Medical Management Guidelines for Blister Agents:
Sulfur Mustard Agent H or HD (C4H8Cl2S)
Sulfur Mustard Agent HT
CAS# Sulfur Mustard Agent H or HD 505-60-2, Sulfur Mustard Agent HT 6392-89-8
UN# Sulfur Mustard Agent H or HD 2927
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Synonyms:
H and HD: Bis(2-chloroethyl) sulfide; bis(beta-chloroethyl)
sulfide; di-2-chloroethyl sulfide;
1-chloro-2(beta-chloroethylthio)ethane; 2,2'-dichloroethyl
sulfide; sulfur mustard; Iprit; Kampstoff "Lost"; mustard
gas; senfgas, S-yperite; yellow cross liquid; yperite
HT: Mixture of bis(2-chloroethyl) sulfide and
bis[2-(2-chloroethylthio)-ethyl]ether
- People whose skin or clothing is contaminated with
sulfur mustard can contaminate rescuers by direct contact or
through off-gassing vapor.
- 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 absorbed by the skin, causing
erythema and blisters. Ocular exposure to these agents may
cause incapacitating damage to the cornea and conjunctiva.
Inhalation damages the respiratory tract epithelium and may
cause death.
General Information
Description
Sulfur mustards are vesicants and alkylating agents. They
are colorless when pure but are typically a yellow to brown
oily substance with a slight garlic or mustard odor. H
contains about 20 to 30% impurities (mostly sulfur);
distilled mustard is known as HD and is nearly pure; HT is a
mixture of 60% HD and 40% agent T (a closely related
vesicant with a lower freezing point). Sulfur mustards
evaporate slowly. They are very sparingly soluble in water
but are soluble in oils, fats, and organic solvents. They
are stable at ambient temperatures but decompose at
temperatures greater than 149 °C.
Routes of Exposure
Inhalation
Sulfur mustards are readily absorbed from the respiratory
tract; injury develops slowly and intensifies over several
days. The odor of sulfur mustards does not provide adequate
warning of detection. The LCt50 (the product of
concentration times time that is lethal to 50% of the
exposed population by inhalation) is approximately 1,500
mg-min/m3. The vapors are heavier than air. When
inhaled, these agents may cause systemic effects. The
estimated Ct for airway injury is 100 to 200 mg-min/m3.
Skin/Eye Contact
Mustard vapor and liquid are absorbed through the eyes,
skin, and mucous membranes. Clinical effects do not occur
until hours after exposure. The median incapacitating dose
for the vapor is 200 mg-min/m3. A Ct of 12 to 70
mg-min/m3 produces eye lesions. Direct contact
with the liquid can cause skin and eye burns that develop an
hour or more after exposure. A 10 µg droplet is capable of
producing blisters. Skin, eye, and airway exposure to vapor
sulfur mustard and skin and eye exposure to liquid mustard
may cause systemic toxicity. The lethal dose is about 100
mg/kg or 1 to 1.5 teaspoons of liquid.
Ingestion
Ingestion may cause local effects and systemic absorption.
Sources/Uses
Sulfur mustards were first developed in the
early-to-mid-1800s and were introduced as chemical warfare
agents in 1917 during World War I. They have been used
extensively in chemical warfare and remain a major threat.
More than a dozen countries have sulfur mustard in their
chemical arsenals. Destruction of U.S. stockpiles of
chemical agents, including sulfur mustards, was mandated by
the Chemical Weapons Convention to take place before April
2007.
Standards and Guidelines
Airborne Exposure Limit (as recommended by the Surgeon
General's Working Group, U.S. Department of Health and Human
Services) is 0.003 mg/m3 as a time-weighted
average (TWA) for the workplace.
