• Sulfur mustards are yellow to brown oily liquids with a slight garlic or mustard odor. Although volatility is low, vapors can reach hazardous levels during warm weather. Sulfur mustards are vesicants causing skin, eye, and respiratory tract injury. Although these agents cause cellular changes within minutes of contact, the onset of pain and other clinical effects are typically delayed for 1 to 24 hours. Sulfur mustards are highly reactive alkylating agents that damage tissues at the point of contact and are also absorbed systemically.
• Responders should obtain assistance in identifying the chemical(s) from container shapes, placards, labels, shipping papers, and analytical tests. General information on these identification technicques is located in Emergency Response Guidebook.
• Identification Tools - CHEMM-IST, WISER, Nerve Agents Chemical Properties
• Devices - M8, M9 chemical agent detector paper (liquid agents), Chemical Agent Detector C2 Kit (liquid and vapor), M18A3 chemical agent detectors (vapor), M256A1 chemical agent detector kit (liquid and vapor), Draeger CDS Kit (vapor and aerosol), Chemical Agent Monitor (CAM) (vapor)
• A comprehensive source for the selection of chemical identification equipment is the Guide for the Selection of Chemical Detection Equipment for Emergency First Responders, Guide 100-06, January 2007, 3rd Edition published by the Department of Homeland Security to assist with this process.

PPE required: level B-C

Most likely B-C PPEs will be adequate. Levels As may be required if the hospital is close to the site of exposure and/or there is concern for vapor exposure (bring in HAZMAT for Level A PPEs).

Respiratory Protection: Positive-pressure, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to potentially unsafe levels of mustard vapor.

Skin Protection: Chemical-protective clothing is recommended because of the potential of inflammatory and corrosive effects

• Level A - protective clothing is the highest level of protection Level A includes a Self Contained Breathing Apparatus (SCBA) with a fully encapsulating vapor tight suit with gloves and booties attached to the suit (tanks last from 1/2 hour to 1 hour).
• Level B - requires the use of SCBA but has lesser skin protection. Level Bs are chemical resistant suits that are designed for splashes of liquids but not for gas or vapor hazards. A young soldier can last about 2 hours on a hot day with a external air hose.
• Level C is similar to B with the exception of the type of respiratory protection. The SCBA is replaced with an Air Purifying Respirator.
• Level D protective clothing is utilized when there are no respiratory hazard and no major skin hazard considerations. Level D for hospital personnel includes scrubs, safety glasses, shoe covers, and possibly a face shield.

Link to reference section for acute event PPE related safety information

Chemical casualty triage is based on walking feasibility, respiratory status, age, and additional conventional injuries. The triage officer must know the natural course of a given injury, the medical resources immediately available, the current and likely casualty flow, and the medical evacuation capabilities.

• SALT Mass Casualty Triage - United States Government Recommendation
• START Adult Triage Algorithm
• JumpSTART Pediatric Triage Algorithm

• Check triage tag/card for any previous treatment or triage.
• Survey for evidence of associated traumatic/blast injuries.
• Observe for sweating, labored breathing, coughing/vomiting, secretions.
• Severe casualty triaged as immediate if assisted breathing is required.
• Blast injuries or other trauma, where there is question whether there is chemical exposure, victims must be tagged as immediate in most cases. Blast victim's evidence delayed effects such as ARDS, etc.
• Mild/moderate casualty: self/buddy aid, triaged as delayed or minimal and release is based on strict follow up and instructions.
• If there are chemical exposure situations which may cause delayed but serious signs and symptoms, then over-triage is considered appropriate to the proper facilities that can observe and manage any delayed onset symptoms.
• Expectant categories in multi-casualty events are those victims who have experienced a cardiac arrest, respiratory arrest, or continued seizures immediately. Resources should not be expended on these casualties if there are large numbers of casualties requiring care and transport with minimal or scant resources available.
• In a given category prioritize a child, pregnant woman over a non-pregnant adult.

