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

Updated: Mar 04, 2022
  • Author: Daniel J Dire, MD, FACEP, FAAP, FAAEM; Chief Editor: Zygmunt F Dembek, PhD, MS, MPH, LHD  more...
  • Print

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 as follows, 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; alternatively, 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 [8]

Emergency Department Care

No specific treatment or antidote can reverse or prevent the cellular effects of mustard agents. [12] Symptomatic treatment is used to address affected organ systems.

Treatment of eye exposure

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.

In patients with severe blepharospasm and photophobia, use cycloplegic eye drops (atropine or homatropine) three times a day 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; however, 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

Treatment of skin exposure

Mild mustard erythema requires no specific treatment. One animal study suggests rapid application of povidone-iodine ointment to unbroken and unblistered skin within 20 minutes of exposure may lessen the severity of dermal toxicity and reduce the incidence of blister formation. [2] 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.

Additional measures include the following:

  • If wounds become infected, culture them as one would a thermal burn 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.

Treatment of respiratory exposure

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

Treatment of systemic toxicity from mustard is supportive, as follows:

  • Atropine sulfate (0.4-0.8 mg SC) may be used in reducing gastrointestinal hyperactivity
  • General discomfort, restlessness, and pain may be treated with sedative and/or narcotic analgesics

For 12 hours prior to discharge, observe patients who are exposed to mustard and who are initially asymptomatic.

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 restore 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, 8]



Consultations include the following:

  • 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.


Chronic health problems that may develop after mustard exposure include the following:

  • Respiratory diseases (asthma, pulmonary fibrosis, bronchiectasis)
  • Skin lesions (dermal scarring)
  • Neoplasms (gastrointestinal cancers, chronic myelocytic leukemia, respiratory cancers, skin cancers)
  • Ocular problems (keratitis, corneal ulcers, conjunctivitis)


The Israel Defense Force has developed a topical skin protectant, Dermostyx protective solution (IB1), that is a passive protective lotion. When applied before exposure, this lotion may significantly reduce the toxicity of sulfur mustard chemical warfare agents. [13]  It has been approved by the Isreal Ministry of Health for use by the Israel Defense Forces (IDF) and first responders. [14]