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

Medical Aspects of Chemical Warfarerecommended for adult use as a 5% mafenidecream 77,80 ; however, it is not recommended in prematureor newborn infants up to 2 months old becauseit may lead to liver problems. 87,88 Mafenide acetatecaused methemoglobinemia in two 2-year-old childrentreated with the cream for 50% surface areaburns. 87,88 One of the patients died from the exposureto mafenide. Furthermore, a burned 12-year-old patientwho was treated with 5% mafenide acetate solutionto eradicate pseudomonas aeruginosa growthreportedly developed methemoglobinemia. 89 The patient’smethemoglobin level was 34.5% 24 hours afterapplication of 5% mafenide acetate cream. Mafenidemay also be unsuitable in pediatrics because it cancause severe pain when applied to partial-thicknesswounds and burns, 80 and it is contraindicated forpatients with metabolic acidosis. If mafenide is usedfor pediatric burns, the healthcare provider shouldbe aware of this rare, lethal complication in the pediatricpopulation and should monitor methemoglobinlevels concurrently.While skin healing can take months, pigmentchanges (hyper- or hypopigmentation) can persist. 77,80Not all burn injuries require treatment at a burn center,but patients will require aggressive pain managementand close observation for the systemic effectsof mustard exposure wherever they are treated. Skingrafting, although rare, has been successfully used fordeep burns. 90Ophthalmology. Ophthalmologic consultation forpediatric mustard injuries will contribute to preventionof ocular scarring and infection. 77 Eyes exposedto mustard should be irrigated to remove traces ofvesicant. Severe ocular involvement requires topicalantibiotics (tobramycin OD) applied several times aday. 77 Topical steroids may be useful in the first 48hours after exposure. Temporary vision loss may alsooccur after mustard exposure 77–79 because of palpebraledema and not corneal damage. 77Respiratory System. Pulmonary examination isnecessary because the conducting and ventilation portionsof the respiratory tract are affected by mustardvapor. 10,77,78 Bronchodilators diminish hyperreactiveairways and should be used if a prior history of asthmaor hyperreactive airways is documented. Furthersupport with humidified oxygen may be required.Ventilatory support may be required for severe cases ofmustard vapor exposure before laryngeal spasm makesintubation difficult. Bronchoscopy is critical for diagnosis,therapeutic dilation for mustard-induced tracheobronchialstenosis, and removal of pseudomembranesthat cause airway obstruction. 77Antibiotic therapy should not be given during thefirst 3 to 4 days after mustard exposure because thetoxic bronchitis produced by mustard is nonbacterial.77 Sputum must be continually monitored withGram’s stains and culture growth to identify thespecific organism responsible for any late-developingsuperinfection. 77 Leukopenia in children, a grave signof mustard exposure, necessitates aggressive supportwith combination antibiotic treatment. 77Gastrointestinal Tract. Atropine or common antiemeticscan be given to provide relief from nauseaand vomiting, which are early signs of mustardintoxication. 76 The best choices for pediatric-specificantiemetics include medications such as promethazine,metoclopramide, and ondansetron. 77 Persistent vomitingand diarrhea are a later sign of systemic toxicityand require prompt fluid replacement. 76,77Bone Marrow Suppression. Mustard, a radiometric,affects rapidly dividing tissues like bone marrow, inaddition to the gastrointestinal tract. 77,80 It also destroyshematopoietic precursor cells; white blood cells havethe shortest lifespan and decrease in number first,followed by red blood cells and thrombocytes. 77 Resultantbone marrow suppression can be treated withfilgrastim injections, 77,80 which stimulate marrow tocreate and release white blood cells.Other Treatment Considerations. Fluid status,electrolytes, and urine output should be monitoredin mustard-intoxicated patients. Tetanus prophylaxisshould also be administered because tetanus may befatal even after a small partial-thickness burn. 91Pulmonary AgentsIn January 2002 a Central Intelligence Agency reportstated that terrorist groups may have less interest inbiological weapons compared to chemicals such as cyanide,chlorine, and phosgene, which can contaminatefood and water supplies. 92 Industrial chemicals, suchas chlorine and phosgene, have advantages that makethem likely candidates to be used by terrorists in thefuture. Additionally, both are fairly easy to manufactureand handle. In the United States, millions of tonsof chlorine and phosgene are produced annually tomanufacture various products. 92 A detailed discussionof the general mechanisms of chlorine and phosgenetoxicity can be found in Chapter 10, Toxic InhalationalInjury and Toxic Industrial Chemicals.Clinical PresentationPediatric signs and symptoms of chlorine gas exposureinclude predominantly ocular, nasal, oropharyngeal,and pulmonary membrane irritation. 92 Respiratorycomplaints are the hallmark of intoxication bythese choking agents. 92 Minor chlorine exposure can672