- Email: [email protected]
Exposure to liquid sulfur mustard
CASE REPORT
Exposure to Liquid Sulfur Mustard From the US Army Health Clinic, Pine Bluff Arsenal, Pine Bluff, AR.
CPT Kurt G. Davis, MD CPT Gary Aspera, MPH
Received for publication February 18, 2000. Revision received October 27, 2000. Accepted for publication November 27, 2000. Address for reprints: Kurt G. Davis, MD, 10901 Loma de Rio, El Paso, TX 79934; 915-569-2602, fax 915-569-2698; E-mail [email protected]. 47/1/114322 doi:10.1067/mem.2001.114322
Chemical weapons continue to pose a serious threat to humanity. With the use of chemical weapons by terrorists in Tokyo, and the projected disarming of the chemical weapon stockpile in this country, the possibility that emergency physicians will encounter patients contaminated by chemical munitions, such as sulfur mustard, exists. Mustard is a vesicating agent with a long latency between exposure and symptoms. Exposure can cause burns, conjunctivitis, pneumonia, and death. We describe 3 workers exposed to mustard at a chemical weapon storage facility. This article reports the first case of an exposure to mustard at a storage facility, as well as the first documented incident occurring in the United States. All physicians who manage patients in an acute care setting should be aware of the presentation and emergency treatments involving patients contaminated with mustard. [Davis KG, Aspera G. Exposure to liquid sulfur mustard. Ann Emerg Med. June 2001;37:653-656.] INTRODUCTION
Despite the fact that the Geneva Protocol has banned the use of chemical weapons in warfare,1 more than 30,000 tons of these deadly chemicals still exist.2 Through their potential use by terrorists or in industrial accidents, it is possible that emergency physicians will treat patients exposed to chemical warfare agents. Sulfur mustard [bis-(2-chloroethyl) sulfide] is a vesicating chemical agent that can produce significant morbidity. Mustard exposure has a long latent period followed by the dose-dependent development of burns, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and possibly death. It was originally used as a weapon in World War I, where it was responsible for more than 80% of the documented chemical casualties.3 It has been used sporadically since that time, with the most recent incident being the Iran-Iraq War (1980-1988).4,5 In addition, there
JUNE 2001
37:6
ANNALS OF EMERGENCY MEDICINE
6 5 3
EXPOSURE TO LIQUID SULFUR MUSTARD Davis & Aspera
have been reports of mustard contamination by civilian fishermen or military souvenir collectors.6,7 The cases in the literature to date have dealt with the care of patients after their initial stabilization and referral to a tertiary care facility. We present the first report of patients exposed to mustard while working at a chemical weapon storage facility, as well as the first exposure occurring in this country. The initial presentation and treatment of patients exposed to mustard are also discussed. CASE REPORT
On June 12, 1998, three individuals presented to our outpatient medical clinic complaining of blister formation. The day before presentation, all 3 individuals had been involved in collecting routine chemical samples from an allegedly uncontaminated chemical storage site. During the collection process, all wore personal protective equipment consisting of chemical protective masks and butyl rubber aprons, boots, and gloves. At no time did any of them notice symptoms or any unusual odor. All 3 underwent the standard decontamination process with soap and water at the work site. The evening before presentation 2 of the 3 individuals began to notice mild symptoms of burning and pruritus. The following morning, all 3 noticed blisters on awakening and presented for evaluation. Patient 1 is a 47-year-old white man who presented with three 5-mm vesicles on his lower abdomen and back. Each vesicle contained straw-colored fluid and was surrounded by an erythematous base. The following day, he subsequently developed multiple smaller vesicles on the anterior aspect of his neck, each measuring roughly 2 mm in diameter, and a 3-mm vesicle on the left knee. Patient 2 is a 42-year-old black man who presented with a 4×6-cm circumferential lesion on the right side of the lower abdomen (Figure). The lesion consisted of multiple small vesicles around the periphery that subsequently coalesced into a large single bulla. Patient 3 is a 51-year-old black man who presented with a single 5-mm blister on his left thigh. All 3 men had normal vital signs, clear sclerae, and normal breath sounds and chest radiographic results, and denied symptoms of dyspnea, nausea, vomiting, or diarrhea. Current tetanus immunization status was documented; CBC count, serum electrolyte levels, liver function enzyme studies, and urinalysis were performed according to protocol and all were within normal limits. A diagnosis of mild chemical burns secondary to sulfur mustard was
6 5 4
made based on the laboratory results from the samples collected by the patients the previous day. The particular pattern of burns was later deemed to be secondary to areas either not covered by the personal protective equipment or areas superficially decontaminated because of the low perceived risk. Their burns were treated on an outpatient basis, with silver sulfadiazine cream and daily sterile dressing changes. All 3 patients had good results with this treatment, and their burns healed with minimal scar formation, although 2 did develop significant hypopigmentation at the burn sites. DISCUSSION
Sulfur mustard is an oily liquid, with a characteristic garlic odor, that poses a hazard as either a liquid or vapor. When mustard contamination first occurs, no symptoms are apparent. If the mustard is not rapidly removed, it penetrates the skin, forming a reactive sulfonium ion, leading to irreversible cell damage.8 No known antidote exists.3 Although mustard can cause significant morbidity, the effects from exposure are seldom fatal, with a mortality rate of 2% to 3%. A potential lethal exposure is approximately 100 mg/kg or 5 to 7 mL, the amount of mustard that will lightly cover 25% of the body surface area.3 Death is usually from pulmonary complications, such as acute chemical pneumonitis9 or pneumonia, typically exacerbated by the hematopoietic suppression.10 Therefore,
Figure.
