title: The toxicology of zinc chloride smoke producing bombs and screens.
abstract: BACKGROUND
  Zinc chloride (ZnCl2)-based smoke bombs and screens are in use since the Second World War (1939-1945). Many case descriptions on ZnCl2smoke inhalation incidents appeared since 1945.
  
  
  OBJECTIVE
  We provide a comprehensive overview of the clinical symptoms and underlying pathophysiology due to exposure to fumes from ZnCl2smoke producing bombs. In addition, we give a historical overview of treatment regimens and their outcomes.
  
  
  METHODS
  We performed a literature search on Medline, Scopus and Google Scholar databases using combinations of the following search terms "smoke bomb", "smoke screen", "ZnCl2", "intoxication", "poisoning", "case report", "HE smoke", "hexachloroethane smoke", "smoke inhalation" and "white smoke". We retrieved additional reports based on the primary hits. We collected 30 case reports from the last seven decades encompassing 376 patients, 23 of whom died. Of all the patient descriptions, 31 were of sufficient detail for prudent analysis.
  
  
  CONCLUSIONS
  Intoxication with clinical signs mainly took place in war situations and in military and fire emergency training sessions in enclosed spaces. Symptoms follow a biphasic course mainly characterised by dyspnoea, coughing and lacrimation, related to irritation of the airways in the first six hours, followed by reappearance of early signs complemented with inflammation related signs and tachycardia from 24 h onwards. Acute respiratory stress syndrome developed in severely affected individuals. Chest radiographs did not always correspond with clinical symptoms. Common therapy comprises corticosteroids, antibiotics and supplemental oxygen or positive pressure ventilation in 64% of the cases. Of the 31 patients included, eight died, three had permanent lung damage and 15 showed complete recovery, whereas in five patients outcome was not reported. Early signs likely relate to caustic reactions in the airway lining, whereas inhaled ZnCl2particles may trigger an inflammatory response and associated delayed fibrotic lung damage. Smoke bomb poisoning is a potentially lethal condition that can occur in large cohorts of victims simultaneously.
authors.affiliation: a Honours Program CRU2006 Bachelor, University Medical Center Utrecht , Utrecht , The Netherlands.
authors.forename: Ayman
authors.initials: A
authors.lastname: El Idrissi
authors.affiliation: a Honours Program CRU2006 Bachelor, University Medical Center Utrecht , Utrecht , The Netherlands.
authors.forename: Lisanne
authors.initials: L
authors.lastname: van Berkel
authors.affiliation: a Honours Program CRU2006 Bachelor, University Medical Center Utrecht , Utrecht , The Netherlands.
authors.forename: Nadia E
authors.initials: NE
authors.lastname: Bonekamp
authors.affiliation: a Honours Program CRU2006 Bachelor, University Medical Center Utrecht , Utrecht , The Netherlands.
authors.forename: Diana J Z
authors.initials: DJ
authors.lastname: Dalemans
authors.affiliation: b Department of Medical Physiology, Division of Heart & Lungs , University Medical Center Utrecht , Utrecht , The Netherlands.
authors.forename: Marcel A G
authors.initials: MA
authors.lastname: van der Heyden
mesh_terms: D000818:Animals; D054042:Bombs; D002712:Chlorides / Q000506:poisoning*; D006801:Humans; D019570:Inhalation Exposure / Q000009:adverse effects; D012906:Smoke / Q000009:adverse effects*; D015208:Smoke Inhalation Injury / Q000503:physiopathology* / Q000628:therapy; D013997:Time Factors; D014857:Warfare; D017967:Zinc Compounds / Q000506:poisoning*
chemical_list: D002712:Chlorides; D012906:Smoke; D017967:Zinc Compounds; C016837:zinc chloride
keywords: ARDS; Smoke bomb; ZnCl2; hexachloroethane; metal fume fever; poisoning; smoke screen