CBRNE - Vesicants, Mustard - Hd, Hn1-3, H Treatment & Management

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

Prehospital Care

  • Patients contaminated with mustard agents endanger unprotected health care providers. Decontaminate patients exposed to mustard agents before transport and entry into medical treatment facilities to prevent vapor accumulation. Providers attending contaminated patients should have protective masks, butyl rubber gloves (latex gloves are NOT adequate), and chemical protective overgarments.
  • Unless carried out within 1-2 minutes, decontamination of victims exposed to mustard agents does not prevent subsequent blistering. After that brief window, decontamination still should be carried out to prevent secondary contamination.
    • The first step is to cut away all of the victim's clothing. Also cut away and discard mustard-contaminated hair.
    • Exposed skin and scalp can be decontaminated using the military M291 or M258A1 skin decontamination kits. Alternately, use 0.5% aqueous chlorine solution to thoroughly wash the skin and hair. Wash off the decontamination solutions within 3-4 minutes with soap and water. If the victim already has erythematous skin, decontaminating the skin with just soap and water is recommended.
    • Immediately flush the eyes with water or buffered normal saline.[3]
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Emergency Department Care

  • No specific treatment or antidote can reverse or prevent the cellular effects of mustard agents.
  • Apply steroid ointments and antibiotic ointments and relegate their further use to an ophthalmologist. Ophthalmic ointments containing boric acid 5% provide lubrication.
    • Do not patch the eyes and do not allow the eyelids to stick together. Sterile petroleum jelly can be used to lubricate and prevent sealing of the eyelids.
    • Use cycloplegic eye drops (atropine or homatropine) 3 times a day in patients with severe blepharospasm and photophobia for pain and to prevent future synechiae formation. Keep patients in a darkened room.
    • Systemic narcotic analgesics are recommended for pain control. Do not use topical ophthalmic anesthetics.
    • Hospitalization seldom is required for mild eye exposures; early and prolonged hospitalization with ophthalmologist consultation is required for moderate and severe cases. The eyes usually recover within 2 weeks, but corneal scarring may lead to long-term visual dysfunction.
    • Mild mustard erythema requires no specific treatment. One animal study suggests rapid application of povidone-iodine ointment within 20 minutes of exposure may protect the skin from vesication. Topical steroid creams or sprays or calamine lotion may provide symptomatic relief of annoying pruritus. Address tetanus immunization in patients with cutaneous or ocular involvement.
  • Debride ruptured vesicles or bullae. Cleanse the underlying skin with sterile saline. Small areas of involvement can be dressed with petroleum gauze. Facial lesions are best covered with bacitracin ointment and left open.
    • Applying a 1/8-inch thick layer of mafenide acetate or silver sulfadiazine burn cream may treat larger areas of involvement best. Clean and redress these larger wounds twice a day. Multiple or large areas of vesication are cleansed easily with whirlpool bathing. HD-induced lesions heal slowly, often ulcerate, and vesicate repeatedly.
    • Culture wounds that become infected similar to thermal burns and administer appropriate parenteral antibiotics.
    • Avoid overhydration, since fluid losses generally are less than with thermal burns.
    • Liberal uses of narcotic analgesics are warranted to treat painful skin lesions.
    • Povidone iodine applied to unbroken and unblistered skin may lessen the severity of dermal toxicity and reduce the incidence of blister formation.[2]
  • Mild respiratory tract injury requires no specific treatment. Symptomatic treatment with antitussive medication and steam or cool mist inhalations may be tried.
    • Hospitalization is required for moderate or severe respiratory tract injuries. Inhaled beta-agonists may benefit patients with bronchospasm.
    • Patients with respiratory obstruction, hypoxia unresponsive to supplemental oxygen, or respiratory failure should undergo endotracheal intubation and mechanical ventilation. Direct antibiotic therapy for secondary bacterial pneumonia toward the specific organisms recovered and their antibiotic sensitivities.
    • Nebulized N -acetylcysteine (NAC) may possibly reduce lung injury.[2]
  • Treatment of systemic toxicity from mustard is supportive.
    • Atropine sulfate (0.4-0.8 mg SC) may be used in reducing GI hyperactivity.
    • General discomfort, restlessness, and pain may be treated with sedative and/or narcotic analgesics.
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Consultations

  • Seek ophthalmologic consultation as soon as possible when eye involvement is present. Admit patients with corneal findings to the hospital.
  • Involve plastic surgeons in the care of those with cutaneous injuries admitted to the hospital.
  • Consult hematology and/or oncology specialists for patients with aplastic anemia, which is much more common after HN exposure.
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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

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  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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