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

Medical Aspects of Chemical WarfareTABLE 21-5PEDIATRIC SIGNS OF MUSTARD EXPOSUREOcular Cutaneous Respiratory OtherConjunctivitis (94%)Eye burningPalpebral edema (81%)Apraxia of eyelid opening (63%)Keratitis (38%)Blepharospasm (25%)Corneal ulceration (19%)Chemosis (6%)PhotophobiaLacrimationOphthalmodyniaDiplopiaItchy eyesErythema (94%)Hyperpigmentation (75%)Ulceration (69%)Erosion (63%)Blister (56%)Edema (50%)Vesicles (31%)Hypopigmentation (13%)Dermal pain and burningDry cough (81%)Dyspnea (63%)Crepitation (50%)Wheezing (25%)Burning sensation of the upperrespiratory tractSore throatSneezingNasal secretionsDysphoniaData source: Azizi MD, Amid MH. Clinical presentation of chemical warfare injuries in children and teenagers. Med J Islamic Rep Iran.1990;4(2):103–108.junctions are not fully developed, 46–50 the time betweenexposure and the onset of blisters is shortened in children,and the number and severity of blisters increases.76 Ocular symptoms tend to be more pronounced inchildren because of their inability to protect themselvesand their tendency to rub their eyes. 76,78 Children arealso more susceptible to pulmonary injury for reasonspreviously discussed. 76,78 One case report looked atthe long-term effects of mustard exposure in a child. 10The child suffered a severe chemical pneumonia andchronic bronchiolitis. Finally, signs of gastrointestinaltoxicity may be greater in children because of fluid lossand lower intravascular volume reserves. 76The decision to evacuate and hospitalize adultmustard casualties is based on the extent of exposure(total body surface area affected > 5% requires hospitalization),severity of the skin lesions, and the extentof multiple organ involvement, 80 but the threshold tohospitalize children with mustard injuries should belower.TreatmentDecontamination and supportive therapy are themainstays of treatment for mustard exposure; antidotesdo not exist. 76 Adult decontamination mayinclude bleach solutions; however, this method cancause greater toxicity in children, so soap and waterare the preferred agents to use for decontaminatingchildren (Table 21-6). 76 Supportive care consists ofmanaging pulmonary and skin manifestations withmedications such as cough suppressants and topicalsilver sulfadiazine. 76–78There are currently no standardized guidelines ofcasualty management nor drugs available to preventmustard’s effects on skin and mucous membranes. 77,80Treatment includes prompt decontamination, blisteraspiration or deroofing (epidermal removal), physicaldebridement, irrigation, topical antibiotics, and steriledressing for cutaneous mustard injuries. 77,80 Currenttreatment strategies rely on symptomatic managementto relieve symptoms, prevent infections, and promotehealing. The general recommendations for treatingmustard casualties are described in Chapter 8 of thistextbook, the Medical Management of Chemical CasualtiesHandbook, 81 the Field Management of Chemical CasualtiesHandbook, 82 the NATO Handbook on the Medical Aspectsof NBC Defensive Operations, 83 and other references. 80Iranian physicians treating pediatric casualties ofmustard vapor during the Iran-Iraq War found thatmost pediatric casualties presented with multiple organsystem involvement (skin, ocular, gastrointestinal,bone marrow, respiratory, etc). 78Dermatological Management. The goal of blistermanagement is to keep the patient comfortable andthe lesions clean and to prevent infection. Becausechildren are especially anxious at the sight of bullaeand erythema, in addition to the burning, pruritus, andallodynia associated with mustard blisters, anxiolyticsmay be appropriate to calm pediatric casualtiesand prevent them from picking at bullae. 77 Burningand itching associated with erythema can be relievedby calamine lotion or soothing creams, such as 0.25%camphor, menthol corticosteroids, antipruritics (ie,670