Centipedes

Centipedes

Centipedes, despite their resemblance to millipedes, are not very closely related, and are placed in a separate class within the arthropods known as Chilopoda, from the Greek words for "jaw feet". This is a reference to the venomous fangs, which are actually formed from modified legs. The centipedes are some of the oldest terrestrial animals on earth, and some of the very first creatures to crawl from the sea onto the land were probably very similar in appearence to modern centipedes.

All of the centipedes are nocturnal predators which live by actively hunting down insects and other small prey animals. They are found mostly in tropical forest areas, but have also established themselves in temperate forests and desert areas. Although popularly referred to as "hundred-leggers", most centipedes have between 15 and 30 pairs of legs, one pair on each body segment.

There are four orders of centipedes within the class Chilopoda. One of these is the Lithiobiomorpha, known as stone centipedes. Small and secretive, they live under rocks and in leaf litter and are not often seen. The snail centipedes, of the order Geophilomorpha, are small yellow animals that live in rotting logs and soil. The centipedes most often seen by people in the United States are the house centipedes, of the order Scutigeromorpha. They are of small size and have long thin legs. Most of these are found in southern Europe and the Middle East -- in the United States, they cannot survive outdoors and instead live in people's houses. The largest of the chilopods are the tropical centipedes in the order Scolopendromorpha. Found in warm and damp areas of the world, the tropical centipedes are several inches long, with the largest species approaching one foot in length.

Almost all of the "pedes" available in the pet trade are from the order Scolopendromorpha. These are large arthropods, averaging five or six inches in length and either 21 or 23 pairs of legs. The largest members of the group can reach lengths of twelve inches. The scolopendromorphs are fast-moving and aggressive, and can inflict painful wounds. All are predators which attack their prey with venomous fangs, and in some species the venom is powerful enough to kill small vertebrates. Although there are has only been one reported case of a human death resulting from a centipede, they can deliver painful bites and should not be handled.

Some of the larger scolopendromorph centipedes have lifespans of over ten years.

Keeping and Raising Millipedes and Centipedes

Invertebrates rule the earth. Despite the attention given to the backboned vertebrates--the fish, amphibians, reptiles, birds and mammals-- it is the invertebrates, animals without backbones, which have always dominated life on our planet. Invertebrate animals have flourished in every possible ecological niche, from the deepest depths of the oceans to the thinnest mountain air, from sweltering deserts to steaming jungles to freezing polar regions. Of the 26 major groups of animals, known as "phyla", all but one consists solely of invertebrates. Of all the animals known to science, over 99% are species without backbones.

Today, invertebrates such as tarantulas, scorpions, millipedes and centipedes are the fastest-growing sector of the exotic pet trade. A wide variety of species are now inexpensively available from breeders, dealers and pet shops. So if you are looking for a fascinating pet that is unusual, easy to care for, doesn't take up much room, and doesn't require much maintenance, perhaps one of the several invertebrate species is for you.

This book provides biological information and care requirements for two commonly-kept varieties of invertebrates -- centipedes and millipedes. These animals require only the most simple of accomodations and the most minimal of care. Once rare in captivity, they are now becoming more readily available, and the number of people keeping these unusual animals continues to grow rapidly.

Although these animals have many husbandry needs in common and there will thus be some overlap between sections, each section of this book is designed as an independent unit. If you are keeping only one variety of these animals, you will find all the care information you need in that particular section.

All living things are classified by biologists into a hierarchical system of categories, sorted according to their biological characteristics (their "morphology") and their evolutionary history (their "phylogeny"). This science of classification is known as "taxonomy".

The basic unit of taxonomy is the species, which is biologically defined as "a set of populations of organisms, the members of which are capable of exchanging genetic material under natural conditions by breeding to form fertile offspring". A few species are further broken down into subspecies, which are distinct populations that vary from each other in noticeable ways, but which are still capable of interbreeding with each other to form fertile offspring and are thus still members of the same species. Taxonomically, a group of species that are closely related to each other through anatomy and common descent are placed together in the same genus (the plural is genera). Species that are more distantly related are placed together in successively higher and more inclusive categories. A group of related genera forms a family, and a group of related families forms an order. Groups of orders form a taxonomic class, and a group of related classes forms a phylum (plural is phyla). A group of related phyla form a taxonomic kingdom, which is the highest category of taxonomy.

Biologists refer to a particular species by its scientific name, which is made up of two parts. The first half of the scientific name consists of the organism's genus designation, followed by its species name. If we are referring to a subspecies, then the scientific name will have three parts, consisting of the genus, species and subspecies designations.

All of the organisms in this book are animals. Biologically, the kingdom Animalia includes all of the multicellular organisms that do not have rigid cell walls and do not have chloroplasts for photosynthesis (rigid cell walls and chloroplasts are the distinguishing characteristics of plants). The animal kingdom is itself divided into a large number of phyla. The animals that we are most familiar with are all members of the phylum Chordata, which consists of all organisms which have a stiffened spinal tube or bony spinal column at some point in their lives.

The animals covered here, however, are all members of the phylum Arthropoda, which contains all of the various invertebrate organisms that possess a stiffened exoskeleton, usually made of chitin, and a number of multi-jointed legs and other appendages. Included in the arthropods are such diverse animals as insects, spiders, crabs, myriapods and scorpions. Invertebrate animals that do not have stiff exoskeletons and jointed legs, such as sponges, snails, clams and squid, are not arthropods. The arthropods are by far the largest of all the existing phyla, with a variety of species that dwarfs all the other living groups.

The animals covered here fall into two distinct classes within the arthropod phylum. The centipedes are members of the class Chilopoda, which differs significantly from the class Diplopoda, where the millipedes are placed. Biologically, these two classes are as different from each other as birds are from frogs or fish.

The classes Chilopoda and Diplopoda are further divided into a number of different orders. There are four different orders within the chilopod class, of which the Scolopendramorpha are the most important to hobbyists, while the most common pet millipedes belong to the Spirostreptida order within the diplopod class. Within each of these orders, a variety of different families are found. Most of the centipedes found on dealer lists are members of the family Scolopendramorphidae within the Scolopendramorpha order, while most of the petshop millipedes are members of the Spirostrepidae family. Each of these families contains in turn a wide variety of genera and species which identify their members.

While all of these tongue-twisting Latin designations and categories may seem like a waste of time, they are in fact vitally important to the hobby of keeping invertebrates as pets. For most people, all of these animals look superficially alike, and it is a virtual impossibility to tell one species from another. In many cases, however, identification may be very important, since some species can have environmental and husbandry needs that may be quite different from those of closely related species. Keeping a desert species of millipede or centipede in a rainforest habitat, for instance, will quickly kill it, and vice versa. In the case of potentially dangerous animals such as large centipedes, an accurate identification and the ability to distinguish harmless species from those that are potentially medically significant is an absolute necessity for the sake of safety.

