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

Vesicantsdiagnosis. Friction, plants, insects, and other diseasesalso cause blisters.Laboratory TestsNo “routine” laboratory test for mustard exposureexists. Investigational studies have demonstratedthe presence of significant amounts of thiodiglycol, amajor metabolite of mustard, in the urine of mustardcasualties (except for being a breakdown productfrom sulfur mustard, thiodiglycol is harmless). In twostudies, Iranian casualties had higher amounts of thiodiglycolin their urine than did control subjects. 103,104In a third study, the urinary thiodiglycol secreted bya laboratory worker accidentally exposed to mustardwas quantitatively measured for a 2-week period (hispostrecovery urine was used as a control); the halflifeof thiodiglycol was 1.18 days. 24 In a more recentaccident, thiodiglycol was also found in the patient’sblister fluid. The procedure for analysis of thiodiglycolis described in the US Army’s Technical BulletinMedical 296, Assay Techniques for Detection of Exposureto Sulfur Mustard, Cholinesterase Inhibitors, Sarin, Soman,GF, and Cyanide. 105 The procedure for handling urinesamples of suspected victims is on USAMRICD’s Website (http://ccc.apgea.army.mil). See also Chapter 22,Medical Diagnostics.Patient ManagementDecontamination within 1 or 2 minutes after exposureis the only established, effective means of preventingor decreasing tissue damage from mustard. Thisdecontamination is not done by medical personnel; itmust be performed by the soldier immediately afterthe exposure. Generally, a soldier will not seek medicalhelp until the lesions develop hours later. By thattime, skin decontamination will not help. Mustardfixes to the skin within minutes, and tissue damagewill already have occurred. 65If any mustard remains on the skin, thorough decontaminationlater will prevent further spreading to otherareas. After several hours, spreading will have occurred,because oily substances flow on warm skin. Decontaminationat that time, however, will prevent mustard fromspreading to personnel who handle the casualty and possiblecontamination of the MTF. By the time skin lesionsdevelop, most mustard will have been absorbed and fixedto tissue. Unless the site was occluded, the remainingunabsorbed agent will have evaporated.Mustard droplets disappear from the surface ofthe eye very quickly. The eye should still be flushedas soon as possible. All mustard casualties must bethoroughly decontaminated before they enter a cleanMTF. This should be done with the realization that bythe time a contaminated soldier reaches an MTF, thisdecontamination will rarely help the casualty; it does,however, prevent exposure to medical personnel.Mustard casualties generally fall into three categories.Individuals in the first category may be returnedto duty. These individuals have a small area oferythema or one or more small blisters on noncriticalareas of their skin; eye irritation or mild conjunctivitis;and/or late-onset, mild upper respiratory symptoms,such as hoarseness or throat irritation and a hackingcough. If these casualties are seen 48 to 72 hours afterexposure, there is good reason to believe that the lesionwill not progress significantly, and they can be givensymptomatic therapy and returned to duty.The second category includes casualties who appearto have non-life–threatening injuries, but who are unableto return to duty. Casualties with the followingconditions must be hospitalized for further care:• a large area of erythema (with or withoutblisters);• an extremely painful eye lesion or an eye lesionthat hinders vision; or• a respiratory injury with moderate symptomsthat include a productive cough and dyspnea.Some of these conditions may develop into life-threateninginjuries. For example, an area of erythema causedby liquid mustard that covers 50% or more of the bodysurface area suggests that the individual was exposedto a potentially lethal dose. Likewise, dyspnea occurringwithin 4 to 6 hours after the exposure suggestsinhalation of a potentially lethal amount of mustard.The third category comprises those casualties whoappear to have life-threatening injuries when they firstpresent at an MTF. Life-threatening injuries includelarge skin burns caused by liquid mustard and earlyonset of moderate to severe pulmonary symptoms.Some of the casualties in this category will die fromtheir injuries. Because conditions listed in categorytwo may become life-threatening (category three), thecategories should be used only to assess a casualty’spresenting condition.Many mustard casualties will fall into the first category,the majority will fall into the second category,and only a very small percentage of casualties willfall into the third category. Data from World War I, inwhich only 3% of mustard injuries were lethal despitethe unsophisticated medical care at that time (eg, noantibiotics, intravenous fluids, or electrolytes), suggestthat most mustard casualties are not severely injuredand most will survive.Most casualties of mustard exposure will, however,277