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

Medical Aspects of Chemical Warfarebeginning to present with erythema or those who arein the latent period and suspect an exposure may haveoccurred, systemic administration of an antiinflammatoryagent will likely help decrease the amount of damageultimately induced. HD-induced inflammatoryresponses themselves likely contribute to the severityof the pathology, and numerous animal studies haveshown the benefits of prophylactic or therapeutic useof antiinflammatory agents. 32,146–148 It remains to bedetermined which nonsteroidal antiinflammatory drug(NSAID) or combination of drugs, route of administration,length of administration, and dosing regimen isthe most efficacious in preventing or ameliorating theeffects of HD on skin. It is likely that an NSAID willneed to be administered for 2 to 5 days. Topically deliveredintracellular scavengers such as 4-methyl-2-mercaptopyridine-1-oxideand dimercaprol have proveneffective in animal experiments in reducing the severityof HD-induced cutaneous injuries, and concurrentuse of one of these agents with an NSAID may yieldthe best results. 49,148 Corticosteroid antiinflammatoryagents, such as hydrocortisone (given systemically ortopically for cutaneous HD injuries) and dexamethasone(tested in vitro on primary alveolar macrophagesand given topically for ocular HD injuries), also appearto be promising therapeutic agents. 147–150 Othertopical, steroidal, antiinflammatory agents of muchgreater potency that would likely be very efficaciousif used early in the lesion development stage, such asbetamethasone dipropionate, clobetasol propionate,and diflorasone diacetate. Superpotent (class 1), potent(class 2) and upper midstrength (class 3) topicalcorticosteroids should be tested for their efficacy inameliorating HD-induced cutaneous injury.Depletion of GSH and accumulation of endogenousoxidants and ultimate formation of potent oxidizingspecies (eg, toxic lipid peroxides) may be contributoryfactors in HD-induced cytotoxicity. 31 Topically appliedHD has been shown to negatively affect antioxidantenzymes in blood cells and body tissues of rats. 151 Severalantioxidants have been shown to protect liver andlung from oxidative damage following inhalation orpercutaneous exposure to HD in a mouse model. 152 Ithas been suggested that administration of antioxidantsmay be protective and useful. 153 Thus, initial antioxidanttreatment aimed at affecting the progression oflesions that is instituted during the erythema phasemay prove to be of benefit. The effectiveness and roleof the interruption of the inflammatory cascade by theinclusion of topical and systemic antioxidant agentsas well as a determination of the optimal timing forsuch therapy are important and intriguing avenuesfor investigation. 138Placement of an occlusive or semiocclusive dressingwill likely prove helpful in promoting autolyticdebridement and preventing desiccation. Debridementplays a central role in improving the healing ofcutaneous HD lesions, and beginning the process earlymay be beneficial. How soon following exposure thesedressings can be applied remains to be determined.Although maintaining a moist environment has longbeen known to facilitate wound healing, caution needsto be observed because very early occlusion that increasesmoisture levels in the skin will exacerbate thelesion. 154–157 Additionally, there is a period followingexposure to sulfur mustard during which off-gassingof unbound HD occurs in weanling pigs and Africangreen monkeys. 131,158 These studies have suggestedthat off-gassing after a large exposure can continuefor 24 to 36 hours. Limiting the escape of this unboundHD by occlusive dressings may worsen the lesion, sodelayed placement of occlusive dressings for at least24 hours following exposure should be considered.Keeping clothing off of the exposed area to preventvapor build-up may also be of benefit.Injury assessment. Before HD injuries can be appropriatelytreated, assessment of the injuries must occur.TBSA of the injuries should be established and depthof injury determined. TBSA can be determined usingWallace’s rule of nines and the Lund and Browderchart for estimating burn severity. 159,160 Determinationof injury depth is a more challenging task; however,accurate depth assessment is important because it dictateshow aggressive treatment must be to minimizeor prevent cosmetic and functional deficits.In thermal burns, depth of injury is typically assessedby physical examination, with a goal of woundhealing by day 14. Surface appearance, assessment ofintact sensation, the pinprick test to assess pain, theblanch-capillary return test to evaluate microcirculation,and surface temperature difference betweenburned and unburned skin are often utilized. 161 Usingthese methods, diagnosing very superficial burns(which will heal nonoperatively) and very deep burns(which will require immediate excision and grafting) isrelatively easy for the experienced burn surgeon. Burnsof intermediate depth are more often problematic. Atpresent, no technology reliably predicts which intermediate-depthburns will require grafting and whichwill heal nonoperatively, a decision best left to theexperienced burn surgeon. Determining depth of HDinjuries is even more challenging. First, the full extentof cutaneous injury can take several days to manifest.Secondly, superficial appearances do not accuratelypredict depth of injury nor need for grafting. The presenceof blisters in thermal burns is generally associatedwith superficial dermal injuries, but blistering in HDinjuries can occur in deep dermal/full-thickness inju-282