the temperature. There is a high risk of infection and medical control of pain may be necessary. For these reasons, rewarming should not be attempted onsite unless medical assistance cannot be obtained within a reasonable amount of time. (Abbot, 1996, Currance, et al., 2007, H2 Safety Best Practices, 2011)

It is safest to do nothing except protect the affected area with a loose cover and transport the injured person to a medical facility. (H2 Safety Best Practices, 2011)

3.5 Inducing Vomiting

How to respond to accidental ingestion of a chemical has been the subject of much debate. What is clear is that the recommendation to induce vomiting or perform gastric emptying CANNOT be made without careful consideration of many factors, including:

Although it is a difficult issue to study, some researchers have shown clinical benefit from gastric emptying in patients with serious overdoses when gastric emptying is accomplished within 1 hour after ingestion. Other researchers are unable to describe any benefit at all. Detailed review of these studies can be found in references Nelson, et al., 2011 and AACT/EAPCCT, 2004.

Thus, inducing vomiting after a chemical ingestion is a selective rather than a routine procedure – the benefit of which is largely unproven.

3.6 Syrup of Ipecac

The American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT) have issued a position statement on the use of Syrup of Ipecac. The position statement is a systematically developed clinical guideline based on high-quality research evidence. This position statement is accepted by other organizations, including the Canadian Association of Poison Control Centres and the American Board of Applied Toxicology. The Position Statement on Ipecac Syrup concludes that:

The American Association of Poison Control Centers also conducted an evidence-based review of the use of ipecac syrup for the out-of-hospital management of ingested poisons. (Manoguerra, et al., 2005) This review is supported by a detailed review of the literature and concludes that:

In June 2003, an Advisory Committee recommended to the US Food and Drug Administration (FDA) that the over-the-counter status of syrup of ipecac be rescinded, making it available only by prescription. The FDA acceptance of this recommendation will likely end the use of ipecac as a treatment for toxic ingestions (Shannon, 2003). To date, the FDA has not made a decision on the status of ipecac syrup, however most pharmacies no longer stock it. (Pfister, et al., 2010)

3.7 Oral Dilution with Water or Milk

Much of what we know about the benefits of diluting an ingested chemical with water or milk is based on in vitro (test tube) and ex vivo (using harvested rat esophagi) studies.

Based on their evaluation of the evidence for dilution with milk or water, the American Heart Association and American Red Cross state:

3.8 Activated Charcoal

Single-dose activated charcoal treatment involves the oral administration or instillation by nasogastric tube of an activated charcoal water solution. The activated charcoal adsorbs toxic chemicals in the gastrointestinal tract, decreasing the absorption of the chemical and reducing or preventing systemic toxicity.

The American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists have issued a position statement on the use of single-dose activated charcoal. (AACT/EAPCCT, 2005) The position statement is a systematically developed clinical guideline based on high-quality research evidence. The position statement on single-dose activated charcoal is accepted by other organizations, including the Canadian Association of Poison Control Centres and the American Board of Applied Toxicology and concludes that:

The current consensus is that activated charcoal should NOT be routinely administered as a first-aid procedure, for the following reasons:

4. A Step-by-Step Guide to Making Recommendations

This section presents a system to help make appropriate, consistent, easy-to-apply first-aid recommendations for Safety Data Sheets.

The mandatory label phrases of the GHS, 3rd and 4th revised editions, have been consulted during preparation of these Safety Data Sheet phrase recommendations. The decision trees provided in this publication contain additional details and/or specific treatments that are not included in the GHS mandatory label text. The GHS label text has been incorporated or kept consistent for all hazards, except:

4.1 Information Needed to Make Recommendations

Before using this system, certain information about the chemical or product must be gathered. This information can be derived from the Hazard(s) Identification, Physical and Chemical Properties, Stability and Reactivity, and Toxicological Information sections of the Safety Data Sheet. The specific information needed from each of these four areas and the reason for its inclusion is described in this section. Evaluation of a product's properties against criteria, such as those established in the OSHA Hazard Communication Standard, the Canadian Controlled Products (WHMIS) Regulations, or the GHS can help answer some questions.

