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    Occupational and Environmental Review

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    Occupational and Environmental Medicine REVIEW c Michael |. Greenberg, M.D., M.P.H. Graw-Hill Medical | Publish ing Division Occupational and Environmental Medicine Review ‘Copyright © 2006 by The McGraw-Hill Companies, Ine, All rights reserved. Printed in the United States of America. Except a3 permitted under the, United States Copycight Act of 1976, no part of thia publication may be eproduced or distributed in any form or by any means, oF stored ina data base or retrieval sysiem, without he prior written, permission of the publisher. 1234567890 CUSICUS 09876 ISBN-0.07-146438-7 Notice Medicine is an ever-changing science, As nest-fesearch ani clinical oxpecieince. bronden our knowledge, changes in treatment and drug therapy are soguirec: Phe authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complcte and generally accord with the standards accopted atthe time of publication, However, in view of the possibilty of human etor or ctanges in medical sciences, ncither the authors-nor the gublisher nor any other party who has been invoived in the preparation er publication of this work warrants that the information contained hevein is sn ‘every respect accurate or complete, and they-disclaim all responsibtity for any errors or omissions or For the rexults obtained from use of the information contained in this work: Readers are encouraged to coafiem the information contained herein wih olher sources. Por example and in particular, readers are advised to check the product information sheet inckided in the package of each drug they plan 10 administer to be ecrtain that the information contained in this work is accurate and that changes bave not been made in the recommended dose or in the contraindications for administration. This recommendation is of particuit importance in Sonnection with-new or infrequently ured deugs, ‘The editors were Catherine A. Johnson and Mursha Loeb. + Tlic production supervisor Was Phil Galen. ‘The cover designer was Handel Low. ‘Von Hoftinann Graphies was printer and binder ‘This book.is printed on acid-free paper. (Oe is on file at the 13 rary of Congres: INTERNATIONAL EDITION ISBN: 0-07-110877-7 Copyright © 2006, Exclusive rights by The McGraw-Hill Companies, lie. for manufacture and export. This baok cannot be re-exported from the.country to which itis consigned hy MeGraw-I1iH, ‘The International Edicion is not avaitable in Nonh America, Editor-in-Chief: Michael 1. Greenberg, M.D., MPH Professor of Emergency Medicine Professor of Public Health Drexel University College of Medicine Clinical Professor of Emergeney Medicine ‘Temple University School of Medicine Philadelphia, PA, Associate Editors: Robert Hendrickson, M.D, Assistant Professor of Emergency Medicine Department of Emergency Medicine .- Oregon Health Sciences University Portland, Oregon Maj, (Dr.) Keegan M. Lyons, USAF, MC, FS Chief, Occupational Medicine Edwards AFB, CA James Madsen, M.D,; MPH, Col, MC-FS, USA’ Scientific Advisor Chemical Casualty Care Division, USAMRICD United Staies Army Medical Research Institute : of Chemivat Defense (USAMRICD) Michael J, Meier, M.D., MPH LCDR, MC-USN Ajthony Morocco, M.D. Attenditig Physician/Attending Toxicologist Department of Emergency Medicine Guam Memorial Hospital Oka, Tamuning, Gitam Scott Phillips, M.D. Associate Professor of Medicine and Surgery Division of Pharmacology aiid Toxicology University of Colorado Health Sciences Center Medical Toxicologist Newfields, LLC Denver, CO Javier Waksman, M.D. Medical Toxicologist Newfields, LLC Denver, CO INTRODUCTION Occupational and Environmental Medicine Review: Pearls of Wisdom, will help you improve aus knowledge bass in medicine. Originally designed as «study ai w improve performance on the Bosnds exam, {155 Look is fall oF useful information. few swords are appropriate in discussing intent, format, limitations ad ace, wee Occupational and Environmental Meidicine Review is primarily intended as a shidy aid, the text is written in a fire question/answer format. This way; seas receive immediate gratification, Moreover, misleading