Chapter 15

15.

Blister Agents

v Blister Agents

Sulfur Mustard Agent H or HD (C₄ H₈ Cl₂S) Sulfur Agent HT CAS# Sulfur Mustard Agent H or HD 505-60-2Sulfur Agent HT 6392-89-8 UN# Sulfur Mustard Agent H or HD 2927

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.

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 149ºC.
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 ¼g 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.
Incompatibilities	Sulfur mustards are rapidly corrosive to brass and steel at 149ºF (65ºC); they are destroyed by strong oxidizing agents. These agents hydrolyze to form hydrochloric acid (HCl) and thiodiglycol.

Physical Properties

Table 1. Physical Properties of Sulfur Mustards

Property Agent H and HD Agent HT

Description Colorless when pure but usually Clear yellowish liquid

a pale yellow, dark brown or black

oily liquid. The vapor is colorless.

Warning properties Faint garlic or mustard odor (odor Slight garlic or mustard-

threshold 0.6 mg/m³) like odor

Molecular weight 159.08 daltons 159.08 daltons (HD);

263.2 daltons(T)

Boiling point (760 mm Hg) = 419ºF (217.5ºC) (760 mm Hg) = >442ºF

(>228ºC)

Freezing point 58.1ºF (14.5ºC) 32 to 34.3ºF

(0 to 1.3ºC)

Specific gravity 1.27 g/mL (water = 1.0) No data

Vapor pressure 0.072 mm Hg at 68°F (20ºC); No data

0.11 mm Hg at 77ºF (25ºC)

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 68ºF (20°C) 1.27 g/mL

Flash point 221ºF (105ºC) 212ºF (100ºC)

Solubility in water 0.8 g/L at 68ºF (20ºC) Practically insoluble

Volatility 600 mg/m³ (20ºC) No data

NAERG# 153 153

vHealth 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 protiens, 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 5^th and 10^th day due to pulmonary insufficiency complicated by infection due to immune system comprise.
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 mustard may cause cutaneous sensitization and chronic respiratory disease. Repeated exposure results 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 2. Clinical Effects and Time of Onset by Severity of Exposure to Sulfur Mustard

Tissue Severity of exposure Clinical effects Time to first effect

Eyes
Mild

Moderate

Severe
Tearing, itching, burning, gritty feeling
Above effects and reddening, lid edema, moderate pain

Marked lid edema, possible corneal damage, severe pain

4-12 hours

3-6 hours

1-2 hours

Airways
Mild

Severe
Rhinorrhea, sneezing, epistaxis, hoarseness, hacking cough
Above effects and productive cough, mild to severe dyspnea

6-24 hours

2-6 hours

Skin Mild
Severe
Erythema
Erythema and vesication
2-24 hours
2-24 hours

vPrehospital 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 and possibly be retriaged to a higher category.

Table 3. Triage 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.

vEmergency 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.

vGeneral 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.

vBlister Agents Sulfur Mustard (H, HD, and HT)–Patient Information Sheet

This chapter provides information and follow-up instructions for persons who have been exposed to sulfur mustard.

Whataresulfur mustards?

Sulfur mustards are yellowish to brown liquids that have been used as chemical warfare agents since 1917.

Whatimmediate healtheffectscanresultfromexposure tosulfurmustards?

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.

Cansulfurmustard poisoningbetreated?

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.

Areanyfuture healtheffectslikelytooccur?

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.

Whattestscan be doneifapersonhasbeenexposed tosulfurmustards?

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.

Wherecanmore informationaboutsulfurmustardsbefound?

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.

[ ] 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?

ATSDR can tell you where to find occupational and environmental health clinics. Their specialists can recognize, evaluate, and treat illnesses resulting from exposure to hazardous substances. You can also contact your community or state health or environmental quality department if you have any more questions or concerns.

For more information, contact:

Agency for Toxic Substances and Disease Registry

Division of Toxicology

1600 Clifton Road NE, Mailstop E-29

Atlanta, GA 30333

Phone: 1-888-42-ATSDR (1-888-422-8737)

FAX: (404)-498-0093

Email: ATSDRIC@cdc.gov

vBlister Agent Mustard

NIOSH Emergency Response Card

UN #: 2810 (Guide 153) H; HD; HS Mustard Gas

Bis-(2-chloroethyl) sulfide

CAS # 505-60-2; sulfur mustard

39472-40-7; 68157-62-0 1,1', thiobis[2, chloroethane]

Chemical Formula: C4H8Cl2S

RTECS #: WQ0900000 Molecular mass: 159.08

Types of Hazard Exposure Acute Hazard/ Clinical Signs/Symptoms Prevention/Personal Protective Equipment
First Aid / Fire Fighting

FIRE N/A N/A Water, fog, foam, CO 2 , dry chemical. Avoid methods that cause splashing or spreading. Fight fire from as far a distance as possible.

