Bis(2-Chloroethyl)sulfide

CAS RN: 505-60-2

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) The role of gastrointestinal decontamination is not clear for mustard ingestion. Most patients will have severe vomiting and gastrointestinal irritation, so it is unlikely that gastric lavage will remove additional poison. Activated charcoal is also unlikely to be of utility since the toxic effects occur rapidly upon contact with tissue.
  • B) Treat systematic effects as outlined in the INHALATION EXPOSURE section.
0.4.3 INHALATION EXPOSURE
  • A) PERSONNEL PROTECTION
    • 1) Rescue personnel must wear protective clothing, eye protection, and lung protection respirator or air pack.
  • B) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Initial treatment of victims should include immediate removal of the victim from the contaminated area, stabilization of general and hemodynamic status, maintenance of the airway, and oxygenation. Remove contaminated clothing and wash exposed skin thoroughly with soap and water as soon as possible (ideally within 2 minutes as mustard fixes to the skin within minutes). In a mass casualty situation, if water is in short supply, adsorbent powders such as flour, talcum powder or Fuller's earth may be applied to the skin and then wiped off with a damp cloth. Administer inhaled beta agonists to patients with bronchospasm.
  • C) MANAGEMENT OF SEVERE TOXICITY
    • 1) Patients with significant airway or pulmonary toxicity should be intubated. Maintain adequate nutritional status and replace loss of fluid and electrolytes. Monitor CBC. If neutropenia develops, place the patient in isolation, and administer granulocyte stimulating factors. Sodium thiosulfate can be administered intravenously (12.5 g IV over 10 minutes) or via nebulizer (2.5% solution). Animal studies suggests that it may reduce damage if given within 20 to 30 minutes of exposure.
    • 2) DERMAL EXPOSURE: Remove contaminated clothing and wash thoroughly with soap and water as soon as possible (within minutes). If skin erythema is mild, no treatment is required. For pruritus, use topical steroid cream or compound calamine lotion (containing 1% each of phenol and menthol). If the blisters have been broken, remove the ragged roof; if not broken, drain under aseptic conditions. Clean the area with tap water or saline with application of petrolatum gauze when the areas are small. For large blisters, apply thick layer of 10% mefenide acetate (Sulfamylon(R)) or silver sulfadiazine burn cream. Appropriate antibiotics drug may be given locally or systemically if infection develops.
    • 3) EYE EXPOSURE: Irrigate exposed eyes with copious amounts of tepid water for at least 15 minutes. Sterile petroleum jelly is used to prevent the lid margins from sticking together. In mild lesions, a steroid antibiotic eye ointment can be applied. In severe lesions, administer mydriatics (one drop of atropine sulfate solution (1%)). To prevent infection, administer a few drops of 15% solution of sodium sulfacetamide every 4 hours; if infection develops administer every 2 hours.
    • 4) INHALATION EXPOSURE: Administer inhaled beta agonists for bronchospasm or persistent cough. Administer supplemental oxygen. Inhaled sodium thiosulfate (2.5% solution nebulized) may help prevent injury. Patients with severe respiratory distress required intubation. Bronchoscopy may be required to remove pseudomembranes from the respiratory tract.
  • D) DECONTAMINATION
    • 1) PREHOSPITAL: Move patient from the toxic environment to fresh air. As soon as possible, remove contaminated clothing and wash exposed area extremely thoroughly with soap and water. Cut away and discard contaminated hair. Dilute (0.5%) hypochlorite solutions (prepared by a 10:1 dilution of 5% chlorine bleach with water) may also be used for skin decontamination. Irrigate eyes with water or saline.
    • 2) HOSPITAL: If the patient has not had prehospital skin and eye decontamination, remove contaminated clothing and wash exposed area extremely thoroughly with soap and water. Cut away and discard contaminated hair. Dilute (0.5%) hypochlorite solutions (prepared by a 10:1 dilution of 5% chlorine bleach with water) may also be used for skin decontamination. Irrigate eyes with water or saline. The role of gastrointestinal decontamination is not clear for mustard ingestion. Most patients will have severe vomiting and gastrointestinal irritation, so it is unlikely that gastric lavage will remove additional poison. Activated charcoal is also unlikely to be of utility since the toxic effects occur rapidly upon contact with tissue.
  • E) AIRWAY MANAGEMENT
    • 1) Maintain open airway and perform orotracheal intubation if there are symptoms of airway or pulmonary injury.