Physical Properties
Table 1. Physical Properties of Sulfur Mustards
| Property |
Agent H and HD |
Agent HT |
| Description |
Colorless when pure but usually a pale yellow, dark brown or black oily liquid. The vapor is colorless |
Clear yellowish liquid |
| Warning properties |
Faint garlic or mustard odor (odor threshold 0.6 mg/m3) | Slight garlic or mustard-like odor |
| Molecular weight |
159.08 daltons |
159.08 daltons (HD); 263.2 daltons (T) |
| Boiling point |
(760 mm Hg) = 419 °F (217.5 °C) |
(760 mm Hg) = >442 °F (>228 °C) |
| Freezing point |
58.1 °F (14.5 °C) |
32 to 34.3 °F (0 to 1.3 °C) |
| Specific gravity |
1.27 g/mL (water = 1.0) |
No data |
| Vapor pressure |
0.072 mm Hg at 68 °F (20 °C); 0.11 mm Hg at 77 °F (25 °C) |
No data |
| Vapor density |
5.4 to 5.5 (air = 1.0) |
6.92 (air = 1.0) |
| Liquid density |
1.24 to 1.27 g/mL at 68 °F (20 °C) |
1.27 g/mL |
| Flash point |
221 °F (105 °C) |
212 °(100 °C) |
| Solubility in water |
0.8 g/L at 68 °F (20 °C) |
Practically insoluble |
| Volatility |
600 mg/m3(20 °C) |
No data |
| NAERG# |
153 |
153 |
Incompatibilities
Sulfur mustards are rapidly corrosive to brass and steel at
149 °F (65 °C); they are destroyed by strong oxidizing agents.
These agents hydrolyze to form hydrochloric acid (HCl) and
thiodiglycol.
Health Effects
- 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 delayed for 1 to 24
hours.
- Sulfur mustards are alkylating agents that may cause
bone marrow suppression and neurologic and gastrointestinal
toxicity.
Acute Exposure
Sulfur mustards are vesicants and alkylating agents;
however, the biochemical mechanisms of action are not
clearly understood. They are highly reactive and combine
rapidly with proteins, DNA, or other molecules. Therefore,
within minutes following exposure intact mustard or its
reactive metabolites are not found in tissue or biological
fluids. Sulfur mustards also have cholinergic activity,
stimulating both muscarinic and nicotinic receptors. The
onset of clinical symptoms and their time of onset depend on
the severity of exposure (Table 1). The death rate from
exposure to sulfur mustard is low (2 to 3% during World War
I). Death usually occurs between the 5th and 10th
day due to pulmonary insufficiency complicated by infection
due to immune system compromise.
Ocular
The eye is the most sensitive tissue to sulfur mustard
effects. Sulfur mustard vapor or liquid may cause intense
conjunctival and scleral pain, swelling, lacrimation,
blepharospasm, and photophobia; however, these effects do
not appear for an hour or more. Miosis due to cholinergic
effects may occur. High concentrations of vapor or liquid
can cause corneal edema, perforation, blindness, and later
scarring.
Dermal
Direct skin exposure to sulfur mustards causes erythema and
blistering. Generally, a pruritic rash will develop within 4
to 8 hours followed by blistering 2 to 18 hours later.
Contact with the vapor may result in first and second degree
burns, while contact with the liquid typically produces
second and third degree chemical burns. An area of burn
covering 25% or more of the body surface area may be fatal.
Respiratory
Dose-dependent inflammatory reactions in the upper and
lower airway begin to develop several hours after exposure
and progress over several days. Burning nasal pain,
epistaxis, sinus pain, laryngitis, loss of taste and smell,
cough, wheezing, and dyspnea may occur. Necrosis of
respiratory epithelium can cause pseudomembrane formation
and local airway obstruction.
Gastrointestinal
Ingestion may cause chemical burns of the GI tract and
cholinergic stimulation. Nausea and vomiting may occur
following ingestion or inhalation. Early nausea and vomiting
is usually transient and not severe. Nausea, vomiting, and
diarrhea occurring several days after exposure indicates
damage to the GI tract and thus is a poor prognostic sign.
CNS
High doses of sulfur mustards can cause hyperexcitability,
convulsions, and insomnia.
Hematopoietic
Systemic absorption of sulfur mustard may induce bone
marrow suppression and an increased risk for fatal
complicating infections, hemorrhage, and anemia.
Delayed Effects
Years after apparent healing of severe eye lesions,
relapsing keratitis or keratopathy may develop.
Potential Sequelae
Persistent eye conditions, loss of taste and smell, and
chronic respiratory illness including asthmatic bronchitis,
recurrent respiratory infections, and lung fibrosis may
persist following exposure to sulfur mustards.
Chronic Exposure
Prolonged or repeated acute exposure to sulfur mustards may
cause cutaneous sensitization and chronic respiratory
disease. Repeated exposures result in cumulative effects
because mustards are not naturally detoxified by the body.
