Medical Management Guidelines
(MMGs) |
for |
Blister Agents: |
Nitrogen Mustard (HN-1) |
(C6H13Cl2N) |
Nitrogen Mustard (HN-2) |
(C5H11Cl2N) |
Nitrogen Mustard (HN-3) |
(C6H12Cl3N) |
|
CAS#
|
Nitrogen Mustard (HN-1) 538-07-8
Nitrogen Mustard (HN-2) 51-75-2
Nitrogen Mustard (HN-3) 555-77-1 |
|
|
UN# |
Nitrogen Mustard (HN-1) 2810
Nitrogen Mustard (HN-2) 2927
Nitrogen Mustard (HN-3) 2810 |
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Synonyms:
HN-1: Bis(2-chloroethyl)ethylamine; 2-chloro-N-(2-chloroethyl)-N-ethylethanamine;
2,2'-dichlorotriethylamine; ethylbis(2-chloroethyl)amine;
ethyl-S
HN-2: MBA; mechlorethamine; mustine;
2,2'-dichloro-N-methyldiethylamine; dichloren; caryolysin;
mechlorethanamine; chlormethine; bis(2-chloroethyl)methylamine
HN-3: Tris(2-chloroethyl)amine; 2-chloro-N,N-bis(2-chloroethyl)ethanamine;
2,2',2"-trichlorotriethylamine
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- People whose skin or clothing is contaminated with nitrogen
mustard can contaminate rescuers by direct contact or through
off-gassing vapor.
- Nitrogen mustards are colorless to yellow, oily liquids
with variable odors.
- Nitrogen mustards are absorbed by the skin causing erythema
and blisters. Ocular exposure to these agents may cause
incapacitating injury to the cornea and conjunctiva. When
inhaled, nitrogen mustard damages the respiratory tract
epithelium and may cause death.
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General
Information |
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Description |
Nitrogen mustards are vesicants and alkylating
agents. They are colorless to pale yellow, oily liquids that
evaporate slowly. HN-1 has a faint, fishy or musty odor. It
is sparingly soluble in water but miscible with acetone and
other organic solvents. At temperatures greater than 194ºC,
it decomposes.
HN-2 has a fruity odor at high concentrations
and a soapy odor at low concentrations. Its solubility is
similar to HN-1.
HN-3 is odorless when pure but has been
reported to have a butter almond odor. It is the most stable
of the nitrogen mustards but decomposes at temperatures greater
than 256ºC. It has a much lower vapor pressure than HN-1
or HN-2 and is insoluble in water.
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Routes of Exposure |
Inhalation |
Inhalation is an important route of exposure.
Nitrogen mustard vapors are heavier than air. 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 for HN-1 and HN-3, and 3,000 mg-min/m³
for HN-2.
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Skin/Eye Contact |
Exposure to nitrogen mustard vapor can
cause injury to the eyes, skin, and mucous membranes at low
concentrations. Direct contact with the liquid can cause skin
and eye burns. The median incapacitating dose for the eyes
is 100 mg-min/m³ for HN-2 and 200 mg-min/m³ for
HN-1 and HN-3. Absorption may occur after skin or eye exposure
to liquid or vapor nitrogen mustard and may cause systemic
toxicity.
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Ingestion |
Ingestion is an uncommon route for exposure
but can lead to local effects such as esophageal or gastrointestinal
burns and systemic absorption.
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Sources/Uses |
Nitrogen mustards were first developed
in the late 1920s and early 1930s. HN-1 was originally designed
to remove warts but was later identified as a potential chemical
warfare agent; HN-2 was designed as a military agent but was
later used in chemotherapy; HN-3 was developed as a military
agent. None of the nitrogen mustards have been used on the
battlefield, and none are included in U.S. stockpiles.
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Standards and Guidelines |
HN-1: Airborne Exposure Limit (as recommended
by the Surgeon General's Working Group, U.S. Department of
Health and Human Services) = 0.003 mg/m³ as a time-weighted
average (TWA) for the workplace. No standards exist for HN-2
or HN-3.
