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

Medical Aspects of Chemical Warfareupper respiratory irritation, cough, dyspnea, and skinburns, as well as pulmonary lesions if exposures occurin confined spaces. 144 Hospitalizations were reportedby Thorburn following the release of CN into 44 prisoncells. 144 Twenty-eight inmates sought medical attention,and eight of them were hospitalized. All eight complainedof malaise, lethargy, and anorexia. Five hadpharyngitis, three of whom developed pseudomembranousexudates several days later. Three also developedtracheobronchitis with purulent sputum, butno infiltrates were seen on chest radiographs. Fourinmates had facial burns, and three had bullae on thelegs. The most severely affected had first- and seconddegreeburns over 25% of his body. Another inmatewas admitted 5 days after the incident with a papulovesicularrash on his face, scalp, and trunk, whichhad appeared 2 days earlier. Ten inmates were treatedas outpatients for first- and second-degree burns, andsix had localized papulovesicular rashes. Ten hadconjunctivitis with edema of the conjunctiva, and insome, the eyelids were closed by the swelling. Nonehad corneal injuries or permanent eye damage. Thepatients with laryngotracheobronchitis were treatedwith bronchodilators, postural drainage, and positivepressureexercises. Two were given short-term, highdoses of steroids, but none received antibiotics. Onerequired bronchodilator therapy 3 months later, butthe others made prompt recoveries.Stein and Kirwin 145 reported another prison incidentin which inmates confined to individual cellswere exposed to a “prolonged gassing” with CN estimatedto last 110 minutes. The windows and doorswere closed and the ventilation was off. The CN wasdisseminated by at least six thermal grenades of CN,fourteen 100-g projectiles of CN, and more than 500mL of an 8% solution of CN. The calculated dosageof the exposure from just the CN projectiles was aCt of 41,000 mg•min/m 3 . Following the exposuresome of the prisoners had coughing and varyingdegrees of illness, and at least three received medicaltreatment, although details were not available tothe authors. One prisoner was found dead under hisbunk 46 hours postexposure. Other prisoners reportedthat the prisoner who died had “red eyes,” vomitedbloody material, and had sought medical attentionon several occasions. The autopsy findings includedcyanosis of the face and head, edema and congestionof the lungs, alveolar hemorrhage, necrosis of the mucosallining of the lungs, bronchopneumonia, and noevidence of physical injury. The lungs had subpleuralpetechiae, hyperemia, mild edema, and patchy areasof consolidation. Microscopic examination showedbronchopneumonia clustered around exudate-filledbronchioles. The larynx and tracheobronchial tree werelined with an exudative pseudomembrane, which onmicroscopic examination proved to be a fibrin-richexudate containing polymorphonuclear leukocytesand their degenerating forms. There was no evidenceof gastrointestinal hemorrhage, but other organs hadpassive hyperemia. 145Chapman and White 146 reported the death of anindividual who had locked himself in a room in hishouse during an altercation with the police. A singleCN grenade containing 128 g of CN was throwninto the room, which was approximately 27 m 3 . Theindividual remained in the room for 30 minutes, fora Ct of 142,000 mg•min/m 3 . This exposure is about10 times higher than the estimated human LCt 50. Onadmission to the hospital, his respirations were 24 perminute, conjunctiva were suffused, pupils were smalland unreactive, and mucoid discharge from his noseand mouth was abundant. His lungs were clear, andan occasional premature ventricular contraction wasevident on the electrocardiogram. He remained in asemicomatose condition for approximately 12 hours,then suddenly developed pulmonary edema and died.The relevant findings on autopsy included cyanosis,frothy fluid in the mouth and nose, acute necrosis of themucosa of the respiratory tract with pseudomembraneformation, desquamation of the lining of the bronchioleswith edema and inflammation of the walls, and aprotein-rich fluid in most of the alveolar spaces. Fociof early bronchopneumonia were also present.Stein and Kirwan 145 also obtained information onthree other cases of death following CN exposures fromother medical examiners. Although details were scanty,the autopsy findings were similar in all three cases. Theindividuals were all confined individually in relativelysmall spaces, and the exposures were for 10 minutesin one case and for hours in the other two. 145Thus deaths from high concentrations of CN mayoccur and have been reported. Postmortem examinationsrevealed edema and congestion of the lungs,alveolar hemorrhage, necrosis of the mucosal liningof the lungs, and bronchopneumonia. 144–146Cutaneous effects. Although in animal studies thecutaneous effects seen consisted mainly of erythema, inhumans, pain can occur without tissue injury and maybe bradykinin mediated. Local tissue irritation andburns may result from the hydrochloric acid formedon moist tissues. 60In his 1925 textbook, Vedder stated that in fieldconcentrations, CN does not damage human skin,although the powder might produce burning or slightrubefaction and sometimes small vesicles. 147 In 1933Kibler 148 reported a case of primary irritant dermatitisin a soldier and three cases in civilian employees whoprobably had allergic dermatitis from working around462