• 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, Mustard 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.

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

PPE required level A

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

Skin Protection: Chemical-protective clothing is recommended because of the potential of chemical burns as well as systemic absorption.

• 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).
• 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.

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 non-critical 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 non-critical 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

• The onset of symptoms from inhaled sulfur mustard vapor is generally slow and intensifies over several days. Both local effects at the site of contact and systemic effects from chemical absorption may develop. Clinical effects often do not occur until hours after exposure.
  • Eye: Effects of exposure to blister agents may not appear for an hour or more. Exposure may cause intense eye pain, swelling, lacrimation, and photophobia. High concentrations may cause corneal edema, perforation, blindness and later scarring.
  • Skin: Direct skin exposure to liquid often causes no immediate pain but erythema and blistering may develop. Pruritic rashes occur within 4 to 8 hours followed by blistering 2 to 18 hours later. Moist skin (axilla, groin) is most susceptible to blistering. Direct skin effects following exposure to sulfur mustard vapor is usually less severe than from liquid contact, depending on the extent of contact. Vapor contact often results in first and second degree burns while liquid contact often causes second and third degree burns.
  • Respiratory: Burning nasal pain, epistaxis, sinus pain, laryngitis, loss of taste and smell, cough, wheezing, and dyspnea may occur. Necrosis of respiratory epithelium may cause pseudomembrane formation and airway obstruction. Exposure concentration-dependent inflammatory reactions in the upper and lower airway begin to develop several hours after exposure and progress over several days.
  • Gastrointestinal: Ingestion may cause chemical burns to the GI tract. Nausea and vomiting may occur after ingestion or inhalation.
  • Systemic Effects: Neurological symptoms at high doses include insomnia, hyperexcitability, and convulsions. Hematopoetic effects include bone marrow suppression and an increased risk for fatal complicating infection, hemorrhage and anemia.
  • Link to hospital clinical sign and symptoms
  • 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.
• 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 Syndrome 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 results in increased mustard absorption as well as increased severity of 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

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.

• Link to Primary and Secondary Survey
  Link to BLS, Adult and Pediatric ALS
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section

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. 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. To 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).

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.

Advanced Treatment

Supportive

Because of the usual delay of onset of symptoms following mustard agent exposure, it is unlikely that first responders will be providing supportive care. If the signs and symptoms of exposure are noted, see Supportive Therapy in the Hospital Management.

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). Patients who are in cardiograms failure should be treated according to advanced life support (ALS) protocols.

• Link to Supportive Treatment in the Hot/Warm Zones
• Link to Basic and Advanced Life Support
• Link to Burn Triage and Treatment

Antidotes

Antidotes - there are no specific antidotes for mustard agents.

Only decontaminated patients or patients not requiring decontamination should be transported to a medical facility. "Body bags" are not recommended.

The patient's names, addresses, and telephone numbers should be recorded. They should be advised to seek medical care promptly if symptoms develop or recur (see Patient Information Sheet ).

PDF documents can be viewed with the free Adobe® Reader™