  • F) ANTIDOTE
    • 1) There is no specific antidote. Animal studies have suggested benefit from sodium thiosulfate and N-acetyl-cysteine (NAC) administered shortly after exposure. There is no human data supporting the use of either therapy, but both have limited side effects. Use of either agent, or both, should be considered if they can be administered soon after exposure. Sodium thiosulfate: Adults: IV: 12.5 g IV over 10 minutes, Inhaled: 2.5% solution nebulized. NAC: IV: 150 mg/kg infusion over 60 minutes followed by 50 mg/kg infusion over 4 hours followed by 6.25 mg/kg/hr infusion for 16 hours. ORAL: 140 mg/kg orally followed by 70 mg/kg every 4 hours for 17 doses.
  • G) ENHANCED ELIMINATION
    • 1) Hemodialysis is of no benefit in mustard exposure.
  • H) PATIENT DISPOSITION
    • 1) HOME CRITERIA: There is no role for home management of any patient with mustard gas exposure.
    • 2) OBSERVATION CRITERIA: Any patient with exposure to mustard gas via any route (ingestion, dermal, inhalational or ocular) should be sent to a medical facility for evaluation and treatment.
    • 3) ADMISSION CRITERIA: Patients with significant dermal burns, persistent respiratory symptoms, or severe eye involvement should be admitted. Patients who are discharged should have frequent follow up for CBC monitoring.
    • 4) CONSULT CRITERIA: Consult a medical toxicologist or poison center for any patient with sulfur mustard exposure. Consult an ophthalmologist for any patients with mustard gas burns to the eye. Consult a pulmonologist for any patients with significant or persistent respiratory distress; bronchoscopy may be necessary. Consult a gastroenterologist for any ingestion as endoscopy may be necessary to assess the extent of injury.
    • 5) TRANSFER CRITERIA: Patients with severe or extensive dermal burns should be transferred to a burn unit.
  • I) PHARMACOKINETICS
    • 1) ABSORPTION: Mustard gas can be toxic by ingestion, inhalation, and skin and eye contact. The latent period for absorption is inversely related to the dose, temperature, and humidity. About 20% of a dermal dose is absorbed through human skin. It can penetrate the skin by contact with either the liquid or vapor.
    • 2) DISTRIBUTION: It accumulates primarily in the adipose tissue. Protein binding is about 10%, volume of distribution is 74.4 L/kg. It is eliminated in the urine as metabolites. Mustard gas is a lipophilic agent, however, its biotransformation is governed by its reaction in aqueous media. The key reaction in sulfur mustard toxicity is the intramolecular cyclization to form an electrophilic ethylene episulfonium intermediate.
0.4.4 EYE EXPOSURE
  • A) EYE EXPOSURE: Irrigate exposed eyes with copious amounts of tepid water for at least 15 minutes. Sterile petroleum jelly is used to prevent the lid margins from sticking together. In mild lesions a steroid antibiotic eye ointment can be applied. In severe lesions, administer mydratics (one drop of atropine sulfate solution (1%)). To prevent infection, administer a few drops of 15% solution of sodium sulfacetamide every 4 hours, if infection develops administer every 2 hours.
  • B) Treat systematic effects as outlined in the INHALATION EXPOSURE section.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) Remove contaminated clothing and wash exposed area extremely thoroughly with soap and water. Cut away and discard contaminated hair. Dilute (0.5%) hypochlorite solutions (prepared by a 10:1 dilution of 5% chlorine bleach with water) may also be used for skin decontamination. If skin erythema is mild, no treatment is required. For pruritus, use topical steroid cream or compound calamine lotion (containing 1% each of phenol and menthol). If the blisters have been broken, remove the ragged roof; if not broken, drain under aseptic conditions. Clean the area with tap water or saline with application of petrolatum gauze when the areas are small. For large blisters, apply thick layer of 10% mefenide acetate (Sulfamylon(R)) or silver sulfadiazine burn cream. Appropriate antibiotics drug may be given locally or systemically if infection develops.
    • 2) The US Military issues the M291 Skin Decontamination Kit which replaced the M2581A Skin Decontamination Kit. Each M291 Kit contains six individual decontamination packets each containing Ambergard XE-555 resin powder. The previously used M2581A Skin Decontamination Kit contained towelettes soaked with phenol+hydroxide and chloramine. A dilute (0.5 percent) hypochlorite (bleach) solution can also be used. Fuller's earth, flour, or talcum powder have been recommended as alternative dermal decontamination agents. These alternative agents are not currently used by the US Military.
    • 3) Treat systematic effects as outlined in the INHALATION EXPOSURE section.
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