Page 93 - 2022 Ranger Medic Handbook

CBRN – Vesicant Agents
Blister or vesicant agents are second only to nerve agents as a concern to the US Military. These are a concern as there
are large stockpiles of them; they are easily manufactured; and they are both incapacitating and lethal. The severity of
vesicant agents will, in part, be affected by the environmental conditions at the time of exposure. Warm, humid condi-
tions increase the severity of blister agents damage and shorten the time of symptom onset. Cold weather may slow the
onset and lessen blister severity. M8 Chemical Detection paper will turn red in the presence of liquid mustard. Precursors
and impure agents are also hazardous and are easily manufactured. SECTION 2
Mustards-Sulfur, Mustard (H) or (HD) and Nitrogen Mustard (HN1, HN2, HN3)
S/Sx: Skin: erythema, small vesicles, bullae, direct coagulation necrosis, and skin sloughing with high dose. Eyes: con-
junctivitis with epithelial necrosis, subcorneal edema, and sloughing. Airway: hoarseness, cough, throat, nasal irritation.
Severe patients can have laryngospasms.
MANAGEMENT: Immediate decontamination by any means available (contact time should be less than 2 minutes) and
symptomatic management.
DISPOSITION: Refer to chemical casualty triage table.
SPECIAL CONSIDERATIONS: Sulfur mustard is a very potent, persistent agent that produces relatively few deaths but
will require a lengthy convalescence of personnel affected. Liquid mustard maybe seen as amber (HD) or dark brown (H)
oily liquid that has an odor comparable to onions or garlic. Liquid mustard absorption can be enhanced by thin epithelial
barriers, heat, moisture, and oils on the skin. The fluid in mustard blisters does not contain mustard. The LD 50 of mustard
liquid is equivalent to 3–7g (about 1 teaspoon). H 1-3 will have shorter latent periods and more severe systemic effects.

Arsenicals-Lewisite (L), MD, ED, PD
S/Sx: Similar to HD with the distinct differences being pain within seconds to minutes after contact, “Lewisite shock” will
have capillary leakage, pulmonary edema (ARDS), hypotension, circulatory failure.
MANAGEMENT: Immediate decontamination by any means available and symptomatic management. British Anti-
Lewisite 3mg/kg IM × 1 for exposure with immediate pain.
DISPOSITION: Refer to chemical casualty triage table.
Oxime-Phosgene (CX)
S/Sx: urticaria with immediate pain. Produces skin lesions similar to acid burns. Blanching or erythematous ringing of
contact site and wheal formation.
MANAGEMENT: Immediate decontamination by any means available and symptomatic management.
DISPOSITION: Refer to chemical casualty triage table.

CBRN – Cyanide Agents
Hydrogen Cyanide (AC), Cyanogen Chloride (CK)
S/Sx: Rapid symptom onset, seizures, respiratory arrest, incontinence, normal pupils or mydriasis.
MANAGEMENT: Remove from exposure area, restore ventilation, and if symptomatic give 1 Cyano Kit. May be redosed
every 5 minutes for persistent symptoms. If not available, use sodium nitrite 300mg of 3% solution IV over 5–20 minutes.
DISPOSITION: Refer to chemical casualty triage table.
SPECIAL CONSIDERATIONS: Cyanide is classified as a blood agent which can affect all systems in the body. Decon-
tamination is usually not required due to the patients “off-gassing.” Cyanide can affect people by inhalation, ingestion,
or percutaneous routes. Hydrogen cyanide (AC) can smell like bitter almonds or peach pits, but most people cannot
detect the odor. Cyanogen chloride can be a pungent, biting odor, which can irritate the eyes, nose, and respiratory tract.
The onset of symptoms from cyanide is within seconds of exposure. The differences between nerve agent symptoms
and cyanide symptoms are the lack of secretions and normal pupils or mydriasis, whereas nerve agent poisonings have
copious secretions and meiosis. Any nitrate given within minutes, with mechanical ventilation, can be very effective in
improving patient health.
2022 RANGER MEDIC HANDBOOK 79