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Mustard Gas or Sulfur Mustard: An Old Chemical Agent as a New Terrorist Threat

Published online by Cambridge University Press:  28 June 2012

Monica Wattana  and
Tareg Bey
Monica Wattana
Affiliation:
Department of Emergency Medicine, University of California, Irvine, Orange, California, USA
Tareg Bey*
Affiliation:
Department of Emergency Medicine, University of California, Irvine, Orange, California, USA
*
Department of Emergency MedicineUniversity of California, Irvine101 The City Drive, Rte 128 Orange, CA 92868USA E-mail: tbey@uci.edu
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Abstract

Sulfur mustard is a member of the vesicant class of chemical warfare agents that causes blistering to the skin and mucous membranes. There is no specific antidote, and treatment consists of systematically alleviating symptoms. Historically, sulfur mustard was used extensively in inter-governmental conflicts within the trenches of Belgium and France during World War I and during the Iran-Iraq conflict. Longitudinal studies of exposed victims show that sulfur mustard causes long-term effects leading to high morbidity. Given that only a small amount of sulfur mustard is necessary to potentially cause an enormous number of casualties, disaster-planning protocol necessitates the education and training of first-line healthcare responders in the recognition, decontamination, triage, and treatment of sulfur mustard-exposed victims in a large-scale scenario.

Keywords

chemical agentsmustard gassulfur mustardterrorist threat
Type
Comprehensive Review
Information
Prehospital and Disaster Medicine , Volume 24 , Issue 1 , February 2009 , pp. 19 - 29
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2009

