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Sulfur Mustards are vesicants (cause blisters) and alkylating agents (introduce radicals to compounds by replacing the hydrogen atoms). They are twice as toxic as cyanide. They are absorbed by the skin, causing erythema (diffused redness over skin) and blisters. Ocular (eye) exposure to these agents may cause incapacitating damage to the cornea and conjunctiva. Inhalation damages the respiratory system.
Special Note: Clinical effects do not occur until 1 to 24 hours after exposure.
On-site cautions: People whose skin or clothing is contaminated with sulfur mustard can contaminate rescuers and care providers by direct contact or through off-gassing vapor. 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. If the skin is decontaminated within 5 minutes, there will be a 50% reduction in symptoms. Later decontamination is not likely to improve the victim's condition but will protect other personnel from exposure. Sodium thiosulfate given IV within minutes after exposure may prevent lethality.
Rescuer protection: Pressure-demand, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to any amount of sulfur mustard. Before transport, all casualties must be decontaminated. Because signs and symptoms of exposure do not occur for several hours post exposure, patients should be observed for at least 6 hours or sent home with instructions to return immediately if symptoms develop. Symptoms may not develop for 24 hours.
Mass casualties/large number triage: Victims who have experienced a cardiac arrest, respiratory arrest, or continued seizures are categorized as expectant and resources should not be expended on these casualties if care and transport resources are scant.
Decontamination of victims (basic)
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.
Skin: Sulfur mustard burns from the bottom layer of skin up. You cannot see skin damage with the human eye. The skin will blister, become very painful, areas will turn black and large areas of skin will fall off and yield only the index skin. This will result in major dehydration.
Treatment area: Patients arriving at the ER directly from the scene of 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 (CCU). The others should be observed for at least 6 hours. The sooner after exposure that symptoms occur, the more likely they are to progress and become severe.
Airway exposure: Patients with more severe effects (laryngitis, shortness of breath, a productive cough) seen at any time post exposure should be admitted directly to the CCU once decontamination has been assured. Less severe cases should be admitted to the routine care ward.
Medical personnel protection (including HAZMAT personnel): These 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 pressure and floor drains to contain contamination. Personnel must wear protection required in the Hot Zone.
If the patient was exposed to vapor only, removal of outer clothing and flushing of exposed skin with soap and water or water alone should be adequate. Place contaminated clothes and personal belongings in a sealed double bag.
Notes: A patient who has gone home and bathed and changed clothes may be considered decontaminated; however, the home will require decontamination. Blister fluid does not contain mustard or other toxic substances.
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