Most casualties from mustard exposure require evacuation to a facility where they can receive care for several days to months. Patients arriving directly from the scene of potential exposure (within 30 - 60 minutes) will rarely have symptoms. The sooner after exposure that symptoms occur, the more likely they are to progress and become severe.

Immediate - mustard casualties, especially those with eye involvement are often classified as immediate for the purposes of decontamination. Immediate decontamination within 2 minutes of exposure can decrease the damage to the tissues. Later decontamination may limit the severity of the lesions. Casualties with liquid mustard burns over 50 % or more of the body surface area, or burns of a lesser extent coupled with more than minimal pulmonary involvement (the median lethal dose of liquid mustard will cover about 25 % of the body surface area), have a guarded outcome and will require intensive care for weeks to months (potentially in an aseptic environment).

Delayed - most mustard casualties are generally classified as delayed for both medical attention and decontamination.

Minimal - these casualties have a very small lesion (< 2 % of body surface area in a noncritical area).

Expectant - at less than 4 hours post exposure casualties with burns over 50 % or more of body surface secondary to liquid exposure; lower respiratory signs (dyspnea).

Category (Priority)	Time of Onset	Clinical Signs
Immediate (1)	< 4 up to 12 hours post exposure	Lower respiratory signs (dyspnea)
Delayed (2)	> 4 hours (eye and skin); or > 12 hours (respiratory) post exposure	Eye lesions with impaired vision; skin lesion covering 2 to 50 % of body surface area for liquid exposure or any body surface burn for vapor exposure; lower respiratory symptoms (cough with sputum production, dyspnea)
Minimal (3)	> 4 hours post exposure	Minor eye lesion with no vision impairment; skin lesion < 2 % of body surface area in noncritical areas; minor upper respiratory symptoms (cough, sore throat)

Quickly ensure that the victim has a patent airway. Maintain adequate circulation. If trauma is suspected, maintain cervical immobilization manually and apply a decontaminable cervical collar and a backboard when feasible. Apply direct pressure to stop arterial bleeding, if present.

• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey
  

• Inhalation - Sulfur mustards are readily absorbed from the respiratory tract.
  • Injury develops slowly and intensifies over several days. The vapors are heavier than air. When inhaled, these agents may cause systemic effects.
• Skin/Eye Contact
  • Mustard vapor and liquid are absorbed through the eyes, skin, and mucous membranes.
  • Skin and eye exposure to vapor sulfur mustard and skin and eye exposure to liquid mustard may cause systemic toxicity.
• Ingestion may cause local and systemic effects.

Clinical Effects and Time of Onset by Severity of Exposure to Sulfur Mustard

Acute

• Skin - dermal exposure produces a dose related injury. After a latent period of 4 - 12 hours, victims develop erythema that may progress to vesicle and /or bulla formation and skin necrosis. Warm, moist, and thin skin is at increased risk of mustard injury, in particular the perineum, scrotum, axillae, antecubital fossa, and the neck (infants, young children, and pregnant women are at increased risk). The vesicule fluid does not contain mustard as the chemical reactions are completed after the first several minutes. Skin exposure to vapor typically results in first and second degree burns while liquid may cause full-thickness burns.
• Eye - latency of ocular effects also occurs after several hours post exposure. Ocular effects include pain, miosis, photophobia, lacrimation, blurred vision, blepharospasm, and corneal damage. Permanent blindness is rare with recovery generally occurring within a few weeks.
• Respiratory Tract - following a latency period of several hours inhalation of sulfur mustard results in chemical tracheobronchitis. Hoarseness, cough, sore throat, and chest pressure are common initial complaints. Productive cough associated with fever and leukocytosis is common 12-24 hours following exposure, and represents a sterile bronchitis or pneumonitis.
• GI - nausea and vomiting are common in the first few hours.
• Bone Marrow suppression may occur secondarily to high dose exposures.
• Link to Toxic Syndromes
• Link to Primary and Secondary Survey