If certain information for the product is not available, and a professional judgement cannot be made using information available for related products, it is prudent to make an assumption that will result in the most conservative first-aid procedures. For example, if the flammability of a product is unknown, assume the product is flammable. If the water solubility of a product is unknown, assume it is not water-soluble. Both of these decisions will result in first-aid recommendations conservative enough to alleviate any potential hazard.

(A worksheet is provided to assist you in gathering the information required for making first-aid decisions).

Is the product used as a solid, liquid or a gas?

This information helps determine which exposure routes and first-aid measures are relevant for a particular product. For example, ingestion is not a relevant route of exposure for a gas.

Is the product soluble in water?

Products are water-soluble if at least 1 gram of the product can dissolve in 1 liter of water (1 g/L). To make their removal easier, products that are not water-soluble should be quickly blotted or brushed from the skin, before flushing with water. In addition, mild, non-abrasive soap may facilitate the removal of products that are not water soluble or are oily or adherent. (Houston and Hendrickson, 2005)

Does the product react with water to produce heat or a more hazardous chemical?

This information allows modification of the recommendation to reduce contact of the chemical with water, by quickly blotting or brushing the chemical away, prior to flushing.

Is the product an oxidizer?

Oxidizers create a fire hazard by producing oxygen or another oxidizing substance. This information is needed so recommendations can advise that contaminated clothing be removed immediately and submersed in water so that it does not become a fire hazard.

Is the product flammable?

The product could be a significant fire hazard in an emergency situation. Recommendations should include warning the first-aid provider to take appropriate precautions, such as removing all sources of ignition. Also, the product should be removed from the exposed person.

Does the product pose an immediate health threat to the first-aid provider?

A product can pose an immediate health threat to the first-aid provider if it is a simple asphyxiant, very acutely toxic by any route of exposure, or corrosive. In these cases, it is essential that the first-aid provider be protected when responding to incidents involving these chemicals. (Note: Advise the use of specific protective equipment, for example, butyl rubber gloves rather than "impervious" gloves).

Is the product non-toxic?

The first-aid provider can be advised that minimal precautionary measures can be taken.

Is the product non-irritating, or a mild, moderate or severe irritant?

The degree of irritancy can be used to determine the duration of rinsing recommended for skin or eye contact. For example, a non-irritant or mild irritant should only need 5 minutes of rinsing/washing. A moderate or severe irritant may require 15-20 minutes of rinsing/washing to ensure complete removal.

Is the product corrosive?

Corrosives may require longer rinsing/washing than irritants to ensure their complete removal. The evidence suggests that strong alkalis, like sodium hydroxide, require prolonged rinsing/washing – 60 minutes. Corrosives like hydrochloric acid may require rinsing/washing for 30 minutes.

Is the product capable of causing frostbite or freezing tissue?

The first-aid provider should be directed to follow special procedures such as rewarming with body heat following a brief contact with a small amount of the liquefied gas, or immediately calling a Poison Center/doctor for more extensive contact or contact with a large amount. Chemicals can cause frostbite or freeze tissue if they have a low boiling point (below 0 deg C (32 deg F)).

Is the product capable of causing pulmonary edema (corrosive to the respiratory tract)?

Pulmonary edema is a life-threatening accumulation of fluid in the lungs. It interferes with the ability of oxygen to cross through the lungs into the body. Oxygen, as a first-aid measure, may help victims who develop symptoms of pulmonary edema. Symptoms of pulmonary edema may not appear for up to 48 hours after exposure. Anyone with a significant exposure to a chemical that can cause pulmonary edema must be made aware of this delay. Chlorine and ammonia are examples of chemicals that can cause rapid pulmonary edema. Phosgene and nitrogen dioxides can cause delayed pulmonary edema.

Is the product capable of interfering with the body's ability to use oxygen?

Oxygen may be helpful as a first-aid measure for chemicals that can interfere with the body's use of oxygen, for example, by:

Is the product fatal/toxic?

If the product is expected to be fatal/toxic toxic by any route of exposure, the Safety Data Sheet should advise first-aid providers to start rescue breathing, and cardiopulmonary resuscitation (CPR) or automated external defibrillation (AED) as appropriate. CPR and AED require advanced first-aid training.

Is the product an aspiration hazard?

