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Evacuation Plan: Evacuate if unstable after decontamination.
Blister Agents
Blister agents such as phosgene, mustard gas or Lewisite attack exposed skin and mucous membranes.
They penetrate clothing and force troops to wear full protective equipment, degrading fighting efficiency. The
mask protects against eye and lung damage but provides only limited protection against systemic effects.
Extensive, slow-healing skin lesions will place a heavy burden on the medic. No drug is available for the
prevention of the effects on the skin and mucous membranes. Phosgene penetrates garments and rubber
easier than other chemical agents and produces a rapid onset of severe and prolonged effects. When mixed
with other chemicals, the rapid skin damage caused by phosgene will make the skin more susceptible to the
second agent. If an unmasked victim were exposed to phosgene before donning his mask, the pain caused
by the agent will prompt him to unmask again.
Subjective: Symptoms
Burns and blisters, itching, pain, conjunctivitis, coughing, shortness of breath, vomiting and diarrhea.
Objective: Signs
Using Basic Tools:
General: Shock after large exposure to Lewisite, resulting from protein and plasma leakage from capillaries
and subsequent hemoconcentration and hypotension.
Eyes: Significant conjunctivitis with possible later scarring. Phosgene in the eye results in immediate pain,
conjunctivitis and keratitis.
Skin: Reddened and extremely pruritic; progresses in 4-24 hours to blistering, which may be severe
depending on agent and exposure. Phosgene may cause immediate pain followed by skin necrosis. Apart
from mucous membranes, the face, neck and skin-on-skin areas (armpits, genitalia, webs of the digits, etc.)
are most susceptible.
Respiratory tract: Swelling impeding the airway, tissue sloughing, hyperactive airways, tracheobronchial
stenosis, pulmonary edema.
GI tract: Nausea and vomiting which may worsen.
Assessment: Diagnosis based on clinical signs and symptoms, environment and probability
Plan:
Treatment
Mask self. Mask patient.
- Burns: Treat burns similarly to second-degree thermal burns (clean, prevent infection). Irrigate copiously
with water to remove any persistent agent. Apply Calamine lotion or suitable substitute to relieve pruritus.
Small blisters (<1cm) should be left alone. Irrigate surrounding area daily and apply Silvadene Cream.
Larger blisters should be unroofed and the area irrigated 4 times daily with soapy water and covered
liberally with Silvadene Cream or suitable substitute. Give systemic pain relief and fluids. - Prevent infection and scarring of eyes: Irrigate copiously with water. Treat mild exposure as conjuctivitis
More severe injuries require daily irrigation, topical antibiotics and a topical mydriatic. Apply Vaseline to
lid edges to prevent adherence, reduce scar formation and allow for a path for infection to drain if present. - Control pain with systemic analgesics.
- Topical steroid may be helpful in the first 48 hrs but of no benefit after that period.
- Maintain adequate oxygenation. Intubate patients with severe pulmonary involvement early to allow for
assisted ventilation and suction of necrotic and inflammatory debris. Oxygen may be necessary for
prolonged period. - Antitussives and demulcents help the severe non-productive cough. Bronchodilators may be necessary
to control airway irritability and systemic steroids may also be of benefit. - Establish IV accesses in an unaffected area. Perform fluid resuscitation with Ringer’s lactate or normal
saline. With severe blistering or if Lewisite is suspected, treat as a significant thermal injury. (See burn
management above).