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Physical Properties |
Table 1. Physical Properties of Nitrogen
Mustards (Blister Agents)
|
Property |
|
HN-1 |
HN-2 |
HN-3 |
Description |
Colorless to pale yellow oily liquid |
Pale amber to yellow oily liquid |
Colorless to pale yellow oily liquid |
Warning properties |
Faint fishy or musty odor |
Faint soapy odor at low concentrations;
fruity odor at high concentrations |
Faint butter almond odor |
Molecular weight |
170.08 daltons |
156.07 daltons |
204.54 daltons |
Boiling point |
(760 mm Hg) = 381ºF (194ºC) |
(760 mm Hg) = 167ºF (75ºC) |
(760 mm Hg) = 493ºF (256ºC) (decomposes) |
Freezing point |
29.2ºF (-34ºC) |
-85 to -76ºF (-65 to -60ºC) |
25.3ºF (-3.7ºC) |
Specific gravity |
No data (water = 1.0) |
No data (water = 1.0) |
No data (water = 1.0) |
Vapor pressure |
0.25 mm Hg at 77ºF (25ºC) |
0.427 mm Hg at 77ºF (25ºC) |
0.0109 mm Hg at 77ºF (25ºC) |
Vapor density |
5.9 (air = 1.0) |
5.4 (air = 1.0) |
7.1 (air = 1.0) |
Liquid density |
1.09 g/mL at 77ºF (25ºC) |
1.15 g/mL at 68ºF (20ºC) |
1.24 g/mL at 77ºF (25ºC) |
Solubility in water |
Sparingly soluble |
Sparingly soluble |
Practically insoluble |
Volatility |
No immediate danger of fire or explosion |
No immediate danger of fire or explosion;
however, polymerization results in components which present
an explosion hazard in open air. |
No immediate danger of fire or explosion;
however, polymerization results in components which present
an explosion hazard in open air |
NAERG# |
153 |
153 |
153 |
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Incompatibilities |
HN-1 is corrosive to ferrous alloys at
temperatures of 149ºF (68ºC) and higher. HN-2 and
HN-3 do not have any incompatible actions on metals or other
materials.
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Health
Effects |
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- Nitrogen mustards are vesicants causing skin, eye, and
respiratory tract injury. Although these agents cause cellular
changes within several minutes of contact, the onset of
pain and other clinical effects is delayed for hours.
- Nitrogen mustards are alkylating agents that may cause
bone marrow suppression and neurologic toxicity.
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Acute Exposure |
Nitrogen mustards are vesicants and alkylating
agents; however, the mechanisms of action are not clearly
understood. They are highly reactive and combine rapidly with
proteins, DNA, or other molecules. Therefore, within minutes
following exposure intact mustard or its reactive metabolites
are not found in tissue or biological fluids.
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CNS |
High doses of nitrogen mustards have
caused tremors, seizures, incoordination, ataxia, and coma
in laboratory animals.
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Respiratory |
Damage to the mucosa of the airways begins
within hours and may progress over several days. Nasal and
sinus pain or discomfort, pharyngitis, laryngitis, cough,
and dyspnea may occur. Pulmonary edema is uncommon.
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Gastrointestinal |
Ingestion may cause chemical burns of
the GI tract and hemorrhagic diarrhea. Nausea and vomiting
may occur following ingestion, dermal, or inhalation exposure.
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Ocular |
Exposure to nitrogen mustard vapor or
liquid may cause intense conjunctival and scleral inflammation,
pain, swelling, lacrimation, photophobia, and corneal damage.
High concentrations can cause burns and blindness.
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Dermal |
Direct skin exposure to nitrogen mustards
causes erythema and blistering. Generally, a rash will develop
within several hours, followed by blistering within 6 to 12
hours. Prolonged contact, or short contact with large amounts,
may result in second- and third-degree chemical burns.
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Hematopoietic |
Systemic absorption of nitrogen mustard
may induce bone marrow suppression and an increased risk for
fatal complicating infections, hemorrhage, and anemia.
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Delayed Effects |
Chemotherapeutic doses of HN-2 have been
associated with menstrual irregularities, alopecia, hearing
loss, tinnitus, jaundice, impaired spermatogenesis, generalized
swelling, and hyperpigmentation.
