Vesicants and Cyanide Agents
INTRODUCTION
Vesicants are second only to nerve agents as a concern to the U.S. military. The vesicant agents are mustard, Lewisite, and phosgene oxime. Of these, mustard is the one of most concern due to the delay in the onset of recognizable symptoms, the small amount of agent needed to cause tissue damage, and the resulting systemic damage which can result in death. Soldier medic must be able to recognize if a patient has been exposed to a vesicant, the signs and symptoms associated with each type of vesicant as well as the appropriate methods of treatment.
(1) Sulfur mustard (HD)
(2) Lewisite (L)
(3) Phosgene oxime (CX)
(4) Hydrogen Cyanide
(1) Vesicants as a group are often referred to as "blister agents" due to the fact that blisters often form at the site of exposure
(2) Severity of vesicant damage is affected by the environmental conditions at the time of exposure
(a) Warm, humid conditions will increase the severity of vesicant damage and shorten the time for symptom onset
(b) Cold weather can retard the time of symptom onset, and if the exposed skin remains cold, it can lessen the severity of vesicant damage
(1) Mild exposure
(a) Skin
(i) Erythema - resembles a sunburn
(ii) Blisters (later)
(iii) The fluid contained within a blister will not cause further blister formation
(b) Eyes
(i) Itching
(ii) Tearing
(iii) Gritty feeling
(iv) Burning
(v) Photo phobia
(c) Respiratory
(i) Runny nose
(ii) Sneezing
(iii) Epistaxis
(iv) Hoarseness
(v) Hacking cough
(2) Moderate exposure - eyes
(a) Reddening of the eye
(b) Swelling of eyelids
(c) Moderate pain
(3) Severe exposure
(a) Eyes
(i) Severe pain
(ii) Severe edema of the eyelids and conjunctiva
3) Corneal damage (e.g., ulcers, opacification)
(b) Respiratory
(i) Productive cough with clear, foamy sputum
(ii) Pulmonary edema
(iii) Cyanosis
(iv) Shock
(v) Cardiac failure
(c) Systemic effects
(i) Destruction of bone marrow's ability to produce RBCS, WBCS, and platelets
(ii) Nausea and vomiting
(1) Don protective mask and go to MOPP level 4
(2) Decontaminate exposed skin with the M291 kit
(3) Apply calamine lotion or topical steroid for erythema (done after life-threatening conditions are corrected)
(4) Cover blisters less than the size of a quarter with petrolatum impregnated gauze dressings. If blisters are larger or numerous, evacuate for further treatment
(5) If eyes are affected
(a) Irrigate with saline or water from the casualty's canteen
(b) Place Vaseline on the eyelids to prevent sticking
(c) Do not cover eyes
(d) Evacuate immediately
(6) If respiratory system is affected
(a) Maintain airway
(b) Given humidified oxygen (if available)
(c) Provide mechanical ventilation with supplemental oxygen if needed
(d) Ensure casualty is kept at rest
(e) Evacuate immediately
WARNING: Death is mainly a result of sepsis, infection, and pulmonary damage.
(1) Eyes
(a) Liquid form will cause rapid and devastating effects to the eye
(b) Pain and blepharospasm (involuntary contraction of eyelid muscles) experienced upon contact
(c) Swelling of the eyelids, conjunctiva and cornea
(d) Eyelids will normally be completely closed within one hour
(2) Skin
(a) Immediate pain which diminishes after blisters form
(b) Necrosis of the epithelium occurs within 5 to 10 minutes with area having a grey appearance
(c) Blisters are usually formed at the exposure site within 12 to 18 hours
(3) Respiratory
(a) Burning sensation of the nasal mucosa
(b) Pulmonary edema
(1) Immediate decontamination using the M291 kit
(2) Eyes
(a) Irrigate with saline or water from the casualty's canteen
(b) Place Vaseline on the eyelids to prevent sticking
(c) Do not cover or bandage eyes
(3) Respiratory support
(a) Maintain airway
(b) Given humidified oxygen (if available)
(c) Provide mechanical ventilation with supplemental oxygen if needed
(d) Ensure casualty is kept at rest
(4) Cover blisters less than the size of a quarter with petrolatum impregnated gauze dressings. If blisters are larger or numerous, evacuate for further treatment
(5) Evacuate immediately for further supportive care (e.g., maintenance of fluid balance, nutrition)
(1) Skin
(a) Pain on contact from either the liquid or solid
(b) Blanching along with a surrounding ring of erythema occurs 20 seconds after contact
(c) Wheal (similar to a bee sting) occurs within 30 minutes
(d) Necrosis of skin at the site of contact
(2) Eye
(a) Immediate pain
(b) Severe edma of the eyelids and conjuctiva
(c) Corneal Damage
(1) Immediate decontamination using the M291 kit
(2) Eyes
(a) Irrigate with saline or water from the casualty's canteen
(b) Place Vaseline on the eyelids to prevent sticking
(c) Do not cover to bandage eyes
(3) Respiratory support
(a) Maintain airway
(b) Given humidified oxygen (if available)
(c) Provide mechanical ventilation with supplemental oxygen if needed
(d) Ensure casualty is kept at rest
(4) Evacuate immediately for further treatment of the necrotic skin
(1) Recall the effects and treatment for Phosgene Oxime agent exposure.
Signs, Symptoms and Treatment for Cyanide Exposure (Hydrogen Cyanide), (Blood Agent)
(1) Moderate, from low concentrations - within minutes
(a) Transient increase in rate and depth of breathing
(b) Dizziness
(c) Nausea and vomiting
(d) Headache
(2) Severe
(a) Convulsions - within 30 seconds
(b) Respiratory arrest - within 2-4 minutes
(c) Cardiac arrest - within 4-8 minutes
(3) The onset of symptoms may occur so rapidly that the casualty will have expired before the medic has a chance to render care
(1) Contaminated environment
(a) Mask self then casualty
(b) Evacuate immediately to treatment facility for cyanide treatment (IV with sodium nitrite and sodium thiosulfate)
(c) Administer positive pressure ventilation, if available
(2) Non-contaminated environment
(a) Maintain casualty's airway
(b) Supplemental oxygen with assisted ventilation (if needed)
(c) Evacuate immediately to treatment facility for cyanide treatment (IV with sodium nitrite and sodium thiosulfate)
SUMMARY
The soldier medic must be resourceful in utilizing available manpower for expediting treatment of vesicant agent casualties. Remember that it only takes a small amount of vesicant agent to cause severe damage in a casualty.