Explosion N/A N/A N/A

Route of Exposure

Synopsis: Severe irritant. Contact with vapor or liquid can be fatal. Do not breathe fumes. Skin contact must be avoided at all times. Seek medical attention Immediately.

Inhalation:

Delayed effects between 2 and 24 hours after exposure

Runny nose.

Dry/barking cough.

Hoarseness.

"Toneless" voice.

Hemorrhage and necrosis of lung tissue resulting in coughing up blood.

Difficulty breathing.

Hold breath until respiratory protective mask is donned.
Pressure demand, self-contained breathing apparatus (SCBA CBRN, if available) is recommended in response situations to any amount of agent.

CBRN, Full Facepiece APR (when available) is recommended in non-routine, emergency situation environments less than IDLH but above REL or PEL levels.
Immediately remove from source of exposure.
If breathing is labored give oxygen.

If breathing has stopped give artificial respiration. Mouth-to-mouth only when no facial contamination.

Seek medical attention immediately.

Skin: Rapid penetration (within 1-2 minutes) without irritation.
Reddening, swelling, and blisters (small to very large) in 4-24 hours depending on dose.

Warm, moist, thin-skinned areas are the most sensitive to this agent.

Butyl rubber, neoprene, nitrile or PVC (Polyvinyl Chloride) gloves, Responder® CSM protective clothing including PVC boots.
Immediately remove contaminated clothing and wash exposed area thoroughly with soap and water. Contaminated clothing can expose rescue workers through direct contact or through off-gassing vapor.
(See Decontamination section.)

Eyes:	The eyes are the most Chemical goggles sensentive organ and effects and face shield. occur between 1-12 hours after exposure. Tearing (lacrimation.) Light sensitivity. Irritation of lining of eye (conjunctiva) and cornea. Severe necrosis. Blindness.	Immediately flush with large amounts of tepid water for at least 15 minutes. Do not cover with bandages. Use dark or opaque goggles. Seek medical attention immediately.
Ingestion:	Nausea and vomiting Do not eat, drink, or smoke common in first few during work. Wash hands hours and limited before eating. to 24 hours.	Do not induce vomiting. Give milk to drink. Seek medical attention immediately. (See Inhalation for other symptoms. )
Occupational exposure limits (OELs):	OSHA PEL: N/A NIOSH REL: N/A ACGIH TLV: N/A TLV : 0.003 mg/m3 (U.S. Military) General Population Limit (72 hours) 0.0001 mg/m 3 (U.S. Military) NIOSH IDLH: N/A See Acute Exposure Guidelines Levels below.	(See Acute Exposure Guideline Levels below.)
Sampling and analytical methods:	NIOSH: N/A OSHA: N/A