Many of the invertebrates sold in the pet trade, however, are unfortunately identified only vaguely, if at all. Most are sold under a "common name" that may in fact have been made up on the spot by the importer or wholesaler. In some cases, the same animal may be offered through different dealers under completely different names. The large centipede Scolopendra subspinipes, for instance, can be found for sale under names ranging from "Vietnamese centipede" to "orange-legged jungle centipede" to "Asian forest centipede".

For all of these reasons, every effort should be made to obtain an accurate Latin name for any invertebrate pet you may purchase. Most of the larger and more responsible dealers will identify all of their animals by Latin name as well as common name. However, it must be recognized that the invertebrate animals are very poorly studied, and large gaps exist in our knowledge. A positive identification of the more uncommon species may depend on esoteric examination of genitalia or internal structures, and this can only be done by an expert --and the number of competent experts who are working with these animals can usually be counted on the fingers of one hand. A number of uncommon or unusual centipedes, for instance, particularly those being imported for the first time, can currently only be tentatively identified to the genus level. With some centipedes and millipedes, which are even more poorly known, even this level of identification may not be possible, and it is not unusual, for instance, to see millipedes that are completely unidentified, and carried on price lists simply as "class Diplopoda" (the biological equivilent of looking at a mammal and not being able to tell if it is a wolf or a deer). The problem of unidentified species is likely to get even worse as the hobby of keeping invertberates continues to grow, and importers begin bringing in more and more exotic and rare animals to enliven and expand their lists. A tremendous amount of work remains to be done in invertebrate taxonomy.

For the beginner, it is best to stick with the common and widely available species listed in this book, that can be readily identified by a full Latin name. This allows specific husbandry and care information to be researched as well as scientific and biological information. Save the more exotic and lesser known species until you have some experience under your belt.

Millipedes

Millipedes are members of the arthropod class Diplopoda. They are grouped together with the centipedes into the subphylum Myriapoda. The class name Diplopoda means "doubled feet", and refers to the fact that millipedes have two pairs of legs for each body segment, while centipedes have only one. (Embryonic millipedes have only one pair of legs per segment, but during their development adjacent segments become fused to form one, resulting in the same number of legs on half as many body segments.) Millipedes are known in the popular vernacular as "thousand-leggers", but few species actually have more than 250 pairs of legs (the record belongs to the species Illacme plenipes, which has 375 pairs, or 750 legs in total). Although they have many more legs than the fast-moving centipedes, millipedes are leisurely and plodding and are incapable of moving quickly.

There are several different groups of millipedes. Nearly all of the millipedes found in pet shops and dealer lists belong to the group known as spirostraptids. They are long and cylindrical, and are nearly round in cross section. The spirostrepdids move like tracked bulldozers, using their many legs and their flat faces to push their way through the substrate in search of food.

Another group of millipedes, the colobgnathids, have tapering bodies that they use to worm their way through leaf litter and dirt. The polydesmid group of millipedes has a prominent keel or ridge along the sides of their back, which they use to dig their way through soil or dirt. The glomerids and sphaerothiids look like large versions of pillbugs or roly-polies. They are shorter and wider than most millipedes, and curl themselves up into a ball when frightened.

All of the typical pet "millis" are slow-moving and easy to handle. They are inoffensive scavengers, feeding largely on decaying plant material, and lack the poison claws found in centipedes. Some of the large tropical millipedes, however, can secrete a noxious substance from the metathoracic glands on their cuticle when handled, and a few species are capable of defending themselves from predators by expelling a tiny cloud of repellant chemicals. Their usual defense mechanism is to curl the body like a watchspring, protecting the soft underbelly and exposing the hard chitinous shell. Millipedes have lived up to seven years in captivity.

Handling a Centipede

The painful results of a centipede bite have been well known for centuries. In 1740, the English naturalist Charles Owen wrote, "The Scolopendra is a small venomous worm, and amphibious. When it wounds any, there follows a Blueness about the affected Part, and an Itche all over the Body, like that caused by Nettles. Its Weapons of Mischief are much the same as those of the Spider, only much larger; its Bite is very tormenting, and produces not only pruriginous Pain in the Fleshe, but very often Distractions of the Minde."

The venom apparatus consists of modified legs, on either side of the body just behind the head. These are known as maxillipeds, or sometimes as forcipules. The fang itself consists of a hollow tube with a sharp tip, like a hypodermic needle. The venom glands are found inside the body wall at the base of the fangs. When the centipede attacks, muscles surrounding the venom gland squeeze it and force venom through the hollow maxilliped and into the prey's body.

Very little scientific study of centipede venoms has been done, but it is known that some centipede venoms contain the active ingredient 5-hydroxytryptamine. The venom of the North American giant centipede, Scolopendra heros, contains cytolisins which break down cell walls.

Smaller centipedes, such as the orangish Scolopocryptops specimens found under rocks throughout the northeastern United States, produce nothing more than a painful but localized reaction, similar to a bee sting. The larger tropical species found in the pet trade, however, pack more of a punch, and can produce systemic symptoms as well as severe pain at the site of the bite---some people bitten by tropical scolopendromorphs have suffered nausea, vomiting, headaches and swelling in the lymph nodes. The centipede's venom can sometimes have a necrotic effect at the site of the bite, which can produce a painful open sore that takes some time to heal.

There is only one case in the scientific literature of a human death caused by a centipede bite -- a seven year old girl in the Phillipines died after being bitten on the head by a fullgrown tropical centipede, probably the large species Scolopendra subspinipes. Despite the potential danger, however, centipedes are not considered to be a major medical concern in any of the areas where they are found. Nevertheless, be aware that your pet centipede is a venomous animal, and treat it with the respect it deserves. A small percentage of people are allergic to centipede venom, and for these people any bite, no matter how small the pede or how weak the venom, can turn into a life-threatening emergency. If you are allergic to bee stings, the chances are good that you will also experience a reaction to centipede venom.

All of the tropical centipedes should be treated with caution. They should not ever be touched or handled with bare hands. If it is necessary to handle one, to move it to another tank for instance, great care should be exercised. These animals can move very quickly and bite readily, and unlike other animals that move rapidly away from potential danger, centipedes will immediately go on the attack towards any perceived threat.

Smaller centipedes are rather delicate and should be moved carefully. The best method is to place a small container (such as a deli cup) into the tank and then "herd" the centipede into it using an artist's soft-bristled paintbrush. Once the centipede runs inside the container, snap the lid on and it will be safely confined. This method can also be used (with more care) for larger tropical centipedes. To prevent escapes, transfer operations should always be carried out in an enclosed area to prevent the centipede from getting away if it makes a break for it. A bathtub works well (make sure you plug the drain). Keep all of your fingers well out of the way. If you offer a centipede any chance to get a fang into your flesh, it will happily oblige.

