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

Updated: Mar 29, 2023
  • Author: Christopher P Holstege, MD; Chief Editor: Zygmunt F Dembek, PhD, MS, MPH, LHD  more...
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Prehospital Care

Initial care of patients contaminated with mustard agents should focus on removing the patient from the environment and initiating rapid decontamination procedures. Decontamination performed in the first 1-2 minutes following exposure is the most effective means of preventing injury as well as assisting to mitigate cross-contamination with others. [4] Decontamination helps to prevent further absorption and protect others involved in patient care from exposure.

Decontamination should be undertaken in the field, before transport to a medical facility. Providers attending contaminated patients should have protective masks, butyl rubber gloves (latex gloves are not adequate), and chemical protective overgarments. The Occupational Safety and Health Administration's (OSHA's) Hazardous Waste Operations and Emergency Response (HAZWOPER) standard (29 CFR 1910.120[q]) provides additional information for responding to hazardous substance releases, including blister agents.

The level of personal protective equipment (PPE) needed depends on the sites where first responders are operating. [38]

Level A PPE (maximal protection) is needed for scenes in which the identity of the chemical weapon is unknown or levels of the agent are above Immediately Dangerous to Life and Health (IDLH) limits. It comprises the following:

  • Self-contained breathing apparatus (SCBA)
  • Fully encapsulated chemically resistant suit
  • Chemically resistant inner and outer gloves
  • Chemically resistant boots

Level B PPE (highest level of respiratory protection, less skin protection) is indicated for decontamination zones above IDLH levels. It comprises the following:

  • SCBA
  • Chemically resistant suit
  • Chemically resistant inner and outer gloves
  • Chemically resistant boots
  • SCBA

Level C PPE is indicated for decontamination zones with levels under IDLH. It comprises the following:

  • Air purifier respirator (APR) or powered air purified respirator (PAPR)
  • Chemically resistant suit
  • Chemical-resistant inner and outer gloves
  • Chemical resistant boots

Level D PPE is indicated for zones where the concentration of the contaminant is below the exposure limit (minimal protection). It consists of work clothing with minimal protection.

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, in order to prevent secondary contamination of first responders and medical personnel at treating facilities. The decontamination procedure is as follows:

  • Remove all clothing, to decrease penetration into the skin; clothing acts as an occlusive dressing that increases absorption. Removed clothing should be bagged and left at the scene.
  • Eyes should be flushed immediately with water or saline solution.
  • Exposed skin and scalp can be decontaminated using Reactive Skin Decontamination Lotion (RSDL), which is a packaged sponge that helps wipe away chemical agents. This has replaced the military’s M291 skin decontamination kit and is now the preferred agent. If RSDL is unavailable, 0.5% aqueous hypochlorite solution can be used. [38]
  • Following this, victims should be washed with soap and water.
  • Transport decontaminated patients to a medical facility for further treatment.

Emergency Department Care

There is no specific antidote or treatment regimen to reverse the effects of mustard agents. Care for exposed persons is supportive.

Treatment of Eye Exposure

Following irrigation, examine the eyes for corneal injury with fluorescein. Topical anesthetic can be applied for the initial exam but should not be used for continued pain relief. Use of topical anesthetics increases the risk of inadvertent corneal scarring, which can worsen infection. Instead, systemic narcotics should be used for pain control. [4]

Topical antibiotic ointment should be applied 3-4 times a day to reduce the risk of infection. Do not patch the eyes and do not allow the eyelids to stick together, as that can increase the risk of infection. Apply sterile petroleum jelly to lubricate and prevent sealing of the eyelids. In patients with mild injury (conjunctivitis), lubricating drops may provide pain relief. The efficacy of topical steroids has not been established, but these agents may be beneficial within the first 48 hours after injury. [4]

In patients with severe blepharospasm and photophobia, use cycloplegic eye drops (atropine or homatropine) three times a day for pain and to prevent adhesion formation. A darkened room or sunglasses may be helpful. All severe injuries require admission with emergent ophthalmologic evaluation. [4]

Treatment of Skin Exposure

Once all clothing has been removed and the patient has been decontaminated, evaluate the extent of erythema and blistering. Mild erythema does not require any specific treatment. Treat pruritis with calamine lotion, topical steroid creams, or silver sulfadiazine. [39]  Mild erythema does not require treatment.

There is no consensus on the treatment of blisters or bullae. If blisters or bullae have ruptured, debride the remaining material, clean the skin with sterile water or saline, and cover it with a sterile dressing. [39]  Chlorhexidine, povidone-iodine, and silver sulfadiazine can be utilized as disinfectants. [34]  Once the site is cleansed, apply topical antibiotic ointment to prevent infection. If infection occurs, treat with intravenous antibiotics. Control pain with narcotic analgesics. Ensure tetanus immunization is up to date.