or confusing “foils” are not provided, This elintinates the risk of erroneously assimilating an incovrect piece of information that rakes a big impression, Questions thensselves often contain a“ peatf" intended to reinforce the answer. Addianal “hooks” may be atached tothe answer in various forms; including mnemonics, visual hnagery, repetition, ans! humor, Additional information, not requested in he question, may be included in tne answer, ‘mphasis has been placed on disilling trivia and key facis that are easily overlooked, quickly forgotten and that somichow seem ta be needed on board examinations. Mewy questions have answers without éxplanstions. ‘This enhances ease of reading and rate of fearing Pxplamations may olten occue in alater question/answer. Upon reading an answer, the reader may think, “Hy, why is that?” or “Are you sure?” If this happens 10 you, go check! Teuly assimilating these disparate Tactsinto-a framework of knowledge absolutely requires further reading of the surrounding concepts, Iafermation learned in cesponse 19 seeking an answer to a particular question is retained mich better than information that passively, observed. Take advantage of this! Use this book with your preferred texts handy and open. Occupational and Environmental Medicine Review risks accuracy to the simptest kemei—tie dynami¢ knowledge base and elinial ew research sad practice occasionally dev ‘This text is designed 1 maximize your score mentors for direction for practice. by aggressively pruning complex concepts down practice of medicine is not Tike that! Funhermore, cs from that which likely represents the right answer fortest purposes fn a test, Refer 1 your most cuerent sources of information’ sad Decipational arid Environmental Medicine Review is also designed to be re-used several times to allow merporization, “< hollow bullet is provided for any scheme of keeping track of questions mswered correctly or incorrectly, We welcome your comments, supgestions and criticism, Great effort has been made to verify these questions and uinswers. Some unsivers may not be the ansiver you would prefet. Most often this is attributable to verianee Denveen original sources. Please make us aware of any errors you find, We hope to make conti and would greatly appreciate any input with regard to-formal, argenization, questions, 1ous improvements, content, presentation, or about specific Stay hard aie! good luck! MiG TABLE OF CONTENTS UPATTIONAL MEDICINE INDUSTRIAL. ILYGIENE ASPECTS FOR THE OCCUPATIONAL PHYSICIAN. OCCUPATIONAL TOXICOLOGY... LEAD sn MERCURY CADIUM SOLVENTS... ose CHEMICAL CARCINOGENESIS. WORKPLACE ORUG TESTIN ERGONOMIC: CARPAL TUNNEL SYNDROME NOISE VIBRATION. OCCUPATIONAL RELATED CANCER, OCCUPA TIOMAL EPIDEMIOLOGY... STATISTICS sor SILICOSIS. sn TRAUMATIC EMERGENCIES o uy MUSCULOSKELETAL... - - 139 IONIZING RADIATION ss v9 OCCUPATIONAL RELATED INFECTIOUS DISEASHS. : 6s WORKERS" COMPENSATION. fens vas OCCUPATIONAL RELATED HEMATOLOGICAL PROHLEMS OCCUPATIONAL RELATED HEPATIC DP IBLEMS seus 19 OCCUPATIONAL RELATED RENAL PROBLEMS. REGULATORY ISSUES....... a 207 215 ENVIRONMENTAL MEDICINE, HEAT-RELATED ILLNESS... ao 0235 ALTITUDE. RELATED ILLNESS 2283 UNDERSEA MEDICINE 251 BITES AND STINGS. COLD-RELATED MEDICAL PROBLEMS. ENVIRONMENTAL DISASTERS... WATER POLLUTION. OUTDOOR AIR POLLUTION... WEAPONS OF MASS DESTRUCTION jross.0e- MASS-CASUALTY WEAPONS I: GENERAL, TOXINS AND RADIATION MASS-CASUALTY WEAPONS II: BIOLOGICAL AGENTS, MASS-CASUALTY WEAPONS III; CHEMICAL AGENTS. BIBLIOGRAPHY... OCCUPATIONAL MEDICINE INDUSTRIAL HYGIENE ASPECTS FOR THE OCCUPATIONAL PHYSICIAN © What is Indrstrial Hygiene? ‘The health profession devoted to the recognition, evaluation and control of occupational and environmental hazards. © How does a fume differ trom a smoke? Fuines contain particles usuatly less than | micron, while smoke particles are less than 0.1 microns and are usually produced by incomplete combustion of carbonaceous materials, O The estimated average cost ofeach employee injury/aceident is approximately? $20,000, © OSHA fines are the result of violations involved in employee accidents is set at a iaaximum of for each egregious auid/or flagrani violation. $70,000. © What