• The delay between exposure and the development of symptoms may present a diagnostic challenge, particularly if the exposure was undetected and the symptoms are mild.
• A mild exposure affecting the eyes may appear similar to allergic or infectious conjunctivitis or mild eye trauma such as a corneal abrasion.
• A respiratory vapor exposure may initially mimic allergic rhinitis or an asthmatic episode.
• Skin exposures may present as burns, which may be attributed to other etiologies, including a scald, or an infectious rash such as staphylococcal scalded skin syndrome.
• Skin exposure is initially painless with the erythema, skin burning, and pain occuring later. Agents such as lewisite are instantly painful.
• GI symptoms may be limited to nausea and vomiting which may be consistent with a mild gastroenteritis.
• Link to Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST)

• Children exposed to nitrogen mustards are likely to experience increased severity of the same clinical effects seen in exposed adults.
• Infants, toddlers, and young children do not have the motor skills to escape from the site of an incident.
• Exposure may be greater due to the higher number of respirations per minute in children and pregnant women.
• The high vapor density of gases places their highest concentration close to the ground which is in the lower breathing zone of children.
• The more permeable skin of newborns and children in conjunction with a larger surface-to mass ratio may also result in increased exposure.
• The increase in number/dilatation of blood vessels in the skin in pregnancy can result in increased mustard absorption as well as direct skin injury.
• Vesicants and corrosives produce greater injury to children because of poor keratinization of their skin
• Having less fluid reserve increases the child's risk of rapid dehydration or shock after vomiting and diarrhea.
• Link to Primary and Secondary Survey

Because of the delay in onset of clinical symptoms following mustard exposure it is unlikely supportive therapy will be needed in the hot/warm zones. If there are signs and symptoms of mustard agent toxicity:

• Link to Advanced Treatment in the Treatment Area
• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

If victims can walk, lead them out of the Hot/Warm Zones to the Decontamination Zone. Victims who are unable to walk may be removed on backboards or gurneys; if these are not available, carefully carry or drag victims to safety. Should there be a large number of casualties, and if decontamination resources permit, separate decontamination corridors should be established for ambulatory and non-ambulatory victims.

Consider appropriate management of chemically contaminated children, such as measures to reduce separation anxiety if a child is separated from a parent or other adult.

• Link to Management of the Deceased

Personnel should continue to wear the same level of protection as required in the Hot/Warm Zones

Link to Hot/Warm Zones - Rescuer Protection

If exposure levels are determined to be safe, decontamination may be conducted by personnel wearing a lower level of protection than that worn in the Hot/Warm Zones. However, do not attempt resuscitation without a barrier.

If the victim is symptomatic, immediately institute emergency life support measures. If warranted, treatment should be given simultaneously with decontamination procedures. Quickly ensure that the victim has a patent airway and is ventilating well. Assist ventilation with a bag-valve-mask device equipped with a canister or air filter if necessary. Maintain adequate circulation. Stabilize the cervical spine with a decontaminable collar and a backboard if trauma is suspected. Direct pressure should be applied to control heavy bleeding, if present.

• Link to Supportive Treatment in the Hot/Warm Zones
• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

Antidotes - there are no specific antidotes for mustard agents

Set up Considerations

• Use pictorial and written posted instructions for victims to self decontamination when able, use locale-appropriate multilingual signage.
• Double bag contaminated clothing etc. (place hearing aids, valuables in small bag). Place bag in container by showers.
• Victims who are able may assist with their own decontamination.
• Children and the elderly are at increased risk for hypothermia - provide warm showers, blankets
• Privacy must be considered if possible.
• The decontamination system should be designed for use in children of all ages, by parentless children, the non-ambulatory child, the child with special needs, and also allow families to stay together.
• Use step-by-step child friendly instructions that explain to the children and parents what they need to do, why they are doing it and what to expect.
• Take into consideration that infants when wet are slippery and will need a way to get them through the decontamination process - i.e. plastic buckets, car seats, stretchers...
• Designate a holding area and provide staff to support and supervise the children.
• Recommended age appropriate staffing ratios for untended children:
  • 1 adult to 4 infants
  • 1 adult to 10 preschool children
  • 1 adult to 20 school-age children