A 4×6-cm circumferential lesion on the right side of the lower abdomen developed after exposure to sulfur mustard. The lesion consisted of multiple small vesicles around the periphery that subsequently coalesced into a large single bulla.
ANNALS OF EMERGENCY MEDICINE
37:6 JUNE 2001
EXPOSURE TO LIQUID SULFUR MUSTARD Davis & Aspera
patients who have sustained a potentially lethal dose of sulfur mustard may present initially with what appears to be a large first- or second-degree burn. Nearly all patients exposed to mustard develop skin burns in some form. In a review of 535 patients from the Iran-Iraq conflict, 92% of individuals admitted with mustard exposure developed skin lesions.5 The warm moist areas of the body, such as the perineum, axillae, and antecubital fossae, are the most vulnerable areas. The initial presentation can be subtle, with the first symptom being a stinging sensation followed by the development of erythema up to 24 hours after exposure. Although it is unusual to develop symptoms less than 12 hours after exposure,5 symptoms have been reported as early as 2 to 3 hours after a large dose11 or in children.4 The erythema is accompanied by pruritus and a painful burning sensation. Small vesicles develop on the periphery after an additional 2 to 18 hours, often coalescing to form large fluid-filled bullae. The fluid is clear of any mustard contaminant,12 however, and poses no threat to either the patient or health care worker in the event of lysis. The eyes are also commonly involved, with mustard rapidly penetrating the epithelial layer. Symptoms are dominated by pain, photophobia, lacrimation, and decreased vision.13 This progresses to conjunctivitis, blepharospasm, corneal ulceration, and corneal edema in more severely exposed individuals. Conjunctivitis occurred in up to 85% of the Iranian casualties, with 8% subsequently developing corneal edema.4 The long-term consequences of ocular exposure can be devastating, with 0.5% developing ulcerative keratitis, and ultimately blindness.13 Respiratory symptoms are the most serious and the most common cause of mortality.3 The pulmonary sequelae usually develop over the course of several days, but may present management difficulties in the acute setting. The mucous membranes can become edematous, and erythema of all areas of the tracheobronchus may be visualized.9 There can be considerable ulceration of the upper airway, followed by the formation of purulent discharge and fibrinous pseudomembranes,10 which can slough, leading to airway obstruction and subsequent respiratory failure.3 Sulfur mustard also can cause gastrointestinal symptoms and hematopoietic suppression. Nausea and vomiting are common sequelae, seen in 69% of exposed children.4 Although less commonly reported in adults, exposure occasionally presents as upper gastrointestinal tract bleeding.5 Leukopenia is common in mustard
JUNE 2001
37:6
ANNALS OF EMERGENCY MEDICINE
exposed casualties and was reported in half of the severely injured casualties from the Iran-Iraq conflict. This can complicate the management of these patients, often leading to serious infectious complications.5 The initial management of any casualty potentially exposed to a chemical agent is decontamination. This should be performed by gently bathing with soap and water. Avoid vigorous scrubbing and the use of 0.5% hypochlorite solution, as these have been shown to cause deeper tissue penetration of the mustard.14 Once the chemical has penetrated the skin, it cannot be removed, even by an adequate decontamination. The decontamination process serves mainly to prevent contamination of the health care setting and health care workers. Burns should be covered with an antibiotic ointment and dressed in a sterile manner. If the burns are superficial and cover a small percentage of the body, they can be safely managed on an outpatient basis with daily dressing changes. However, if the burns cover 20% to 25% of the body, the patient has been exposed to a potentially lethal dose of mustard and