are the four major elements that make up st basic safety and health progeam? Management, commitment, and employee involvement; wwork'site hazards analysis, hazard prevention and contol, and safety and health training, © Aspart of work site hazard analysis all reeognize hazards are those hazards that are —~—_lo the work being performed. ‘Typical © Usually in America (men, women and ehikven, young and old) how many will have an injury So se. ere that Chey will Lose 3 day of work or school or go to a hospital or physician for treatment due to an accident at work, at home, traveling, or at play al school? Lind 2 OCCUPATIONAL AND ENVIRONMENTAL MEDICINE REVIEW QO The OSHA hazard cominunication standard requires what § componenis? ‘Written hazard communication program, maintain a list of all hazardous cheinicals in the workplace, available MSDS, container labels, worker education, and training. Q The: most commonly used heavy-duty abrarive for metal surfaces are Silica sand, metal shot, slags, or silicon carbide. © Name three major types of blasting used to deliver abrasives in the workplace, Pressure blasting, hydroblasting, centrifugal wheel blasting, © Name'the two main types of degressing processes. Cold decreasing, vapor decreasing, © Retroplating is done to provide what properties to either metal, plastie or rubber Appearance, to reduce electrical resistance, (o provide electrical insulation, a base for soldering OF to.improve wear ability. © Name seven cornmon pla ng mefals used in electroplating processes. Cadmium, chromium, copper, gold, nic silver and zine. © Approximately how many workers are involved in electroplating in the U.S.2 169,000. © Name five grinding wheel abrasives. Aluminum oxide, silicon-carbide, natural diamonds, synthetic diamonds, eubic boron nitride © Vibration white finger syndrome has been associated with what grinding techniques? Portable gririders and pedestal mounted wheel grinders. ©. Ithas been estimated that _ coolants and cutting fluids? cases of dermatitis occur each year from contact with 400,000. © Soluble oils frequently cause what type of dermatitis? INDUSTRIAL HYGIENE ASPECTS FOR THE OCCUPATIONAL PHYSICIAN B Eczematous. © Straight oils Ginsoiuble) cut f fluids cause what type of dermatitis? Follioulitis © Cutting fluid coolant sampling f-chniques exist for determination of contamination by what substances? ‘ Bacteria, yeast, and fungi. © The characteristic smeil of a. machine shop is related to what? Oil mist from hot cutting fluids. © Name the three main types of cutting fluids. Mineral oil; emulsified oils, and synthetics. Mineral oil base is composed ‘of what percentages of paraffinic or naphthenic oils? 60-100%, © Emulsified oil (Soluble oil) is an opaque milky-appearing mineral oil that is typically diluted with water to what ratio? 1S ~ 1:50. Synthetic cutting oils are comprised of what percent water? 50-80% Conventional paint is an inorgariie pigment dispersed in a vehicle, which also consists: of _? Binder, solvent, selected fillers and additives. © Describe the two-part drying process of conventional varnishes. Evaporation of the solvent followed by oxidation of the resin binder, pigmesited varnish. © Pigmented varnish is also known as ___? Enamel. u ‘OCCUPATIONAL AND ERSVIRONMENTAL MEDICINE REVIEW O Give five exampies of white pigments included in paints. Bentonite, kaolin clay, tale, titanium dioxide and zine oxide. © Give several examples of extenders used to cu ‘stro! viscosity in paints. Tale, clay, calcium carbonate, batite, and silica, © Pigments and extenders represent a potential hazard during what process? Sanding, ot surface preparation, OQ Name four fungicides that have been included in paints. Copper, zinc naphthenate, copper oxide, and Tributyltin oxide. Q Waterborne paints represent what % of construction industry paints? 