Washing Instructions

• If there will be significant delay to decontamination, have the victims rinse off with water exposed skin surfaces and disrobe (disposable clothing kits should be available).
• Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag (removal of clothing, at least to the undergarment level will reduce victim's contamination by 85 %).
• If clothes have been exposed to contamination, then extreme care must be taken when undressing to avoid transferring chemical agents to the skin - i.e. any clothing that has to be pulled over your head should be cut off instead of being pulled over your head.
• If exposure to liquid agent is suspected, cut and remove all clothing and wash skin immediately with soap and water.
• If exposure to vapor only is certain, remove outer clothing and wash exposed skin with soap and water.
• Cover all open wounds with plastic wrap prior to performing head to toe decontamination.
• Flush the exposed skin and hair with plain water for 2 to 3 minutes then wash twice with mild soap. Rinse thoroughly with water. Be careful not to break the patient/victim's skin during the decontamination process.
• Flush exposed or irritated eyes with plain water or saline for at least 15 minutes by tilting the head to the side, pulling eyelids apart with fingers, and pouring water slowly into eyes. Remove contact lenses if easily removable without additional trauma to the eye. If a corrosive material is suspected or if pain or injury is evident, continue irrigation while transferring the victim to the Support Zone.
• Scraping with a wooden stick, i.e. a tongue depressor or popsicle stick, can remove bulk agent.
• Caution - many people shower as they do it at home rather than conducting a rapid decontamination of their bodies. Too aggressive scrubbing can lead to further damage to skin and open wounds.
• Utilizing large amounts of water by itself is very effective (limit pressure in infants).
• If water supplies are limited, and showers are not available an alternative form of decontamination is to use absorbent powders such as flour, talcum powder, or Fuller's earth (0.5% sodium hypochlorite solution is contraindicated).
• Sodium hypochlorite is not recommended for use in infants and young children.
• Certification of decontamination is accomplished by any of the following: processing through the decontamination facility; M8, M9 tape; M256A1 ticket; or by the Chemical Agent Monitor (CAM)
• If still contaminated, repeat shower procedure.

Decontamination of First Responder

• Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
• Reactive Skin Decontamination Lotion (RSDL) - designed to be carried by First Responders and warfighters, this lotion was found to be highly effective in removing and or neutralizing groups of chemical warfare agents. RSDL performed significantly better than the predicate device against the agents tested. The foam applicator immediately removes the CW agent off the skin and the CW Agent is chemically changed to a non-toxic form. Once the CW Agent is decontaminated, RSDL leaves a non-toxic residue that can be rinsed off when operational conditions allow.
• Avoid combining bleach (hypochlorite) with RSDL - the combination is combustible
• Links - RSDL background information
• Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE has been removed.
• Place all PPE in labeled durable 6-mil polyethylene bags.

Decontamination of Infants and Children

• Video: Decontamination of Infants and Children (HHS/AHRQ, Children's Hospital Boston) (Watch video)
  • Decontamination of Children (HHS/AHRQ) provides a step-by-step decontamination demonstration in real time, and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination.

Wound Management

• Link to Wound Management

References

• Medical Management of Chemical Casualties Handbook, 2nd edition, September, 1995
• Braue EH, Boardman CH. Decontamination of Chemical Casualties
• Jagminas L. CBRNE - Chemical Decontamination (eMedicine)

Following decontamination the patient should be reassessed; noting changes in triage category (if any), the need for or the modification of supportive therapy (See ABC reminders/Advanced Treatment).

ABC Reminders

Quickly access airway patency. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Ensure adequate respiration and pulse. Document oxygen saturation. Place on a cardiac monitor.

Link to Primary and Secondary Survey

If the patient is symptomatic, immediately institute emergency life support measures.

In cases of respiratory compromise, secure airway and respiration via endotracheal intubation or laryngeal mask airway (LMA) (use Bag Valve Mask (BVM) if unable to secure airway). There is no antidote for sulfur mustard toxicity. Decontamination within 1 or 2 minutes after exposure is the only effective means of decreasing the effects caused by ensuing tissue damage. Treatment is supportive, typically with delayed onset of symptoms.