Decontamination Spillagedisposal	Patients/Victims : Remove clothes and place contaminated clothes and personal belongings in a sealed double bag. Decontamination of mustard-exposed victims by either vapor or liquid should be performed within the first two minutes following the exposure to prevent tissue damage. If not accomplished within the first several minutes, decontamination should still be performed to ensure any residual liquid mustard is removed from the skin or clothes or to ensure any trapped mustard vapor is removed with the clothing. Removing trapped mustard vapor will prevent vapor off-gassing or subsequent cross-contamination of other emergency responders/health care providers or the healthcare facility. Physical removal of the mustard agent, rather than detoxification or neutralization, is the most important principle in patient decontamination. Mustard is not detoxified by water alone and will remain in decontamination effluent (in dilute concentrations) if hydrolysis has not taken place. (1) Patients exposed to vapor should be decontaminated by removing all clothing in a clean air environment and shampooing or rinsing the hair to prevent vapor off-gassing. (2) Patients exposed to liquid should be decontaminated by– a. Washing in warm or hot water at least three times. Use liquid soap (dispose of container after use and replace), large volumes of water, and mild to moderate friction with a single-use sponge or washcloth in the first and second washes. Scrubbing of exposed skin with a brush is discouraged, because skin damage may occur which may enhance absorption. The third wash should be to rinse with large amounts of warm or hot water. Shampoo can be used to wash the hair. The rapid physical removal of a chemical agent is essential. If warm or hot water is not available, but cold water is, use cold water. Do not delay decontamination to obtain warm water. b. Rinsing the eyes, mucous membranes, or open wounds with sterile saline or water. (3) The healthcare provider should – a. Check the casualty after the three washes to verify adequate decontamination before allowing entry to the medical treatment facility. If the washes were inadequate, repeat the entire process. b. Be prepared to stabilize conventional injuries during the decontamination process. Careful decontamination can be a time consuming process. The health care provider may have to enter the contaminated area to treat the casualty during this process. Medical personnel should wear the proper PPE and evaluate the exposed workers. Equipment: Use 5% solution of common bleach (sodium hypochlorite) or calcium hypochlorite solution (48 ounces per 5 gallons of water) to decontaminate scissors used in clothing removal, clothes and other items. Environment: (See Spillage Disposal.) Common bleach (sodium hypochlorite or NaOCl), superchlorinated bleaches (calcium hypochlorite or Ca(OCl) 2 ) and chloramine can be used. Cover with vermiculite, diatomaceous earth, clay, or fine sand and neutralized as soon as possible using large amounts of 5% sodium hypochlorite solution. Scoop up all material and place in an approved container. After sealing, decontaminate the exterior and label. All leaking containers should be packed with sorbent (e.g., vermiculite) and placed between the interior and exterior containers. Label and dispose according to regulations. Conduct general area monitoring. If sodium hypochlorite solution is not available then use the following in order of preference: Calcium Hypochlorite and Super Tropical Bleach Slurry (STB). WARNING: Pure, undiluted Calcium Hypochlorite (HTH) will burn on contact with liquid blister agent.
Packaging & labeling	UN # 2810 (Guide 153) Proper Shipping Name: Toxic liquids, organic, n.o.s. Hazard Class: 6.1, Packing Group I, Hazard Zone B. Label: Poison. Marking: Toxic liquids, n.o.s. Bis-(2-chloroethyl) sulfide UN 2810, Inhalation Hazard Placard: Poison NFPA 704 Signal: Health - 4 Flammability - 1 Reactivity - 1 Special - 0
Important data	Physical State; Appearance: Pure liquid is colorless and odorless. Forms yellow prisms on cooling. Agent grade material is yellow to dark brown or black and the odor is variously described as similar to burning garlic, horseradish, a characteristic sweetish odor, or a weak, sweet, agreeable odor. Physical Dangers: Rapidly corrosive to brass at 65 °C. Will corrode steel at a rate of 0.0001 in. of steel per month at 65 °C. Chemical Dangers: Stable at ambient temperatures. Decomposition temperature is 300-351 °F (149-177 °C). Reacts with water yielding hemi-mustard (a short-lived blister agent), thiodyglycol, and hydrogen chloride (HCl) with a half-life of 16 min. (see Environmental). On contact with acid or acid fumes, it emits highly toxic fumes of oxides of sulfur and chlorine. When heated to decomposition, oxides of sulfur and chlorine are emitted. Routes of Exposure: The substance can be absorbed into the body by all routes. Tender skin, mucous membranes and perspiration-covered skin are more sensitive to the effects. Inhalation Risk: Mustard, chlorinated sulfur compound, is a blister agent (vesicant) that causes severe, delayed damage to the respiratory tract. It is an alkylating agent that damages the cells within the bone marrow that are necessary for making blood cells. Effects of Short-Term Exposure: Mustard damages the tissues, the eyes, skin and respiratory tract. The skin healing process is very slow. Exposure to nearly lethal doses can injure the bone marrow, lymph nodes, and spleen causing a drop in white blood cell counts and an increased risk for developing infections. Mustard exposure can also cause a cholinergic toxicity: excessive saliva, tearing, urination, gastrointestinal cramping and diarrhea, vomiting, small pupils. Effects of Long-Term or Repead Exposure: The rate of detoxification is very slow in the body and repeated exposures produce cumulative effects including chronic lung impairment (cough, shortness of breath, chest pain), cancer of the mouth, throat, respiratory tract and skin, and leukemia. It may also cause birth defects. A human carcinogen.
Physical properties	Melting Point: 57.2°F (13-14°C) Boiling Point: 419°F-422° F (215-217°C) (decomposes) Vapor Pressure (25°C): 0.11 mm Hg Vapor density: 5.4 (Air=1) Volatility: 600 mg/m3 at 20°C Specific Gravity: 1.27 at 20°C (liquid) 1.34 at 13°C (solid) aqueous solubility (20°C): 0.8 g/L Miscible with the organophosphorus nerve agents. Soluble in fats and oils, gasoline, kerosene, acetone, carbon tetrachloride, alcohol, tetrachloroethane, ethylbenzoate, and ether. Estimated log Kow : 1.37 - 2.41 log Kbenzene-water : 0.15 Flashpoint: 220°F (104°C) Flammability: (can be ignited by large explosive charges)
Environmental data	Bulk mustard can persist for decades in soil or water. When exposed to sea water, mustard forms a thick outer "crust" over a core of mustard which allows the mustard to be brought to the surface where it can injure unsuspecting fishermen who may snare plastic lumps of mustard gas in their nets. Mustard and a number of its hydrolysis products are oxidized (air, oxygen, hypochlorite, hydrogen peroxide, nitric acid, potassium permanganate, and chromic acid) to give the less toxic sulfoxide and sulfone analogs. Mustard and its hydrolysis products do not significantly degrade in sunlight and are stable at less than 49°C.
Acute exposure guidelines	10 min 30 min 1hr 4 hr 8 hr AEGL 1 (discomfort, non-disabling) - mg/m3 0.06 0.02 0.01 0.003 0.001 AEGL 2 (irreversible or other serious, long-lasting effects or impaired ability to escape) - mg/m 3 0.09 0.03 0.02 0.005 0.002 AEGL 3 (life-threatening effects or death) - mg/m 3 0.059 0.041 0.32 0.08 0.04
Additional information	Trade Names and Other Synonyms: • yperite; Y • Kampfstoff Lost • Sulphur mustard gas • Sulfide, bis (2-chloroethyl) • Bis(beta-chloroethyl)sulfide • 1,1'-thiobis(2-chloroethane) • 1-chloro-2(beta-chloroethylthio)ethane • Beta, beta’-dichlorodiethyl sulfide • 2,2’dichlorodiethyl sulfide • Di-2-chloroethyl sulfide Beta, beta’-dichloroethyl sulfide • Iprit S-Lost • S-yperite • Schewefel-lost • Senfgas • Yellow Cross Liquid • EA 1033
Glossary of acronyms	APR -Air-purifying Respirator CBRN - Chemical, Biological, Radiological, Nuclear IDLH - Immediately Dangerous to Life and Health REL - Recommended Exposure Limit PEL - Permissible Exposure Limit SCBA - Self-Contained Breathing Apparatus Important notice: Mustard (ERC: 505-60-2) The user should verify compliance of the cards with the relevant state or territory legislation before use. NIOSH, CDC 2003.