Some chemicals, for example hydrocarbons that have low viscosity, can easily get into the lungs (aspirated) during ingestion or vomiting and attack lung tissue. In this case, a Poison Center or doctor should be called immediately, and vomiting should never be induced.

Is the product capable of causing toxicity to the first-aid provider through mouth-to-mouth contact?

Chemicals that are fatal/toxic if absorbed through the skin (e.g., cyanide compounds) could harm the first-aid provider during rescue breathing. Therefore, direct mouth-to-mouth contact should be avoided, and barrier devices should be used.

4.2 Decision Trees

Before using the decision trees, the information identified in Section 4.1 should be collected and summarized on the worksheet found below. The worksheet can then be used to answer questions posed in the decision trees. This process will produce appropriate, consistent first-aid recommendations for most workplace chemical products.

Note: Several special situations have been identified. These exceptions are listed in Appendix 2 and should be reviewed before using the decision trees.

• Decision Tree for Inhalation Exposure 

• Decision Tree for Skin Exposure (page 1) 

• Decision Tree for Skin Exposure (page 2) 

• Decision Tree for Eye Exposure 

• Decision Tree for Ingestion Exposure 

5. Conclusion

This document provides a framework for preparing appropriate and consistent first-aid recommendations for Safety Data Sheets. Examples of recommendations resulting from application of this system are presented in Appendix 1. Once the decision trees have been used for a specific product, the resulting recommendations should be carefully evaluated. This evaluation should be based on the Safety Data Sheet writer or reviewer's specific knowledge of the chemical and how it is used, and the first-aid principles described in Section 2. This process will help ensure the development of well-balanced, appropriate recommendations.

It may be necessary to customize first-aid recommendations based on situational factors. The Safety Data Sheet is only a starting point for developing a comprehensive, worksite-specific first-aid program. A doctor familiar with the product or specializing in occupational health and safety and familiar with the product, toxicity and potential routes of exposure, the work environment and local community medical facilities should evaluate all first-aid procedures. Each emergency situation is unique and it is imperative that the first-aid provider be trained to exercise good judgement before carrying out any first-aid procedure.

Anyone who might be called upon to give first-aid in an emergency should become familiar with the recommended first-aid measures before working with the product. It is impossible to overemphasize the importance of being prepared. Within different jurisdictions, first-aid training requirements vary. However, every first-aid provider should have the training, including applicable advanced training, necessary to use any first-aid procedures required for an exposure to products present in the workplace. First-aid providers should never try to perform a procedure that is beyond their own expertise. If there is any doubt about the appropriateness of any first-aid procedure during an emergency, the nearest Poison Centre should be called and their advice followed.

References

General

• Abbot, J. Prehospital Emergency Care. A guide for paramedics. 3rd ed. The Parthenon Publishing Group Inc., 1996
• American National Standard for emergency eyewash and shower equipment. ANSI Z358.1-2009. American National Standards Institute, 2009
• Agency for Toxic Substances and Disease Registry (ATSDR). Managing hazardous material incidents (MHMI). Vol. III. Medical management guidelines for acute chemical exposures. US Department of Health and Human Services, Public Health Service, ATSDR, 2001
• Edlich, R.F., et al. Modern concepts of treatment and prevention of chemical injuries. Journal of Long-Term Effects of Medical Implants. Vol. 15, no. 3 (2005). p. 303-308
• Globally Harmonized System of Classification and Labelling of Chemicals (GHS). 3rd revised ed. United Nations, 2009
• Globally Harmonized System of Classification and Labelling of Chemicals (GHS). 4th revised ed. United Nations, 2011
• Jones, A.L., et al. Advances, challenges, and controversies in poisoning. Emergency Medicine Journal. Vol. 19 (May 2002). p. 190-192
• Kloeck, W., et al. Early defibrillation: an advisory statement from the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation. Circulation. Vol. 95 (1997). p. 2183-2184
• Houston, M and R.G. Hendrickson. Decontamination. Critical Care Clinics. Vol. 21 (2005). p. 653-672
• Markenson, D., et al. Part 13: First aid: 2010 American Heart Association and American Red Cross Guidelines for First Aid. Circulation. Vol. 122, suppl. 3 (Oct. 2010). p. S582-S605
• Markenson, D., et al. Part 17: First aid: 2010 American Heart Association and American Red Cross Guidelines for First Aid. Circulation. Vol. 122, suppl. 3 (Oct. 2010). p. S934-S946
• Nelson, L.S., et al. Goldfrank's Toxicologic Emergencies. 9th ed. The McGraw-Hill Companies, Inc., 2011