Antidotes - there are no specific antidotes for mustard.

Eye

• Sulfur mustard is very rapidly taken up by eye tissues, allowing only a very brief period during which decontamination is of any value in removing the material and preventing injury. Animal data with sulfur mustard indicate that the window of opportunity to remove the unabsorbed compound is very short; perhaps ≤5-10 min.
• Mild conjunctivitis beginning more than 12 hours after exposure is unlikely to progress to a severe lesion. A thorough eye examination, including assessment of visual acuity, should be done. The patient should be treated with a soothing eye solution, such as Visine or Murine, sent home, and instructed to return if the symptoms worsen.
• Early symptoms: Conjunctivitis occurring within 12 hours of exposure or more significant findings such as lid swelling/inflammation indicates a need for inpatient care and observation. Ophthalmic injuries usually heal completely with routine chemical burn care. Victims may become blinded because of a combination of blepharospasm and corneal edema, which completely resolves in most cases. Severe eye injuries may require topical mydriatics, anesthetics, and petroleum jelly to prevent the formation of lid synechiae.
• Sulfur mustard has also been noted to cause many long-term ophthalmologic problems in individuals gassed in military operations or occupationally exposed to the agent. A wide variety of flushing solutions have been recommended in the literature on the basis of anecdotal reports, including water, normal saline, 1.5% sodium bicarbonate solution, saturated sodium sulfate or magnesium sulfate solutions (hypertonic solutions), boric acid solutions, 0.5% dichloramine-T solution in a solvent, and dilute solutions of sodium hypochlorite or potassium permanganate. General toxicologic experience would indicate that prompt flushing is likely to have some value and is unlikely to cause additional harm. In the absence of other information, and considering practical possibilities, it is reasonable to recommend a simple water or saline flush.
• Recommendations for treatment of the affected eye after decontamination are varied and include steroids, antibiotic ointments, topical analgesics, and even no treatment at all. Studies in a rabbit model have shown the potential benefits of anti-inflammatory drugs such as dexamethasone and diclofenac. These studies showed some biochemical and pathological evidence of effectiveness, but neither drug treatment decreased corneal erosions. Anti-inflammatory drugs have shown good effects in other forms of irritant eye injury.
• This reference includes a combination of FDA-labeled as well as off-labeled indications. Refer to DailyMed for the labeling status of the individual medications.

Skin exposure

• Early or significant symptoms: Erythema beginning less than 12 hours after exposure, with or without blistering, should be admitted for further evaluation. A patient with significant erythema or blistering should be treated in the same manner. Military recommendations are to keep skin lesions clean and treat with topical antibiotics. Small blisters need not be debrided but larger bullae should be unroofed. Skin healing can take weeks to months, although skin grafting is rarely necessary.
• Note - mustard blister fluid does not contain any appreciable concentration of mustard.
• Later symptoms: A small area of erythema beginning later than 12 hours after exposure is unlikely to progress to a significant lesion. The patient should be examined, treated with a soothing lotion, sent home and instructed to return if progression occurs.

Airway exposure

• Later or mild symptoms: Patients with a mild cough, irritation of the nose and sinuses, and/or sore throat beginning later than 12 hours after exposure should be told to use a cool steam vaporizer, cough drops, and lozenges, sent home and instructed to return if symptoms worsen.
• Significant symptoms: Patients with severe effects (laryngitis, shortness of breath, productive cough) seen any time post-exposure should be admitted directly to critical care unit after decontamination. Those with less severe effects should be admitted to a routine care ward. Respiratory tract injuries are treated with antitussives, inhaled bronchodilators, mucolytics, and oxygen supplementation. Early intubation should be considered for severe airway involvement to assist in ventilation, provided positive airway pressures, and facilitate removal of pseudomembranes and debris.
• Several anti-inflammatory and sulfhydryl-scavenging agents have shown benefit in animals as prophylactic therapy (or if given immediately upon exposure).
• Bronchospasm and obstruction from sloughed membranes occur in the more serious cases. Productive cough associated with fever and leukocytosis is common 12-24 hours after exposure and represents a sterile bronchitis or pneumonitis. Secondary bacterial pneumonias may occur after that time period.

