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

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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
Medical Aspects of Chemical Warfare4. Dacre JC, Goldman M. Toxicology and pharmacology of the chemical warfare agent sulfur mustard. Pharmacol Rev.1996;48:289–326.5. Jacobson LO, Spurr C, Barron ESG, Smith T, Lushbaugh C, Dick GF. Nitrogen mustard therapy. JAMA. 1946;32:263–271.6. Gilman A. The initial clinical trial of nitrogen mustard. Am J Surg. 1963;105:574–578.7. Goodman LS, Wintrobe MM, Dameshek W, Goodman MJ, Gilman A, McLennan MT. Nitrogen mustard therapy. JAMA.1946;132:126–132.8. Rhoads CP. Nitrogen mustards in the treatment of neoplastic disease: official statement. JAMA. 1946;131:656–658.9. Fries AA, West CJ. Dichloroethylsulfide: mustard gas. In: Fries AA, West CJ, eds. Chemical Warfare. New York, NY:McGraw Hill; 1921:150–179.10. Graef I, Karnofsky DA, Jager VB, Krichesky B, Smith HW. The clinical and pathologic effects of nitrogen and sulfurmustards in laboratory animals. Am J Pathol. 1948;24:1–47.11. Gilchrist HL. Statistical consideration of gas casualties, I: Gas casualties. In: Weed FW, ed. Medical Aspects of Gas Warfare.Vol 14. In: The Medical Department of the United States Army in the World War. Washington, DC: Government PrintingOffice; 1926: 273–279.12. Balali-Mood M, Farhoodi M, Panjvani FK. Report of three fatal cases of war gas poisoning. In: Proceedings of the 2ndWorld Congress on New Compounds in Biological and Chemical Warfare, 24–27 August 1986. Ghent, Belgium: InternationalAssociation of Forensic Toxicologists; 1986. Abstract.13. Alexander SF. Medical report of the Bari Harbor mustard casualties. Mil Surg. 1947;101:1–17.14. Infield G. Disaster at Bari. New York, NY: Bantam; 1988.15. Deeter DP, Gaydos JC, eds. Occupational Health: The Soldier and the Industrial Base. Part 3, Vol 2. In: Zajtchuk R, BellamyRF, eds. Textbooks of Military Medicine. Washington, DC: US Department of the Army, Office of The Surgeon General,and Borden Institute; 1993.16. Carus WS. Chemical Weapons in the Middle East. Washington, DC: The Washington Institute for Near East Policy; 1988.Research Memorandum 9.17. Willems JL. Clinical management of mustard gas casualties. Ann Med Milit Belg. 1989;3S:1–61.18. Aasted A, Darre MD, Wulf HC. Mustard gas: clinical, toxicological, and mutagenic aspects based on modern experience.Ann Plast Surg. 1987;19:330–333.19. Aasted A, Wulf HC, Darre E, Niebuhr E. Fishermen exposed to mustard gas: clinical experiences and cancer riskevaluation. Ugeskr Laeger. 1985;147:2213–2216.20. Jorgensen BS, Olesen B, Berntsen O. Mustard gas accidents near Bornholm. Ugeskr Laeger. 1985;147:2251–2254.21. Wulf HC, Aasted A, Darre E, Neibuhr E. Sister chromatid exchanges in fishermen exposed to leaking mustard gasshells. Lancet. 1985;1:690–691.22. Hobbs FB. A fatal case of mustard gas poisoning. Br Med J. 1944;2:306–307.23. Heully F, Gruninger M. Collective intoxication caused by the explosion of a mustard gas shell. Ann Med Legal.1956;36:195–204.24. Jakubowski EM, Sidell FR, Evans RA, et al. Quantification of thiodiglycol in human urine after an accidental sulfurmustard exposure. Toxicol Methods. 2000;10:143–150.296
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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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xxii
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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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Nerve Agents235. Suzuki T, Morita H
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Nerve Agents274. Pellegrini JE, Bak
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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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