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References

1. North Atlantic Treaty Organization (NATO): NATO handbook on the medical aspects of NBC defensive operations AMedP-6(B). Available at http://www.fas.ord/nuke/guide/usa/doctrine/dod/fm8-9/3ch1.htm#s1. Accessed 11 December 2008.Google Scholar
2. International Humanitarian Law—Geneva Protocol 1925. Available at http://www.icrc.org/ihl.nsf/intro/280?OpenDocument. Assessed 11 December 2008.Google Scholar
3. The Chemical Weapons Convention (CWC). Available at http://www.un.org/depts/dda/wmd/cwc. Accessed 11 December 2008.Google Scholar
4. Saladi, R, Smith, E, Persaud, A: Mustard: A potential agent of chemical warfare and terrorism. Clin Exp Dermatol 2006;31:1–5.CrossRefGoogle Scholar
5. Shohrati, M, Peyman, M, Peyman, A, et al. : Cutaneous and ocular late complications of sulfur mustard in Iranian veterans. Cutan Ocul Toxicol 2007;26:73–81.CrossRefGoogle ScholarPubMed
6. Szinicz, L: History of chemical and biological warfare agents. Toxicology 2005;214:167–181.CrossRefGoogle ScholarPubMed
7. Bey, T, Walter, FG: Senfgas, Stickstofflost, Lewisit und Phosgenoxim. Hautschädigende Militärkampfstoffe und deren Bedeutung für die Rettungsdienste, Feuerwehren, Polizei und das Militär. (Mustard gas, nitrogen mustards, lewisite and phosgene oxime. Vesicant-type chemical warfare agents and their significance to the emergency medical services, fire departments, law enforcement agencies and the military [in German with English abstract]. Notfall Rettungsmed 2003;6:327–336.CrossRefGoogle Scholar
8. Ghanei, M, Harandi, A: Long term consequences from exposure to sulfur mustard: A review. Inhal Toxicol 2007:19;451–456.CrossRefGoogle ScholarPubMed
9. Khateri, S, Ghanei, M, Keshavarz, S, et al. : Incidence of lung, eye, and skin lesions as late complications in 34,000 Iranians with wartime exposure to mustard agent. J Occup Environ Med 2003;45:1136–1143.CrossRefGoogle Scholar
10. Papirmeister, B, Feister, AJ, Robinson, SL, et al. : Medical Defense Against Mustard Gas: Toxic Mechanisms and Pharmacological Implications. Boca Raton: CRC Press, 1991, p 359.Google Scholar
11. Davis, K, Aspera, G: Exposure to liquid sulfur mustard. Ann Emerg Med 2001;37:653–653.CrossRefGoogle ScholarPubMed
12. Evison, D, Hinsley, D, Rice, P: Chemical weapons. BMJ 2002;324:332–335.CrossRefGoogle ScholarPubMed
13. Williams, KE: Physical properties of sulfur mustard HD. Available at http://chppm-www.apgea.army.mil/dts/docs/dethhd.pdf. Accessed 29 May 2008Google Scholar
14. Anonymous: Chemical casualties: Vesicants (blister agents). J R Army Med Corps 2002;148:358–370.CrossRefGoogle Scholar
15. Sidell, FR, Urbanetti, JS, Smith, WJ, et al. : Vesicants. In: Sidell, FR, Takafuji, ER, Franz, DR (eds) Textbook of Military Medicine. Part I, Warfare, Weaponry, and the Casualty. Medical Aspects of Chemical and Biological Warfare. Washington, DC: Office of the Surgeon General, Department of the Army, Walter Reed Army Medical Center, 1997, pp 197–228.CrossRefGoogle Scholar
16. Borak, J, Sidell, F: Agents of chemical warfare: sulfur mustard. Ann Emerg Med 1992;21:303–308.CrossRefGoogle ScholarPubMed
17. Compton, JAG (ed): Blister Agents. In: Military Chemical and Biological Agents Chemical and Toxicological Properties. Caldwell, NJ: Telford Press, 1988, pp 6–86.Google Scholar
18. Peters, RA, Sinclair, H, Thompson, R: An analysis of the inhibition of pyruvate oxidation by arsenicals in relation to the enzyme theory of vesication. Biochem J 1946;40:516–524.CrossRefGoogle Scholar
19. Kehe, K, Szinicz, L: Medical aspects of sulphur mustard poisoning. Toxicology 2005;214:198–209.CrossRefGoogle ScholarPubMed
20. Papirmeister, B, Gross, CL, Meier, HL, et al. : Molecular basis for mustardinduced vesication. Fundam Appl Toxicol 1985;5:s134–s149.CrossRefGoogle ScholarPubMed
21. Korkmaz, A, Yaren, H, Topal, T, Oter, S: Molecular targets against mustard toxicity: Implication of cell surface receptors, peroxynitrite production, and PARP activation. Arch Toxicol 2006;80:662–670.CrossRefGoogle ScholarPubMed
22. Mellor, SG, Rice, P, Cooper, GJ: Vesicant burns. Br J Plast Surg 1991;44:434–437.CrossRefGoogle ScholarPubMed
