Emergency Medicine Book

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Sulfur MustardAka: Lewisite, Vesicant, Blister Agent

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  1. History
    1. First used on Battlefield by Germany in 1917
      1. Mustard produced most chemical casualties in WWI
    2. Other military use
      1. Italy (1930) in Abyssinia
      2. Egypt (1960) in Yemen
      3. Iraq (1980) in Iran and against the Kurds
    3. Current high risk regions for use
      1. Former Warsaw Pact Countries
      2. Third world countries
    4. Medical uses
      1. Previously used as chemotherapeutic Alkylating Agent
  2. Mechanism
    1. Very potent Alkylating Agent
      1. Binds DNA and related molecules
    2. Causes adverse effects similar to radiation
  3. Toxicity: Sulfur Mustard
    1. Vapor Exposure
      1. Unprotected LCT50: 1500 mg-min/m3
      2. Respiratory Protection LCT50: 10,000 mg-min/m3
    2. Liquid Exposure
      1. LD50: 100 mg/kg (7 grams or 1 teaspoon in an adult)
  4. Types of Vesicants
    1. Sulfur mustard
    2. Lewisite (Similar to Sulfur Mustard except:)
      1. Immediate effect within minutes
      2. No hematopoietic effects
    3. Phosgene
      1. Pulmonary Intoxicant with local vesicant effects
  5. Symptoms
    1. Initially asymptomatic (long latency of hours)
  6. Signs: Skin (Onset in 2-24 hours after exposure)
    1. Erythema
    2. Blister
  7. Signs: Eye
    1. Mild: Onset in 4-12 hours
      1. Tearing, itching, burning
      2. Gritty feeling
    2. Moderate: Onset in 3-6 hours
      1. Conjunctivitis
      2. Lid swelling
    3. Severe: Onset in 1-2 hours
      1. Marked lid swelling
      2. Corneal Opacity
      3. Severe pain
  8. Signs: Lung
    1. Mild: Onset in 12-24 hours
      1. Rhinorrhea
      2. Sneezing
      3. Epistaxis
      4. Hoarseness
      5. Hacking cough
    2. Severe: Onset in 2-4 hours
      1. Productive cough
      2. Dyspnea
  9. Signs: Gastrointestinal
    1. Variable effects
  10. Differential Diagnosis
    1. Vesicant agents
      1. Latent period (initially asymptomatic)
        1. Sulfur Mustard
      2. Immediate Pain or irritation within minutes
        1. Lewisite
        2. Phosgene oxime
    2. Contact Dermatitis (e.g. Poison Ivy)
  11. Labs
    1. Complete Blood Count (CBC)
      1. Bone Marrow stem cell suppression
      2. Leukocytes decrease by 3-5 days after exposure
    2. Thiodiglycol
      1. Urinary metabolite of sulfur mustard
      2. Currently available from Theater Army Medical Lab
  12. Detection
    1. Odor
      1. Mustard
      2. Garlic
      3. Onions
      4. Horseradish
      5. Black Pepper
      6. Fish
    2. Detection Kit
      1. M256A1 (3.0 mg/m3)
      2. M272 (2.0 mg/m3)
      3. MINICAMS (0.00003 mg/m3)
      4. ICAD (10.0 mg/m3)
      5. M18A2 (0.5 mg/m3)
      6. M21 (150.0 mg/m3)
      7. M90 (0.2 mg/m3)
      8. M93A1 Fox (0.01-1 ug/l)
      9. ACAMS (0.003 mg/m3)
      10. Bubbler (0.003 mg/m3)
      11. CAM (0.1 mg/m3)
      12. DAAMS (0.003 mg/m3)
  13. Triage
    1. Immediate
      1. Severe pulmonary effects
    2. Delayed
      1. Burns 5% to 50% BSA from liquid sulfur mustard
      2. Mild-Moderate pulmonary effects
      3. Sulfur Mustard related eye injuries
    3. Minimal
      1. Burns <5% Body Surface Area from sulfur mustard
      2. No face or airway burns
      3. Minor Eye Injury
      4. Mild airway symptoms onset after 12 hours
    4. Expectant
      1. Severe pulmonary effects onset within 4-6 hours
      2. Burns 50% BSA from liquid sulfur mustard (2x LD50)
  14. Management
    1. See Vesicant Exposure Management
  15. Complications
    1. Short-term: first 24 hours
      1. Laryngospasm
      2. Airway obstruction
    2. Short-Term: first 2 days
      1. Secondary Bacterial Pneumonia
    3. Short-Term: first 2-5 days
      1. Superinfection
      2. Septic Pneumonia
      3. Bone Marrow suppression
    4. Long-term complications
      1. Tracheobronchial stenosis
      2. Upper airway cancer (chronic repeated exposure)
  16. Prognosis: Indicators of poor outcome
    1. Pulmonary symptom onset in first 4 hours after exposure
    2. Burns from liquid exposure >50% body surface involved
    3. Leukopenia <500 cells
    4. Need for continuous Mechanical Ventilation
      1. Death in 5-10 days after exposure
    5. Prolonged Vomiting or voluminous Diarrhea > 48 hours
  17. 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

Vesicants (C0042578)

ConceptsHazardous or Poisonous Substance (T131)
MSHD007509
EnglishVesicant, Vesicants
Spanishagente vesicante
Parent ConceptsChemical Warfare Agents (C0007991)
SourcesMSH, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


lewisite (C0064880)

ConceptsOrganic Chemical (T109) , Hazardous or Poisonous Substance (T131)
MSHC035965
Englishlewisite
Spanishlewisita
Parent ConceptsVesicants (C0042578)
SourcesMSH, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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