Carcinogenicity
The International Agency for Research on Cancer (IARC) has
classified sulfur mustard as carcinogenic to humans (Group
1). Epidemiological evidence indicates that repeated
exposures to sulfur mustard may lead to cancers of the upper
airways.
Reproductive and Developmental Effects
There is limited evidence that repeated exposures to sulfur
mustards may cause defective spermatogenesis years after
exposure. Sulfur mustard has been implicated as a potential
developmental toxicant because of its similarity to nitrogen
mustard; however, data are inconclusive.
Table 1. Clinical Effects and Time of Onset by Severity of Exposure to Sulfur Mustard
| Tissue and Severity of exposure |
Clinical effects |
Time to first effect |
| Eyes - mild |
Tearing, itching, burning, gritty feeling |
4-12 hours |
| Eyes - moderate |
Above effects and reddening, lid edema, moderate pain |
3-6 hours |
| Eyes - severe |
Marked lid edema, possible corneal damage, severe pain |
1-2 hours |
| Airways - mild |
Rhinorrhea, sneezing, epistaxis, hoarseness, hacking cough |
6-24 hours |
| Airways - severe |
Above effects and productive cough, mild to severe dyspnea |
2-6 hours |
| Skin - mild |
Erythema |
2-24 hours |
| Skin - severe |
Erythema and vesication |
2-24 hours |
Prehospital Management
- Victims whose skin or clothing is contaminated with
liquid sulfur mustard can contaminate rescuers by direct
contact or through off-gassing vapor.
- Sulfur mustards are extremely toxic and may damage the
eyes, skin, and respiratory tract and suppress the immune
system. Although these agents cause cellular changes within
minutes of contact, the onset of pain and other symptoms is
delayed.
- There is no antidote for sulfur mustard toxicity.
Decontamination within 1 or 2 minutes after exposure is the
only effective means of decreasing tissue damage. Sodium
thiosulfate given IV within minutes after exposure may
prevent lethality
Hot Zone
Responders should be trained and appropriately attired
before entering the Hot Zone. If the proper personal
protective equipment (PPE) is not available, or if the
rescuers have not been trained in its use, call for
assistance in accordance with local Emergency Operational
Guides (EOG). Sources of such assistance include local
Hazmat teams, mutual aid partners, the closest metropolitan
strike system (MMRS) and the U.S. Soldier and Biological
Chemical Command (SBCCOM)-Edgewood Research Development and
Engineering Center SBCCOM may be contacted (from 0700-1630
EST call 410-671-4411 and from 1630-0700 EST call
410-278-5201), ask for the Staff Duty Officer.
Rescuer Protection
Sulfur mustard vapor and liquid are readily absorbed by
inhalation and ocular and dermal contact.
Respiratory protection: Pressure-demand,
self-contained breathing apparatus (SCBA) is recommended in
response situations that involve exposure to any amount of
sulfur mustard.
Skin/ocular protection: Personal protective
equipment (PPE) and butyl rubber chemical-protective gloves
are recommended at all times when these chemicals are
suspected to be involved.
Multi-Casualty Triage
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. General principles of triage for
chemical exposures are presented in the box on the following
page. There are four triage categories: immediate (priority
1), delayed (priority 2), minimal (priority 3), and
expectant (priority 4). Clinical signs and effects of sulfur
mustards associated with each of these categories are
presented in Table 2.
Before transport, all casualties must be decontaminated.
If needed, consult with the base station physician or the
regional poison control center for advise concerning
management of multiple casualties.
Because signs and symptoms of exposure do not occur for
several hours postexposure, patients should be observed for
at least 6 hours or sent home with instructions to return
immediately if symptoms develop. Patients whose clinical
effects and time of onset indicate moderate or severe
exposure (see Table 1) and patients who have ingested sulfur
mustard should be transported to a medical facility for
evaluation.
Symptoms may not develop for 24 hours. Patients who are
seen at least 24 hours after exposure and whose symptoms
indicate mild exposure (see Table 1) may be sent home after
treatment and once their names, addresses, and telephone
numbers have been recorded. They should be advised to rest
and to seek medical care promptly if additional symptoms
develop (see Follow-up Instructions, included with
the Sulfur Mustard Patient Information Sheet below).
Consult with the base station physician, closest
Metropolitan Medical Response System, or the regional poison
control center for advice regarding triage of multiple
victims.
General principles of triage for chemical exposures are
as follows:
- 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 victims 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
overtriage 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.