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Potential Sequelae |
Chronic respiratory and eye conditions
may persist following exposure to large amounts of nitrogen
mustards. Narrowing of the esophagus and severe corrosive
damage to the stomach lining can result from ingesting formalin.
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Chronic Exposure |
In laboratory animal studies, prolonged
or repeated exposures to nitrogen mustards have caused cancer,
developmental and reproductive effects, and hepatic toxicity.
Repeated exposures result in cumulative effects because mustards
are not naturally detoxified by the body.
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Carcinogenicity |
The International Agency for Research
on Cancer (IARC) has classified nitrogen mustard as probably
carcinogenic to humans (Group 2A). There is some evidence
that it causes leukemia in humans, and it has been shown to
cause leukemia and cancers of the lung, liver, uterus, and
large intestine in animals.
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Reproductive and
Developmental Effects |
Nitrogen mustards may decrease fertility.
A few case reports have linked treatment with HN-2 to fetal
abnormalities in humans. Nitrogen mustards have produced developmental
effects in animals.
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Prehospital
Management |
|
- Victims whose skin or clothing is contaminated with liquid
nitrogen mustard can contaminate rescuers by direct contact
or through off-gassing vapor.
- Nitrogen 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 nitrogen mustard toxicity. Decontamination
of all potentially exposed areas within minutes after exposure
is the only effective means of decreasing tissue damage.
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Hot Zone |
Rescuers should be trained and appropriately
attired before entering the Hot Zone. If the proper equipment
is not available, or if the rescuers have not been trained
in its use, call for assistance from the U.S. Soldier and
Biological Chemical Command-Edgewood Research Development
and Engineering Center (from 0700-1630 EST call 410-671-4411,
and from 1630-0700 EST call 410-278-5201; ask for the Staff
Duty Officer).
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Rescuer Protection |
Nitrogen 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
nitrogen 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.
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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).
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 most signs and symptoms of nitrogen
mustard 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 who develop significant dermal, ocular, or airway
injury and patients who have ingested nitrogen mustard should
be transported to a medical facility for evaluation.
Symptoms may not develop for 24 hours.
Patients with mild symptoms who are seen long enough after
exposure to minimize the likelihood that the lesions will
worsen may be sent home after 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
Nitrogen Mustard Patient Information Sheet).
Consult with the base station physician
or 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. For
nitrogen mustards, potentially exposed individuals should
be observed for 6 - 8 hours and, if signs or symptoms appear,
be sent to the hospital.
- 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.
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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.
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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.
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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.
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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).
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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 heavy bleeding, if present.
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Basic Decontamination |
The eyes and skin must be decontaminated
within 1 or 2 minutes after exposure 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,
cut and remove all clothing and wash skin immediately 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 exposed areas 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.
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Transfer to Support
Zone |
As soon as basic decontamination is complete,
move the victim to the Support Zone.
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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.
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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, as needed. Direct pressure should
be applied to stop bleeding, if present.
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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.
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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.
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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.
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Emergency
Department Management |
|
- Patients whose skin or clothing is contaminated with liquid
nitrogen mustard can contaminate rescuers by direct contact
or through off-gassing vapor.
- Nitrogen 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 nitrogen 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.
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Decontamination
Area |
Previously decontaminated patients may
be treated or held for observation. Others require decontamination
as described below.
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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 who have seizures or ventricular dysrhythmias due to other
exposures or trauma, should be treated in the conventional
manner.
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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).
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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 cool water and enough
water pressure to quickly 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.
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Critical Care Area |
Be certain that appropriate decontamination
has been carried out (see Decontamination Area above).
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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.
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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.
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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, 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.
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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.
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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.
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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.
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Antidotes and Other
Treatments |
There is no antidote for nitrogen mustard.
Treatment is supportive.
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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.
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Disposition |
As discussed above, consider hospitalizing
patients who have had significant exposures.
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Delayed Effects |
Significant systemic absorption of nitrogen
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.
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Patient Release |
Patients who have sustained mild exposure
may be discharged. Discharged patients should be advised to
rest and to seek medical care promptly if symptoms develop
(see page 22, Follow-up Instructions, included with
the Nitrogen Mustard Patient Information Sheet).