Table 2. Clinical Effects and Time of Onset by Severity of Exposure to Sulfur Mustard
Tissue	Severity of exposure	Clinical effects	Time to first effect
Eyes	Mild Moderate Severe	Tearing, itching, burning, gritty feeling Above effects and reddening, lid edema, moderate pain Marked lid edema, possible corneal damage, severe pain	4-12 hours 3-6 hours 1-2 hours
Airways	Mild Severe	Rhinorrhea, sneezing, epistaxis, hoarseness, hacking cough Above effects and productive cough, mild to severe dyspnea	6-24 hours 2-6 hours
Skin	Mild Severe	Erythema Erythema and vesication	2-24 hours 2-24 hours

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.

Types of Hazard Exposure	Acute Hazard/ Clinical Signs/Symptoms	Prevention/Personal Protective Equipment	First Aid / Fire Fighting
FIRE	N/A	N/A	Water, fog, foam, CO 2 , dry chemical. Avoid methods that cause splashing or spreading. Fight fire from as far a distance as possible.
Explosion	N/A	N/A	N/A
Route of Exposure
Synopsis:	Severe irritant. Contact with vapor or liquid can be fatal.	Do not breathe fumes. Skin contact must be avoided at all times.	Seek medical attention Immediately.
Inhalation:	Delayed effects between 2 and 24 hours after exposure Runny nose. Dry/barking cough. Hoarseness. "Toneless" voice. Hemorrhage and necrosis of lung tissue resulting in coughing up blood. Difficulty breathing.	Hold breath until respiratory protective mask is donned. Pressure demand, self-contained breathing apparatus (SCBA CBRN, if available) is recommended in response situations to any amount of agent. CBRN, Full Facepiece APR (when available) is recommended in non-routine, emergency situation environments less than IDLH but above REL or PEL levels.	Immediately remove from source of exposure. If breathing is labored give oxygen. If breathing has stopped give artificial respiration. Mouth-to-mouth only when no facial contamination. Seek medical attention immediately.
Skin:	Rapid penetration (within 1-2 minutes) without irritation. Reddening, swelling, and blisters (small to very large) in 4-24 hours depending on dose. Warm, moist, thin-skinned areas are the most sensitive to this agent.	Butyl rubber, neoprene, nitrile or PVC (Polyvinyl Chloride) gloves, Responder® CSM protective clothing including PVC boots.	Immediately remove contaminated clothing and wash exposed area thoroughly with soap and water. Contaminated clothing can expose rescue workers through direct contact or through off-gassing vapor. (See Decontamination section.)