Some keepers handle their centipedes using a long pair of tongs or forceps that have been padded at the tips with foam rubber (a method also used to handle scorpions). If the tongs are at least twelve inches in length, the centipede will not be able to reach up and bite you with its fangs. This method should not be used by beginners, however---the exoskeleton of a centipede is not as thick as a scorpion's, and too much pressure can rupture the centipede's body wall and cause death. Centipedes also move very quickly, and it may be very difficult to grasp the pede without causing it to shed a large number of legs. It is far safer for both you and the centipede to prod it into a suitable container using a brush.

It may be best to slow down the centipede somewhat before attempting to move or handle it. This can be accomplished by placing the entire centipede tank in the refrigerator for about fifteen minutes. Centipedes, like all arthropods, are ectotherms and are dependent on their external environment for body heat. The cooler the temperature, the less quickly they are capable of moving. Keep in mind, however, that your centipede is a tropical animal, and cooling it to unnaturally low levels like this will cause it considerable stress. It may also kill the animal if cooled too far or too long. The idea is to cool it enough to slow down its movements, not to immobilize it.

rbc morphology

Acanthocytes are a subgroup of schistocytes consisting of small spherical cells with several finger-like projections from the RBC surface distributed in an irregular manner. The ends of the projections tend to be slightly thickened. Acanthocytes are typically found in large numbers in hereditary abetalipoproteinemia (Bassen-Kornsweig disease, Chapter 22), in moderate numbers in severe liver disease or in anorexia nervosa, and in small numbers in association with schistocytes of other types in other conditions.
Red blood cell crenation (echinocytes) are RBCs that appear normal except for uniform small triangular projections arranged in a uniform manner around the circumference of the cell, like the outer edge of a gearwheel. When most of the RBCs have this appearance, they are most commonly artifactual; but in lesser numbers they may be found in liver disease, renal disease, hyperlipidemia, and in some RBC enzymopathies.
Bite cells (degmacytes) are RBCs with a semicircular defect in one area of the outer edge. When present in significant number, bite cells are suggestive of hemolytic anemia due to an oxidizing agent (Heinz body anemia).
Sickle cells are crescent-shaped RBCs pointed at one or both ends found in some patients with homozygous sickle cell anemia (Chapter 5). Hemoglobin SC disease may sometimes display stubby sickled cells with a short thick bar protruding from the center that represents an Hb C crystal.
Elliptocytes (ovalocytes) are oval RBCs found in varying numbers in persons with congenital elliptocytosis and occasionally in small numbers in normal persons. When seen on edge, the cells may look somewhat like short rods and, rarely, may superficially resemble an atypical sickle cell.
Target cells consist of a peripheral ring and central disk of Hb. Target cells are found in large numbers in Hb C disease (Chapter 5) and in lesser numbers with certain other abnormal hemoglobins, in thalassemia, and in chronic liver disease.
Teardrop cells look like RBCs in which one side has been gently pulled out to a sharp point while the opposite side is still rounded. These cells are most characteristically associated with myeloid metaplasia (myelofibrosis, Chapter 7) but can also be present in lesser numbers in other myeloproliferative syndromes, such as chronic myelocytic leukemia.
Stomatocytes are RBCs that have a rectangular or slit-like central pallor configuration. This may be due to hereditary stomatocytosis or may be drug induced. A few stomatocytes may be found in normal persons and in a variety of diseases.
Rouleaux are RBCs partially adhering to each other with the overall appearance of a partially spread out stack of coins. The RBC central clear area is usually absent. This appearance is similar to that normally seen in the very thick areas of a peripheral blood smear. However, with rouleaux there are a moderate number of free single RBCs intermingled with the RBC stacks, whereas there are no free RBCs in thick areas of the smear. Considerable rouleaux formation suggests the possibility of abnormal serum proteins (such as the monoclonal proteins of multiple myeloma).
Red Blood Cell Inclusions (Fig. 2-1)
Basophilic stippling describes a moderate number of small dark blue dotlike structures scattered fairly uniformly throughout the hemoglobinated area of the RBC. Stippling is derived from nuclear remnants, so that the cell represents a reticulocyte and thus may be seen in many of the same conditions as polychromatophilic RBCs. However, stippling is especially associated with lead poisoning (Chapter 35).





Fig. 2-1 Abnormal RBC. A, normal RBC; B, spherocyte; C, target cell; D, elliptocyte; E, echinocyte; F, sickle cell; G, stomatocyte; H, acanthocyte; I, J, K, L, schistocytes; M, teardrop RBC; N, distorted RBC with Hb C crystal protruding; O, degmacyte; P, basophilic stippling; Q, pappenheimer bodies; R, howell-Jolly body.


Howell-Jolly bodies are small, round, blue-black inclusions that are considerably larger than basophilic stippling and ordinarily occur only one to an RBC. Howell-Jolly bodies may be present in any severe anemia but are more likely to be seen in severe hemolytic anemias and after splenectomy.
Pappenheimer bodies are small dark-staining granular inclusions that tend to occur in small numbers, are irregularly distributed, and often occur in small groups. They actually are hemosiderin granules that can be confirmed with ferricyanide iron stains. They are found after splenectomy, in some patients with sideroblastic anemias, and occasionally in patients with severe hemolytic anemia.
Three types of RBC inclusions cannot be seen with Wright's or Giemsa stain. All three require supravital staining techniques or other special procedures. Reticulocytes (discussed in detail later) are the stage in RBC maturation just before full maturity. Their number serves as an index of bone marrow RBC production. Hemoglobin H inclusions can sometimes be seen on a reticulocyte preparation as uniformly distributed small round dots somewhat resembling basophilic stippling but of slightly differing sizes. If a reticulocyte is affected, the Hb H inclusions coexist with the more irregular and more linear reticulum structures. Heinz bodies also require a special staining procedure and may need RBC pretreatment with a strong oxidizing agent such as phenylhydrazine. Heinz body formation is most often found in anemias due to RBC enzyme defects, "unstable" hemoglobins (Chapter 5), and certain uncommon hemoglobins such as hemoglobin Koln and Zurich. The Heinz bodies are small, scattered, dotlike structures of varying size in the RBC derived from denatured hemoglobin.