23. Watson, A, Opresko, D, Young, R, Hauschild, V: Development and application of acute exposure guideline levels (Acute Emergency Guideline Levels) for chemical warfare, nerve, and sulfur mustard agents. J Toxicol Environ Health B Crit Rev 2006;9:163–263.CrossRefGoogle Scholar
24. Balali-Mood, M, Hefazi, M: Comparison of early and late toxic effects of sulfur mustard in Iranian veterans. Basic Clin Pharmacol Toxicol 2006;99:273–282.CrossRefGoogle ScholarPubMed
25. National Research Council (NRC) Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Enviornmental Studies, Commission on Life Sciences, National Research Council: Standing Operating Procedures for Developing Acute Exposure Guideline Levels for Hazardous Chemicals. Washington, DC: National Academy Press, 2001, pp 1–202.Google Scholar
26. Hartmann, HM: Evaluation of risk assessment guideline levels for the chemical warfare agents mustard, GB, and VX. Regul Toxicol Pharmacol 2002:35:347–356.CrossRefGoogle ScholarPubMed
27. US Army Soldier and Biological Chemical Command: Material Safety Data Sheet. Mustard Gas. Available at http://www.castleviewuk.com/Frameless/Safe/msds/ex/MSDS_mustard.htm. Accessed 29 May 2008.Google Scholar
28. Rusch, G, Garrett, R, Tobin, P, et al. : The development of acute exposure guideline levels for hazardous substances. Drug Chem Toxicol 2002;25:339–348.CrossRefGoogle ScholarPubMed
29. Javadi, MA, Yazdani, S, Sajjadi, H, et al. : Chronic and delayed-onset mustard gas keratitis: Report of 48 patients and review of literature. Ophthalmology 2005;112:617–625.CrossRefGoogle ScholarPubMed
30. Vidan, A, Luria, S, Eisenkraft, A, Hourvitz, A: Ocular injuries following sulfur mustard exposure: Clinical characteristics and treatment. IMAJ 2002;4:577–578.Google ScholarPubMed
31. Momeni, AZ, Enshaeih, S, Meghadadi, M, Amindjavaheri, M: Skin manifestations of mustard gas: A clinical study of 535 patients exposed to mustard gas. Arch Dermatol 1992;128:775–780.CrossRefGoogle ScholarPubMed
32. Dacre, JC, Goldman, M: Toxicology and pharmacology of the chemical warfare agent sulfur mustard. Pharmacol Rev 1996;48:289–326.Google ScholarPubMed
33. Ghanei, M, Vosoghi, AA: An epidemiologic study to screen for chronic myelocytic leukemia in war victims exposed to mustard gas. Environ Health Perspect 2002;110:519–521.CrossRefGoogle ScholarPubMed
34. Tabarestani, M, Farhoudi, M, Balali, M: Stem Cell and Erythroid Precursors Disorders in Three Patients with Sulfur Mustard Poisoning. In: Proceedings of the First International Medical Congress on Chemical Warfare Agents in Iran, June 1988, Mashhad University of Medical Sciences, Mashhad, Iran. Mashhad, Mashhad University Press, 1988;F10.Google Scholar
35. Tabarestani, M, Balali, M, Farhoudi, M: Hematologic findings of sulfur mustard poisoning in Iranian combatants. Med J Islamic Rep of Iran 1990;3:185–189.Google Scholar
36. Newman-Taylor, AJ, Morris, AJR: Experience with mustard gas casualties. Lancet 1991;337:242.CrossRefGoogle ScholarPubMed
37. Willems, J: Clinical management of mustard gas casualties. Ann Med Militaris Belgicae 1989;3:s1–s61.Google Scholar
38. Beebe, GW: Lung cancer in WWI veterans: Possible relation to mustard gas injury and the 1918 influenza epidemic. J Natl Cancer Inst 1960;25:1231–1252.Google Scholar
39. Yamada, A: On the late injuries following occupational inhalation of mustard gas with special relationship to carcinoma of the respiratory tract. Acta Pathol Jpn 1963:13;131–155.Google Scholar
40. Hefazi, M, Maleki, M, Mahamoudi, M, et al. : Delayed complications of sulfur mustard poisoning in the skin and the immune system of Iranian veterans 16–20 years after exposure. Int J Dermatol 2006;45:1025–1031.CrossRefGoogle ScholarPubMed
41. Panahi, Y, Davoodi, SM, Khalili, H, et al. : Phenol and menthol in the treatment of chronic skin lesions following mustard gas exposure. Singapore Med 2007;48:392–395.Google ScholarPubMed
42. Smith, KJ: The prevention and treatment of cutaneous injury secondary chemical warfare agents. Application of these findings to other dermatologic conditions and wound healing. Dermatol Clin 1999;17:41–60.CrossRefGoogle ScholarPubMed
43. Rice, P, Brown, R, Lam, D, et al. : Dermabrasion—A novel concept in the surgical management of sulphur mustard injuries. Burns 2000;26:34–40.CrossRefGoogle ScholarPubMed
