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What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

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Presentation on theme: "What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?"— Presentation transcript:

1 What Agent Caused More Chemical Casualties in World War I Than All Other Chemical Agents Combined?

2 What chemical agent caused over 5000 known casualties as recently as the 1980's and was also used on civilian populations including children?

3 What chemical agent is in the arsenals of at least a dozen countries around the globe and ready to use against a perceived enemy?

4 MUSTARD Clifton E. Yu, MD LTC, MC Department of Pediatrics 444 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

5 Vesicants Agent that causes vesicles or blisters Main vesicant in production today: sulfur mustard Lewisite and Phosgene Oxime (CX) also classified as vesicants--lesser availability and history of use 555 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

6 Mustard--Why So Important? No antidote Causes lots of morbidity Relatively easy to synthesize Delayed symptoms Children more susceptible to its toxic effects 666 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

7 History 1000 B.C.--arsenic smokes used by Chinese against invading Mongol tribes 423 B.C.--Spartans used burning sulfur and coal smoke to attack Athenians in Peloponnesian War sulfur mustard first synthesized chlorine, phosgene, and particularly mustard used by both British and Germans resulting in thousands of casualties 777 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

8 888 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

9 History (cont.) nitrogen mustard synthesized used by Italy against Abyssinia Japan allegedly uses mustard gas against China during invasion of Manchuria 1960's--used by Egypt against Yemen 1980's--extensive use of mustard gas against Iranian soldiers and civilians during Iran-Iraq War 999 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

10 Characteristics of Chemical Agents Volatility--degree to which a substance vaporizes Persistence--refers specifically to how long the substance stays in the environment and is inversely related to volatility 10 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

11 Characteristics of Mustard Oily, yellow to dark brown liquid Garlic or mustard odor Considered a persistent agent Is "radiomimetic" Thought to work as an alkylating agent 11 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

12 12 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center Detection Smell M8, M9 paper, various detectors Clinical recognition

13 Clinical Effects Skin, Eyes, Respiratory Tract Bone Marrow, GI, CNS in Severe Exposures 13 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

14 Skin Effects Latent period of several hours after exposure Erythema, then blister formation With high dose, skin sloughing Blister fluid not hazardous 14 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

15 15 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

16 16 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

17 Ocular Effects Most often caused by vapor Conjunctival inflammation Corneal damage Severe lid edema Rarely permanent blindness 17 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

18 Respiratory Effects Vapor induced Upper respiratory tract irritation Dyspnea and productive cough Severe necrotizing tracheobronchitis with pseudomembrane formation Secondary bacterial infection 18 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

19 Bone Marrow Involvement occurs in severe cases Usually occurs on day 3 to 5 ANC less than 500 or a precipitous drop portends a high risk of sepsis and death 19 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

20 GI Tract Usually manifested by nausea and vomiting Generally transient and not severe Thought to be caused by cholinergic activity of mustard Delayed nausea and vomiting thought secondary to generalized cytotoxic activity and mucosal damage to GI tract 20 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

21 CNS Symptoms not usually prominent Common complaints in World War I were apathy, depression, and intellectual dullness 83% of hospitalized Iranians in one study had CNS complaints--usually mild and non- specific 21 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

22 Treatment Decon, Decon, Decon !!! -only effective means of preventing or decreasing tissue damage -must be performed before entry into a clean MTF Remainder of treatment depends on the other organ systems involved 22 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

23 Skin Treat like a burn Erythema treated with soothing lotion, e.g. calamine Carefully unroof larger blisters Irrigation of denuded areas 3-4X daily 23 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

24 Skin (cont.) Topical antibiotics, e.g. Silvedene Systemic antipruritics Systemic analgesics Fluids and electrolytes 24 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

25 Eyes Eyes Thorough irrigation Cycloplegics (e.g. homatropine) Topical antibiotics Vaseline to edges of eyelids Systemic analgesics (e.g. NSAID's) 25 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

26 Pulmonary Upper airway symptoms--steam inhalation, cough suppressants Avoid using antibiotics early on Intubation if lower resp. sx's progress -attempt before laryngospasm or significant edema develop -direct laryngoscopy with suctioning if evidence of pseudomembrane formation 26 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

27 Pulmonary (cont.) No evidence steroids beneficial routinely Prolonged assisted or controlled ventilation- -bad prognosis 27 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

28 Bone Marrow If neutropenic, some advocate gut sterilization with non-absorbable antibiotics Bone marrow transplant or transfusion-- may be life-saving in selected cases 28 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

29 GI Atropine (0.4 to 0.6 mg IM or IV for adults) or another anti-cholinergic may be helpful IV fluids 29 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

30 Summary Decontamination Treat like a burn patient Liberal use of analgesics Fluids and electrolytes (less than for standard burns) System specific treatment as necessary 30 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

31 But What About Children? Very little in literature Recent experience with childhood mustard exposure from Iran-Iraq War (Momeni and Aminjarahari, Int. J. Derm. Vol 33, March 1994) Earlier onset of skin lesions, more severe More frequent and severe opthalmic, pulmonary, and GI involvement 31 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

32 Skin Earlier lesions, more bullae First index case may therefore be a child Traditional decontamination with sodium hypochlorite (bleach) may be harmful to child's skin Use copious amounts of soap and water instead 32 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

33 Eyes More frequent and severe eye findings Same therapeutic interventions 33 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

34 Pulmonary Higher incidence of lung involvement Increased minute ventilation in children May have to intubate sooner 34 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

35 GI Increased involvement probably dose related Children more likely to have protracted emesis Atropine or other anti-cholinergic in age- appropriate doses may be helpful 35 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

36 Pediatric Exposure--Summary Earlier and more severe skin lesions (soap and water for decontamination) Pay early attention to eyes in virtually all children Be on lookout for earlier and more severe lung involvement May have to treat GI symptoms more aggressively (and watch for increase in dehydration) 36 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center

37 BE PREPARED!!! …and get ready for inhalants next week 37 Clifton Yu, MD Department of Pediatrics Walter Reed Army Medical Center


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