--
Dr.Hari kumar
9885845482

Segmented Neutrophils

in peripheral smear

Segmented Neutrophils

 (Polymorphonuclear Neutrophils, PMNs, Segs, Polys)
Neutrophils, the most numerous and important type of leukocytes in the body's reaction to inflammation, constitute a primary defense against microbial invasion through the process of phagocytosis. These cells can also cause some body tissue damage by their release of enzymes and endogenous pyogenes. In their immature stage of development, neutrophils are referred to as "stab" or "band" cells. The term band stems from the appearance of the nucleus, which has not yet assumed the lobed shape of the mature cell.
This test determines the presence of neutrophilia or neutropenia. Neutrophilia is an increase in the absolute number of neutrophils in response to invading organisms and tumor cells. Neutropenia occurs when too few neutrophils are produced in the marrow, too many are stored in the blood vessel margin, or too many have been called to action and used up.
Reference Values
Normal Absolute count: 3000–7000/mm 3 or 3–7 × 10 9/L

NOTE
All references are using this SI unit for reporting.

Black adults: 1.2–6.6 × 10 9/L Differential: 50% of total WBC 0%–3% of total PMNs are stab or band cells
Procedure

1.Obtain a 5-mL blood sample in EDTA coagulant and place it in biohazard bag.

2.Count as part of the differential.
Clinical Implications

1.Neutrophilia (increased absolute number and relative percentage of neutrophils) >8.0 × 10 9/L or 8000/mm 3; for African Americans: >7.0 × 10 9/L or 7000/mm 3

        a.Acute, localized, and general bacterial infections. Also, fungal and spirochetal and some parasitic and rickettsial infections.

        b.Inflammation (eg, vasculitis, rheumatoid arthritis, pancreatitis, gout), and tissue necrosis (myocardial infarction, burns, tumors).

        c.Metabolic intoxications (eg, diabetes mellitus, uremia, hepatic necrosis)

        d.Chemicals and drugs causing tissue destruction (eg, lead, mercury, digitalis, venoms)

        e. Acute hemorrhage, hemolytic anemia, hemolytic transfusion reaction

        f.Myeloproliferative disease (eg, myeloid leukemia, polycythemia vera, myelofibrosis)

        g.Malignant neoplasms—carcinoma

        h.Some viral infections (noted in early stages) and some parasitic infections

2.Ratio of segmented neutrophils to band neutrophils: normally 1%–3% of PMNs are band forms (immature neutrophils).

        a.Degenerative shift to left: in some overwhelming infections, there is an increase in band (immature) forms with no leukocytosis (poor prognosis).

        b.Regenerative shift to left: there is an increase in band (immature) forms with leukocytosis (good prognosis) in bacterial infections.

        c.Shift to the right: decreased band (immature) cells with increased segmented neutrophils can occur in liver disease, megaloblastic anemia, hemolysis, drugs, cancer, and allergies.

        d.Hypersegmentation of neutrophils with no band (immature) cells is found in megaloblastic anemias (eg, pernicious anemia) and chronic morphine addiction.

topics read : Types of hemoglobins in humans

:

Types of hemoglobins in humans

In the embryo:

• Gower 1 (ξ₂ε₂)
• Gower 2 (α₂ε₂) ( PDB 1A9W)
• Hemoglobin Portland (ξ₂γ₂)

In the fetus:

• Hemoglobin F (α₂γ₂) ( PDB 1FDH)

In adults:

• Hemoglobin A (α₂β₂) (PDB 1BZ0) - The most common type.
• Hemaglobin A₂ (α₂δ₂) - δ chain synthesis begins late in the third trimester and in adults, it has a normal level of 2.5%
• Hemoglobin F (α₂γ₂) - In adults Hemoglobin F is restricted to a limited population of red cells called F cells.
• Hemoglobin S - The globular makeup of a sickle-celled hemoglobin.

Calcium Hypochlorite poisoning( bleaching powder poisoning )

Medical Management Guidelines
for
Calcium Hypochlorite
(CaCl₂O₂)
Sodium Hypochlorite
(NaOCl)

CAS#: Calcium Hypochlorite 7778-54-3, Sodium Hypochlorite 7681-52-9
UN#: Calcium Hypochlorite 1748, Sodium Hypochlorite 1791

Synonyms of calcium hypochlorite include Losantin, hypochlorous acid, calcium salt, BK powder, Hy-Chlor, chlorinated lime, lime chloride, chloride of lime, calcium oxychloride, HTH, mildew remover X-14, perchloron, and pittchlor.

Synonyms of sodium hypochlorite include Clorox, bleach, liquid bleach, sodium oxychloride, Javex, antiformin, showchlon, chlorox, B-K, Carrel-dakin solution, Chloros, Dakin's solution, hychlorite, Javelle water, Mera Industries 2MOm³B, Milton, modified dakin's solution, Piochlor, and 13% active chlorine.

• Persons contaminated with calcium hypochlorite dust, or whose clothing or skin is soaked with industrial-strength hypochlorite solutions may be corrosive to rescuers and may release harmful vapor. Individuals exposed only to gases released by hypochlorite pose little risk of secondary contamination to others.
• Calcium hypochlorite is generally available as a white powder, pellets, or flat plates; sodium hypochlorite is usually a greenish yellow, aqueous solution. Although not flammable, they may react explosively. Calcium hypochlorite decomposes in water to release chlorine and oxygen; sodium hypochlorite solutions can react with acids or ammonia to release chlorine or chloramine. Odor may not provide an adequate warning of hazardous concentrations.
• Both hypochlorites are toxic by the oral and dermal routes and can react to release chlorine or chloramine which can be inhaled. The toxic effects of sodium and calcium hypochlorite are primarily due to the corrosive properties of the hypochlorite moiety. Systemic toxicity is rare, but metabolic acidosis may occur after ingestion.

• General Information
• Health Effects
• Prehospital Management
• Emergency Department Management
• Patient Information Sheet
• Follow-up Instructions
• Contact Information

General Information

Description

Calcium hypochlorite is generally available as a white powder, pellets, or flat plates. It decomposes readily in water or when heated, releasing oxygen and chlorine. It has a strong chlorine odor, but odor may not provide an adequate warning of hazardous concentrations. Calcium hypochlorite is not flammable, but it acts as an oxidizer with combustible material and may react explosively with ammonia, amines, or organic sulfides. Calcium hypochlorite should be stored in a dry, well ventilated area at a temperature below 120ºF (50ºC) separated from acids, ammonia, amines, and other chlorinating or oxidizing agents.

Sodium hypochlorite is generally sold in aqueous solutions containing 5 to 15% sodium hypochlorite, with 0.25 to 0.35% free alkali (usually NaOH) and 0.5 to 1.5% NaCl. Solutions of up to 40% sodium hypochlorite are available, but solid sodium hypochlorite is not commercially used. Sodium hypochlorite solutions are a clear, greenish yellow liquid with an odor of chlorine. Odor may not provide an adequate warning of hazardous concentrations. Sodium hypochlorite solutions can liberate dangerous amounts of chlorine or chloramine if mixed with acids or ammonia. Anhydrous sodium hypochlorite is very explosive. Hypochlorite solutions should be stored at a temperature not exceeding 20ºC away from acids in well-fitted air-tight bottles away from sunlight.

