II. History
- First used on Battlefield by Germany in 1917
- Mustard produced most chemical casualties in WWI
- Other military use
- Italy (1930) in Abyssinia
- Egypt (1960) in Yemen
- Iraq (1980) in Iran and against the Kurds
- Current high risk regions for use
- Former Warsaw Pact Countries
- Third world countries
- Medical uses
- Previously used as chemotherapeutic Alkylating Agent
III. Mechanism
- Very potent Alkylating Agent
- Binds DNA and related molecules
- Causes adverse effects similar to radiation
IV. Toxicity: Sulfur Mustard
- Vapor Exposure
- Unprotected LCT50: 1500 mg-min/m3
- Respiratory Protection LCT50: 10,000 mg-min/m3
- Liquid Exposure
- LD50: 100 mg/kg (7 grams or 1 teaspoon in an adult)
V. Types: Vesicants
- Mustard Gas (Sulfur Mustard)
- Lewisite (Similar to Sulfur Mustard except:)
- Immediate effect within minutes
- No hematopoietic effects
-
Phosgene
- Pulmonary Intoxicant with local Vesicant effects
VI. Symptoms
- Initially asymptomatic (long latency of hours)
VII. Signs: Skin (Onset in 2-24 hours after exposure)
- Erythema
- Blister
VIII. Signs: Eye
- Mild: Onset in 4-12 hours
- Eye tearing, itching, burning
- Gritty feeling
- Moderate: Onset in 3-6 hours
- Conjunctivitis
- Lid swelling
- Severe: Onset in 1-2 hours
- Marked lid swelling
- Corneal Opacity or Corneal Ulcer
- Severe Eye Pain
- Globe Rupture may occur
IX. Signs: Respiratory
- Mild: Onset in 12-24 hours
- Rhinorrhea
- Sneezing
- Epistaxis
- Pharyngitis
- Hoarseness
- Hacking cough
- Severe: Onset in 2-4 hours
- Productive cough
- Dyspnea
- Laryngeal edema with Stridor
- Tracheobronchitis with pseudomembrane formation
- Acute Lung Injury
X. Signs: Gastrointestinal
- Variable effects
XI. Differential Diagnosis
- Vesicant agents
- Latent period (initially asymptomatic)
- Sulfur Mustard
- Immediate Pain or irritation within minutes
- Lewisite
- Phosgene oxime
- Latent period (initially asymptomatic)
- Contact Dermatitis (e.g. Poison Ivy)
XII. Labs: Diagnosis
-
Complete Blood Count (CBC)
- Bone Marrow stem cell suppression
- Leukocytes decrease by 3-5 days after exposure
- Thiodiglycol
- Urinary metabolite of Sulfur Mustard
- Available from Theater Army Medical Lab
XIII. Labs: Detection
- Odor
- Mustard
- Garlic
- Onions
- Horseradish
- Black Pepper
- Fish
- Detection Kit
- M256A1 (3.0 mg/m3)
- M272 (2.0 mg/m3)
- MINICAMS (0.00003 mg/m3)
- ICAD (10.0 mg/m3)
- M18A2 (0.5 mg/m3)
- M21 (150.0 mg/m3)
- M90 (0.2 mg/m3)
- M93A1 Fox (0.01-1 ug/l)
- ACAMS (0.003 mg/m3)
- Bubbler (0.003 mg/m3)
- CAM (0.1 mg/m3)
- DAAMS (0.003 mg/m3)
XIV. Management: Triage
- Immediate
- Severe pulmonary effects
- Delayed
- Burns 5% to 50% BSA from liquid Sulfur Mustard
- Mild-Moderate pulmonary effects
- Sulfur Mustard related eye injuries
- Minimal
- Burns <5% Body Surface Area from Sulfur Mustard
- No face or airway burns
- Minor Eye Injury
- Mild airway symptoms onset after 12 hours
- Expectant
- Severe pulmonary effects onset within 4-6 hours
- Burns 50% BSA from liquid Sulfur Mustard (2x LD50)
XV. Management: General
XVI. Complications
- Short-term: first 24 hours
- Laryngospasm
- Airway obstruction
- Short-Term: first 2 days
- Secondary Bacterial Pneumonia
- Short-Term: first 2-5 days
- Superinfection
- Septic Pneumonia
- Bone Marrow suppression
- Long-term complications
- Tracheobronchial stenosis
- Upper airway cancer (chronic repeated exposure)
XVII. Prognosis: Indicators of poor outcome
- Pulmonary symptom onset in first 4 hours after exposure
- Burns from liquid exposure >50% body surface involved
- Leukopenia <500 cells
- Need for continuous Mechanical Ventilation
- Death in 5-10 days after exposure
- Prolonged Vomiting or voluminous Diarrhea > 48 hours
XVIII. References
- Seeyave (2015) Crit Dec Emerg Med 29(5): 13-21
- Medical Response to Chemical Warfare and Terrorism
- US Army Medical Research Institute Chemical Defense
- Video-Teleconference: 4/20/00 to 4/22/99
- Video-Teleconference: 12/5/00 to 12/7/00
- Text: 3rd Edition, December 1998