15-20%. Q What are the fayorable properties of epoxy painit systems? Adhesive properties, resistance to abras ons and chemicals, and stability at high temperatures, OQ Describe the process of soft soldering. Joining of metal by surface adhesion without melting the base metal. Tamishes frequent component of metals, must be removed ditring the soldering and braisirig process © Name three causes for tarnish, Oxides, sulfides, and carbonates. © Fluxis designed to remoye what from a base metal surface until a solder is applied? Absorb gases and tarnish, O Resin, a common base for organic fluxes contains what acid as the active material? Abiotic acid O Describe the three major flux bases. Inorganic, organic non-resin, organic resin Why are organi¢ non-resins favored during the soldering process? Me INDUSTRIAL HYGIENE ASPECTS FOR THE OCCUPATIONAL PHYSICIAN 15 “They are less corrosive and slower acting and do not present the handling hazards that inorganic acids do. QO Solder generally contains what percent of metals? 65% tin and 35% lead. © Traces of other meta Is are commonly found in-solder arid they inelude__? Cadmiuni, bismuth, copper, iron, aluminum, nickel, zine. The number of specia! solders may contain antimony concentrations up to _? 3%. O Im general-how many types of common flux materials are there? 10, © ow is braising different from soldering? raising is clefined as @ technique for joining metals that are heated above 800° F, wheseas soldering is conducted below 800° F, Shielded metal are welding is also commonly called Stick oretectrode welding, O Describe electric are welding. An electric ite is established between the welding rod and the work piece melting the meta) along the seam or stirface. © Most commonly DC voltages of 10-50 are used at a wide range of eurrents, What is the upper amperage that is commonly used iu DC are welding? 2000. © Shielded metal are welding has the potential to produce what? Nitrogen oxides which tend not to exceed 0.5 ppia under normal operating conditions. ‘2 What are other names for gas tungsten are welding? Tungsten inert gas, heliare welding. 16 OCCUPATIONAL AND ENVIRONMENTAL MEDICINE REVIEW O Gas tungsten are welding technique is routinely used for welding materials such as Aluminum and magnesium, stainless stcel, nickel alloys, brasses, silver, bronze. © _ mert gas technique of welding introduced welders to what type of electromagnetic radiation? UVB ultraviolet B light, © The use of personal protective equipment (PPE) makes the most sense when? ‘The hazard cannot be fully controlled by using other means. Why should personal protective equipment he viewed a8 an organization/line of defense? It takes significant effort by the organization to ensure that proper PPE is wordi ip every instance. ©. Whatis the possible negative impact of wearing hea g protective de es? Placing these on already hearing impaired workers might make them less able to hear background warning sounds. © What is the most important factor in determinitig whether or not PPE will be worn? User comfort. QO What are the main characteristics important in the selection of chemical protective clothing? Permeation, degradation, and penetration. © Based on EPA personal protective ensembles, describe Level Protection A. Pressvre demand full-face SCBA in a fully encapsulating chemical-resistant suit, which includes gloves and shoes, 2-way communication. © Based on EPA personal protective ensembles, describe Level Protection B. Pressure decnand full-face SCBA, chemical-resistant clothing over alt, tong-sleeved jacket hooded. One or hwoupiéce chemical splash suit or disposable chemical-resistant suit including boots and gloves, hardhat and (we-sway communication © Based on EPA personal protective ensembles, describe Level Protection C, INDUSTHIAL HYGIENE ASPECTS FOR THE OCCUPATIONAL PHYSICIAN y ull-face air purifying canister equipped with respirator, cheanical-sesistant clothing incinding boots and gloves, two-way-radio communication O Based on EPA personal protective ensembles, describe Level Protection D, Coveralls, safety boots and shoes, safety glasses or chemical splash goggles, hardhat. © According to the American National Standards Institute (ANSI) hard hats are categorized in three classes, Describe Class A. Provides protection against imy pact and exposure to low voltage conductors, proof tested at 2200 volts and has a full brim, QO According to the American Nationa. Standards Institute (ANSD hard bats are categorized in three classes. Describe Class B. Baseball cap-like bill that proteudes out over the