- Immediate: casualties who require lifesaving care
within a short time, when that care is available and of
short duration. This care may be a procedure that can be
done within minutes at an emergency treatment station (e.g.,
relief of an airway obstruction, administering antidotes) or
may be acute lifesaving surgery.
- Delayed: casualties with severe injuries who are
in need of major or prolonged surgery or other care and who
will require hospitalization, but delay of this care will
not adversely affect the outcome of the injury (e.g.,
fixation of a stable fracture).
- Minimal: casualties who have minor injuries, can
be helped by nonphysician medical personnel, and will not
require hospitalization.
- Expectant: casualties with severe
life-threatening injuries who would not survive with optimal
medical care, or casualties whose injuries are so severe
that their chance of survival does not justify expenditure
of limited resources. As circumstances permit, casualties in
this category may be reexamined an possibly be retriaged to
a higher category..
Table 2. Traige for Mustard Agent Casualties
| Category (Priority) |
Time of Onset |
Clinical Signs and Symptoms |
| 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). |
| Expectant (4) |
< 4 hours post exposure |
Lower respiratory signs (dyspnea); skin lesion covering 50% or more of body surface area from liquid exposure |
ABC Reminders
Quickly ensure that the victim has a patent airway.
Maintain adequate circulation. If trauma is suspected,
maintain cervical immobilization manually and apply a
cervical collar and a backboard when feasible. Apply direct
pressure to stop arterial bleeding, if present.
Victim Removal
If victims can walk, lead them out of the Hot Zone 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.
Decontamination Zone
Decontamination within 1 or 2 minutes following exposure is
the only effective means for decreasing tissue damage. Later
decontamination is not likely to improve the victim's
condition but will protect other personnel from exposure.
Decontaminable gurneys and back boards should be used if
available when managing casualties in a contaminated area.
Decontaminable gurneys are made of a monofilament
polypropylene fabric that allows drainage of liquids, does
not absorb chemical agents, and is easily decontaminated.
Fiberglass back boards have been developed specifically for
use in HAZMAT incidents. These are nonpermeable and readily
decontaminated. The Chemical Resuscitation Device is
a bag-valve mask equipped with a chemical agent cannister
that can be used to ventilate casualties in a contaminated
environment.
Rescuer Protection
Personnel should continue to wear the same level of
protection as required in the Hot Zone (see
Rescuer Protection under Hot Zone, above).
ABC Reminders
Quickly ensure that the victim has a patent airway.
Maintain adequate circulation. Stabilize the cervical spine
with a decontaminable collar and a backboard if trauma is
suspected. Administer supplemental oxygen if cardiopulmonary
compromise is suspected. Assist ventilation with a
bag-valve-mask device equipped with a cannister or air
filter if necessary. Direct pressure should be applied to
control bleeding, if present.
Basic Decontamination
Early decontamination, preferably within 1 or 2 minutes
after exposure, is the only way to reduce tissue damage.
Flush the eyes immediately with water for about 5 to 10
minutes by tilting the head to the side, pulling eyelids
apart with fingers, and pouring water slowly into eyes. Do
not cover eyes with bandages.
If exposure to liquid agent is suspected, victims should
remove all clothing and wash skin with soap and water. If
shower areas are available, showering with water alone will
be adequate. However, in those cases where water is in short
supply, and showers are not available, an alternative form
of decontamination is to use 0.5% sodium hypochlorite
solution or absorbent powders such as flour, talcum powder,
or Fuller's earth. If exposure to vapor only is certain,
remove outer clothing and wash with soap and water or 0.5%
solution of sodium hypochlorite. Place contaminated clothes
and personal belongings in a sealed double bag.
In cases of ingestion, do not induce emesis. There
is no evidence that administration of activated charcoal is
beneficial.
Transfer to Support Zone
As soon as basic decontamination is complete, move the
victim to the Support Zone.
Support Zone
Be certain that victims have been decontaminated properly
(see Decontamination Zone, above). Victims who have
undergone decontamination pose no serious risk of secondary
contamination to rescuers. In such cases, Support Zone
personnel require no specialized protective gear.
ABC Reminders
Quickly ensure that the victim has a patent airway. If
trauma is suspected, maintain cervical immobilization
manually and apply a cervical collar and a backboard when
feasible. Ensure adequate respiration; administer
supplemental oxygen if cardiopulmonary compromise is
suspected. Maintain adequate circulation. Establish
intravenous access if necessary. Attach a cardiac monitor.
