Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter
VI: Chemical Injury
Blister Agents
United States Department of Defense
The blister (vesicant) agents are cytotoxic alkylating compounds exemplified by the
mixture of compounds collectively known as "mustard" or "mustard gas"
(H). Other blister agents are sulfur mustard (HD), nitrogen mustard (HN), phosgene oxime
(CX), and Lewisite (L), an arsenical vesicant. Mustard vapor injury is a particular threat
in hot climates. High humidity in a hot environment further enhances contact damage to the
skin.
Diagnosis: The diagnosis of chemical skin injury is straight forward once blisters have
appeared, but early and correct recognition of blister agent exposure can be difficult
because:
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Eye inflammation and upper respiratory tract irritation, often the first
effects noted, present a picture similar to that produced by choking agents.
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Although dermal damage occurs within minutes of contact, it cannot always be seen
immediately and is commonly painless until subdermal layers become involved and blisters
form several hours later.
After a 1-12 hour (or more) latent period, during which burning and itching may occur,
erythema appears on exposed skin. In dark-skinned casualties, sulfur mustard lesions may
turn coal black in such areas as the face, neck, axilla, groin, and genitalia. Erythema is
followed by coalescing, translucent, yellowish blisters on a red base. Healing and
resorption of non-infected blisters occur in 1-3 weeks. Broken blisters must be protected
to minimize chances for infection and subsequent scarring of denuded skin.
Lewisite is differentiated from the mustards by pain immediately upon skin contact.
Nasal irritation, sneezing, and pungent odor provide early warning of the presence of
Lewisite vapor. Only those without, or incapable of donning the mask will suffer serious
respiratory effects.
Treatment: Forward treatment of vesicant injuries is mainly preventive and supportive.
Immediate decontamination of the casualty has top priority. Agent droplets should be
removed as expeditiously as possible by blotting or flushing. The M-258A1 decon kit is
extremely effective in inactivating mustard, but it is also quite caustic. A surgical soap
and cool water wash suffices, particularly for widely contaminated skin. Neither scrubbing
nor hot water is recommended since both accelerate absorption and increased vapor
formation. Army TM 8-285 provides further details regarding proper decontamination
procedures.
Eye. Immediately flush the contaminated eye with water. Antibiotic ointment, with or
without steroid, helps minimize infection. In more severe cases, blepharospasm and pain
are extreme, requiring local anesthetic drops or ointment (e.g., tetracaine). Irrigation
with sterile saline will remove crusted exudate.
Respiratory Tract. Inhalation of mustard vapor produces severe irritation of the upper
respiratory tract, with painful cough, bloody sputum, chest pain, and dyspnea. Treatment
is symptomatic at first, since the severity of the broncho-pulmonary lesion may not become
evident for some time. Even asymptomatic patients should be observed for at least 4-6
hours, and not released until after re-examination of the chest. Lewisite vapor produces
similar effects, except for more pronounced nasal irritation and sneezing
Tracheitis and bronchitis are prominent; however, fulminant pulmonary edema is much
less common with the blister agents than with the choking agents. Bronchopneumonia is a
common complication; a change in the appearance of the sputum (culture if possible) is a
clear indication for antibiotic therapy.
Prophylactic antibiotic administration is neither necessary nor recommended.
Skin. Doctrinal (TM 8-285) treatment recommends the opening and draining of blisters
with removal of the blister fluid. Syringe aspiration of bullous fluid from large blisters
might be as effective. Supportive therapy for mustard burns is essentially similar to that
for thermal burns: aggressive fluid replacement, pain relief, and vigilance against
bacterial infection. From the standpoint of personnel, facilities, and re-supply,
forward-positioned medical resources would be severely stressed in the event of widespread
utilization of mustard gas by the enemy.
Systemic. Bone marrow depression with severe leukopenia and thrombocytopenia follows
extensive mustard absorption. Resistance to infection is diminished, with correspondingly
high mortality from pneumonitis or other bacterial infections. Mustard ingested with water
or food may damage gastrointestinal epithelium, resulting in blood and fluid losses.
Arsenical vesicants, such as Lewisite, increase capillary permeability, causing
extensive third-space fluid shifts. Intravascular hemolysis of erythrocytes, and
subsequent hemolytic anemia, complicate the clinical picture and may lead to renal
failure. Intramuscular BAL (1 ml per 50 pounds, not to exceed 4 ml) is given at 4 hour
intervals for a total of 4 doses. In severe cases, follow-up treatment for 3-4 days with
the daily deep IM injections of 1 ml per 100 pounds is recommended.
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Operational Medicine 2001
Health Care in Military Settings
Bureau of Medicine and Surgery
Department of the Navy
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Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
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January 1, 2001 |
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