Inhalation

• British Thoracic Society Emergency Oxygen Guideline Group. Guideline for emergency oxygen use in adult patients. Thorax: An International Journal of Respiratory Medicine. Vol. 63, suppl. VI (Oct. 2008)
• Murphy, R., et al. Emergency oxygen therapy for the COPD patient. Emergency Medical Journal. Vol. 18 (2001). p. 333-339
• Murphy, R., et al. Emergency oxygen therapy for the breathless patient. Guidelines prepared by North West Oxygen Group. Emergency Medical Journal. Vol. 18 (2001). p. 421-423
• Stilp, R.H., et al. Emergency medical response to hazardous materials incidents. Delmar Publishers, 1997

Skin Contact

• Andrews, K., et al. The treatment of alkaline burns of the skin by neutralization. Plastic and Reconstructive Surgery. Vol. 11, no. 6 (May 2003). p. 1918-1921
• Bromberg, B.E., et al. Hydrotherapy in chemical burns. Plastic and Reconstructive Surgery. Vol. 35, no. 1 (Jan. 1965). p. 85-95
• Currance, P.L., et al. Emergency care for hazardous materials exposure. 3rd ed. Mosby Jems, 2007
• Davidson, E.C. The treatment of acid and alkali burns: an experimental study. Annals of Surgery. Vol. 85, no. 4 (Apr. 1927). p. 481-489
• Gruber, R.P., et al. The effect of hydrotherapy on the clinical course and pH of experimental cutaneous chemical burns. Plastic and Reconstructive Surgery. Vol. 55, no. 2 (Feb. 1975). p. 200-204
• H2 safety best practices website. A collaboration of the Pacific Northwest National Laboratory and Los Alamos National Laboratory with funding from the U.S. Department of Energy. Last updated: Mar. 11, 2011
• Leonard, L.G., et al. Chemical burns: effect of prompt first aid. Journal of Trauma. Vol. 22, no. 5 (May 1982). p. 420-423
• Moran, K.D. Chemical burns: a ten-year experience. American Surgery. Vol. 53 (1987). p. 652-653
• Stewart, C. Chemical injuries to the skin. In: The Emergency Textbook of Adult and Pediatric Emergency Medicine. Edited by G. Bosker. Thomson American Heart Health Consultants, 2003
• Yano, K., et al. Experimental study on alkaline skin injuries – periodic changes in subcutaneous tissue pH and the effects exerted by washing. Burns. Vol. 19, no. 4 (1993). p. 320-323
• Yano, K., et al. Effects of washing with a neutralizing agent on alkaline skin injuries in an experimental model. Burns. Vol. 20, no. 1 (1994). p. 36-39
• Yano, K., et al. Effects of washing acid injuries to the skin with water: an experimental study using rats. Burns. Vol. 21, no. 7 (1995). p. 500-502

Eye Contact

• ACOEM (American College of Occupational and Environmental Medicine). ACOEM Guideline. The use of contact lenses in an industrial environment. ACOEM, 2008
• Chau, J.P.C., et al. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews on Evidence-based Nursing. Xxxx Quarter 2011. p. 1-10
• Clark, D.E. Chemical injury to the eye. Chemical Health and Safety. Vol. 9, no. 2 (Mar./Apr. 2002). p. 6-9
• Cullen, A.P. Contact lens emergencies. Chemical Health & Safety. Vol. 2, no. 1 (Jan./Feb. 1995). p. 22-24
• Kuckelkorn, R., et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmologica Scandinavia. Vol. 80, no. 1 (Feb. 2002). p. 4-10
• Kuckelkorn, R., et al. Poor prognosis of severe chemical and thermal eye burns: the need for adequate emergency care and primary prevention. International Archives of Occupational and Environmental Health. Vol. 67, no. 4 (1995). p. 281-284
• National Institute for Occupational Safety and Health (NIOSH). Eye Safety for Emergency Response and Disaster Recover. Last reviewed: May 27, 2009
• Saari, et al. Management of chemical eye injuries with prolonged irrigation. Acta Opthtalmologica. Vol. 161, Suppl. (1984). p. 52-59

