Page 26 - JSOM Winter 2018

Pneumonitis and Respiratory Failure Secondary to
Civilian Exposure to a Smoke Bomb in a Partially Enclosed Space

Brian P. Murray, DO ; S. Aaron Ralston, DO *;
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1
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Camille A. Dunkley, MD ; Joseph E. Carpenter, MD ;
Robert J. Geller, MD ; Ziad Kazzi, MD 1
1

ABSTRACT
Smoke grenades are used during drills, police and military ex- TABLE 1 Summary of Case Reports Related to Zinc Chloride
ercises, and crowd control. We report on a 25-year-old man Exposure
who was exposed to a Superior 3C smoke bomb. He was ini- First
tially stable but developed respiratory distress after 3 days and Author Summary
ultimately developed pulmonary fibrosis with marked loss in Thirteen soldiers were exposed to zinc chloride during
pulmonary function. The Superior 3C smoke bomb is similar 6 a combat exercise when wind blew in and trapped the
in composition to the British Military’s L83A1/2 and L132A1 Zerahn smoke within the enclosed area. Despite sparse initial
symptoms, they developed quantifiable damage to lung
and the US M18 smoke grenades, all commonly used as mul- parenchyma 4 weeks after exposure.
tipurpose smoke-producing devices for combat and training. Twenty soldiers were exposed for 5–10 minutes to dense
They are primarily composed of zinc oxide and hexachlore- Hsu 5 fumes without mask protection in an enclosed tunnel. At
thane, the combustion of which produces zinc chloride. These least five developed acute respiratory distress syndrome.
devices are safe when used properly in open air but can cause A 21-year-old patient inhaled zinc oxide/hexachloro-
significant morbidity in an enclosed space. This case empha- ethane when trapped in a small bathroom with the de-
sizes the potential hazards of using smoke bombs even in Gil 4 vice. Fever and tachypnea developed 6 hours later. Radio-
logic evaluation showed mixed interstitial-alveolar bilat-
semienclosed spaces and the potential delay in the develop- eral infiltrates. Despite supportive care, the patient died
ment of significant pulmonary complications. of multiorgan failure 9 days later.
A 23-year-old man exposed to smoke from a grenade

Keywords: smoke bomb; pneumonitis; pneumomediastinum; within an enclosed tunnel for 10–15 minutes without

pneumothorax; pulmonary fibrosis; zinc chloride protective breathing apparatus developed acute respira-
Chian 3 tory distress syndrome complicated by bilateral pneumo-
thorax and pneumomediastinum 48 hours after inhala-

tion. He was reported to have survived after receiving
Introduction extracorporeal life support and corticosteroids.
The civilian C3 smoke bomb and the US M18 smoke grenade
are similar in composition function. The M18 colored-smoke Case Presentation
grenade is commonly used in all branches of the military, in While evading capture by police, a 25-year-old man attempted
conventional and Special Operations forces, for many pur- to hide in a semi-enclosed storm drain. To encourage volun-
poses, including creating concealment, simulating battle con- tary self-extrication from the storm drain with a minimum of
ditions and other gasses, such as CS and chemical weapons. violence and risk, the police officers used a Superior 3C smoke
It is also used as a location marker for aircraft and ground bomb. He continued to resist police capture within the con-
forces. Similar devices, such as the one used in th case re- fines of the drain for 20–30 minutes until he emerged, cough-
1
ported in this article, are also used as crowd-dispersal agents ing and short of breath, and was taken to a local emergency
by law enforcement. These devices are safe when used in an department for evaluation. He initially complained of burning
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open space, causing only mild upper respiratory irritation; eyes, throat irritation, and cough. He denied past medical his-
however, when used in an enclosed space, they may be highly tory, allergies, tobacco or recreational drug use, but admitted
dangerous and can even result in death. US Army regulations to social ethanol consumption. He had emigrated from Mex-
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state the M18 should not be used in enclosed spaces. ico and worked in construction. The patient was unaware of
any previous occupational or environmental exposures prior
With such a wide variety of uses, the number of military per- to his arrival in the United States. He was subsequently treated
sonnel exposed to these devices each year is extremely large. with symptomatic care, improved, and released into police
Although most of these exposures occur in relatively safe, open- custody, with a prescription for antibiotics and prednisone for
air conditions, there are multiple case reports of patients ex- presumed bronchitis.
posed in confined areas, often with significant morbidity (Table
1). Statistics on such enclosed exposures are not tracked, but He was brought to another emergency department 3 days
3–6
with such a high volume of use, they are likely underreported. later, now with shortness of breath and pleuritic chest pain.
*Correspondence to S. Aaron Ralston, DO, MC, USA, Emory University School of Medicine, 80 Jesse Hill Jr Dr SE, PO Box 26066, Atlanta,
GA 30303-3050; or sralsto@emory.edu
1 Maj Murray, USAF, MC; MAJ Ralston, MC, USA; Dr Dunkley; Dr Carpenter; Dr Geller; and Dr Kazzi are at Emory University School of
Medicine, Atlanta, GA.

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