Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical WarfareClinical EffectsThe organs most commonly affected by mustardare the skin, eyes, and airways (Table 8-3): the organswith which mustard comes into direct contact. Aftera significant amount of mustard has been absorbedthrough the skin or inhaled, the hemopoietic system,gastrointestinal tract, and CNS are also damaged.Mustard may also affect other organs, but rarely dothese produce clinical effects.During World War I, 80% to 90% of US mustardcasualties had skin lesions, 86% had eye involvement,and 75% had airway damage; these percentages arenot significantly different from those seen in Iraniancasualties. 62 Of a group of 233 severely injured Iraniansoldiers sent to western European hospitals by theIranian government for treatment during the Iran-IraqWar, 95% had airway involvement, 92% had eye signsand symptoms, and 83% had skin lesions. 63 In a seriesof 535 Iranian casualties, including civilians, admittedto a dermatology ward, 92% had skin lesions and 85%had conjunctivitis; of the total number of patients, 79%TABLE 8-3INITIAL CLINICAL EFFECTS FROM MUSTARDEXPOSUREOnset ofOrgan Severity Effects First EffectEyes Mild Tearing 4–12 hitchingBurningGritty feelingModerate Above effects, plus: 3–6 hreddeninglid edemaModerate painSevere Marked lid edema 1–2 hPossible corneal damagesevere painAirways Mild Rhinorrhea 6–24 hsneezingepistaxishoarsenesshacking coughSevere Above effects, plus: 2–6 hProductive coughMild-to-severe dyspneaSkin Mild Erythema 2–24 hSevere Vesication 4–12 hhad erythema and 55% had blisters. Casualties withmore serious problems, including injury to the pulmonarytract, were admitted to other wards. 64The slightly higher percentage of airway and eyeinvolvement in Iranian soldiers versus US World WarI casualties is perhaps attributable to the higher ambienttemperature in the area (compared with Europe),which caused more vaporization. The difference mightalso have resulted from the limited availability of Iranianprotective equipment or poor mask seals with facialhair. In 1984, the year the first Iranian casualties weretreated in Europe, protective clothing and gas maskswere not commonly worn by Iranian soldiers. 17Mustard-related death occurs in about 3% of thecasualties who reach an MTF; of those who die, mostdie 4 or more days after exposure. Table 8-4 illustratesthe breakdown, in percentages, of British troops whodied after exposure to mustard during World WarI. 62 Of the casualties who died, 84% spent at least 4days hospitalized. The causes of death from mustardexposure are pulmonary insufficiency from airwaydamage, superimposed infection, and sepsis. Rarely,the mustard exposure is overwhelming and causesdeath within 1 to 2 days; in these circumstances, deathresults from neurological factors or massive airwaydamage. 10,23 The Willems report on Iranian casualtiestreated in western European hospitals describes morerecent treatment of mustard casualties. Clinical filesof 65 of these casualties were studied in detail. 17 Eightpatients died between 6 and 15 days after exposure.One patient died 185 days after exposure: he hadreceived ventilatory support for an extended periodbecause of severe bronchiolitis complicated by a seriesof loculate pneumothoraces. Most patients returned toIran in fairly good condition after 2 to 10 weeks of treatment.The duration of hospitalization was determinedTABLE 8-4DAY OF DEATH AFTER EXPOSURE IN WORLDWAR I FATAL MUSTARD CASUALTIES*Day of Death (After Exposure)Percentage of Deaths≤1 12 23 54 85 22≥6 62*In 4,167 British troops who died from mustard exposure.Data source: Gilchrist HL. A Comparative Study of World War CasualtiesFrom Gas and Other Weapons. Edgewood Arsenal, Md: US ChemicalWarfare School; 1928: 14.266