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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.
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General
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
nitrogen mustard can contaminate medical personnel and others
by direct contact or through off-gassing vapor.
- Nitrogen 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 nitrogen mustard toxicity. Medical
treatment is supportive.
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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.
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ABC Reminders |
Patients may have other injuries and
must be evaluated using the concepts of BLS and ALS.
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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).
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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.
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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.
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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.
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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.
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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. Critical Care Unit once decontamination has been assured.
Those with less severe effects should be admitted to a routine
care ward.
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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.
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Medical Management |
General |
There is no antidote for nitrogen 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.
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Skin Exposure |
Most burns are second degree although
third degree burns may occur after liquid exposure. In general,
small blisters (i.e., <1 cm) should remain roofed and larger
ones (>1 cm) 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.
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|
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
may 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.
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|
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 throat 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.
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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.
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|
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 exposure.
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|
Disposition and
Follow-up |
Patients with moderate to severe exposures
will require hospitalization, as described above
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|
Patient Release |
Patients who have sustained mild exposure
may be discharged. Discharged patients should be advised to
rest and to seek medical care promptly if symptoms develop
(see below, Follow-up Instructions, included with the
Nitrogen Mustard Patient Information Sheet).
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Follow-up |
Follow-up evaluation of respiratory,
neurological, and bone marrow function should be arranged
for severely exposed patients.
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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.
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|
Blister
Agents Nitrogen Mustard (HN-1, HN-2, and HN-3) Patient Information
Sheet |
|
This handout provides information and
follow-up instructions for people who have been exposed to
nitrogen mustards.
Print this handout only. 18k
|
|
What are nitrogen
mustards? |
Nitrogen mustards are compounds that
were initially developed as chemical warfare agents or pharmaceuticals.
They have never been used on the battlefield. HN-2 has been
used in chemotherapy.
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|
What immediate
health effects can be caused by exposure to nitrogen mustards? |
Nitrogen mustards cause injury to the
skin, eyes, nose and throat. Eye damage may occur within minutes
of exposure. Nausea and vomiting also may occur shortly after
exposure. Skin rashes, blisters, and lung damage may develop
within a few hours of exposure but may take 6 hours or more.
Nitrogen mustards can also suppress the immune system.
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|
Can nitrogen mustard
poisoning be treated? |
There is no antidote for nitrogen 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 nitrogen mustard will need
to be treated in a hospital.
|
|
Are any future
health effects likely to occur? |
Adverse health effects, such as chronic
respiratory diseases, may occur from exposure to high levels
of these agents. Severe damage to the eye may be present for
a long time following the exposure.
|
|
What tests can
be done if a person has been exposed to nitrogen mustard? |
There are no routine tests to confirm
exposure.
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|
Where can more
information about nitrogen mustard be found? |
More information about nitrogen mustards
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.
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Follow-up
Instructions |
|
Keep this page and take it with you to
your next appointment. Follow only the instructions
checked below.
Print instructions only. 18k
|
|
[ ] Call your doctor or the Emergency
Department if you develop any unusual signs or symptoms within
the next 24 hours, especially:
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|
- 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.
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|
[ ] Call for an appointment with Dr.____
in the practice of ________.
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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.
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|
[ ] Return to the Emergency Department/Clinic
on ____ (date) at _____ AM/PM for a follow-up examination.
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|
[ ] Do not perform vigorous physical
activities for 1 to 2 days.
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|
[ ] You may resume everyday activities
including driving and operating machinery.
|
|
[ ] Do not return to work for _____days.
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|
[ ] 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.
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|
[ ] Avoid drinking alcoholic beverages
for at least 24 hours; alcohol may worsen injury to your stomach
or have other effects.
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|
[ ] Avoid taking the following medications:
________________
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|
[ ] You may continue taking the following
medication(s) that your doctor(s) prescribed for you: _______________________________
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[ ] Other instructions: ____________________________________
_____________________________________________________
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|
- 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 ____________
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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 F-32
Atlanta, GA 30333
Phone: 1-888-42-ATSDR (1-888-422-8737)
FAX: (770)-488-4178
Email: ATSDRIC@cdc.gov
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