Ingestion

• American Academy of Clinical Toxicology and European Association of Poison Control Centres and Clinical Toxicologists (AACT/EAPCCT). Position statement: single-dose activated charcoal. Clinical Toxicology. Vol. 43, (2005). p. 61-87
• American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT). Position paper: ipecac syrup. Journal of Toxicology. Clinical Toxicology. Vol. 42, no. 2 (2004). p. 133-143
• Isbister, G.K., et al. Feasibility of prehospital treatment with activated charcoal: who could we treat, who should we treat? Emergency Medicine Journal. Vol. 20, no. 4 (2003). p. 375-378
• Manoguerra, A.S., et al. Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons. Clinical Toxicology. Vol. 1 (2005). p. 1-10
• Olsen, K.R. Activated charcoal for acute poisoning: one toxicologist's journey. Journal of Medical Toxicology. Vol. 6 (2010). p. 190-198
• Pfister, R.L., et al. Ipecac: A lesson in clinical guidelines. The Internet Journal of Allied Health Sciences and Practice. Vol. 8, no. 2 (Apr. 2010)
• Seger, D. Single-dose activated charcoal-backup and reassess. Journal of Toxicology. Clinical Toxicology. Vol. 42, no. 1 (2004). p. 101-110
• Shannon, M. The demise of ipecac. Pediatrics. Vol. 112 (Nov. 2003). p. 1180-1181

Special Situations

• Robinett, D.A., et al. Special considerations in hazardous materials burns. The Journal of Emergency Medicine. Vol. 39, no. 5 (2010). p. 544-553

Cyanide compounds:

• Agency for Toxic Substances and Disease Registry (ATSDR). Managing hazardous material incidents (MHMI). Vol. III. Medical management guidelines for acute chemical exposures. Medical Management Guidelines (MMGs) for hydrogen cyanide. US Department of Health and Human Services, Public Health Service, ATSDR. Last reviewed: Mar. 3, 2011
• Cummings, T.F., et al. The treatment of cyanide poisoning. Occupational Medicine. Vol. 54 (2004). p. 82-85
• Hall, A.H., et al. Which cyanide antidote? Critical Reviews in Toxicology. Vol. 39, no. 7 (2009). p. 541-552
• Hamel, J. A review of acute cyanide poisoning with a treatment update. Critical Care Nurse. Vol. 31, no. 1 (Feb. 2011). p. 72-82
• Shepherd, G., and L.I. Velez. Role of hydroxocobalamin in acute cyanide poisoning. The Annals of Pharmacotherapy. Vol. 42, no. 5 (May 2008). p. 661-669

Elemental sodium and potassium

• Krenzelok, E.P. Sodium and potassium. In: Hazardous Materials

Hydrofluoric acid

• Heard, K., et al. Oral decontamination with calcium or magnesium salts does not improve survival following hydrofluoric acid ingestion. Journal of Toxicology. Clinical Toxicology. Vol. 41, no. 6 (2003). p. 789-792
• Kirkpatrick, J.J.R., et al. An algorithmic approach to the treatment of hydrofluoric acid burns. Burns. Vol. 21, no. 7 (1995). p. 495-499
• Recommended medical treatment for hydrofluoric acid exposure. Honeywell, Apr. 2006
• Ozcan, M., et al. Possible hazardous effects of hydrofluoric acid and recommendations for treatment approach: a review. Clinical Oral Investigations. Vol. 16 (2012). p. 15-23
• Segal, E.B. First aid for a unique acid: hydrofluoric acid. Chemical Health and Safety. Vol. 7, no. 1 (Jan./Feb. 2000). p. 18-23

