II. 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

III. Mechanism

  1. Very potent Alkylating Agent
    1. Binds DNA and related molecules
  2. Causes adverse effects similar to radiation

IV. 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)

V. Types: Vesicants

  1. Mustard Gas (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

VI. Symptoms

  1. Initially asymptomatic (long latency of hours)

VII. Signs: Skin (Onset in 2-24 hours after exposure)

  1. Erythema
  2. Blister

VIII. Signs: Eye

  1. Mild: Onset in 4-12 hours
    1. Eye 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 or Corneal Ulcer
    3. Severe Eye Pain
    4. Globe Rupture may occur

IX. Signs: Respiratory

  1. Mild: Onset in 12-24 hours
    1. Rhinorrhea
    2. Sneezing
    3. Epistaxis
    4. Pharyngitis
    5. Hoarseness
    6. Hacking cough
  2. Severe: Onset in 2-4 hours
    1. Productive cough
    2. Dyspnea
    3. Laryngeal edema with Stridor
    4. Tracheobronchitis with pseudomembrane formation
    5. Acute Lung Injury

X. Signs: Gastrointestinal

  1. Variable effects

XI. 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)

XII. Labs: Diagnosis

  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. Available from Theater Army Medical Lab

XIII. Labs: 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)

XIV. Management: 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)

XV. Management: General

XVI. 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)

XVII. 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

XVIII. References

  1. Seeyave (2015) Crit Dec Emerg Med 29(5): 13-21
  2. 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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Ontology: Mustard Gas (C0026874)

Definition (NCI) A pale yellow, oily, highly toxic, volatile, liquid alkylating compound with a sweet to garlic-like odor that evaporates to a poisonous gas. Mustard gas is a vesicant that was first used in chemical warfare in World War I, but is now only used in small amounts in research studies involving alkylating agents. Exposure to this substance is corrosive to the eyes, skin and lungs and leads to blindness and blistering of the skin and can cause severe and sometimes fatal respiratory damage. Mustard gas is a mutagen and is a known carcinogen that is associated with an increased risk of developing lung and other respiratory tract cancers. (NCI05)
Definition (MSH) Severe irritant and vesicant of skin, eyes, and lungs. It may cause blindness and lethal lung edema and was formerly used as a war gas. The substance has been proposed as a cytostatic and for treatment of psoriasis. It has been listed as a known carcinogen in the Fourth Annual Report on Carcinogens (NTP-85-002, 1985) (Merck, 11th ed).
Concepts Hazardous or Poisonous Substance (T131) , Organic Chemical (T109)
MSH D009151
SnomedCT 76533004
English Bis(beta-chloroethyl) Sulfide, Di 2 chloroethyl Sulfide, Di-2-chloroethyl Sulfide, Dichlorodiethyl Sulfide, Gas, Mustard, Mustard Gas, Mustard, Sulfur, Mustardgas, Sulfide, Di-2-chloroethyl, Sulfide, Dichlorodiethyl, Sulfur Mustard, Yellow Cross Liquid, Yperite, dichlorodiethyl sulfide, Sulfur Mustard Gas, 2,2'-Dichlorodiethyl Sulfide, 1,1'-Thiobis(2-chloroethane), Mustard Gas [Chemical/Ingredient], mustard gas, gas mustard, mustard sulfur, Ethane, 1,1'-thiobis(2-chloro)-, Bis(2-Chloroethyl) Sulfide, sulfur mustard, yperite, bis(beta-chloroethyl) sulfide, yellow cross liquid, DICHLORODIETHYLSULFIDE, Mustard gas, Dichlorodiethyl sulfide, Dichlorodiethyl sulphide, Mustard gas (substance)
Swedish Senapsgas
Czech yperit
Finnish Sinappikaasu
Russian IPRIT, DIKHLORDIETILSUL'FID, SERUSODERZHASHCHII IPRIT, GORCHICHNYI GAZ, ГОРЧИЧНЫЙ ГАЗ, ДИХЛОРДИЭТИЛСУЛЬФИД, ИПРИТ, СЕРУСОДЕРЖАЩИЙ ИПРИТ
Japanese イペリット, サルファマスタード, サルファーマスタード, マスタードガス, 硫化ジクロロジエチル
Italian Bis(beta-cloroetil)solfuro, Diclorodietil solfuro, Mostarda solforata, Iperite, Di-2-cloroetil solfuro, Mostarda sulfurea, Gas mostarda
Polish Iperyt, Gaz gorczyczny, Gaz musztardowy
French Ypérite, Gaz moutarde
Spanish diclorodietilo sulfuro, gas de mostaza (sustancia), gas de mostaza, Gas Mostaza, Mostaza Sulfurada, Sulfuro de Diclorodietilo
German Dichlordiethylsulfid, Lost, Senfgas
Portuguese Diclorodietil Sulfeto, Gás de Mostarda, Mostarda Sulfúrica

Ontology: Vesicants (C0042578)

Concepts Hazardous or Poisonous Substance (T131)
MSH D007509
SnomedCT 105889000
French Produits vésicants, Agents vésicants, Vésicants
Portuguese Vesicantes
Spanish Vesicantes, agente vesicante (sustancia), agente vesicante
German Vesicantia, Blasenziehende Mittel
English vesicant, vesicants, Vesicant (substance), Vesicant, Vesicants
Italian Vescicanti

Ontology: lewisite (C0064880)

Concepts Hazardous or Poisonous Substance (T131) , Organic Chemical (T109)
MSH C035965
SnomedCT 74981003
English dichloro(2-chlorovinyl)arsine, lewisite, Lewisite, Dichloro(2-chlorovinyl) arsine, Lewisite (substance)
Spanish dicloro (2-clorovinilo) arsina, lewisita (sustancia), lewisita