Routes of Exposure

Inhalation

Hypochlorite solutions can liberate toxic gases such as chlorine. Chlorine's odor or irritant properties generally provide adequate warning of hazardous concentrations. However, prolonged, low-level exposures, such as those that occur in the workplace, can lead to olfactory fatigue and tolerance of chlorine's irritant effects. Chlorine is heavier than air and may cause asphyxiation in poorly ventilated, enclosed, or low-lying areas.

Children exposed to the same levels of gases as adults may receive a larger dose because they have greater lung surface area:body weight ratios and higher minute volumes:weight ratios. Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways. In addition, they may be exposed to higher levels than adults in the same location because of their short stature and the higher levels of chlorine found nearer to the ground.

Skin/Eye Contact

Direct contact with hypochlorite solutions, powder, or concentrated vapor causes severe chemical burns, leading to cell death and ulceration.

Because of their relatively larger surface area:weight ratio, children are more vulnerable to toxicants affecting the skin.

Ingestion

Ingestion of hypochlorite solutions causes vomiting and corrosive injury to the gastrointestinal tract. Household bleaches (3 to 6% sodium hypochlorite) usually cause esophageal irritation, but rarely cause strictures or serious injury such as perforation. Commercial bleaches may contain higher concentrations of sodium hypochlorite and are more likely to cause serious injury. Metabolic acidosis is rare, but has been reported following the ingestion of household bleach. Pulmonary complications resulting from aspiration may also be seen after ingestion.

Sources/Uses

Sodium and calcium hypochlorite are manufactured by the chlorination of sodium hydroxide or lime. Sodium and calcium hypochlorite are used primarily as oxidizing and bleaching agents or disinfectants. They are components of commercial bleaches, cleaning solutions, and disinfectants for drinking water and waste water purification systems and swimming pools (Teitelbaum 2001).

Standards and Guidelines

AIHA WEEL:

STEL (15-min) = 2 mg/m³

Physical Properties - Calcium Hypochlorite

Description: White powder, pellets or flat plates

Warning properties: Chlorine odor; inadequate warning of hazardous concentrations

Molecular weight: 142.98 daltons

Boiling point (760 mm Hg): Decomposes at 100ºC (HSDB 2001)

Freezing point: Not applicable

Specific gravity: 2.35 (water = 1)

Water solubility: 21.4% at 76ºF (25ºC)

Flammability: not flammable

Physical Properties - Sodium Hypochlorite

Description: Clear greenish yellow liquid

Warning properties: Chlorine odor; inadequate warning of hazardous concentrations

Molecular weight: 74.44 daltons

Boiling point (760 mm Hg): Decomposes above 40ºC (HSDB 2001)

Freezing point: 6ºC (21ºF)

Specific gravity: 1.21 (14% NAOCl solution) (water=1)

Water solubility: 29.3 g/100 g at 32ºF (0ºC)

Flammability: not flammable

Incompatibilities

Calcium or sodium hypochlorite react explosively or form explosive compounds with many common substances such as ammonia, amines, charcoal, or organic sulfides

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Health Effects

• Hypochlorite powder, solutions, and vapor are irritating and corrosive to the eyes, skin, and respiratory tract. Ingestion and skin contact produces injury to any exposed tissues. Exposure to gases released from hypochlorite may cause burning of the eyes, nose, and throat; cough as well as constriction and edema of the airway and lungs can occur.
• Hypochlorite produces tissue injury by liquefaction necrosis. Systemic toxicity is rare, but metabolic acidosis may occur after ingestion.

Acute Exposure

The toxic effects of sodium and calcium hypochlorite are primarily due to the corrosive properties of the hypochlorite moiety. Hypochlorite causes tissue damage by liquefaction necrosis. Fats and proteins are saponified, resulting in deep tissue destruction. Further injury is caused by thrombosis of blood vessels. Injury increases with hypochlorite concentration and pH. Symptoms may be apparent immediately or delayed for a few hours. Calcium hypochlorite decomposes in water releasing chlorine gas. Sodium hypochlorite solutions liberate the toxic gases chlorine or chloramine if mixed with acid or ammonia (this can occur when bleach is mixed with another cleaning product). Thus, exposure to hypochlorite may involve exposure to these gases.

Children do not always respond to chemicals in the same way that adults do. Different protocols for managing their care may be needed.

Gastrointestinal

Pharyngeal pain is the most common symptom after ingestion of hypochlorite, but in some cases (particularly in children), significant esophagogastric injury may not have oral involvement. Additional symptoms include dysphagia, stridor, drooling, odynophagia, and vomiting. Pain in the chest or abdomen generally indicates more severe tissue damage. Respiratory distress and shock may be present if severe tissue damage has already occurred. In children, refusal to take food or drink liquid may represent odynophagia.

Ingestion of hypochlorite solutions or powder can also cause severe corrosive injury to the mouth, throat, esophagus, and stomach, with bleeding, perforation, scarring, or stricture formation as potential sequelae.

Dermal

Hypochlorite irritates the skin and can cause burning pain, inflammation, and blisters. Damage may be more severe than is apparent on initial observation and can continue to develop over time.

Because of their relatively larger surface area:body weight ratio, children are more vulnerable to toxins affecting the skin.

Ocular

Contact with low concentrations of household bleach causes mild and transitory irritation if the eyes are rinsed, but effects are more severe and recovery is delayed if the eyes are not rinsed. Exposure to solid hypochlorite or concentrated solutions can produce severe eye injuries with necrosis and chemosis of the cornea, clouding of the cornea, iritis, cataract formation, or severe retinitis.

Respiratory

Ingestion of hypochlorite solutions may lead to pulmonary complications when the liquid is aspirated. Inhalation of gases released from hypochlorite solutions may cause eye and nasal irritation, sore throat, and coughing at low concentrations. Inhalation of higher concentrations can lead to respiratory distress with airway constriction and accumulation of fluid in the lungs (pulmonary edema). Patients may exhibit immediate onset of rapid breathing, cyanosis, wheezing, rales, or hemoptysis. Pulmonary injury may occur after a latent period of 5 minutes to 15 hours and can lead to reactive airways dysfunction syndrome (RADS), a chemical irritant-induced type of asthma.

Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways. Children may also be more vulnerable to gas exposure because of increased minute ventilation per kg and failure to evacuate an area promptly when exposed.

Metabolic

Metabolic acidosis has been reported in some cases after ingestion of household bleach.

Potential Sequelae

Exposure to toxic gases generated from hypochlorite solutions can lead to reactive airways dysfunction syndrome (RADS), a chemical irritant-induced type of asthma. Chronic complications following ingestion of hypochlorite include esophageal obstruction, pyloric stenosis, squamous cell carcinoma of the esophagus, and vocal cord paralysis with consequent airway obstruction.

