CBRNE - Vesicants, Organic Arsenicals - L, ED, MD, PD, HL Treatment & Management

The top 2 priorities are protecting the caregiver and removing the offending agent from the casualty as quickly as possible. Then assess airway, breathing, and circulation (ABCs) as usual. See CBRNE - Personal Protective Equipment.  All medical personnel who may come into contact with vesicant vapor or liquid should wear protective gear. 

The activated charcoal in the chemical protective mask adequately adsorbs these agents.  Protective boots, gloves, pants, and jacket (eg, mission-oriented protective posture [MOPP] gear) protect the skin; however, organic arsenicals attack rubber and can cause it to break down with prolonged exposure. This is especially true of lewisite (L). See CBRNE - Chemical Detection Equipment.

Vesicant agents irreversibly bind to the skin within minutes. Remove the agent as quickly as possible. See CBRNE - Chemical Decontamination.

Remove liquids via any means available. The military has specially developed charcoal-based kits (eg, M258A1 kit, M291 kit). If specialized kits are not available, rags, leaves, sticks, or just about any other material can be used to blot off liquid agent.

Flushing the eyes or skin is another solution. Dilute hypochlorite (0.5% solution) can be used on the skin. Live steam or alkaline solutions (eg, sodium hydroxide) can be used to decontaminate closed spaces.

As with any chemical disaster, the emergency department's disaster plan should have a system in place to efficiently triage contaminated patients.

After assessing for life-threatening conditions, additionally decontaminate patients in the triage area as indicated.

Once in the emergency department, reassess ABCs as usual.

Assessment of volume status is a must. Patients who have been in hot protective gear are predisposed to volume depletion and hyperthermia. Correction of fluid and/or electrolyte abnormalities is essential in these patients.

Vesicants may present a hazard from wound contamination. Potential risk to healthcare providers and the surgeon from possibly contaminated wounds arises from agent on foreign bodies in the wound and from thickened agents. Once a victim has been undressed and fully decontaminated, danger to the caretakers is minimal. Occasionally, intact lewisite or equally damaging breakdown products have been found in blister fluid.

Blisters smaller than 2 cm and erythematous areas can be covered with topical antibiotics, calamine lotion, or other soothing creams.  Denude fluid-filled vesicles larger than 2 cm and irrigate them with sterile saline. Apply topical antibiotics such as silver sulfadiazine. Intense pain and itching may require systemic analgesics and antipruritics.

Kale and colleagues evaluated the topical delivery of nordihydroguaretic acid (NDGA) to treat exposure to arsenic warfare chemicals. They reported that a 3% NDGA solution delivered the maximum amount of drug in a 24 hour period and was non-toxic for topical administration. Although the results of the study supported a reduction in symptoms, further research is needed. ^[7]

Upper respiratory symptoms can be alleviated with humidified oxygen and cough suppressants. Reserve antibiotics for patients with pulmonary damage who develop fever. Specific antimicrobial therapy then is based on Gram stain and cultures.

Eyes may be irrigated with normal saline, followed by application of topical antibiotics. Petroleum jelly can be applied to the edges of the lids to prevent them from sticking together.

Patients with only minor skin and eye lesions can be discharged with outpatient follow-up care. Victims of severe toxicity from an organic arsenical may require prolonged care for dermatologic, ophthalmic, and pulmonary sequelae.

Consultation can be made to various departments (eg, dermatology, ophthalmology) as needed.  A 24-hour hotline regarding CW agents is available at 800-424-8802. Help also can be obtained by calling the US Army Medical Research Institute of Chemical Defense at 410-436-3628.