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  1. See answer to Pretest question (c).

  2. Immediate follow-up for the acutely ill patient consists of monitoring liver and kidney functions for up to 2 weeks. The patient’s cardiac and pulmonary systems and clotting ability should also be evaluated periodically since abnormalities can occur secondary to hepatic and renal damage. If the patient shows no improvement, liver biopsy may be considered since liver enzyme levels are not always reliable predictors of liver damage. Liver biopsy is contraindicated in patients with coagulation disorders.

    Persons exposed to CCl4 who have survived without permanent physiologic damage have experienced nausea, dizziness, vision changes, abdominal pain, or delirium up to 24 hours after exposure. The patient’s two coworkers, however, may suffer effects because of their unique circumstances. See answers to Challenge questions 1 and 2.

    All three persons (the patient and his two coworkers) should be counseled to avoid other hepatotoxic agents such as ethanol, drugs, solvents, and chlorinated compounds. The 40-year-old worker (with possible liver injury as a result of alcoholism and hepatitis B), who was discharged the morning after the incident, and the acutely ill 25-year-old patient may be at increased risk for hepatocellular carcinoma; they should be monitored periodically. It may be advisable for the 25-year-old patient to get the hepatitis B vaccine as a preventive measure. The 30-year-old woman, who used full protective gear and whose symptoms disappeared quickly, is probably at minimal risk. See Challenge question and answer 2.

  3. It is important that the company establish a protocol for periodic health examinations of all employees. A complete exposure history for each employee should be maintained and made available to the physician. Under the OSHA Hazard Communication regulation (right-to-know provisions), MSDSs for hazardous chemicals in the workplace must be made available to the workers, their physician, and designated worker representative. All employees using a respirator should be fit-tested and all should be properly trained before entering a hazardous environment. Proper supervision is necessary at all times. Employees who are ill should not be allowed to remain at work, nor should employees be permitted to work without the requisite protective gear.

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