What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

What Agent Caused More What Agent Caused More Chemical Casualties in World Chemical Casualties in World War I Than All Other Chemical War I Than All Other Chemical

Agents Combined?Agents Combined?

What chemical agent caused What chemical agent caused over 5000 known casualties as over 5000 known casualties as recently as the 1980's and was recently as the 1980's and was

also used on civilian also used on civilian populations including populations including

children?children?

What chemical agent is in the What chemical agent is in the arsenals of at least a dozen arsenals of at least a dozen

countries around the globe and countries around the globe and ready to use against a ready to use against a

perceived enemy?perceived enemy?

MUSTARDMUSTARD

Clifton E. Yu, MD

LTC, MC

Department of Pediatrics

4 4 4Clifton Yu, MDClifton Yu, MDDepartment of PediatricsDepartment of Pediatrics

Walter Reed Army Medical CenterWalter Reed Army Medical Center

VesicantsVesicants

Agent that causes vesicles or blisters Main vesicant in production today: sulfur

mustard Lewisite and Phosgene Oxime (CX) also

classified as vesicants--lesser availability and history of use



Mustard--Why So Mustard--Why So Important?Important?

No antidote Causes lots of morbidity Relatively easy to synthesize Delayed symptoms Children more susceptible to its toxic

effects



HistoryHistory 1000 B.C.--arsenic smokes used by Chinese

against invading Mongol tribes 423 B.C.--Spartans used burning sulfur and

coal smoke to attack Athenians in Peloponnesian War

1854--sulfur mustard first synthesized 1917--chlorine, phosgene, and particularly

mustard used by both British and Germans resulting in thousands of casualties





History (cont.)History (cont.) 1934--nitrogen mustard synthesized 1935--used by Italy against Abyssinia 1937--Japan allegedly uses mustard gas

against China during invasion of Manchuria 1960's--used by Egypt against Yemen 1980's--extensive use of mustard gas against

Iranian soldiers and civilians during Iran-Iraq War



Characteristics of Chemical Characteristics of Chemical AgentsAgents

Volatility--degree to which a substance vaporizes

Persistence--refers specifically to how long the substance stays in the environment and is inversely related to volatility



Characteristics of MustardCharacteristics of Mustard

Oily, yellow to dark brown liquid Garlic or mustard odor Considered a persistent agent Is "radiomimetic" Thought to work as an alkylating agent



12 12Clifton Yu, MDClifton Yu, MDDepartment of PediatricsDepartment of Pediatrics


DetectionDetection

Smell M8, M9 paper, various detectors Clinical recognition

Clinical EffectsClinical Effects

Skin, Eyes, Respiratory Tract

Bone Marrow, GI, CNS in Severe Exposures



Skin EffectsSkin Effects

Latent period of several hours after exposure

Erythema, then blister formation With high dose, skin sloughing Blister fluid not hazardous







Ocular EffectsOcular Effects

Most often caused by vapor Conjunctival inflammation Corneal damage Severe lid edema Rarely permanent blindness



Respiratory EffectsRespiratory Effects

Vapor induced Upper respiratory tract irritation Dyspnea and productive cough Severe necrotizing tracheobronchitis with

pseudomembrane formation Secondary bacterial infection



Bone MarrowBone Marrow

Involvement occurs in severe cases

Usually occurs on day 3 to 5

ANC less than 500 or a precipitous drop portends a high risk of sepsis and death



GI TractGI Tract

Usually manifested by nausea and vomiting Generally transient and not severe Thought to be caused by cholinergic activity

of mustard Delayed nausea and vomiting thought

secondary to generalized cytotoxic activity and mucosal damage to GI tract



CNSCNS

Symptoms not usually prominent Common complaints in World War I were

apathy, depression, and intellectual dullness 83% of hospitalized Iranians in one study

had CNS complaints--usually mild and non-specific



TreatmentTreatment Decon, Decon, Decon !!!

-only effective means of preventing or decreasing tissue damage

-must be performed before entry into a clean MTF

Remainder of treatment depends on the other organ systems involved



SkinSkin

Treat like a burn Erythema treated with soothing lotion, e.g.

calamine Carefully unroof larger blisters Irrigation of denuded areas 3-4X daily



Skin (cont.)Skin (cont.)

Topical antibiotics, e.g. Silvedene Systemic antipruritics Systemic analgesics Fluids and electrolytes



EyesEyes

Thorough irrigation Cycloplegics (e.g. homatropine) Topical antibiotics Vaseline to edges of eyelids Systemic analgesics (e.g. NSAID's)



PulmonaryPulmonary

Upper airway symptoms--steam inhalation, cough suppressants

Avoid using antibiotics early on Intubation if lower resp. sx's progress -attempt before laryngospasm or significant edema develop -direct laryngoscopy with suctioning if evidence of pseudomembrane formation



Pulmonary (cont.)Pulmonary (cont.)

No evidence steroids beneficial routinely

Prolonged assisted or controlled ventilation--bad prognosis



Bone MarrowBone Marrow

If neutropenic, some advocate gut sterilization with non-absorbable antibiotics

Bone marrow transplant or transfusion--may be life-saving in selected cases



GIGI

Atropine (0.4 to 0.6 mg IM or IV for adults) or another anti-cholinergic may be helpful

IV fluids



SummarySummary

Decontamination Treat like a burn patient Liberal use of analgesics Fluids and electrolytes (less than for

standard burns) System specific treatment as necessary



But What About Children?But What About Children? Very little in literature Recent experience with childhood mustard

exposure from Iran-Iraq War (Momeni and Aminjarahari, Int. J. Derm. Vol 33, March 1994)

Earlier onset of skin lesions, more severe More frequent and severe opthalmic,

pulmonary, and GI involvement



SkinSkin

Earlier lesions, more bullae First index case may therefore be a child Traditional decontamination with sodium

hypochlorite (bleach) may be harmful to child's skin

Use copious amounts of soap and water instead



EyesEyes

More frequent and severe eye findings

Same therapeutic interventions



PulmonaryPulmonary

Higher incidence of lung involvement

Increased minute ventilation in children

May have to intubate sooner



GIGI

Increased involvement probably dose related

Children more likely to have protracted emesis

Atropine or other anti-cholinergic in age-appropriate doses may be helpful



Pediatric Exposure--SummaryPediatric Exposure--Summary

Earlier and more severe skin lesions (soap and water for decontamination)

Pay early attention to eyes in virtually all children Be on lookout for earlier and more severe lung

involvement May have to treat GI symptoms more aggressively

(and watch for increase in dehydration)



BE PREPARED!!!BE PREPARED!!!…and get ready for inhalants next week



What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

Documents

clifton yu

mustard clifton

mc department of pediatrics

md ltc

mustard odor

nitrogen mustard

sulfur mustard lewisite

extensive use of mustard