Vesicant Exposure Management

Aka: Vesicant Exposure Management, Sulfur Mustard Exposure Management, Blister agent Exposure Management

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II. Management: Approach

  1. ABC Management
  2. Decontamination Immediately
    1. Hypochlorite 0.5%
    2. M291 Kit
    3. Copious amounts of water
  3. Systemic Antidote for suspected severe exposure
    1. Sodium thiosulfate (sulfur donor)
      1. May be helpful if given within 20 minutes
    2. British-Anti-Lewisite (BAL, Dimercaprol) IM
      1. Indicated only if Lewisite exposure suspected
      2. Used now to chelate Heavy Metals
      3. Reduces Lewisite systemic effects
      4. Topical BAL for eye and skin also effective
      5. Caution: Potential significant adverse effects
  4. Other agents with potential benefit
    1. NSAIDs (e.g. Ibuprofen) reduce inflammatory injury
  5. Supportive care
    1. Hydration
      1. Moderate fluid Resuscitation
      2. Losses are not nearly as great as for burn patients
    2. Systemic Analgesics and antipruritics
    3. Consider Parenteral nutrition

III. Management: Skin Changes

  1. Erythema
    1. Calamine or 0.25% camphor/Menthol/calamine
  2. Blisters
    1. Unroofing larger Blisters (>2 cm) is controversial
  3. Denuded skin
    1. Irrigate 3-4 times per day with saline
    2. Cover liberally with Silver Sulfadiazine or mafenide
    3. Topical Antibiotics for unroofed skin Blisters
    4. Whirlpool bath irrigation for large involvement
  4. Fluid therapy associated with burns
    1. Less fluid needed than in standard Burn Management

IV. Management: Eye Changes

  1. Conjunctival irritation
    1. Homatropine ophthalmic ointment
      1. Prevents synechiae formation
    2. Erythromycin ointment or other Topical Antibiotic
    3. Vaseline to Eyelids
      1. Prevents adhesions and scarring
      2. Permits drainage of underlying infection
    4. Topical Steroids may be useful in first 48h
      1. Confirm no concurrent infection
    5. Usually heals in 1-3 weeks
  2. Pain
    1. Avoid Topical Analgesics except for Eye Exam
    2. Use systemic Analgesics
    3. Sunglasses for photophobia

V. Management: Pulmonary Changes

  1. Upper airway effects (Pharyngitis, cough)
    1. Steam inhalation
    2. Cough Suppressants
  2. Lower airway effects (Productive cough, Dyspnea)
    1. Avoid Antibiotics in first 24 hours
      1. Usually sterile Bronchitis or pneumonitis
    2. Respiratory Infection onset at 72 hours
      1. Evaluate clinically (fever, Sputum Gram Stain)
    3. Bronchodilators
    4. Consider systemic or Inhaled Steroids
  3. Impending Airway compromise
    1. Consider intubation early
    2. Apply early PEEP or CPAP
    3. Consider early bronchoscopy for pseudomembrane

VI. Management: Gastrointestinal Changes

  1. Antiemetic prn

VII. Management: Severe Marrow Suppression

  1. Granulocyte Colony Stimulating Factor (GCSF, Neupogen)
    1. Resource: Bill Young Marrow Donor (1-800-MARROW-3)

VIII. References

  1. Medical Response to Chemical Warfare and Terrorism
    1. US Army Medical Research Institute Chemical Defense
    2. Video-Teleconference: 4/20/00 to 4/22/99
    3. Video-Teleconference: 12/5/00 to 12/7/00
    4. Text: 3rd Edition, December 1998

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