Direct pressure should be applied to stop bleeding, if
present.
Additional Decontamination
In cases of ingestion, do not induce emesis. If the
victim is alert and able to swallow, give 4 to 8 ounces of
milk or water to drink. There is no evidence that
administration of activated charcoal is beneficial.
Advanced Treatment
Intubate the trachea in cases of respiratory compromise.
When the patient's condition precludes endotracheal
intubation, perform cricothyrotomy if equipped and trained
to do so.
Treat patients who have bronchospasm with bronchodilators.
Trauma patients who are comatose, hypotensive, or have
seizures or cardiac dysrhythmias should be treated according
to advanced life support (ALS) protocols.
Transport to Medical Facility
Report the condition of the patient, treatment given, and
estimated time of arrival at the medical facility to the
base station and the receiving medical facility.
Emergency Department Management
- Patients whose skin or clothing is contaminated with
liquid sulfur mustard can contaminate rescuers by direct
contact or through off-gassing vapor.
- Sulfur mustards are extremely toxic and may damage eyes,
skin, and respiratory tract and suppress the immune system.
Although these agents cause cellular changes within minutes
of contact, the onset of pain and other symptoms is delayed.
Thus, patients arriving immediately from the scene of
exposure are not likely to have signs and symptoms.
- There is no antidote for sulfur mustard toxicity.
Decontamination of all potentially exposed areas within
minutes after exposure is the only effective means of
decreasing tissue damage. Thus, by the time a patient
arrives in the emergency department, decontamination can
only prevent secondary exposure to medical staff; it does
not limit the patient's injury. Medical treatment is
supportive.
Decontamination Area
Previously decontaminated patients may be treated or held
for observation. Others require decontamination as described
below.
ABC Reminders
Evaluate and support the airway, breathing, and
circulation. Intubate the trachea in cases of respiratory
compromise. If the patient's condition precludes intubation,
surgically create an airway.
Treat patients who have
bronchospasm with bronchodilators.
Patients who are comatose
or hypotensive, or have seizures or ventricular dysrhythmias
due to other exposures or trauma should be treated in the
conventional manner.
Personal Protection
If contaminated patients are expected to arrive at the
Emergency Department, they must be decontaminated before
being allowed to enter the facility. Decontamination can
take place inside the hospital only if there is a
decontamination facility with negative air pressure and
floor drains to contain contamination. Personnel should wear
the same level of protection required in the Hot Zone (see
Rescuer Protection under Hot Zone, above).
Basic Decontamination
Flush the eyes with water for about 5 to 10 minutes. Do not cover eyes with bandages; if necessary, use dark or opaque goggles to relieve discomfort from photophobia.
If a liquid splash is suspected, clothing must be removed and the patient showered using soap and water. Showering should be accomplished using warm water and low water pressure to reduce the potential for agent penetration of the skin. If the patient was exposed to vapor only, remove outer clothing and wash exposed skin with soap and water. Place contaminated clothes and personal belongings in a sealed double bag.
In cases of ingestion, do not induce emesis. If the victim is alert and able to swallow, give 4 to 8 ounces of milk or water to drink if not already administered. There is no evidence that administration of activated charcoal is beneficial.
Treatment Area
Be certain that appropriate decontamination has been
carried out (see Decontamination Area, below).
ABC Reminders
Evaluate and support the airway, breathing, and circulation
(as in ABC Reminders, above). Establish intravenous
access and continuously monitor cardiac rhythm in seriously
ill patients.
Patients who are comatose, hypotensive, or who have
seizures or ventricular dysrhythmias due to other exposures
or trauma should be treated in the conventional manner.
Triage
Patients arriving at the emergency department directly
from the scene of potential exposure (within 30-60 minutes)
will rarely have symptoms. Following decontamination,
patients with signs of airway involvement should be admitted
directly to the Critical Care Unit. The others should be
observed for at least 6 hours. Patients arriving later
should be evaluated as described below. The sooner after
exposure that symptoms occur, the more likely they are to
progress and become severe.
Eye Exposure
Mild conjunctivitis beginning more than 12 hours after
exposure is unlikely to progress to a severe lesion. The
patient should have a thorough eye examination (including a
test for visual acuity). The patient should be treated with
a soothing eye solution, such as Visine or Murine, sent
home, and told to return if there is worsening.
