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

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Vesicantsmainly by the time needed for healing of the deeperskin lesions. Despite medical advances since WorldWar I, there was a 14% mortality rate among this group;this higher rate is because some of the most severelyinjured Iranian patients were sent to Europe.SkinThe threshold amount of mustard vapor requiredto produce a skin lesion (erythema) is a Ct of about200 mg•min/m 3 . This amount varies greatly dependingon a number of factors, including temperature,humidity, skin hydration, and body site. Warm, moistareas with thin skin, such as the perineum, externalgenitalia, axillae, antecubital fossae, and neck aremuch more sensitive than other areas of the body. Aliquid droplet of about 10 µg will produce vesication.About 80% evaporates, and 10% enters the circulation,leaving about 10% on the skin surface to cause localtopical injury. As little as 1 µg can cause simple vesicleformation. Evaporation of small droplets is rapid andnearly complete in 2 to 3 minutes; amounts largerthan several hundred milligrams may take hours toevaporate. 65Mustard vapor rapidly penetrates the skin at therates of 1.4 µg/cm 2 /min at 70°F, and 2.7 µg/cm 2 /minat 88°F. 27 Liquid mustard penetrates the skin at 2.2 µg/cm 2 /min at 60°F and at 5.5 µg/cm 2 /min at 102°F. 65The mildest and earliest form of visible skin injuryis erythema, which resembles sunburn (Figure 8-2).Erythema begins to appear 1 to 24 hours after theFig. 8-2. Erythema of the chest of an Iranian casualty as itappeared 5 days after his exposure to mustard. He also hada pulmonary injury with an associated bronchopneumoniafrom infection with Haemophilus influenzae.Reproduced with permission from: Willems JL. Clinicalmanagement of mustard gas casualties. Ann Med Milit Belg.1989;3S:13.Fig. 8-3. The back of an Iranian casualty seen 16 hours afterexposure to mustard. Note the large bullae that have resultedfrom coalescence of small vesicles.Reproduced with permission from: Willems JL. Clinicalmanagement of mustard gas casualties. Ann Med Milit Belg.1989;3S:8.skin is exposed to mustard, although onset can belater. Erythema is usually accompanied by pruritus(itching), burning, or stinging. After a small exposure,this might be the extent of the lesion. More commonly,small vesicles will develop within or on the peripheryof the erythematous areas (like a string of pearls);these vesicles will later coalesce to form larger blisters(Figure 8-3). The effects from liquid mustard appearmore rapidly than the effects from mustard vapor.Characteristically, the onset of erythema is about 4to 8 hours after mustard exposure. Vesication beginsabout 2 to 18 hours later and may not be complete forseveral days.The typical bulla (large blister) is dome-shaped,thin-walled, superficial, translucent, yellowish, andsurrounded by erythema; it can be 5 cm in diameteror larger (Figure 8-4). The blister fluid is initially thinand clear or slightly straw-colored; later it turns yellowishand tends to coagulate. 17,65,66 The blister fluiddoes not contain mustard and is not itself a vesicant.Thiodiglycol, a breakdown product of mustard, hasbeen found in blister fluid and can be used to aid indiagnosis. Vapor injury is generally a first- or seconddegreeburn; liquid mustard may produce deeperdamage comparable to a third-degree burn.After exposure to extremely high doses, such asthose resulting from contact with liquid mustard, lesionsmay be characterized by a central zone of coagulationnecrosis, with blister formation at the periphery.These lesions are more severe, take longer to heal, andare more prone to secondary infection than lesionsresulting from smaller doses. 29267
Medical Aspects of Chemical WarfareabFig. 8-4. Large and extensive bullae on (a) the hands and (b)the feet of Iranian casualties as they appeared 5 days afterexposure to mustard. In (c), also day 5, some of the bullaeare disrupted and have a purulent base. Note the extensiveedema of the surrounding skin. The whitish material is anantimicrobial salve.Reproduced with permission from: Willems JL. Clinicalmanagement of mustard gas casualties. Ann Med Milit Belg.1989;3S:14, 15.cThe healing time for mustard skin lesions dependson the severity of the lesion. Erythema heals withinseveral days, whereas severe lesions may require severalweeks to several months to heal, depending on theanatomical site, the total area of skin surface affected,and the depth of the lesion (Figure 8-5). 17A characteristic of the cutaneous mustard injurythat Willems reported in the Iranian casualties wastransient blackening, or hyperpigmentation, of the affectedskin (Figure 8-6). 17 When the hyperpigmentedskin exfoliated, epithelium of normal color wasexposed. Vesication was not necessary for hyperpigmentationto occur. The syndrome of hyperpigmentationand exfoliation was commonly recognized inWorld War I casualties, but less commonly in laboratoryexperiments using liquid mustard. 17 When theinitial skin damage, inflammation, only stimulatesthe melanocyte (pigment cell), increased pigmentation(hyperpigmentation) can be seen. When themelanocyte is destroyed, hypopigmentation occurs,which lasts several months and occasionally becomespermanent. This blotchy hyperpigmentation andabFig. 8-5. Healing of a deep erosive mustard burn of the hand. (a) The appearance on day 49. Epithelialization occurred byingrowth of cells from patches of less injured skin. (b) The appearance on day 66, when complete epithelialization had occurred.The thin and fragile nature of the new skin is clearly apparent.Reproduced with permission from: Willems JL. Clinical management of mustard gas casualties. Ann Med Milit Belg.1989;3S:36.268