Mustard injury to the skin is considered a chemical burn, which meets the criteria for referral to a burn center. [40]  Patients with more than mild erythema should be transferred for specialized care. Significant lesions may require skin grafting. Mustard injury is different from chemical burns and involves less fluid loss. Formulas for calculating fluid loss in thermal burns may overestimate fluid loss in mustard injury. [4]

Treatment of Respiratory Exposure

Mild respiratory symptoms (throat irritation, nonproductive cough, hoarseness) can be treated supportively. Nebulized saline or cough suppressants may be useful. [36]  Hypoxia should be treated with supplemental oxygen.

Patients in severe respiratory distress or with signs of airway compromise should be intubated early. The development of airway edema may make later attempts at intubation more difficult. Severe mustard injury can cause chemical pneumonitis similar to acute respiratory distress syndrome (ARDS), with bilateral infiltrates on chest imaging. A lung protective strategy for mechanical ventilation should be employed. Frequent suctioning of debris and secretions may be required. Bronchoscopy allows for direct visualization of airways and can assist with the clearance of debris. [4, 36]

Bronchodilators can help reduce bronchospasm. Albuterol/ipratropium bromide (Combivent Respimat, DuoNeb) should be administered. Greater efficacy has been seen using a combination of beta-2 agonists plus an anticholinergic agent in mustard exposures than using one agent alone. [37] Corticoteroids can be considered if the patient shows no response to bronchodilators. [4]

Pneumonia is a late complication of mustard exposure. It typically does not develop in the first few days. If pneumonia develops, begin antibiotic treatment.  

Treatment of Systemic Toxicity

Nausea/vomiting should be treated with antiemetics. If cholinergic symptoms are found, atropine should be used. Intravenous fluids should be given for dehydration and electrolytes repleted as necessary.  

Leukopenia increases susceptibility to infection and subsequent sepsis. If neutropenic fever develops, empiric antibiotic therapy should be initiated. Granulocyte colony-stimulating factor (G-CSF) has shown efficacy and should be considered if neutropenia develops. [41]

Thrombocytopenia and anemia lag behind leukopenia. If traumatic injuries are present, transfusion of platelets or red blood cells may be required.



Consultations include the following:

  • Medical toxicology or local Poison Control Center for assistance in the management of chemical weapons exposures
  • Medical intensive care unit for critically ill or intubated patients
  • Ophthalmology for treatment of eye exposures
  • Plastic surgery/burn specialists for care of cutaneous injury
  • Dermatology for management of cutaneous injury  
  • Hematology/oncology for assistance in managing pancytopenia


Chronic respiratory complications are the most common cause of long-term disability following mustard exposure. In a cohort of Iranian mustard victims, 42.5% developed chronic lung lesions and respiratory signs and symptoms. [42]  The most common respiratory effects are dyspnea, chronic cough, and sputum production. [37, 43]  Bronchiolitis, asthma, tracheobronchiomalacia, and airway stenosis (in severely-exposed patients) are the most common long-term conditions associated with exposure. [37]  Pulmonary function test results evolve from an obstructive pattern to a restrictive pattern over time. [43]

Chronic ocular complaints are the next most common complication. In a cohort of Iranian mustard victims, 39.3% developed chronic ocular issues. [44]  Chronic inflammation of the eyes may occur or delayed keratitis may develop. [22, 45]  Itching, burning, and photophobia are the three most common complaints, with conjunctivitis, peri-limbal hyperpigmentation, and vascular tortuosity being the three most common exam findings. [46]  Delayed keratitis involves an asymptomatic period after mustard exposure with abrupt recurrence of keratitis, corneal opacification, corneal ulceration, neovascularization, pain, decreased visual acuity, and vision loss. [22]  This delay can span from 1 to 40 years following exposure, with most cases occurring between 15 and 20 years post-exposure. [22, 24, 46, 47]  Delayed keratitis can happen unpredictably, with periods of exacerbation and remission. [24]  

Chronic dermal findings are also prevalent, affecting 24.5% of Iranian mustard victims. [44]  The most common complaints are itching and burning, with hyperpigmentation, erythematous papular rash, and dry skin being the most common physical exam findings. [46, 48] Hypopigmentation can also occur but is less common. Chronic skin findings are usually noted in the groin, back, thorax, abdomen, and axillary areas. [46]

The International Agency for Research on Cancer (IARC) has determined that there is sufficient evidence to classify sulfur mustard as a known human carcinogen (IARC Group 1) due to its alkylating effects on DNA. The strongest evidence exists for lung and laryngeal cancers, especially among occupational workers. [49]  Increased rates of cancers have been noted in acutely exposed Iranian war veterans, however, no specific type of cancer has been found to be statistically significant when compared with the general population. [42, 50]



Dermostyx (IB1) is a topical skin protectant (TSP) developed by the Israeli Defense Forces (IDF) to provide passive protection against percutaneous exposure to chemical agents, including sulfur mustard. When applied to the skin prior to exposure, this lotion forms a protective barrier that reduces the size and severity of skin lesions caused by vesicants, has an efficacy of 12 hours, has minimal side effects, and does not interfere with decontamination procedures. [51, 52]