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

VesicantsClinical EffectsPhosgene oxime affects the skin, eyes, and lungs.The effects are almost instantaneous, and it causesmore severe tissue damage than other vesicants. Acharacteristic of phosgene oxime is the immediatepain or irritation it produces on the skin, in the eyes,and in the airways. No other chemical agent producessuch an immediately painful onset followed by rapidtissue necrosis.SkinPain occurs immediately on contact with the liquidor solid form of this agent. Approximately 5 to 20 secondsafter solutions containing 8% to 70% phosgeneoxime were applied, pain and blanching occurred atthe application site. Following the initial exposure, thesite became grayish, with a border of erythema. Within5 to 30 minutes after the exposure, edema formedaround the edges of the tissue; the tissue later becamenecrotic. During the next 30 minutes, a wheal formedbut disappeared overnight. The edema regressed overthe following 24 hours and the original blanched areabecame pigmented. A dark eschar formed over thefollowing 7 days; this gradually healed from below bygranulation. The lesion extended into the underlyingpanniculus and muscle and was surrounded by aninflammatory reaction. In some subjects, healing wasincomplete 4 to 6 months after exposure. 262 In bothanimal and human subjects, the skin had completelyabsorbed the phosgene oxime within seconds—by thetime pallor appeared. 262EyeEye lesions from phosgene oxime are similar tothose caused by lewisite; these lesions result in immediatepain, conjunctivitis, and keratitis. 261–263 An exactdescription of these effects, however, is not available.AirwaysThe main lesion of phosgene oxime in the lungsis pulmonary edema. This effect occurs after eitherinhalation or systemic absorption of the agent. Thepulmonary edema may be accompanied by necrotizingbronchiolitis and thrombosis of pulmonary venules.A large amount of phosgene oxime on the skin mayproduce pulmonary edema after a several-hour delay;pulmonary thromboses are prominent. 262Patient ManagementThere is no antidote for phosgene oxime, nor isthere a recommended therapeutic regimen. Medicalpersonnel should treat necrotic areas of the skin thesame way other necrotic lesions are treated, by keepingthem clean and preventing infection. The eye lesionsrequire the same care as would be done for damagefrom a corrosive substance. The pulmonary lesion,noncardiac pulmonary edema, should be managedas suggested in Chapter 10, Toxic Inhalational Injuryand Toxic Industrial Chemicals. Decontamination,or self-aid, must be accomplished immediately aftercontact because the agent is absorbed from the skinwithin seconds.SummaryThe US military has considered vesicants to bemajor chemical warfare agents since 1917. Mustard,however, is the only vesicant known to have beenused on the battlefield. Mustard and lewisite (in muchsmaller amounts), are known to be in the stockpiles ofother countries.Mustard was used on a large scale in World WarI, causing a great number of casualties; it was alsoused during the Iran-Iraq War. Data from World WarI indicate that more than 95% of mustard casualtiessurvived but most required lengthy hospitalizations;data from the Iran-Iraq War are not as complete. Ifmustard is ever used again, military medical personnelmust be prepared to accept and care for largenumbers of casualties, who will require long-termcare.REFERENCES1. Prentiss AM. Chemicals in War: A Treatise on Chemical War. New York, NY: McGraw-Hill; 1937.2. Heller CE. Chemical Warfare in World War I: The American Experience, 1917-1918. Fort Leavenworth, Kan: US ArmyCommand and General Staff College, Combat Studies Institute; 1984. Leavenworth Papers No. 10.3. Medema J. Mustard gas: the science of H. Nucl Biol Chem Defense Technol Int. 1986;1:66–71.295