Conjunctivitis beginning earlier and other effects such as
lid swelling and signs/symptoms of inflammation indicate a
need for inpatient care and observation.
Skin Exposure
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. A patient with a significant area of
erythema or one seen earlier with a significant area of
erythema with or without blistering should be admitted for
further evaluation.
Airway Exposure
A patient with a mild, non-productive cough, irritation of
the nose and sinuses, and/or a sore throat that began later
than 12 hours after exposure should be told to use a cool
steam vaporizer and lozenges or cough drops and sent home
with instructions to return if the symptoms worsen. Patients
with more severe effects (laryngitis, shortness of breath, a
productive cough) seen at any time postexposure should be
admitted directly to the Critical Care Unit once
decontamination has been assured. Those with less severe
effects should be admitted to a routine care ward.
Ingestion Exposure
Do not induce emesis. If a large dose has been
ingested and the patient's condition is evaluated within 30
minutes after ingestion, cautious orogastric lavage might
remove ingested material. However, the risk of potential
bleeding and perforation must be considered. There is no
evidence that activated charcoal is beneficial.
Antidotes and Other Treatments
There is no antidote for sulfur mustard. Treatment is
supportive.
Laboratory Tests
Routine laboratory studies should be done for all patients
requiring admission. These include 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.
Disposition
As discussed above, consider hospitalizing patients who
have had significant exposures.
Delayed Effects
Significant systemic absorption of sulfur mustard may
produce a fall in the leukocyte count beginning on days 3 to
5. Erythrocytes and thrombocytes may subsequently fall if
bone marrow damage is severe and in this case the risk of
life-threatening infection rises.
Patient Release
Patients who have sustained mild exposure (see Table 1) may
be discharged. Discharged patients should be advised to rest
and to seek medical care promptly if symptoms progress (see,
Follow-up Instructions, included with the Sulfur Mustard
Patient Information Sheet below).
Reporting
Other people may still be at risk in the setting where this
incident occurred or away from the setting due to secondary
contamination. If a public health risk exists, notify your
state or local health department or other responsible public
agency.
General Medical Management
- Since there are no immediate effects from mustard, most
patients will go home or elsewhere from the incident and
present to a medical facility hours later when effects
occur. These patients must not be allowed to enter the
facility until they have been decontaminated.
- Patients whose skin or clothing is contaminated with
liquid sulfur mustard can contaminate medical personnel and
others by direct contact or through off-gassing vapor.
- Sulfur mustards are extremely toxic and may damage the
eyes, skin, and respiratory tract and suppress the immune
system. Although these agents cause cellular changes within
minutes of contact, the onset of pain and other symptoms is
delayed.
- There is no antidote for sulfur mustard toxicity.
Medical treatment is supportive
Decontamination Area
A patient who arrives at a general medical facility
(non-emergency) probably will not have undergone
decontamination. Such a patient must be decontaminated as
described below before being allowed to enter the facility.
ABC Reminders
Patients may have other injuries and must be evaluated
using the concepts of BLS and ALS.
Personal Protection
Medical personnel or others (e.g., HAZMAT personnel) must
meet incoming patients outside the facility or, if
available, in the facility's decontamination area.
Decontamination can take place inside the medical facility
only if there is a decontamination area with negative air
pressure and floor drains to contain contamination.
Personnel must wear protection required in the Hot Zone (see
Rescuer Protection under Hot Zone, above).
Basic Decontamination
A patient who has arrived directly from the scene must be
decontaminated before being admitted to the facility. If a
liquid splash is suspected, clothing must be removed and the
patient showered using soap and water. If the patient was
exposed to vapor only, removal of outer clothing and
flushing of exposed skin (face, hair, and arms/hands) with
soap and water or water alone is adequate. Place
contaminated clothes and personal belongings in a sealed
double bag.
A patient who has gone home and bathed and changed clothes
may be considered decontaminated; however, the home will
require decontamination. Otherwise, patients should undergo
the decontamination procedures described above.
Initial Evaluation
Patients arriving at the medical facility directly from the
scene of potential exposure (within 30-60 minutes) will
rarely have signs and symptoms. Patients with signs of
airway involvement should be admitted directly to the
Critical Care Unit once decontamination has been assured.
The others should be observed for at least 6 hours.