Neutropenia

• Sulfur mustard induced neutropenia can be treated with granulocyte colony-stimulating factor (off label use).

Ingestion exposure

• Do not induce emesis.
• If the ingestion is small and the patient is alert and able to swallow, give 4 to 8 ounces of milk or water to drink.

There is no evidence that activated charcoal is beneficial. Cardiorespiratory failure should be treated according to advanced life support (ALS) protocols.

Other Aspects of Supportive Care:

• Provide fluid and nutritional support and resuscitation
• Ensure adequate pain control
• Treat complicating injuries/infections

Link to Basic and Advanced Life Support

Link to Burn Triage and Treatment

• Respiratory Tract - chronic respiratory sequale include chronic bronchitis, bronchiectasis, pulmonary fibrosis, interstitial lung disease, emphysema, and bronchiolitis obliterans.
• Eye - a delayed keratitis may also occur, sometimes many years after ocular exposure.
• Skin - long term dermal effects include; changes in pigmentation, increased sensitivity to sunlight, burns easily in bright sunlight, increased incidence of melanocytic nevi and cherry angiomas, and lacks sweat glands.
• Neurological - chronic neuropathic symptoms may occur in burned areas.

• Routine lab studies should be obtained on all patients requiring admission: CBC, glucose, and serum electrolytes.
• Chest x-ray and pulse oximetry (or ABG measurements) are recommended for inhalation exposures.
• A test for urine thiodiglycol, a metabolite of mustard, can be performed at specialized laboratories, but is not a routine laboratory measure.
• The CDC and USAMRID can perform a sulfur mustard adduct assay which can demonstrate the sulfur mustard injury for weeks after injury (this is not FDA approved).

• Link to Surveillance for Possible Chemical Emergencies
• Link to Management of the Deceased

Follow-up Instructions

• Call your doctor or the Emergency Department if you develop any unusual signs or symptoms within the next 24 hours, especially:
  • coughing, wheezing, shortness of breath, or discolored sputum
  • increased pain or discharge from injured eyes
  • increased redness, pain, or a pus-like discharge from injured skin
  • fever or chills
• No follow-up appointment is necessary unless you develop any of the symptoms listed above.
• Call for an appointment with Dr. _____________ in the practice of ___________________.
  When you call for your appointment, please say that you were treated in the Emergency Department at ____________ Hospital by _______________ and were advised to be seen again in ______ days.
• Return to the Emergency Department/Clinic on __________ (date) at ____________ AM/PM for a follow-up examination.
• Do not perform vigorous physical activities for 1 to 2 days.
• You may resume everyday activities including driving and operating machinery.
• Do not return to work for _______ days.
• You may return to work on a limited basis. See instructions below.
• Avoid exposure to cigarette smoke for 72 hours; smoke may worsen the condition of your lungs.
• Avoid drinking alcoholic beverages for at least 24 hours; alcohol may worsen injury to your stomach or have other effects.
• Avoid taking the following medications: ________________________________
• You may continue taking the following medication(s) that your doctor(s) prescribed for you:
  _________________________________________________________________
  _________________________________________________________________
  _________________________________________________________________
  
• Other instructions:
  _________________________________________________________________
  _________________________________________________________________
  _________________________________________________________________
  
  

• Provide the Emergency Department with the name and the number of your primary care physician so that the ED can send him or her a record of your emergency department visit.
  
  
• You or your physician can get more information on the chemical by contacting: ____________________________ or ____________________________, or by checking out the following Internet Web sites: ________________________; ___________________________.

Signature of patient    _____________________________________ Date _____________

Signature of physician _____________________________________ Date _____________

Adapted from Medical Management Guidelines for Blister Agents: Sulfur Mustard Agent H or HD (C4H8Cl2S), Sulfur Mustard Agent HT (ATSDR/CDC)

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