Chronic Exposure

Chronic dermal exposure to hypochlorite can cause dermal irritation.

Carcinogenicity

The International Agency for Research on Cancer has determined that hypochlorite salts are not classifiable as to their carcinogenicity to humans.

Reproductive and Developmental Effects

No information was located regarding reproductive or developmental effects of calcium or sodium hypochlorite in experimental animals or humans. Calcium and sodium hypochlorite are not included in Reproductive and Developmental Toxicants, a 1991 report published by the U.S. General Accounting Office (GAO) that lists 30 chemicals of concern because of widely acknowledged reproductive and developmental consequences.

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Prehospital Management

• Rescue personnel are at low risk of secondary contamination from victims who have been exposed only to gases released from hypochlorite solutions. However, clothing or skin soaked with industrial-strength bleach or similar solutions may be corrosive to rescuers and may release harmful gases.
• Ingestion of hypochlorite solutions may cause pain in the mouth or throat, dysphagia, stridor, drooling, odynophagia, and vomiting. Hypochlorite irritates the skin and can cause burning pain, inflammation, and blisters. Acute exposure to gases released from hypochlorite solutions can cause coughing, eye and nose irritation, lacrimation, and a burning sensation in the chest. Airway constriction and noncardiogenic pulmonary edema may also occur.
• There is no specific antidote for hypochlorite poisoning. Treatment is supportive.

Hot Zone

Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained in its use, assistance should be obtained from a local or regional HAZMAT team or other properly equipped response organization.

Rescuer Protection

Hypochlorite is irritating to the skin and eyes and in some cases may release toxic gases.

Respiratory Protection: Positive-pressure, self-contained breathing apparatus (SCBA) is recommended in response to situations that involve exposure to potentially unsafe levels of chlorine gas.

Skin Protection: Chemical-protective clothing should be worn due to the risk of skin irritation and burns from direct contact with solid hypochlorite or concentrated solutions.

ABC Reminders

Quickly establish a patent airway, ensure adequate respiration and pulse. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible.

Victim Removal

If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. Victims who are unable to walk may be removed on backboards or gurneys; if these are not available, carefully carry or drag victims to safety.

Consider appropriate management in victims with chemically-induced acute disorders, especially children who may suffer separation anxiety if separated from a parent or other adult.

Decontamination Zone

Victims exposed only to chlorine gas released by hypochlorite who have no skin or eye irritation do not need decontamination. They may be transferred immediately to the Support Zone. All others require decontamination as described below.

Rescuer Protection

If exposure levels are determined to be safe, decontamination may be conducted by personnel wearing a lower level of protection than that worn in the Hot Zone (described above).

ABC Reminders

Quickly establish a patent airway, ensure adequate respiration and pulse. Stabilize the cervical spine with a collar and a backboard if trauma is suspected. Administer supplemental oxygen as required. Assist ventilation with a bag-valve-mask device if necessary.

Basic Decontamination

Rapid decontamination is critical. Victims who are able may assist with their own decontamination. Remove and double-bag contaminated clothing and personal belongings.

Flush exposed skin and hair with copious amounts of plain tepid water. Use caution to avoid hypothermia when decontaminating victims, particularly children or the elderly. Use blankets or warmers after decontamination as needed.

Irrigate exposed or irritated eyes with saline, Ringer's lactate, or D₅W for at least 20 minutes. Eye irrigation may be carried out simultaneously with other basic care and transport. Remove contact lenses if it can be done without additional trauma to the eye. If a corrosive material is suspected or if pain or injury is evident, continue irrigation while transferring the victim to the support zone.

In cases of ingestion, do not induce emesis or offer activated charcoal.

Victims who are conscious and able to swallow should be given 4 to 8 ounces of water or milk; if the victim is symptomatic, delay decontamination until other emergency measures have been instituted. Dilutants are contraindicated in the presence of shock, upper airway obstruction, or in the presence of perforation.

Consider appropriate management of chemically contaminated children at the exposure site. Provide reassurance to the child during decontamination, especially if separation from a parent occurs.

Transfer to Support Zone

As soon as basic decontamination is complete, move the victim to the Support Zone.

Support Zone

Be certain that victims have been decontaminated properly (see Decontamination Zone above). Victims who have undergone decontamination or have been exposed only to vapor pose no serious risks of secondary contamination to rescuers. In such cases, Support Zone personnel require no specialized protective gear.

ABC Reminders

Quickly establish a patent airway, ensure adequate respiration and pulse. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Administer supplemental oxygen as required and establish intravenous access if necessary. Place on a cardiac monitor, if available.

Additional Decontamination

Continue irrigating exposed skin and eyes, as appropriate.

In cases of ingestion, do not induce emesis or offer activated charcoal.

Victims who are conscious and able to swallow should be given 4 to 8 ounces of water or milk; if the victim is symptomatic, delay decontamination until other emergency measures have been instituted. Dilutants are contraindicated in the presence of shock, upper airway obstruction, or in the presence of perforation.

Advanced Treatment

In cases of respiratory compromise secure airway and respiration via endotracheal intubation. Avoid blind nasotracheal intubation or use of an esophageal obturator: only use direct visualization to intubate. When the patient's condition precludes endotracheal intubation, perform cricothyrotomy if equipped and trained to do so.

Treat patients who have bronchospasm with an aerosolized bronchodilator such as albuterol.

Consider racemic epinephrine aerosol for children who develop stridor. Dose 0.25-0.75 mL of 2.25% racemic epinephrine solution in water, repeat every 20 minutes as needed cautioning for myocardial variability.

Patients who are comatose, hypotensive, or having seizures or who have cardiac arrhythmias should be treated according to advanced life support (ALS) protocols.

Transport to Medical Facility

Only decontaminated patients or those not requiring decontamination should be transported to a medical facility. "Body bags" are not recommended.

Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.

If a chemical has been ingested, prepare the ambulance in case the victim vomits toxic material. Have ready several towels and open plastic bags to quickly clean up and isolate vomitus.

Multi-Casualty Triage

Consult with the base station physician or the regional poison control center for advice regarding triage of multiple victims.

Patients who have ingested hypochlorite, or who show evidence of significant exposure to hypochlorite or chlorine (e.g., severe or persistent cough, dyspnea or chemical burns) should be transported to a medical facility for evaluation. Patients who have minor or transient irritation of the eyes or throat may be discharged from the scene after their names, addresses, and telephone numbers are recorded. They should be advised to seek medical care promptly if symptoms develop or recur (see Patient Information Sheet below).