44. Evison, D, Brown, RF, Rice, P: The treatment of sulphur mustard burns with laser debridement. J Plast Reconstr Aesthet Surg 2006;59:1087–1093.CrossRefGoogle ScholarPubMed
45. Ghanei, M, Shohrati, M, Harandi, A, et al. : Inhaled corticosteroids and longacting beta2-agonists in treatment of patients with chronic bronchiolitis following exposure to sulfur mustard. Inhal Toxicol 2007;19:889–894.CrossRefGoogle Scholar
46. Macintyre, AG, Christopher, GW, Eltzen, E Jr, et al. : Weapons of mass destruction events with contaminated casualties. JAMA 2000;283:242–249.CrossRefGoogle ScholarPubMed
47. Karayilanoglu, T, Kenar, L, Gulec, M: Evaluations over the medical emergency responding to chemical terrorist attack. Mil Med 2003;168:591–594.CrossRefGoogle ScholarPubMed
48. Kenar, L, Karayilanoglu, T, Eryilmaz, M, et al. : Chemical release at the airport and lessons learned from the medical perspective. J Hazard Mater 2007;144:396–399.CrossRefGoogle ScholarPubMed
49. Carmona, RH: The science of surge: An all-hazard approach is critical improving public health preparedness. Acad Emerg Med 2006;13:1097–1097.Google ScholarPubMed
50. Kahn, CA: Personnel communication, May 2008.Google Scholar
51. Buryakov, IA: Express analysis of explosives, chemical warfare agents and drugs with multicapillary column gas chromatography and ion mobility increment spectrometry. J Chromatogr B Analyt Technol Biomet Life 2004;800:75–82.CrossRefGoogle ScholarPubMed
52. Schwenk, M, Kluge, S, Jaroni, H: Toxicological aspects of preparedness and aftercare for chemical-incidents. Toxicology 2005;214:232–248.CrossRefGoogle ScholarPubMed
53. Capacio, BR, Smith, JR, DeLion, MT, et al. : Monitoring sulfur mustard exposure by gas chromatography-mass spectrometry analysis of thiodiglycol cleaved from blood proteins. J Anal Toxicol 2004;28:306–310.CrossRefGoogle ScholarPubMed
54. Makas, AL, Troshkov, ML: Field gas chromatography-mass spectrometry for fast analysis. J Chromatogr B Anal Technol Biomed Life Sci 2004;800:55–61.CrossRefGoogle ScholarPubMed
55. Bowerbank, CR, Smith, PA, Drown, DB, et al. : Chemical detection in deployment toxicology using high speed gas chromatography with a solvating mobile phase and time-of-flight mass spectrometry. Drug Chem Toxicol 1999;22:57–71.CrossRefGoogle ScholarPubMed
56. Muir, B, Quick, S, Slater, BJ, et al. : Analysis of chemical warfare agents. II. Use of thiols and statistical experimental design for the trace level determination of vesicant compounds in air samples. J Chromatogr A 2005;1068:315–326.CrossRefGoogle ScholarPubMed
57. D'Agostino, PA, Hancock, JR, Chenier, CL: Mass spectrometric analysis of chemical warfare agents and their degradation products in soil and synthetic samples. Eur J Mass Spectrom 2003;9:609–701.CrossRefGoogle ScholarPubMed
58. Garner, A, Laurence, H, Lee, A: Practicality of performing medical procedures in chemical protective ensembles. Emerg Med Australas 2004;16:108–113.Google ScholarPubMed
59. Koenig, KL, Boatright, CJ, Hancock, JA, et al. : Health care facilities' “war on terrorism”: A deliberate process for recommending personal protective equipment. Am J Emerg Med 2007;25:185–195.CrossRefGoogle Scholar
60. Hurts, G: Decontamination. In: Sidell, FR, Takafuji, ER, Franz, DR (eds) Textbook of Military Medicine. TMM Publications Borden Institute, Part I, Warfare, Weaponry, and the Casualty. Medical Aspects of Chemical and Biological Warfare. Washington, DC: Office of the Surgeon General, Department of the Army, Walter Reed Army Medical Center, 1997, pp 351–359.Google Scholar
61. Levitin, H, Siegelson, H, Dickinson, S, et al. : Decontamination of mass casualties—Re-evaluating existing dogma. Prehospital Disast Med 2003;18:200–207.CrossRefGoogle ScholarPubMed
62. Kollek, D: Canadian emergency department preparedness for a nuclear, biological or chemical event. CJEM 2003;5:18–26.CrossRefGoogle ScholarPubMed
63. Taysee, L, Daulon, S, Delamanche, S, et al. : Skin decontamination of mustards and organophosphates: Comparative efficiency of Reactive Skin Decontamination Lotion and Fuller's earth in domestic swine. Hum Exp Toxicol 2007;26:135–141.CrossRefGoogle Scholar
64. Robinson, J, Leitenberg, M (eds): The Rise in CB Weapons. The Problem of Chemical and Biological Warfare. Volume 1: The Use of CB Weapons. Stockholm: Alquist and Wiksell Humanities Press, 1971.Google Scholar