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What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?. What chemical agent caused over 5000 known casualties as recently as the 1980's and was also used on civilian populations including children?.

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What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

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  1. What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

  2. What chemical agent caused over 5000 known casualties as recently as the 1980's and was also used on civilian populations including children?

  3. What chemical agent is in the arsenals of at least a dozen countries around the globe and ready to use against a perceived enemy?

  4. MUSTARD Clifton E. Yu, MD LTC, MC Department of Pediatrics Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 4 4 4

  5. Vesicants • Agent that causes vesicles or blisters • Main vesicant in production today: sulfur mustard • Lewisite and Phosgene Oxime (CX) also classified as vesicants--lesser availability and history of use Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 5 5 5

  6. Mustard--Why So Important? • No antidote • Causes lots of morbidity • Relatively easy to synthesize • Delayed symptoms • Children more susceptible to its toxic effects Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 6 6 6

  7. History • 1000 B.C.--arsenic smokes used by Chinese against invading Mongol tribes • 423 B.C.--Spartans used burning sulfur and coal smoke to attack Athenians in Peloponnesian War • 1854--sulfur mustard first synthesized • 1917--chlorine, phosgene, and particularly mustard used by both British and Germans resulting in thousands of casualties Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 7 7 7

  8. Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 8 8 8

  9. History (cont.) • 1934--nitrogen mustard synthesized • 1935--used by Italy against Abyssinia • 1937--Japan allegedly uses mustard gas against China during invasion of Manchuria • 1960's--used by Egypt against Yemen • 1980's--extensive use of mustard gas against Iranian soldiers and civilians during Iran-Iraq War Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 9 9 9

  10. Characteristics of Chemical Agents • Volatility--degree to which a substance vaporizes • Persistence--refers specifically to how long the substance stays in the environment and is inversely related to volatility Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 10 10 10

  11. Characteristics of Mustard • Oily, yellow to dark brown liquid • Garlic or mustard odor • Considered a persistent agent • Is "radiomimetic" • Thought to work as an alkylating agent Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 11 11 11

  12. Detection • Smell • M8, M9 paper, various detectors • Clinical recognition

  13. Clinical Effects • Skin, Eyes, Respiratory Tract • Bone Marrow, GI, CNS in Severe Exposures Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 13 13 13

  14. Skin Effects • Latent period of several hours after exposure • Erythema, then blister formation • With high dose, skin sloughing • Blister fluid not hazardous Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 14 14 14

  15. Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 15 15 15

  16. Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 16 16 16

  17. Ocular Effects • Most often caused by vapor • Conjunctival inflammation • Corneal damage • Severe lid edema • Rarely permanent blindness Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 17 17 17

  18. Respiratory Effects • Vapor induced • Upper respiratory tract irritation • Dyspnea and productive cough • Severe necrotizing tracheobronchitis with pseudomembrane formation • Secondary bacterial infection Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 18 18 18

  19. Bone Marrow • Involvement occurs in severe cases • Usually occurs on day 3 to 5 • ANC less than 500 or a precipitous drop portends a high risk of sepsis and death Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 19 19 19

  20. GI Tract • Usually manifested by nausea and vomiting • Generally transient and not severe • Thought to be caused by cholinergic activity of mustard • Delayed nausea and vomiting thought secondary to generalized cytotoxic activity and mucosal damage to GI tract Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 20 20 20

  21. CNS • Symptoms not usually prominent • Common complaints in World War I were apathy, depression, and intellectual dullness • 83% of hospitalized Iranians in one study had CNS complaints--usually mild and non-specific Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 21 21 21

  22. Treatment • Decon, Decon, Decon !!! -only effective means of preventing or decreasing tissue damage -must be performed beforeentry into a clean MTF • Remainder of treatment depends on the other organ systems involved Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 22 22 22

  23. Skin • Treat like a burn • Erythema treated with soothing lotion, e.g. calamine • Carefully unroof larger blisters • Irrigation of denuded areas 3-4X daily Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 23 23 23

  24. Skin (cont.) • Topical antibiotics, e.g. Silvedene • Systemic antipruritics • Systemic analgesics • Fluids and electrolytes Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 24 24 24

  25. Eyes • Thorough irrigation • Cycloplegics (e.g. homatropine) • Topical antibiotics • Vaseline to edges of eyelids • Systemic analgesics (e.g. NSAID's) Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 25 25 25

  26. Pulmonary • Upper airway symptoms--steam inhalation, cough suppressants • Avoid using antibiotics early on • Intubation if lower resp. sx's progress -attempt before laryngospasm or significant edema develop -direct laryngoscopy with suctioning if evidence of pseudomembrane formation Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 26 26 26

  27. Pulmonary (cont.) • No evidence steroids beneficial routinely • Prolonged assisted or controlled ventilation--bad prognosis Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 27 27 27

  28. Bone Marrow • If neutropenic, some advocate gut sterilization with non-absorbable antibiotics • Bone marrow transplant or transfusion--may be life-saving in selected cases Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 28 28 28

  29. GI • Atropine (0.4 to 0.6 mg IM or IV for adults) or another anti-cholinergic may be helpful • IV fluids Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 29 29 29

  30. Summary • Decontamination • Treat like a burn patient • Liberal use of analgesics • Fluids and electrolytes (less than for standard burns) • System specific treatment as necessary Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 30 30 30

  31. But What About Children? • Very little in literature • Recent experience with childhood mustard exposure from Iran-Iraq War (Momeni and Aminjarahari, Int. J. Derm. Vol 33, March 1994) • Earlier onset of skin lesions, more severe • More frequent and severe opthalmic, pulmonary, and GI involvement Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 31 31 31

  32. Skin • Earlier lesions, more bullae • First index case may therefore be a child • Traditional decontamination with sodium hypochlorite (bleach) may be harmful to child's skin • Use copious amounts of soap and water instead Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 32 32 32

  33. Eyes • More frequent and severe eye findings • Same therapeutic interventions Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 33 33 33

  34. Pulmonary • Higher incidence of lung involvement • Increased minute ventilation in children • May have to intubate sooner Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 34 34 34

  35. GI • Increased involvement probably dose related • Children more likely to have protracted emesis • Atropine or other anti-cholinergic in age-appropriate doses may be helpful Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 35 35 35

  36. Pediatric Exposure--Summary • Earlier and more severe skin lesions (soap and water for decontamination) • Pay early attention to eyes in virtually all children • Be on lookout for earlier and more severe lung involvement • May have to treat GI symptoms more aggressively (and watch for increase in dehydration) Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 36 36 36

  37. BE PREPARED!!! …and get ready for inhalants next week Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center 37 37 37

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