should be admitted to a critical care facility despite the benign appearance of the injury or the stable appearance of the patient. The eyes of all individuals should be copiously irrigated. If there are any ocular complaints, the eyes should be stained with fluorescein in an attempt to assess for the corneal damage that occurs in nearly 10% of patients. Patients with evidence of corneal injury should be treated with antibiotic drops, and the lid margins should be coated with a sterile ointment to prevent adherence of the lid margins.15 Such patients should have prompt evaluation by an ophthalmologist. Any patient with any evidence of respiratory symptoms needs urgent intervention. These patients should undergo emergency intubation, followed by bronchoscopy to assess for damage and to remove any necrotic debris.16 Preparations should be made for performing a tracheostomy in the event that any obstruction is unrelieved by bronchoscopy or direct laryngoscopy. Most chemical weapons remaining in the United States, such as mustard, are stored at remote, rural sites throughout the country. They are housed in either concrete igloos, or steel 1-ton containers and have remained untouched for several years. They are now being destroyed, which obviously necessitates increased handling. Adherence to guidelines regarding protective equipment and decontamination procedures is necessary to avoid exposure. Physicians who care for patients in an acute care setting must be familiar with the presentation and treatment of patients exposed to sulfur mustard.
6 5 5
EXPOSURE TO LIQUID SULFUR MUSTARD Davis & Aspera
REFERENCES 1. Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or other Gases, and of Bacteriological Methods of Warfare. Signed at Geneva, June 19, 1925. 2. SIPRI Yearbook 1993: World Armament and Disarmament. Stockholm, Sweden: Stockholm International Peace Research Institute; 1993. 3. Sidell FR, Urbanetti JS, Smith WJ, et al. Vesicants. In: Zajtchuk R, Bellamy RF, eds. Medical Aspects of Chemical and Biological Warfare. Washington, DC: Office of the Surgeon General-Department of the Army, United States of America; 1997:197-228. 4. Momeni AZ, Aminjavaheri M. Skin manifestations of mustard gas in a group of 14 children and teenagers: a clinical study. Int J Dermatol. 1994;33:184-187. 5. Momeni AZ, Enshaeih S, Meghdadi M, et al. Skin manifestations of mustard gas. Arch Dermatol. 1992;128:775-780. 6. Aasted A, Wulf HC, Darre E, et al. Fishermen exposed to mustard gas: clinical experiences and cancer risk evaluation. Ugeskr Laeger. 1985;147:2213-2216. 7. Ruhl CM, Park SJ, Danisa O, et al. A serious skin sulfur mustard burn from an artillery shell. J Emerg Med. 1994;12:159-166. 8. Hambrook JL, Howells DJ, Schock C. Biological fate of sulphur mustard (1,1´-thiobis(2chlorethane)): uptake, distribution and retention of 35S in skin and in blood after cutaneous application of 35S-sulphur mustard in rat and comparison with human blood in vitro. Xenobiotica. 1993;23:537-561. 9. Freitag L, Firusian N, Stamitis G, et al. The role of bronchoscopy in pulmonary complications due to mustard gas inhalation. Bronchoscopy. 1991;5:1436-1441. 10. Eisenmenger W, Drasch G, Clarmann M, et al. Clinical and morphological findings on mustard gas [bis(2-chloroethyl)sulfide] poisoning. J Forensic Sci. 1991;36:1688-1698. 11. Requena L, Requena C, Sanchez M, et al. Cutaneous lesions from mustard gas. J Am Acad Dermatol. 1988;19:529-536. 12. Smith W, Dunn A. Medical defense against blistering chemical warfare agents. Arch Dermatol. 1991;127:1207-1213. 13. Solberg Y, Alcalay M, Belkin M. Ocular injury by mustard gas. Surv Ophthalmol. 1997;41:461-466. 14. Gold MB, Bongiovanni R, Scharf BA. Hypochlorite solution as a decontaminant in sulfur mustard contaminated skin defects in the euthymic hairless guinea pig. Drug Chem Toxicol. 1994;17:499-527. 15. Murray VSG, Volans GN. Management of injuries due to chemical weapons. BMJ. 1991;302:129-130. 16. Pradkash UBS. Chemical warfare and bronchoscopy. Chest. 1991;100:1486-1487.
