Mustard Vesicants / Blistering Agents

1. Mustard Vesicants / Blistering Agents Back of Iranian Soldier exposed to mustard agent. Department of Defense Image

2. Vesicants / Blistering Agents • Sulfur Mustard • Nitrogen Mustard “Blind leading the blind”, WWI mustard agent casualties. Department of Defense image.

3. Overview: The Mustards • Sulfur mustard (HD) • 2,2'-di(chloro-ethyl)-sulfide • Named for its garlicky mustard odor • Nitrogen mustard (HN) • HN1: N-ethyl-2,2'di(chloro-ethyl) amine • HN2: N-methyl-2,2'di(chloro-ethyl) amine • HN3: 2,2', 2''tri(chloro-ethyl) amine

4. Overview: The Mustards • HD and HN3 are the most feared • HD is most likely to be used by terrorists • Easily manufactured and can be dispersed as a vapor • Most stable and persistent • Attacks eyes, mucous membranes, lungs, and blood forming organs • No effective therapy available

5. Overview: Toxicity • Dermal exposure • Burns from vapor or liquid exposure, occurring at 200 mg min/m3 • Inhalation exposure • Airway damage at 100 mg min/m3 • Lethal respiratory dose is ~1500 mg min/m3 • Eye exposure • Damage can occur at 10 mg min/m3

6. Protective Equipment • Penetrates natural cell membranes and numerous man-made materials • Ordinary clothing or surgical gear offer no protection • Respirator, protective overgarments, gloves and over-boots are required • Equipment must be changed regularly

7. Detection • Use single and three-color detector papers to detect liquid agent • Area detectors and water monitoring devices are available • Mass spectrometric and immunoassay methods can confirm exposure

8. Decontamination • Efficient and quick • Serious damage within 2 minutes • Skin: Physical absorption and/or chemical inactivation • Avoid water decon when possible • Exposure may spread/worsen

9. Decontamination • Mucous Membranes and Eyes • Flush immediately with water • Flush eyes with water, isotonic sodium bicarbonate (1.26%), or saline (0.9%)

10. Decontamination • Wounds • Mustards may be carried into wounds on cloth or other fragments • Special decon techniques are required • Techniques are for soft-tissue and extremity wounds

11. Signs and Symptoms • Eyes • Mild conjunctivitis: 1 to 2 week recovery • Severe conjunctivitis: 2 to 5 week recovery • Mild corneal involvement with erosions: 2 to 3 month recovery • Severe corneal involvement with ischemic necrosis: several months of recovery Moderate, mustard eye conjunctivitis. Department of Defense Image

12. Signs and Symptoms • Dermal: latent period for several hours post exposure • Sequence of skin changes seen with increasing exposure rates • Erythema (2-48 hours post exposure) • Blisters • Deep burning, leading to full thickness skin loss

13. Signs and Symptoms • Respiratory Tract • After 4-6 hours latent period • Irritation and congestion of mucous membranes of the nasal cavity and throat • Irritation of epithelium of the trachea and large bronchi

14. Signs and Symptoms • Fragments of necrotic epithelium cause obstruction • Infection complications in 48 hours • Serious exposure leads to death • Pulmonary edema, asphyxia due to obstruction • Bacterial infection; impaired immune response

15. Signs and Symptoms • Gastrointestinal Tract • Ingestion of contaminated water or food • Destroys mucous membranes of GI tract • Produces nausea, vomiting, abdominal pain, diarrhea and prostration from fluid loss. • Bloody stools • Significant blood loss and hemorrhagic shock

16. Signs and Symptoms • Systemic Effects • Bone marrow • Deplete all elements of the bone marrow • Development of severe leukopenia or aplastic anemia • Systemic Action • Can cause serious multi-organ injury

17. Treatment • No specific treatment available • Aim of therapy is to relieve symptoms, prevent infection, and promote healing • Great majority (97%) of casualties survive

18. Treatment • Caveats • Eyes • Do not use topical anesthetics or bandage the eyes • Use systemic, narcotic analgesics and protective goggles when needed • Skin • Relieve intense pruritis with cool compresses or corticosteroids in solution • Do not use creams or ointments

19. Treatment • Caveats • Respiratory Tract • Treat symptomatically • Be alert for pneumonia

20. Long Term Medical Sequelae • Victims likely to experience • Prolonged psychological manifestations include chronic depression, loss of libido, anxiety • Local effects • Visual impairment, scarring of the skin, chronic bronchitis, bronchial stenosis, and increased agent sensitivity

21. Long Term Medical Sequelae • Eye damage • Delayed keratitis 6-10 years post exposure, late-onset blindness • Sulfur mustard • Known carcinogen • Increased lung and laryngeal cancer incidence

22. EnvironmentalSequelae • Persistent in cold and temperate climates • Environmental persistency increased by dissolving them in non-volatile solvents

23. Summary • Sulfur mustard (HD) and HN3 are the most likely agents for war • HD is most likely to be used by terrorists

24. Summary • Properties • Chemically stable, persistent in the field • Slowly penetrates protective gear • Attacks eyes, mucous membranes, lungs, skin and blood-forming organs • Immediate decontamination is critical

25. Summary • Symptom-free latent phase • No specific antidote or treatment • Aim of therapy is to relieve symptoms, prevent infection, and promote healing • 97% of mustard casualties survive