Patients arriving later should be evaluated as described
below. The sooner after exposure signs and symptoms occur,
the more likely they are to progress and become severe.
Eye Exposure
Mild conjunctivitis beginning more than 12 hours after
exposure is unlikely to progress to a severe lesion. The
patient should have a thorough eye examination (including a
test for visual acuity). The patient should be treated with
a soothing eye solution such as Visine or Murine, sent home,
and told to return if there is worsening. Conjunctivitis
beginning earlier and other effects such as lid swelling and
signs/symptoms of inflammation indicate admission.
Skin Exposure
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. A patient with a significant area of
erythema or one seen earlier with a significant area of
erythema with or without blistering should be admitted for
further evaluation.
Airway Exposure
A patient with a mild, non-productive cough, irritation of
the nose and sinuses, and/or a sore throat that began later
than 12 hours after exposure should be told to use a cool
steam vaporizer and lozenges or cough drops and sent home
with instructions to return if the symptoms worsen. Patients
with more severe effects (laryngitis, shortness of breath, a
productive cough) seen at any time postexposure should be
admitted directly to the Critical Care Unit once
decontamination has been assured. Those with less severe
effects should be admitted to a routine care ward.
Ingestion Exposure
Do not induce emesis. If a large dose has been
ingested and the patient's condition is evaluated within 30
minutes after ingestion, cautious orogastric lavage might
remove ingested material. However, the risk of potential
bleeding and perforation must be considered. There is no
evidence that activated charcoal is beneficial.
Medical Management
General
There is no antidote for sulfur mustard. Management is
supportive.
A guideline is to keep the wounds (skin, eye, airway) free
from infection. A patient with severe skin burns may require
care in a burn unit.
Skin Exposure
Most burns are second degree although third degree burns
may occur after liquid exposure. In general, small blisters
(i.e., <1cm) remain roofed and larger ones (i.e., >1cm)
should be unroofed. This is a controversial issue, but many
feel that the roof will eventually come off anyway. Blister
fluid does not contain mustard or other toxic substances.
The denuded area should be irrigated two or three times a
day using a whirlpool if the lesion is large (the patient
should be given ample amounts of a systemic analgesic
beforehand). This should be followed by liberal application
of a topical antibiotic. Skin lesions may take many months
to heal. Fluids are not lost as they are in thermal burns,
and fluid replacement should be according to the general
needs of the patient and not according to "burn therapy"
formulas. Systemic antibiotics should be used when there are
signs of infection and a culture indicates the responsible
organism. Patients with a large area of second or third
degree burns should be transferred to a Burn Unit for
further care and reverse isolation.
Eye Exposure
Eye lesions range from conjunctivitis to involvement of the
entire eye including cornea and lids. Erosion of or
perforation of the cornea may occur with very severe
exposure to liquid, but this is rare. Readily available eye
solutions may suffice for conjunctivitis. More severe
lesions should be treated with a topical mydriatic (e.g.,
atropine), topical antibiotics, and vaseline or similar
substance applied to the lid edges several times a day.
Topical analgesics should be used only for an initial
examination (including slit lamp and a test of visual
acuity), but not after. Pain should be controlled with
systemic analgesics. Once the lid edema and blepharospasm
subside and the eyes are open, dark glasses may reduce the
discomfort of photophobia. Some authorities feel that
topical steroids (used within the first 24 hours only) may
reduce inflammation.
Inhalation Exposure
Airway damage may range from irritation of the nose and
sinuses, to pharyngitis, to destruction of the airway mucosa
from the upper airways to the smallest bronchiole. Airway
damage is a common cause of death. Upper airway irritation
(nose, sinuses, pharynx) may benefit from cool steam
inhalation and cough drops or lozenges. A patient with signs
of airway damage below the pharynx should be provided with
oxygen- assisted ventilation as necessary (with PEEP); at
the first sign of damage of the larynx or below, the patient
should be intubated and transferred to the Critical Care
Unit. Bronchodilators should be used if there are signs of
bronchoconstriction; steroids might be used if the usual
bronchodilators are not effective, but otherwise steroids
are not of proven value. Daily sputum cultures should be
done and systemic antibiotics should be begun with signs of
infection and an identified organism. A chemical pneumonitis
may occur in the first several days with infiltrates on
X-ray, an increase in WBC, and a fever, but this is
generally sterile. Organisms generally are not the cause
until the third or fourth day postexposure, and antibiotics
should not be used prophylactically. Patients with airway
damage below the pharynx should be managed on the Critical
Care Unit by a physician experienced in the management of
complicated pulmonary and airway injuries.