6 5 6
ANNALS OF EMERGENCY MEDICINE
37:6 JUNE 2001
Exposure to Liquid Sulfur Mustard From the US Army Health Clinic, Pine Bluff Arsenal, Pine Bluff, AR.
CPT Kurt G. Davis, MD CPT Gary Aspera, MPH
Received for publication February 18, 2000. Revision received October 27, 2000. Accepted for publication November 27, 2000. Address for reprints: Kurt G. Davis, MD, 10901 Loma de Rio, El Paso, TX 79934; 915-569-2602, fax 915-569-2698; E-mail [email protected]. 47/1/114322 doi:10.1067/mem.2001.114322
Chemical weapons continue to pose a serious threat to humanity. With the use of chemical weapons by terrorists in Tokyo, and the projected disarming of the chemical weapon stockpile in this country, the possibility that emergency physicians will encounter patients contaminated by chemical munitions, such as sulfur mustard, exists. Mustard is a vesicating agent with a long latency between exposure and symptoms. Exposure can cause burns, conjunctivitis, pneumonia, and death. We describe 3 workers exposed to mustard at a chemical weapon storage facility. This article reports the first case of an exposure to mustard at a storage facility, as well as the first documented incident occurring in the United States. All physicians who manage patients in an acute care setting should be aware of the presentation and emergency treatments involving patients contaminated with mustard. [Davis KG, Aspera G. Exposure to liquid sulfur mustard. Ann Emerg Med. June 2001;37:653-656.] INTRODUCTION
Despite the fact that the Geneva Protocol has banned the use of chemical weapons in warfare,1 more than 30,000 tons of these deadly chemicals still exist.2 Through their potential use by terrorists or in industrial accidents, it is possible that emergency physicians will treat patients exposed to chemical warfare agents. Sulfur mustard [bis-(2-chloroethyl) sulfide] is a vesicating chemical agent that can produce significant morbidity. Mustard exposure has a long latent period followed by the dose-dependent development of burns, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and possibly death. It was originally used as a weapon in World War I, where it was responsible for more than 80% of the documented chemical casualties.3 It has been used sporadically since that time, with the most recent incident being the Iran-Iraq War (1980-1988).4,5 In addition, there
JUNE 2001
37:6
ANNALS OF EMERGENCY MEDICINE
6 5 3
EXPOSURE TO LIQUID SULFUR MUSTARD Davis & Aspera
have been reports of mustard contamination by civilian fishermen or military souvenir collectors.6,7 The cases in the literature to date have dealt with the care of patients after their initial stabilization and referral to a tertiary care facility. We present the first report of patients exposed to mustard while working at a chemical weapon storage facility, as well as the first exposure occurring in this country. The initial presentation and treatment of patients exposed to mustard are also discussed. CASE REPORT
On June 12, 1998, three individuals presented to our outpatient medical clinic complaining of blister formation. The day before presentation, all 3 individuals had been involved in collecting routine chemical samples from an allegedly uncontaminated chemical storage site. During the collection process, all wore personal protective equipment consisting of chemical protective masks and butyl rubber aprons, boots, and gloves. At no time did any of them notice symptoms or any unusual odor. All 3 underwent the standard decontamination process with soap and water at the work site. The evening before presentation 2 of the 3 individuals began to notice mild symptoms of burning and pruritus. The following morning, all 3 noticed blisters on awakening and presented for evaluation. Patient 1 is a 47-year-old white man who presented with three 5-mm vesicles on his lower abdomen and back. Each vesicle contained straw-colored fluid and was surrounded by an erythematous base. The following day, he subsequently developed multiple smaller vesicles on the anterior aspect of his neck, each measuring roughly 2 mm in diameter, and a 3-mm vesicle on the left knee. Patient 2 is a 42-year-old black man who presented with a 4×6-cm circumferential lesion on the right side of the lower abdomen (Figure). The lesion consisted of multiple small vesicles around the periphery that subsequently coalesced into a large single bulla. Patient 3 is a 51-year-old black man who presented with a single 5-mm blister on his left thigh. All 3 men had normal vital signs, clear sclerae, and normal breath sounds and chest radiographic results, and denied symptoms of dyspnea, nausea, vomiting, or diarrhea. Current tetanus immunization status was documented; CBC count, serum electrolyte levels, liver function enzyme studies, and urinalysis were performed according to protocol and all were within normal limits. A diagnosis of mild chemical burns secondary to sulfur mustard was
6 5 4
made based on the laboratory results from the samples collected by the patients the previous day. The particular pattern of burns was later deemed to be secondary to areas either not covered by the personal protective equipment or areas superficially decontaminated because of the low perceived risk. Their burns were treated on an outpatient basis, with silver sulfadiazine cream and daily sterile dressing changes. All 3 patients had good results with this treatment, and their burns healed with minimal scar formation, although 2 did develop significant hypopigmentation at the burn sites. DISCUSSION
Sulfur mustard is an oily liquid, with a characteristic garlic odor, that poses a hazard as either a liquid or vapor. When mustard contamination first occurs, no symptoms are apparent. If the mustard is not rapidly removed, it penetrates the skin, forming a reactive sulfonium ion, leading to irreversible cell damage.8 No known antidote exists.3 Although mustard can cause significant morbidity, the effects from exposure are seldom fatal, with a mortality rate of 2% to 3%. A potential lethal exposure is approximately 100 mg/kg or 5 to 7 mL, the amount of mustard that will lightly cover 25% of the body surface area.3 Death is usually from pulmonary complications, such as acute chemical pneumonitis9 or pneumonia, typically exacerbated by the hematopoietic suppression.10 Therefore,
Figure.