Hydrogen sulfide

• Agency for Toxic Substances and Disease Registry (ATSDR). Managing hazardous material incidents (MHMI). Vol. III. Medical management guidelines for acute chemical exposures. Medical Management Guidelines (MMGs) for hydrogen sulfide. US Department of Health and Human Services, Public Health Service, ATSDR. Page Last Reviewed: Mar. 3, 2011
• Guidotti, T.L. Hydrogen sulphide. Occupational Medicine. Vol. 46, no. 5 (Oct. 1996). p. 367-371
• Investigation report. Hydrogen sulfide poisoning (2 dead, 8 injured). Georgia-Pacific Naheola Mill, Pennington Alabama, Jan. 16 2002. NTIS PB2003-101293. US Chemical Safety and Hazard Investigation Board, Jan. 2003
• Milby, T.H., et al. Health hazards of hydrogen sulfide: current status and future directions. Environmental Epidemiology and Toxicology. Vol. 1, nos. 3-4 (1999). p. 262-269

Molten Materials

• Baruchin, A.M., et al. Hot bitumen burns: 92 hospitalized patients. Burns. Vol. 23, no. 5 (1997). p. 438-441
• Ebbon, G.P., et al. Petroleum products - first aid emergency and medical advice. Report 1/97. CONCAWE, Mar. 1997
• James, N.K., et al. Review of burns caused by bitumen and the problems of its removal. Burns. Vol. 16 (1990). p. 214-216

Phenol

• Brown, V.K.H., et al. Decontamination procedures for skin exposed to phenolic substances. Archives of Environmental Health. Vol. 30 (Jan. 1975). p. 1-6
• Conning, D.M., et al. The dermal toxicity of phenol: an investigation of the most effective first-aid procedures. British Journal of Industrial Medicine. Vol. 27 (1970). p. 155-159
• Horch, R., et al. Phenol burns and intoxications. Burns. Vol. 20, no. 1 (1994). p. 45-50
• Monterio-Riviere, N.A., et al. Efficacy of topical phenol decontamination strategies on severity of acute phenol chemical burns and dermal absorption: in vitro and in vivo studies with pig skin. Toxicology and Industrial Health. Vol. 17 (2001). p. 95-104
• Pardoe, R., et al. Phenol burns. Burns. Vol. 3 (1976). p. 29-41

White Phosphorus

• Barillo, D.J., et al. Treatment of white phosphorus and other chemical burn injuries at one burn center over a 51-year period. Burns. Vol. 30 (2004). p. 448-452
• Davis, K.G. Case report. Acute management of white phosphorus burn. Military Medicine. Vol. 167, no. 1 (Jan. 2002). p. 83-84
• Eldad, A., et al. The phosphorus burn – a preliminary comparative experimental study of various forms of treatment. Burns. Vol. 17, no. 3 (1991). p. 198-200
• Eldad, A., et al. Phosphorus burns: evaluation of various modalities for primary treatment. Journal of Burn Care & Rehabilitation. Vol. 16, no. 1 (Jan/Feb. 1995). p. 49-55

Note to Physicians / Special Instructions

• American College of Medical Toxicology (ACMT). Position statement: Material Safety Data Sheets. Posted: Aug. 30, 2007
• American National Standard for hazardous workplace chemicals – Hazard evaluation and Safety Data Sheet and precautionary labeling preparation. ANSI Z400.1/Z129.1-2010. American National Standards Institute, May 2010
• Daya, M. Improving the first aid advice on MSDSs. Presented at the Society for Chemical Hazard Communication Spring Meeting, Fort Lauderdale, FL, Apr. 2003