Bone Marrow
If the bone marrow has been damaged, the white blood cell
count in the peripheral blood will start to decrease at
about days 3 to 5 after exposure. This decrease may be
followed by a decrease in red blood cells and platelets.
Often, this decrease is not marked and the marrow recovers.
Transfusions may be useful. Treatment with granulocyte
colony-stimulating factor (GCSF) has been successful
experimentally with nitrogen mustard. Marrow transplants
have not been attempted, but might be useful. A patient with
a marked decrease in white blood cell count should be
transferred to an Oncology or Burn Unit for reverse
isolation.
Laboratory Evaluation
Routine laboratory studies for admitted patients include
glucose, serum electrolytes, and daily CBC. Chest x-ray and
pulse oximetry (or ABG measurement) should be done
frequently on all patients with inhalation effects. A test
for urinary thioglycol (a metabolite of mustard) can be
performed at specialized laboratories, but is not a routine
laboratory measure.
Disposition and
Follow-up
Patients with moderate to severe exposures will require
hospitalization, as described above.
Patient Release
Patients who have sustained mild exposure (see Table 1),
may be discharged. Discharged patients should be advised to
rest and to seek medical care promptly if symptoms progress
(see below, Follow-up Instructions, included with the
Sulfur Mustard Patient Information Sheet).
Follow-up
Follow-up evaluation of respiratory, neurological, and bone
marrow function should be arranged for severely exposed
patients.
Reporting
Other people may still be at risk in the setting where this
incident occurred or away from the setting due to secondary
contamination. If a public health risk exists, notify your
state or local health department or other responsible public
agency.
Patient Information Sheet
This handout provides information and follow-up
instructions for persons who have been exposed to sulfur
mustard.
Print this handout only.pdf icon[44 KB]
What are sulfur mustards?
Sulfur mustards are yellowish to brown liquids that have
been used as chemical warfare agents since 1917.
What immediate health effects can result from exposure to sulfur mustards?
Sulfur mustards produce blistering and cell damage, but
symptoms are delayed for hours. They cause damage to the
skin, eyes, and respiratory tract. The eyes are the most
sensitive. Nausea and vomiting may occur within the first
few hours after exposure. Skin rashes, blisters, and lung
damage may develop within a few hours of exposure but may
take 12 to 24 hours to develop. Sulfur mustard can also
suppress the immune system.
Can sulfur mustard poisoning be treated?
There is no antidote for sulfur mustard, but its effects
can be treated and most exposed people recover. Immediate
decontamination reduces symptoms. People who have been
exposed to large amounts of sulfur mustard will need to be
treated in a hospital.
Are any future health effects likely to occur?
Adverse health effects, such as chronic respiratory
diseases, may occur from exposure to high levels of these
agents. Severe damage to the eyes and skin may be present
for a long time following the exposure.
What tests can be done if a person has been exposed to sulfur mustards?
There are no routine tests to determine if someone has been
exposed to sulfur mustard. Thiodiglycol (a break-down
product of mustard) may be detected in the urine up to 2
weeks following exposure; however, this test is available
only in several specialized laboratories.
Where can more information about sulfur mustards be found?More information about sulfur mustard can be obtained from
your regional poison control center; the Agency for Toxic
Substances and Disease Registry (ATSDR); your doctor; or a
clinic in your area that specializes in toxicology or
occupational and environmental health. Ask the person who
gave you this form for help locating these telephone
numbers.
Follow-up Instructions
Keep this page and take it with you to your next
appointment. Follow only the instructions checked
below.
Print instructions only.pdf icon[44 KB]
[ ] 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 ____________
Where can I get more information?
If you have questions or concerns, please contact your community or state health or environmental quality department or:
For more information, contact:
Agency for Toxic Substances and Disease Registry
Division of Toxicology and Human Health Sciences
4770 Buford Highway
Chamblee, GA 30341-3717
Phone: 1-800-CDC-INFO 888-232-6348 (TTY)
Email: Contact CDC-INFO
ATSDR can also tell you the location of occupational and environmental health clinics. These clinics specialize in recognizing, evaluating, and treating illnesses resulting from exposure to hazardous substances.