wearer's eyes; providing fill protection against impact and exposure to high voltage conductors, proof tested at 20,000 volts °O According to the American National Standards Institute (ANSI) hard hats are categorized in three classes. Describe Class C, Provides protuction against impact only, finds use especially in the forestry industry. Vow is BUMP different than a hardhat elas C2 BUMP caps ace thin-shelled caps with.a front bill worn for strike against hazards in the She tonment in areas oF low head room, They are not designed for protection against falling objects. O Why's it recommended that contact lenses he worn with safety glasses or goggles? Contact lenses are considered to offer ne protectin te th \¢ eye from any hazards because of partial coverage of thé eye by contact lenses, © What is the leading cause of worker fatality in the U.S.? Falls from heights. © Approximately bow many people are injured and killed from falls from heights? 150-200 workers are killed annually with more than (00,000 injured, © Describe a personal fall arrest system used for fall protection. 18 . ‘OPEUPATIONAL AND ENVIRONMENTAL NEDICINE REVIEW. Limit the maximum resting force in a worker to 900 ,'ounds with a body belt or 1800 pounids with a body harness, to be released that a worker may free fall no more than six feet nor contact with any lower level. © According to the ANSI what is (he color code for air purifying HEPA filters? Purple. QO. The biological exposure in s (BED) is an indicator of what? Uptake of a substance in the body. © What does BEI generally indicate? A concentration below which nearly all workers'should not experience adverse health effects. © Air monitoring to determine TLY indicates what? Potential inhalation exposure of an individeal or-a group. Most BEls are based on’a diréct correlation with what? The TLV-TWA and the concentration of the determinant, , which can be expected when the. airborne exposure is at the TLV-TWA. © Regarding urine specimen acceptab ity for BEI testing, what guidelines are indicated for acceptable specimens? Creatinine concentration greater than 0.3 w/. and < 3.0 g/L of a specific gravity »1,010 and < 1.030, OCCUPATIONAL TOXICOLOGY Q Chronic, low-level, exposure to vinyl chloride may put a worker at risk for what cancer? Angiosarcoma of the liver. © What is green-leaf tobacco sickness? Pound in tobacco harvesters who pick leaves by hand without gloves, Absorption of the nicotine from the dew-laden leaves leads to nausea, vomnitinig, headache, pallor, éizziness and diaphoresis. Silo filler’s disease is caused by hizh concentrations of what chemical? Nitrogen dioxide, NO,. © What malignancy can be related to asbestos exposuire? Mesothelioma. © What percent of mesotheliomas are probably due to asbestos exposure? Anywhere Irom 20 to 50% of mesotheliomas occur in individuals with no known asbestos exposure, © What are the two main groups of asbestos fiber? Ampibole and Chrysotile. © What is the OSHA PEL for manganese? 5 mg/m? © Whiat is the primary rouie of exposure for occupational lead expostire? Inhalation. © Manure pits emanate what toxic gases? Hydrogen sulfide, methane. © Which form of asbestos has been most commonly used in construction in the USA? 20 OCCUPATIONAL AND ENVIRONMENTAL MEDICINE REVIEW Chrysotile. O Chronic toxicity from what substance is often misdiagnosed as sarcoidosis? Berrylium. © Arsine gas exposure can result in what hematologic problem? Hemolysis, What is metal fume fever? Headache, shoriness of breath, cliest pain and fever in a patient who has been exposed to heated metal, particularly cadmium and zinc. © Whatis the treatment of metal fume fever? Mainly supportive with analgesics and antipyretics. Patients with metal fume fever gerierally do Rot have significant absorption. However, patients with pneamonitis or pulmonary edema should have levels checked. OQ What is the blood lead level where a worker must be removed from occupational lead exposure according to OSHA standards? S0ug/DL What is the current OSHA standard for airborne asbestos in-the workplace? 0.2 fibers / cc of dir as an 8-hour TWA. O What the latent period between time-of-exposure to asbestos and lng cancer? 