Page 85 - JSOM Summer 2019

will decrease the likelihood that life- or organ-threatening and follow-on care, making prompt triage and corresponding
changes are not missed. Most frequently encountered are in- evacuation critically important.
juries to the eyes, airways, and skin. Another critical system
that is not readily visible is the hematopoietic system, as this Airway Injury
can also be suppressed by mustard exposure. The immunosup- Throughout the subacute period, patients with significant re-
pressive effect will further complicate care as the patient can spiratory injury will develop epithelial sloughing and pseudo-
become predisposed to secondary infections. Ultimately, the membrane formation in the bronchi that can cause respiratory
provider must pay close attention to the state of the patient’s failure. The gas has little effect on the lung parenchyma itself.
injuries, and even outpatients should receive frequent follow Radiographic imaging may reveal a combination of atelectasis
up as discussed next. and emphysematous changes, and this has been pathologically
correlated to inflamed and debris-filled bronchioles when ex-
Ocular Injury amined in human and animal specimens. 20,23,24
Ocular injuries are stratified as mild, moderate, or severe based
on the patient’s symptomology. Mild injuries include symp- Patients may also have clinical symptoms of pneumonia with
19
toms of blepharospasm, tearing, foreign body sensation, and pulmonary infiltrates, sputum production, leukocytosis, and
photophobia. Generally, these patients will exhibit hyperemia fever. Within the early window of 1–4 days, this is generally a
and edema of the eyelids and conjunctiva but without signif- sterile inflammatory process mediated by the evolving vesicant
icant corneal involvement. Moderate injuries are classified as injury. Development of these findings after the fourth day is
the same symptoms as given earlier with additional eye pain more concerning for secondary bacterial infection and should
and dry eye sensation. This translates into corneal involvement warrant consideration of antimicrobial therapy and further di-
under slit lamp examination with findings of corneal epithelial agnostics. Sepsis can become a complicating factor in the sub-
edema, and punctate keratopathy. Unfortunately, these symp- acute period because of concurrent effects of mustard gas on
toms can last for several weeks. Severe eye injury presents the bone marrow, resulting in suppression that may be quite
20
with the aforementioned findings and very severe eye pain and profound. 20,25,26
vision loss. These patients are at risk for corneal perforation
and anterior chamber inflammation and necrosis. Mild respiratory symptoms include irritation of the throat and
a nonproductive cough. Voice changes are also typical and
In terms of management, there are a few principles that ap- may progress to aphonia. Again, though, the full extent of in-
ply to all degrees of severity. At presentation, eye irrigation is jury to the lungs is not immediately known and usually evolves
critical to prevent ongoing irritation from residual liquid on throughout the first several days. Patients presenting with
the adnexal structures. Shielding with sunglasses after irriga- tachypnea will need hospitalization for supportive care and
tion is safe and will mitigate discomfort induced by photosen- monitoring as this indicates a moderate to severe injury. 20,25
sitivity. 19,20 Patching the eyes, which is recommended in the
JTS CPG for ocular injuries, is not indicated as this can lead Early intubation is indicated for patients with declining respi-
to further injury from residual off-gassing and scarring of the ratory function, because laryngospasm can develop due to the
lids. 20,21 vesicant irritation. Management of moderately injured patient
is based on alleviation of bronchospasm with bronchodilator
In mild and moderate injuries, eyes should be treated with top- therapy and airway clearance assistance. There are limited
ical antibiotic drops such as ciprofloxacin every 6 hours for a data to suggest using combination beta agonist and anticholin-
week to prevent infection. 19,22 Steroid drops are also recom- ergic inhaler therapy. Regarding steroids, the general consen-
25
mended, every 8–12 hours for 7 days. Additionally, lubrication sus has been that there is likely no benefit and potential harm
of the eyes and lids should be provided with preservative-free as these patients are already immunocompromised secondary
artificial tears and ointments. Pain should not be controlled to the exposure to mustard gas. 20,25
using topical anesthetics but with systemic analgesics. Mydri-
atic medications (cyclopentolate, atropine ophthalmic, tropi- Severely injured patients will need additional assistance to in-
camide, etc.) can also be used in the case of moderate injuries. clude invasive ventilator support. The aforementioned pseu-
domembrane formation may precipitate respiratory distress
Severe injuries are concerning for risk of perforation and in- and failure necessitating bronchoscopy for hygiene and debris
fection. Patients without evidence of infection or perforation clearance. In the Iraq-Iran conflict, the need for intubation
can be treated with the same regimen as discussed earlier. Con- portended a poor prognosis with a nearly 90% mortality re-
sideration should also be given to adding oral doxycycline to ported in some series. 20
the topical antibiotic regimen for these patients as additional
prophylaxis. High suspicion for active infection should Follow-up care is dictated by severity. Mildly injured patients
19
prompt initiation of broad-spectrum topical antibiotics such require 3–7 days of follow-up specific to respiratory symp-
as gentamycin or vancomycin and ceftazidime. Treatment can toms before returning to duty. More severely injured patients
be further adjusted with assistance of ophthalmology. If cor- may take several weeks to improve or longer.
neal perforation has occurred, then immediate evacuation is
critical, and parenteral antibiotics are recommended. Dermal Injury
Small blisters (<1 cm) are generally left intact. These wounds
Follow-up for these patients depends on the severity of in- are cared for with daily washing of the blister, application of
jury. Mild injury usually resolves within 1 week, and a repeat a topic antibiotic (such as sulfadiazine), and application of
examination at that time is recommended. Moderate inju- a clean dressing. There is limited risk of these progressing
20
ries should be seen daily until corneal symptoms resolve. 19,20 on to full-thickness injuries, and these generally heal in 2–3
Moderate and severe injuries need ophthalmologic evaluation weeks. 27

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