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Emergency Department Management

• Hospital personnel are at low risk of secondary contamination from victims who have been exposed only to gases released from hypochlorite solutions. However, clothing or skin soaked with industrial-strength bleach or similar solutions may be corrosive to rescuers and may release harmful gases.
• Ingestion of hypochlorite solutions may cause pain in the mouth or throat, dysphagia, stridor, drooling, odynophagia, and vomiting. Hypochlorite irritates the skin and can cause burning pain, inflammation, and blisters. Acute exposure to gases released from hypochlorite solutions can cause coughing, eye and nose irritation, lacrimation, and a burning sensation in the chest. Airway constriction and noncardiogenic pulmonary edema may also occur.
• There is no specific antidote for hypochlorite poisoning. Treatment requires supportive care.

Decontamination Area

Unless previously decontaminated, all patients suspected of contact with hypochlorite and all victims with skin or eye irritation require decontamination as described below. Patients exposed only to chlorine gas who have no skin or eye irritation may be transferred immediately to the Critical Care Area. Because hypochlorite is an irritant, don butyl rubber gloves and apron before treating patients.

Be aware that use of protective equipment by the provider may cause anxiety, particularly in children, resulting in decreased compliance with further management efforts.

Because of their relatively larger surface area:weight ratio, children are more vulnerable to toxicants affecting the skin. Also, emergency department personnel should examine children's mouths because of the frequency of hand-to-mouth activity among children.

ABC Reminders

Evaluate and support airway, breathing, and circulation. Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways. In cases of respiratory compromise secure airway and respiration via endotracheal intubation. If not possible, surgically secure an airway.

Treat patients who have bronchospasm with an aerosolized bronchodilator such as albuterol.

Consider racemic epinephrine aerosol for children who develop stridor. Dose 0.25-0.75 mL of 2.25% racemic epinephrine solution in water, repeat every 20 minutes as needed cautioning for myocardial variability.

Patients who are comatose, hypotensive, or having seizures or cardiac arrhythmias should be treated in the conventional manner.

Metabolic acidosis can be managed with intravenous sodium bicarbonate and buffer solutions.

Basic Decontamination

Patients who are able may assist with their own decontamination. Remove and double bag contaminated clothing and personal belongings.

Flush exposed skin and hair with copious amounts of plain water. Use caution to avoid hypothermia when decontaminating victims, particularly children or the elderly. Use blankets or warmers after decontamination as needed.

Irrigate exposed or irritated eyes with saline, Ringer's lactate, or D₅W for at least 20 minutes. Remove contact lenses if it can be done without additional trauma to the eye. Continue irrigation while transporting the patient to the Critical Care Area.

In cases of ingestion, do not induce emesis or offer activated charcoal.

Victims who are conscious and able to swallow should be given 4 to 8 ounces of water or milk. Dilutants are contraindicated in the presence of shock, upper airway obstruction, or in the presence of perforation.

Critical Care Area

Be certain that appropriate decontamination has been carried out (see Decontamination Area above).

ABC Reminders

Evaluate and support airway, breathing, and circulation as in ABC Reminders above. Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways. Establish intravenous access in seriously ill patients if this has not been done previously. Continuously monitor cardiac rhythm.

Patients who are comatose, hypotensive, or having seizures or cardiac arrhythmias should be treated in the conventional manner.

Metabolic acidosis can be managed with intravenous sodium bicarbonate and buffer solutions.

Inhalation Exposure

Administer supplemental oxygen by mask to patients who have respiratory symptoms. Treat patients who have bronchospasm with an aerosolized bronchodilator such as albuterol.

Consider racemic epinephrine aerosol for children who develop stridor. Dose 0.25-0.75 mL of 2.25% racemic epinephrine solution in water, repeat every 20 minutes as needed cautioning for myocardial variability.

Skin Exposure

If concentrated hypochlorite solutions contact the skin, chemical burns may occur; treat as thermal burns. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines.

Because of their relatively larger surface area:body weight ratio children are more vulnerable to toxicants that affect the skin.

Eye Exposure

Irrigate exposed or irritated eyes with saline, Ringer's lactate, or D₅W for at least 20 minutes. Check the pH of the conjunctiva every 30 minutes for 2 hours after irrigation is stopped. If the pH is not neutral an irrigating contact lens should be used to apply continuous irrigation for several hours until the pH of the tissue normalizes. Test visual acuity and examine the eyes for corneal damage and treat appropriately. Immediately consult an ophthalmologist for patients who have corneal injuries.

Ingestion Exposure

In cases of ingestion, do not induce emesis or offer activated charcoal.

Give 4 to 8 ounces of water or milk to alert patients who can swallow if not done previously. Dilutants are contraindicated in the presence of shock, upper airway obstruction, or in the presence of perforation.

Direct visualization of the esophagus is of primary importance for determining the extent of injury. All patients who are suspected of having significant ingestion, or those (such as children) for whom there is an unreliable history, must have early endoscopy within 36 to 48 hours of ingestion. Use of a flexible endoscope is associated with a lower risk of perforation. The esophagus, stomach and duodenum should be endoscopically evaluated because burns of the esophagus do not correlate with the presence of burns in the stomach.

Contraindications for endoscopy include: unstable patient, evidence of perforation, upper airway compromise, or more than 48 hours after ingestion.

Gastric lavage is not generally recommended for hypochlorite ingestion.

Antidotes and Other Treatments

There is no specific antidote for hypochlorite. Treatment is supportive.

Laboratory Tests

The diagnosis of acute hypochlorite toxicity is primarily clinical. However, laboratory testing is useful for monitoring the patient and evaluating complications. Routine laboratory studies for all exposed patients include CBC, glucose, and electrolyte determinations. Patients who have respiratory complaints may require pulse oximetry (or ABG measurements) and chest radiography. Chlorine inhalation may be complicated by hyperchloremic metabolic acidosis; in addition to electrolytes, monitor blood pH.

Disposition and Follow-up

Consider hospitalizing patients who have a suspected significant exposure or have eye burns or serious skin burns. Patients with perforation should be prepared for emergency surgery.

Delayed Effects

Patients who ingested large volumes of hypochlorite, who have unreliable histories, or are symptomatic complaining of pain in swallowing, persistent shortness of breath, severe cough, or chest tightness should be admitted to the hospital and observed until symptom-free. Injury may progress for several hours.

Patient Release

Asymptomatic patients and those who experienced only minor irritation of the nose, throat, eyes, or respiratory tract may be released. In most cases, these patients will be free of symptoms in an hour or less. They should be advised to seek medical care promptly if symptoms develop or recur (see the Hypochlorite--Patient Information Sheet below).

Follow-up

Obtain the name of the patient's primary care physician so that the hospital can send a copy of the ED visit to the patient's doctor.

Follow up is recommended for all hospitalized patients because long-term gastrointestinal or respiratory problems can result. Respiratory monitoring is recommended until the patient is symptom-free. Chlorine-induced reactive airways dysfunction syndrome (RADS) has been reported to persist from 2 to 12 years.