10-30 years or more. © What substance is responsible for chloracne? Polychlorinated biphenyls (PCBs) as well as hexachlorodibeirzo-p-dioxin, poylhrominated dibenzofurans and biphenyls, polychlorinated dibenzofurans and tetrachloroazobenzene. O Workers who furnigate frvits and vegetables at US ports of entry may be exposed t what chemical? Methyl bromide. O What is degreasers flush? DCCUPATIONAL ToxICeLoGY a A disulfiram type reaction associated with alcohol intake following trichloroethylene exposures. © What is the primary mission for NIOSH? : NIOSH’s primary mission is research, What does “OSHA” stand for? Occupational Health and Safeiy Administration, © Which agency originally promulgated the Biologic Exposure Index (BET)? ACGIH. / What chemical is metabotized in the human budy into carbon monoxide? Methylene chloride, © What renowned legal matter altowed female workers to be exposed even though they could be pregnant? UAW versus Johnson Controls. © What documents are re are found? ‘duired to be kept on site where dangerous industrial chemicals Material Safeiy data Sheet (MSDS). 2 Chloracne is associated with exposure to what toxic materials? Polychioirinatcd/polybramiaied compounds © On what part of the body is chloracne most frequently found? Malar eminances and pre-auricular area, © | Which hydrocarbon, ia the occupational setting, hias been associated with the development of peripheral neuropathy? N-hexane, © How does exposure to Porttand cement cause skin burns? When water is added to cement powder calcium oxalate solu results. This can cause a caustic skin burn the appearance of hours, tion with 2 pH of approximately 13 which may bé delayed up to. 24 22 OCCUPATIONAL AND ENVIRONMENTAL MEDIGINE REVIEW Q Occupational exposure to vinyl chloride has been associated with what unusual bony abnormality? Acre-osteolysis. © Whatis Stoddard Solvent? A petroleum distillate thatcontains both aliphatic and aromatic hydrocarbons. It is also known as ‘Varnoline; Varsol, and white spirits. © What is the most common occupationally related skin toxin? Poison ivy O Whatis TSCA? ‘The Toxic Substances Control, Act; allows the EP.* to obtain data from industry regarding the use, production and health effects of chemicals. {OQ What toxic material is responsible for the most occupationally related toxic deaths each year? Carbon monoxide. © What toxic material is responsible for the second most oceupationally refated toxic deaths? Hydrogen sulfide, © Occupations exposure Co benzidine is associated with the development of which cancer? Bladder. © _ Ocenpational exposure to chrorsium compounds is associated with the development of which cancer? Lung, nasal cavity. © _ Ocenpational exposure'to coke oven emissions is associated with the develepment of which cancer? Bladder, lung, skin © What percent of all cancers cat? be attributed to occupationally based exposures? ‘OCCUPATIONAL ToxIGgiaGcY a 2.8%. © What is byssinosis? A pulmonary syndrome associated with occupational exposure to cotton and hemp. 9 What is characteristic of incidents wherein workers succumb to hydrogen sulfide? Multiple deaths; typically well meaning rescuers without praper protective equipment, © What is the treatment for hydrogen sulfide casualties? Remioyall from exposure, immediate administration of oxygen, prompt administration of thiosulfate as in cyanide poisoning, possible sue of hyperbaric oxygen. O What is “PPE”? Personal Protective Equipment. © Occupational exposure to what nematocide has been associated with oligospermia in male workers? Dibromochloropropane (DBCP). © The “Intermediate syndronte” is associated with exposure to what cheinicals? Organophosphate pesticides. © Exposure to what industrial chemical may produce a green tongue? Vanadium. © What characterizes the toxic mechanism of ction of the wood preservative pentachlorophenol? Uncoupling of oxidative phosphorylation producing a hypermetabolic state. LEAD 2 How many workers are exposed to lead every year in the United States? | million. © What.is the most important route of absorption in occupational tead exposure? Tuhalation. © What size of lead particles increases the risk of inhalational absorption?

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