Common blister agents include mustard (HD), nitrogen mustard (HN), and Lewisite (L). Each is chemically different and will cause significant specific symptoms. They are all similar in their physical characteristics and toxicology. Mustards are particularly insidious because they do not manifest their symptoms for several hours after exposure. They attack the eyes and respiratory tract as well as the skin.

There is no effective therapy for mustard once its effects become visible. Treatment is largely supportive: to relieve itching and pain, and to prevent infection.

MUSTARD (HD) AND NITROGEN MUSTARD (HN).-HD and HN are oily, colorless or pale yellow liquids, sparingly soluble in water. HN is less volatile and more persistent than HD but has the same blistering qualities.

Signs and Symptoms of Exposure.-The eyes are the most vulnerable part of the body to mustard gas. Contamination insufficient to cause injury elsewhere may produce eye inflammation. Because the eye is the most sensitive part of the body, the first noticeable symptoms of mustard exposure will be pain and a gritting feeling in the eyes, accompanied by spastic blinking of the eyelids and photophobia. Vapor or liquid may burn any area of the skin, but the burns will be most severe in the warm, sweaty areas of the body: the armpits, groin, and on the face and neck. Blistering begins in about 12 hours but may be delayed for up to 48 hours. Inhalation of the gas is followed in a few hours by irritation of the throat, hoarseness, and a cough. Fever, moist rales, and dyspnea may develop. Brochopneumonia is a frequent complication. The primary cause of death is massive edema or mechanical pulmonary obstruction.

Treatment.-There is no specific antidotal treatment for mustard poisoning. Physically removing as much of the mustard as possible, as soon as possible, is the only effective method for mitigating symptoms before they appear. All other treatment is symptomatic, that is, the relief of pain and itching, and control of infection.

LEWISITE (L).-Lewisite is an arsenical (an arsenic-based compound). This blistering compound is a light-to dark-brown liquid that vaporizes slowly.

Signs and Symptoms of Exposure.-The vapors of arsenicals are so irritating that conscious persons are immediately warned by discomfort to put on the mask. No severe respiratory injuries are likely to occur, except in the wounded who are incapable of donning a mask. The respiratory symptoms are similar to those produced by mustard gas. While distilled mustard and nitrogen mustard cause no pain on the skin during absorption, Lewisite causes intense pain upon contact.

Treatment.-Immediately decontaminate the eyes by flushing with copious amounts of water to remove liquid agents and to prevent severe burns. Sodium sulfacetamide, 30 percent solution, may be

Figure 8-6.-One set of used autoinjectors attached to a pocket flap.

used to combat eye infection within the first 24 hours after exposure. In severe cases, morphine may be given to relieve pain.

In cases of systemic involvement, British Anti- Lewisite (BAL), dimercaprol, is available in a peanut oil suspension for injection. BAL is a specific antiarsenical that combines with the heavy metal to form a water-soluble, nontoxic complex that is excreted. However, BAL is somewhat toxic, and an injection of more than 3 mg/kg will cause severe symptoms.

Aside from the use of dimercaprol for the systemic effects of arsenic, treatment is the same as for mustard lesions.