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The Coat of Arms1818Medical Departm
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Textbooks of Military MedicinePubli
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MEDICAL ASPECTS o fCHEMICAL WARFARE
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ContentsContributorsForeword by The
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ContributorsMICHAEL ADLER, PhDResea
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DONALD M. MAXWELL, MSResearch Chemi
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ForewordThe US military has been co
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PrefaceA significant concern for th
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PrologueThe original edition of Med
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Medical Aspects of Chemical Warfare
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Nerve AgentsChapter 5NERVE AGENTSFR
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Nerve AgentsAbout 10,000 to 30,000
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Nerve Agentsphorofluoridate (DFP) w
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Nerve AgentsFig. 5-2. This schemati
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Nerve AgentsExhibit 5-1 continuedis
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Nerve Agentsactivity but only 15% t
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Nerve AgentsTABLE 5-3CHEMICAL, PHYS
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Nerve AgentsTABLE 5-4EFFECTS OF EXP
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Nerve Agentsaffecting the other eye
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Nerve Agentsmay cause severe rhinor
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Nerve Agentsof jerks and tremor.Cen
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Nerve Agentsand they were decreased
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Nerve Agentsnerve agent toxicity on
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Nerve Agentspatient. Decontaminatio
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Nerve AgentsFig. 5-5. The Mark I ki
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Nerve Agentsadministered intramuscu
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Nerve Agentsthat hydroxamine reacti
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Nerve AgentsOral administration may
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Nerve AgentsTABLE 5-7RECOMMENDED TH
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Nerve Agentsimpairment such as whee
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Nerve Agentssuboptimal, manner. The
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Nerve Agentsthan those who did not.
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Nerve Agentssible for binding nerve
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Nerve Agentsfor comparison was not
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Nerve AgentsTABLE 5-11EFFECTS OF PY
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Nerve Agentstivity of smooth muscle
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Nerve Agents38. Grob D, Lilienthal
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Nerve Agents77. McDonough JH, Shih
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Nerve Agents117. McLeod CG Jr, Sing
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Nerve Agents154. Tryphonas l, Veino
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Nerve Agents193. Funckes AJ. Treatm
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PROCESSMedical Aspects of Chemical
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Triage of Chemical CasualtiesChapte
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Triage of Chemical Casualtiesreceiv
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Triage of Chemical Casualtiesentran
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Triage of Chemical Casualtiescatego
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Triage of Chemical CasualtiesIn a f
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Triage of Chemical Casualtiesnose)
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Triage of Chemical CasualtiesWith n
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Triage of Chemical Casualties14. Sa
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Decontamination of Chemical Casualt
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• Analyze using GC-MS with methan
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Abbreviations and AcronymsAbBreviat
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Abbreviations and AcronymsPADPRP: p
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Medical Aspects of Chemical Warfare (2008) - The Black Vault

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