CBRNE - Vesicants, Mustard - Hd, Hn1-3, H Follow-up

  • Author: Daniel J Dire, MD, FACEP, FAAP, FAAEM; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: May 6, 2011
 

Further Inpatient Care

  • Patients with moderate-to-severe cutaneous effects are best managed in a hospital burn unit. The period of recuperation is much longer than that for thermal burns.
  • Patients with significant pulmonary involvement usually require ICU admission.
  • Topical combination therapy with zinc desferrioxamine and dexamethasone resulted in faster corneal reepithelization and less severe neovascularization in an animal model. Keratoplasty may be necessary to recover visual function.
  • Adequate nutrition and fluid and electrolyte replacement are mandatory for patients with severe poisonings who have vomiting, diarrhea, leukopenia, hemoconcentration, and shock.
  • Patients with severe leukopenia require isolation and may require appropriate antibiotics. Colony-stimulating factors, such as filgrastim and pegfilgrastim, may help reduce the incidence of life-threatening infections associated with neutropenia.[2, 3]
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Further Outpatient Care

  • For 12 hours prior to discharge, observe patients who are exposed to mustard and who are initially asymptomatic.
  • Chronic health problems may develop after mustard exposure including respiratory diseases (asthma, pulmonary fibrosis, bronchiectasis), skin lesions (dermal scarring), neoplasms (gastrointestinal cancers, chronic myelocytic leukemia, respiratory cancers, and skin cancers), and ocular problems (keratitis, corneal ulcers, conjunctivitis).
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Deterrence/Prevention

  • The Israel Defense Force is developing a topical skin protectant (IB1) that is a passive protective lotion and, when applied before exposure, may significantly reduce the toxicity of sulfur mustard chemical warfare agents.[5]
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Patient Education

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Contributor Information and Disclosures
Author

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred Henretig, MD  Director, Section of Clinical Toxicology, Professor, Medical Director, Delaware Valley Regional Poison Control Center, Departments of Emergency Medicine and Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References

  1. Sidell FR, Takafuji ET, Franz DR. Medical Aspects of Chemical and Biological Warfare. Washington, DC: Borden Institute; 1997:197-222.

  2. Geraci MJ. Mustard gas: imminent danger or eminent threat?. Ann Pharmacother. Feb 2008;42(2):237-46. [Medline].

  3. Wattana M, Bey T. Mustard gas or sulfur mustard: an old chemical agent as a new terrorist threat. Prehosp Disaster Med. Jan-Feb 2009;24(1):19-29; discussion 30-1. [Medline].

  4. Lagali N, Fagerholm P. Delayed mustard gas keratitis: clinical course and in vivo confocal microscopy findings. Cornea. May 2009;28(4):458-62. [Medline].

  5. Eisenkraft A, Krivoy A, Vidan A, Robenshtok E, Hourvitz A, Dushnitsky T. Phase I study of a topical skin protectant against chemical warfare agents. Mil Med. Jan 2009;174(1):47-52. [Medline].

  6. Doi M, Hattori N, Yokoyama A, Onari Y, Kanehara M, Masuda K, et al. Effect of mustard gas exposure on incidence of lung cancer: a longitudinal study. Am J Epidemiol. Mar 15 2011;173(6):659-66. [Medline].

  7. Headquarters, Department of the Army. Field Manual 8-285, Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries. Washington, DC: Dec 22 1995.

  8. Iyriboz Y. A recent exposure to mustard gas in the United States: clinical findings of a cohort (n = 247) 6 years after exposure. MedGenMed. 2004;6(4):4. [Medline]. [Full Text].

  9. McManus J, Huebner K. Vesicants. Crit Care Clin. Oct 2005;21(4):707-18, vi. [Medline].

  10. Morad Y, Banin E, Averbukh E, Berenshtein E, Obolensky A, Chevion M. Treatment of ocular tissues exposed to nitrogen mustard: beneficial effect of zinc desferrioxamine combined with steroids. Invest Ophthalmol Vis Sci. May 2005;46(5):1640-6. [Medline].

  11. Pons P, Dart RC. Chemical incidents in the emergency department: if and when. Ann Emerg Med. Aug 1999;34(2):223-5. [Medline].

  12. Richter MN, Wachtlin J, Bechrakis NE, Hoffmann F. Keratoplasty after mustard gas injury: clinical outcome and histology. Cornea. May 2006;25(4):467-9. [Medline].

  13. Saladi RN, Smith E, Persaud AN. Mustard: a potential agent of chemical warfare and terrorism. Clin Exp Dermatol. Jan 2006;31(1):1-5. [Medline].

  14. Smith KJ, Hurst CG, Moeller RB, et al. Sulfur mustard: its continuing threat as a chemical warfare agent, the cutaneous lesions induced, progress in understanding its mechanism of action, its long-term health effects, and new developments for protection and therapy. J Am Acad Dermatol. May 1995;32(5 Pt 1):765-76. [Medline].

  15. US Army Medical Research Institute of Chemical Defense. Medical Management of Chemical Casualties Handbook. 3rd ed. Aug 1999.

 
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Chemical terrorism agents and syndromes. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/chemical.html.
 
 
 
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