Appendix 1 – Examples of Applications

Appendix 2 - Special Situations

Appendix 3 – Explanation of Specific Wording used in First-Aid Recommendations

• "Automated external defibrillation (AED)" The International Liaison Committee on Resuscitation (ILCOR) recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes those assigned to provide first-aid at their workplace and who are trained in the use of an AED. (Kloeck, et al., 1997) For information on establishing an automated external defibrillation program in the workplace, refer to the American College of Occupational and Environmental Medicine (ACOEM) guideline.
• "Gently blot or brush away excess product." The removal of solid particles or thick, non-water soluble liquids from the skin may be facilitated by blotting or brushing them off before washing/rinsing the contaminated area.
• "Do not allow person to rub the affected eye(s)." This reaction is a natural response to an eye irritant but it could cause additional abrasion of the eye.
• "Do not attempt to manually remove anything from the eyes." Efforts to remove a foreign body from the eye(s) could cause penetration or abrasion.
• "Gently flowing" A fast stream of water could cause the product to splash, harming the first-aid provider. In addition, a force of water could add mechanical damage to injured skin or eye(s).
• "While holding the eyelids open" Pain causes forced closing of the eyelids. Therefore, help may be necessary to keep the eyelids open to ensure a thorough flushing of the eye and eyelid.
• "Remove contact lens if present, and easy to do." Nothing should delay starting rinsing. The initial rinsing will likely wash away the contact lens. If not, it can be manually removed by the exposed person or medical personnel if it can be done easily. (ACOEM, 2008, Clark, 2002, Cullen, 1995, NIOSH, 2009) Otherwise, continue rinsing until medical advice/attention is obtained.
• "Immediately" The speed with which first-aid should begin cannot be stressed enough. For example, beginning water flushing within one minute is more effective in reducing injury than beginning water flushing within three minutes. (Yano, et al., 1993, Yano, et al., 1994, Yano, et al., 1995)
• "Lukewarm water" The available evidence indicates that the water temperature should be under 38 deg C (100 deg F) and above 16 deg C (60 deg F). Temperatures of more than 38 deg C (100 deg F) are harmful to the eyes and can enhance chemical interaction with the skin and eyes. Prolonged flushing with cold water (less than 16 deg C (60 deg F) can cause hypothermia and may result in premature cessation of flushing. (ANSI, 2009) For thermal burns, the evidence demonstrates that cooling the burn with water at room temperature (15-25 deg C (59-77 deg F)) within 30 minutes of injury reduces pain, depth of injury, and the need for grafting. (Markenson, et al., 2010a, Markenson, et al., 2010b)
• "Medical advice/attention" Depending on the seriousness of the incident, a medical professional should be verbally consulted (medical advice) or must see the person (medical attention) to determine if medical treatment is necessary.
• "Mild soap" A mild soap can facilitate the removal of non-water soluble, adherent, or oily chemicals without irritating the skin.
• "Take off contaminated clothing" Some authorities estimate that exposure can be reduced by an estimated 75-90% by removing contaminated clothing. (Houston and Hendrickson, 2005) The amount removed will vary depending on the degree of contact and saturation of the clothing, but common sense suggests that quick removal of contaminated clothing will quickly reduce exposure.
• "Trained personnel" Training beyond basic first-aid may be required to perform the procedure safely and effectively. Requirements for advanced training vary between jurisdictions.
• "Water" As a flushing agent, water is readily available and is presumed to serve the following purposes:
  • diluting the chemical,
  • washing away the chemical,
  • decreasing the rate of any chemical reaction with tissue,
  • cooling any heat generated by reaction of the chemical with water or tissue,
  • decreasing tissue metabolism thus reducing inflammation,
  • minimizing hygroscopic activity of hygroscopic chemicals, and
  • normalizing pH levels. (Bromberg, et al., 1965, Yano, et al., 1995)
• An alternative agent may be recommended in exceptional cases if water is clearly inappropriate. (GHS, 2011)

Appendix 4 - Note to Physicians

In its position statement on MSDSs, the American College of Medical Toxicology (ACMT) states:

Essentially, this position statement recommends that the treating physician should contact a Poison Centre to obtain expert advice on the treatment of chemical exposures, rather than consulting a Safety Data Sheet. However, it is important to note that not all countries or states have Poison Centres or access to ACMT trained toxicologists or poison specialists 24 hours a day.

The American National Standard for Hazardous Workplace Chemicals – Hazard Evaluation and Safety Data Sheet and Precautionary Labeling Preparation indicates that the Note to Physicians / Special Instructions sub-section on a Safety Data Sheet should convey "additional information on antidotes, specific treatments and diagnostic procedures outside of customary generic treatment administered by healthcare professionals for exposure to potentially hazardous substances". (ANSI, 2010)

According to the ANSI standard, the information included can relate to both immediate and delayed effects and can address both treatment/therapy and diagnostic procedures. Some considerations include the following:

ANSI advises that Safety Data Sheet authors "discuss with a medical professional the need for, or the appropriateness of, a "Notes to physicians" subsection. A physician should approve all "Notes to physicians". Examples of the type of information that would be appropriate in the Note to Physicians / Special Instructions subsection of a Safety Data Sheet are as follows:

It is beyond the scope of this publication to provide detailed information on the Note to Physicians/Special Instructions subsection of a Safety Data Sheet.