A 4×6-cm circumferential lesion on the right side of the lower abdomen developed after exposure to sulfur mustard. The lesion consisted of multiple small vesicles around the periphery that subsequently coalesced into a large single bulla.
ANNALS OF EMERGENCY MEDICINE
37:6 JUNE 2001
EXPOSURE TO LIQUID SULFUR MUSTARD Davis & Aspera
patients who have sustained a potentially lethal dose of sulfur mustard may present initially with what appears to be a large first- or second-degree burn. Nearly all patients exposed to mustard develop skin burns in some form. In a review of 535 patients from the Iran-Iraq conflict, 92% of individuals admitted with mustard exposure developed skin lesions.5 The warm moist areas of the body, such as the perineum, axillae, and antecubital fossae, are the most vulnerable areas. The initial presentation can be subtle, with the first symptom being a stinging sensation followed by the development of erythema up to 24 hours after exposure. Although it is unusual to develop symptoms less than 12 hours after exposure,5 symptoms have been reported as early as 2 to 3 hours after a large dose11 or in children.4 The erythema is accompanied by pruritus and a painful burning sensation. Small vesicles develop on the periphery after an additional 2 to 18 hours, often coalescing to form large fluid-filled bullae. The fluid is clear of any mustard contaminant,12 however, and poses no threat to either the patient or health care worker in the event of lysis. The eyes are also commonly involved, with mustard rapidly penetrating the epithelial layer. Symptoms are dominated by pain, photophobia, lacrimation, and decreased vision.13 This progresses to conjunctivitis, blepharospasm, corneal ulceration, and corneal edema in more severely exposed individuals. Conjunctivitis occurred in up to 85% of the Iranian casualties, with 8% subsequently developing corneal edema.4 The long-term consequences of ocular exposure can be devastating, with 0.5% developing ulcerative keratitis, and ultimately blindness.13 Respiratory symptoms are the most serious and the most common cause of mortality.3 The pulmonary sequelae usually develop over the course of several days, but may present management difficulties in the acute setting. The mucous membranes can become edematous, and erythema of all areas of the tracheobronchus may be visualized.9 There can be considerable ulceration of the upper airway, followed by the formation of purulent discharge and fibrinous pseudomembranes,10 which can slough, leading to airway obstruction and subsequent respiratory failure.3 Sulfur mustard also can cause gastrointestinal symptoms and hematopoietic suppression. Nausea and vomiting are common sequelae, seen in 69% of exposed children.4 Although less commonly reported in adults, exposure occasionally presents as upper gastrointestinal tract bleeding.5 Leukopenia is common in mustard
JUNE 2001
37:6
ANNALS OF EMERGENCY MEDICINE
exposed casualties and was reported in half of the severely injured casualties from the Iran-Iraq conflict. This can complicate the management of these patients, often leading to serious infectious complications.5 The initial management of any casualty potentially exposed to a chemical agent is decontamination. This should be performed by gently bathing with soap and water. Avoid vigorous scrubbing and the use of 0.5% hypochlorite solution, as these have been shown to cause deeper tissue penetration of the mustard.14 Once the chemical has penetrated the skin, it cannot be removed, even by an adequate decontamination. The decontamination process serves mainly to prevent contamination of the health care setting and health care workers. Burns should be covered with an antibiotic ointment and dressed in a sterile manner. If the burns are superficial and cover a small percentage of the body, they can be safely managed on an outpatient basis with daily dressing changes. However, if the burns cover 20% to 25% of the body, the patient has been exposed to a potentially lethal dose of mustard and should be admitted to a critical care facility