Page 84 - JSOM Summer 2019

FIGURE 1 Acute effects of mustard gas exposure. Images level of care capable of caring for burn patients and the severe
demonstrate erythema and vesicle formation 4–6 hours after complications that may arise as stated next.
initial exposure.
Often, those undergoing decontamination will close their eyes.
Given the high susceptibility of the eye and risk for chronic
scarring and vision loss, it is important to ensure all exposed
patients receive 15 minutes of eye irrigation. While local anal-
gesics can increase corneal damage and should not be used re-
currently, they may be considered to facilitate irrigation. Once
the eyes are appropriately irrigated, a thorough eye examina-
tion should occur. If corneal lesions are visualized, mydriatics
should be used to prevent potential adhesions between the iris
and the cornea. Blepharospasm is a common complication
within 4 hours, new blisters may continue to appear as late as of sulfur mustard exposure. As such, sterile petroleum jelly
2 weeks postexposure. The patient may also note associated should be applied to the eyelids to prevent the eyelids from
pruritus with the erythema and blisters. sticking to each other. 4

Sulfur mustard can affect all mucous membranes of the respi- Those exhibiting respiratory symptoms should undergo close
ratory tract. The latent period from exposure to symptoms monitoring and symptomatic treatment. Humidified oxygen,
may range anywhere between 2 to 48 hours, most commonly, steam, or sterile cool mist inhalations may symptomatically
4–8 hours from exposure. Symptoms may be a result of irrita- improve vocal cord dysfunction or laryngitis. If there is de-
tion in the upper respiratory tract causing rhinorrhea, burning saturation or rales, the patient should be admitted for ob-
sensation in the oropharynx, and hoarseness. The vocal cords servation. Should the respiratory status decline further, it is
may become irritated, resulting in aphonia and stridor. Sulfur recommended to intubate the patient with as large an endotra-
mustard may also affect the lower respiratory tract, resulting cheal as possible to facilitate suction as there is increased risk
in rales on auscultation, dyspnea, cough, and hemoptysis. of respiratory membrane sloughing. 4
17
Symptoms may progress in severity to bronchopneumonia or
necrotic sloughing of the lower respiratory tract, resulting in After thorough decontamination, skin changes should be
obstruction and hypoxia. 4 dressed with clean, dry bandages. One should anticipate
swelling with resuscitation and ensure circumferential ban-
Irritation of the gastrointestinal tract is less common in chem- dages are loose enough to allow for swelling without inducing
ical warfare as the common delivery mechanism results from compartment syndrome. If blisters exist, they are sterile and
an explosion. Sulfur mustard is oily, and while denser than do not contain sulfur mustard in the fluid. It is reasonable
water, may have droplets on the surface of contaminated water in the field environment to keep blisters of all sizes intact to
sources. If one ingests contaminated food or water, one may act as a biologic dressing. Once medically evacuated to a hos-
experience destruction of the gastrointestinal tract. This may pital, small blisters should remain intact. Larger blisters that
result in symptoms as mild as nausea, vomiting, diarrhea, to may spontaneously rupture or blisters that restrict range of
perforation anywhere in the gastrointestinal tract resulting in motion or body position may be unroofed. The blistered or
mediastinitis or peritonitis. newly denuded skin should then be dressed as burned skin
should be dressed. Full-thickness skin injuries are rare but are
There is no preventative medication or antidote. Acute man- a particularly devastating injury that can occur after directly
agement in the early phase of exposure are focused predomi- handling damaged munitions without appropriate protective
nantly on recognition of potential exposure, decontamination, equipment. 18
and symptom management while planning for evacuation.
Sudden onset of similar symptoms in multiple exposed pa- Those patients exhibiting nausea, vomiting, or diarrhea from
tients, particularly after an explosion with an unusual fog or possible gastrointestinal tract exposure should be treated sup-
odor, should cue one to consider sulfur mustard exposure. Sul- portively. There is no reported role for activated charcoal or
fur mustard is commonly associated with yellow-brown vapor whole bowel irrigation. If the patient develops signs or symp-
that smells like onions or garlic. After moving the exposed toms consistent with mediastinitis or abdominal perforation,
individuals from the potentially contaminated environment, appropriate broad-spectrum antibiotics and evacuation to a
the exposed individuals should undergo thorough decontami- surgical care should be accomplished rapidly.
nation with copious irrigation. The first step is to remove any
contaminated clothing or equipment. Next, the exposed skin Those patients exhibiting seizures, coma, and refractory hypo-
areas should be decontaminated with reactive skin decontami- tension are generally associated with severe exposure and
nation lotion (RSDL), then washed with copious 0.5% sodium poor prognosis. One could consider co-exposure to organo-
hypochlorite (bleach) or soap and water. Water alone should phosphate, cyanide, or other toxin and attempt antidotes as a
be avoided as the lack of an emulsifying agent (i.e., soap) will last resort. However, if no change with those additional man-
spread the oil without adequately removing it. After thorough agement options, one could consider expectant management
decontamination, asymptomatic patients should be monitored depending on resource availability or concurrent patient load.
for a minimum of 18 hours. If they remain asymptomatic at
that time, they can be discharged with the expectation of close Subacute Effects and Management
monitoring for possible delayed leukopenia or blister forma-
tion. Those who arrive with symptoms or develop symptoms During the subacute time period (24 hours to 4 weeks after ex-
during the observation time should be evacuated to an elevated posure), standardization of evaluation based on organ systems

82 | JSOM Volume 19, Edition 2 / Summer 2019