Patients who have skin or corneal injury should be re-examined within 24 hours.

Reporting

If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department.

Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, discussing it with company personnel may prevent future incidents. If a public health risk exists, notify your state or local health department or other responsible public agency. When appropriate, inform patients that they may request an evaluation of their workplace from OSHA or NIOSH. See Appendix III for a list of agencies that may be of assistance.

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Patient Information Sheet

This handout provides information and follow-up instructions for persons who have been exposed to calcium or sodium hypochlorite.

Print this handout only. 20k

What is hypochlorite?

Calcium hypochlorite is generally available as a white powder, pellets, or flat plates, while sodium hypochlorite is usually a greenish yellow, aqueous solution. Hypochlorite is used widely in cleaning agents, and in bleaching, drinking-water and swimming-pool disinfecting. Calcium hypochlorite decomposes in water to release chlorine and sodium hypochlorite solutions and can release chlorine gas if mixed with other cleaning agents.

What immediate health effects can be caused by exposure to hypochlorite?

Hypochlorite powder, solutions, and vapor are irritating and corrosive. Swallowing hypochlorite or contact with the skin or eyes produces injury to any exposed tissues. Exposure to gases released from hypochlorite may cause burning of the eyes, nose, and throat; cough; and damage to the airway and lungs. Generally, the more serious the exposure, the more severe the symptoms.

Can hypochlorite poisoning be treated?

There is no antidote for hypochlorite, but its effects can be treated and most exposed persons get well. Persons who have experienced serious symptoms may need to be hospitalized.

Are any future health effects likely to occur?

A single small exposure from which a person recovers quickly is not likely to cause delayed or long-term effects. After a serious exposure, symptoms may worsen for several hours.

What tests can be done if a person has been exposed to hypochlorite?

Specific tests for the presence of hypochlorite in blood or urine generally are not useful to the doctor. If a severe exposure has occurred, blood and urine analyses and other tests may show whether the lungs, heart, or brain have been injured. Testing is not needed in every case.

Where can more information about hypochlorite be found?

More information about hypochlorite can be obtained from your regional poison control center, your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you may wish to discuss it with your employer, the Occupational Safety and Health Administration (OSHA), or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help in locating these telephone numbers.

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Follow-up Instructions

Keep this page and take it with you to your next appointment. Follow only the instructions checked below.

Print instructions only. 20k

[ ] Call your doctor or the Emergency Department if you develop any unusual signs or symptoms within the next 24 hours, especially:

• difficulty swallowing, or pain in the abdomen or chest
• coughing or wheezing, difficulty breathing, shortness of breath, or chest pain
• increased ocular pain or discharge, change in vision
• increased redness or pain or a pus-like discharge in the area of a skin burn

[ ] No follow-up appointment is necessary unless you develop any of the symptoms listed above.

[ ] Call for an appointment with Dr.____ in the practice of ________.

When you call for your appointment, please say that you were treated in the Emergency Department at _________ Hospital by________and were advised to be seen again in ____days.

[ ] Return to the Emergency Department/Clinic on ____ (date) at _____ AM/PM for a follow-up examination.

[ ] Do not perform vigorous physical activities for 1 to 2 days.

[ ] You may resume everyday activities including driving and operating machinery.

[ ] Do not return to work for _____days.

[ ] You may return to work on a limited basis. See instructions below.

[ ] Avoid exposure to cigarette smoke for 72 hours; smoke may worsen the condition of your lungs.

[ ] Avoid drinking alcoholic beverages for at least 24 hours; alcohol may worsen injury to your stomach or have other effects.

[ ] Avoid taking the following medications: ________________

[ ] You may continue taking the following medication(s) that your doctor(s) prescribed for you: _______________________________

[ ] Other instructions: ____________________________________ _____________________________________________________

• Provide the Emergency Department with the name and the number of your primary care physician so that the ED can send him or her a record of your emergency department visit.
• You or your physician can get more information on the chemical by contacting: ____________ or _____________, or by checking out the following Internet Web sites: ___________;__________.

Signature of patient _______________ Date ____________

Signature of physician _____________ Date ____________

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Where can I get more information?

ATSDR can tell you where to find occupational and environmental health clinics. Their specialists can recognize, evaluate, and treat illnesses resulting from exposure to hazardous substances. You can also contact your community or state health or environmental quality department if you have any more questions or concerns.

For more information, contact:

Agency for Toxic Substances and Disease Registry
Division of Toxicology and Environmental Medicine
1600 Clifton Road NE, Mailstop F-32
Atlanta, GA 30333
Phone: 1-800-CDC-INFO • 888-232-6348 (TTY) 
Email: cdcinfo@cdc.gov

Heinz bodies

Heinz bodies

Heinz bodies are misshapen circulating red blood cells with inclusions of denatured haemoglobin due to oxidative damage.

They may be seen in conditions such as glucose-6- phosphatase deficiency , α-thalassemia and after splenectomy

Heinz bodies are formed by damage to the hemoglobin component molecules, usually through oxidations, which causes the damaged molecules to precipitate and damage the cell membrane. Damaged cells are attacked by macrophages in the spleen, where the precipitate and damaged membrane is removed, leading to characteristic " bite cells". The denaturing process is irreversible and the continual elimination of damaged cells leads to Heinz body anemia

Heinz bodies , Heinz-Ehrlich bodies coccoid inclusion bodies resulting from oxidative injury to and precipitation of hemoglobin, seen in the presence of abnormal hemoglobins such as Hb H, Hb Köln, etc. and in erythrocytes with enzyme deficiencies. Refractile in fresh blood smears, they are not visible when stained with Romanowsky dyes but may be stained supravitally. .

Spherocytes

Spherocytes

Spherocytes are red blood cells that are almost spherical in shape. They have no area of central pallor like a normal red blood cell. Large spherocytes (macrospherocytes) are seen in hemolytic anemia. Small spherocytes (microspherocytes) are sometimes seen in severe burn cases.

A variety of spherical forms are seen in hereditary spherocytosis. The cells depicted in this image are from a patient with hereditary spherocytosis.

Dohle bodies

Dohle bodies

Discrete round or oval body's ranging in diameter from just visible to 2 um, which stain sky blue to gray blue with Romanowsky stains, found in neutrophils of patients with infections, burns, trauma, pregnancy, or cancer.

Howell-Jolly bodies

These images were taken from the 1997 Cytohematology Proficiency Test Event - Slide 005. Howell-Jolly bodies are round, purple staining nuclear fragments of DNA in the red blood cell. They are usually observed singly in hemolytic anemia, following splenectomy, and in cases of splenic atrophy. Multiple Howell-Jolly bodies may be observed in cases of megaloblastic anemia.