despite the benign appearance of the injury or the stable appearance of the patient. The eyes of all individuals should be copiously irrigated. If there are any ocular complaints, the eyes should be stained with fluorescein in an attempt to assess for the corneal damage that occurs in nearly 10% of patients. Patients with evidence of corneal injury should be treated with antibiotic drops, and the lid margins should be coated with a sterile ointment to prevent adherence of the lid margins.15 Such patients should have prompt evaluation by an ophthalmologist. Any patient with any evidence of respiratory symptoms needs urgent intervention. These patients should undergo emergency intubation, followed by bronchoscopy to assess for damage and to remove any necrotic debris.16 Preparations should be made for performing a tracheostomy in the event that any obstruction is unrelieved by bronchoscopy or direct laryngoscopy. Most chemical weapons remaining in the United States, such as mustard, are stored at remote, rural sites throughout the country. They are housed in either concrete igloos, or steel 1-ton containers and have remained untouched for several years. They are now being destroyed, which obviously necessitates increased handling. Adherence to guidelines regarding protective equipment and decontamination procedures is necessary to avoid exposure. Physicians who care for patients in an acute care setting must be familiar with the presentation and treatment of patients exposed to sulfur mustard.
6 5 5
EXPOSURE TO LIQUID SULFUR MUSTARD Davis & Aspera
REFERENCES 1. Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or other Gases, and of Bacteriological Methods of Warfare. Signed at Geneva, June 19, 1925. 2. SIPRI Yearbook 1993: World Armament and Disarmament. Stockholm, Sweden: Stockholm International Peace Research Institute; 1993. 3. Sidell FR, Urbanetti JS, Smith WJ, et al. Vesicants. In: Zajtchuk R, Bellamy RF, eds. Medical Aspects of Chemical and Biological Warfare. Washington, DC: Office of the Surgeon General-Department of the Army, United States of America; 1997:197-228. 4. Momeni AZ, Aminjavaheri M. Skin manifestations of mustard gas in a group of 14 children and teenagers: a clinical study. Int J Dermatol. 1994;33:184-187. 5. Momeni AZ, Enshaeih S, Meghdadi M, et al. Skin manifestations of mustard gas. Arch Dermatol. 1992;128:775-780. 6. Aasted A, Wulf HC, Darre E, et al. Fishermen exposed to mustard gas: clinical experiences and cancer risk evaluation. Ugeskr Laeger. 1985;147:2213-2216. 7. Ruhl CM, Park SJ, Danisa O, et al. A serious skin sulfur mustard burn from an artillery shell. J Emerg Med. 1994;12:159-166. 8. Hambrook JL, Howells DJ, Schock C. Biological fate of sulphur mustard (1,1´-thiobis(2chlorethane)): uptake, distribution and retention of 35S in skin and in blood after cutaneous application of 35S-sulphur mustard in rat and comparison with human blood in vitro. Xenobiotica. 1993;23:537-561. 9. Freitag L, Firusian N, Stamitis G, et al. The role of bronchoscopy in pulmonary complications due to mustard gas inhalation. Bronchoscopy. 1991;5:1436-1441. 10. Eisenmenger W, Drasch G, Clarmann M, et al. Clinical and morphological findings on mustard gas [bis(2-chloroethyl)sulfide] poisoning. J Forensic Sci. 1991;36:1688-1698. 11. Requena L, Requena C, Sanchez M, et al. Cutaneous lesions from mustard gas. J Am Acad Dermatol. 1988;19:529-536. 12. Smith W, Dunn A. Medical defense against blistering chemical warfare agents. Arch Dermatol. 1991;127:1207-1213. 13. Solberg Y, Alcalay M, Belkin M. Ocular injury by mustard gas. Surv Ophthalmol. 1997;41:461-466. 14. Gold MB, Bongiovanni R, Scharf BA. Hypochlorite solution as a decontaminant in sulfur mustard contaminated skin defects in the euthymic hairless guinea pig. Drug Chem Toxicol. 1994;17:499-527. 15. Murray VSG, Volans GN. Management of injuries due to chemical weapons. BMJ. 1991;302:129-130. 16. Pradkash UBS. Chemical warfare and bronchoscopy. Chest. 1991;100:1486-1487.
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ANNALS OF EMERGENCY MEDICINE
37:6 JUNE 2001