What Agent Caused More
Chemical Casualties in World
War I Than All Other Chemical
Agents Combined?
What chemical agent caused
over 5000 known casualties as
recently as the 1980's and was
also used on civilian
populations including
children?
What chemical agent is in the
arsenals of at least a dozen
countries around the globe and
ready to use against a
perceived enemy?
MUSTARD
Clifton E. Yu, MD
LTC, MC
Department of Pediatrics
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
4
Vesicants
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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
5
Mustard--Why So
Important?
No antidote
 Causes lots of morbidity
 Relatively easy to synthesize
 Delayed symptoms
 Children more susceptible to its toxic
effects

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
6
History
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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
7
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
8
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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
9
Characteristics of Chemical
Agents

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
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
10
Characteristics 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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
11
Detection
Smell
 M8, M9 paper, various detectors
 Clinical recognition

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
12
Clinical Effects

Skin, Eyes, Respiratory Tract

Bone Marrow, GI, CNS in Severe
Exposures
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
13
Skin Effects
Latent period of several hours after
exposure
 Erythema, then blister formation
 With high dose, skin sloughing
 Blister fluid not hazardous

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
14
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
15
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
16
Ocular Effects
Most often caused by vapor
 Conjunctival inflammation
 Corneal damage
 Severe lid edema
 Rarely permanent blindness

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
17
Respiratory Effects
Vapor induced
 Upper respiratory tract irritation
 Dyspnea and productive cough
 Severe necrotizing tracheobronchitis with
pseudomembrane formation
 Secondary bacterial infection

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
18
Bone 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
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
19
GI 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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
20
CNS
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 nonspecific

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
21
Treatment


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
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
22
Skin
Treat like a burn
 Erythema treated with soothing lotion, e.g.
calamine
 Carefully unroof larger blisters
 Irrigation of denuded areas 3-4X daily

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
23
Skin (cont.)
Topical antibiotics, e.g. Silvedene
 Systemic antipruritics
 Systemic analgesics
 Fluids and electrolytes

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
24
Eyes
Thorough irrigation
 Cycloplegics (e.g. homatropine)
 Topical antibiotics
 Vaseline to edges of eyelids
 Systemic analgesics (e.g. NSAID's)

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
25
Pulmonary



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
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
26
Pulmonary (cont.)

No evidence steroids beneficial routinely

Prolonged assisted or controlled ventilation-bad prognosis
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
27
Bone Marrow

If neutropenic, some advocate gut
sterilization with non-absorbable antibiotics

Bone marrow transplant or transfusion-may be life-saving in selected cases
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
28
GI

Atropine (0.4 to 0.6 mg IM or IV for adults)
or another anti-cholinergic may be helpful

IV fluids
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
29
Summary
Decontamination
 Treat like a burn patient
 Liberal use of analgesics
 Fluids and electrolytes (less than for
standard burns)
 System specific treatment as necessary

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
30
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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
31
Skin
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

Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
32
Eyes

More frequent and severe eye findings

Same therapeutic interventions
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
33
Pulmonary

Higher incidence of lung involvement

Increased minute ventilation in children

May have to intubate sooner
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
34
GI

Increased involvement probably dose related

Children more likely to have protracted emesis

Atropine or other anti-cholinergic in ageappropriate doses may be helpful
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
35
Pediatric 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)
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
36
BE PREPARED!!!
…and get ready for inhalants next week
Clifton Yu, MD
Department of Pediatrics
Walter Reed Army Medical Center
37