You have been logged out of VisualDx or your session has expired.

Please reload this page and sign into VisualDx to continue.

..
  VisualDx Mobile   Select Language

Get VisualDx Mobile

There are VisualDx mobile apps available for iOS and Android devices.

You will need a VisualDx account to use the mobile apps.



Already have an account? Sign In or
sign up for a free trial.

Users with VisualDx accounts earn CME credits for using VisualDx.

Already have an account? Sign In or
sign up for a free trial.

Create a Personal Account

E-mail (username)
Password
Verify Password
First Name
Last Name

Personal Account Created

Mobile Access

You can now download VisualDx for your iOS and Android devices. Launch the VisualDx app from your device and sign in using your VisualDx personal account username and password.

CME Certification

Sign in with your personal account to earn and claim CME credits through VisualDx. Credits can be earned by building a differential or looking up a diagnosis.

Version: 7.10.1411   (build c09c816)
Select Language


Select Region

Send us your feedback

E-mail
Message
This field is required

Oops! There was an issue during submission. Please try again. If the problem persists, email feedback@visualdx.com with your feedback.

Thank You!

We appreciate your feedback and you will be hearing from us soon.

OK

Share This Page

Thank You!

We have sent an e-mail with a link to the current page.

OK

E-mail This Patient Information Sheet

Thank You!

We have sent an e-mail with this patient information.

OK

Image Contributors

Individuals

  • Christine Ahn MD
    Carl Allen DDS, MSD
    Brandon Ayres MD
    Howard P. Baden MD
    Robert Baran MD
    Keira Barr MD
    Gregory J. Basura MD, Ph.D
    Donald Belsito MD
    Jeffrey D. Bernhard MD
    Jesse Berry MD
    Victor Blanco MD
    Benjamin R. Bohaty MD
    William Bonnez MD
    Sarah Brenner MD
    Robert A. Briggaman MD
    Robert Brodell MD
    Roman Bronfenbrener MD
    Walter Brooks MD
    William Buckley MD
    Philip Bulterys MD, PhD (candidate)
    Susan Burgin MD
    Sonya Burton MD
    Sean P. Bush MD, FACEP
    Jeffrey Callen MD
    Scott Camazine MD
    Michael Cardwell
    Shelley D. Cathcart MD
    Robert Chalmers MD, MRCP, FRCP
    Chia-Yu Chu MD, PhD
    Flavio Ciferri MD
    Maria Rosa Cordisco MD
    Noah Craft MD, PhD
    John T. Crissey MD
    Harold E. Cross MD, PhD
    Charles Crutchfield III MD
    Adriana Cruz MD
    Donna Culton MD, PhD
    Bart J. Currie MBBS, FRACP, DTM&H
    Chicky Dadlani MD
    Alexander Dane DO
    C. Ralph Daniel III MD
    Thomas Darling MD, PhD
    William Delaney MD
    Damian P. DiCostanzo MD
    Ncoza Dlova MD
    James Earls MD
    Libby Edwards MD
    Melissa K. Egge MD
    Charles N. Ellis MD
    Rachel Ellis MD
    David Elpern MD
    Nancy Esterly MD
    Stephen Estes MD
    E. Dale Everett MD
    Janet Fairley MD
    David Feingold MD
    Benjamin Fisher MD
    Henry Foong MBBS, FRCP
    David Foster MD, MPH
    Brian D. Foy PhD
    Michael Franzblau MD
    Vincent Fulginiti MD
    Sunir J. Garg MD, FACS
    Kevin J. Geary MD
    Lowell Goldsmith MD, MPH
    Sethuraman Gomathy MD
    Bernardo Gontijo MD, PhD
    Kenneth Greer MD
    Kenneth G. Gross MD
    Alan Gruber MD
    Nathan D. Gundacker MD
    Akshya Gupta MD
    Vidal Haddad MSC, PhD, MD
    Edward Halperin MD, MA
    Ronald Hansen MD
    John Harvey
    Rizwan Hassan MD
    Michael Hawke MD
    Jason E. Hawkes MD
    Peter W. Heald MD
    David G. Hicks MD
    Sarah Hocker DO
    Ryan J. Hoefen MD, PhD
    Li-Yang Hsu MD
    William Huang MD
    Sanjana Iyengar MD
    Alvin H. Jacobs MD
    Shahbaz A. Janjua MD
    Joshua J. Jarvis MD
    Kit Johnson
    Robert Kalb MD
    A. Paul Kelly MD
    Henry Kempe MD
    Loren Ketai MD
    Sidney Klaus MD
    Ashwin Kosambia MD
    Jessica A. Kozel MD
    Carl Krucke
    Mario E. Lacouture MD
    Joseph Lam MD
    Alfred T. Lane MD
    Edith Lederman MD
    Nahyoung Grace Lee MD
    Pedro Legua MD, PhD
    Robert Levin MD
    Bethany Lewis MD
    Sue Lewis-Jones FRCP, FRCPCH
    Taisheng Li MD
    Christine Liang MD
    Shari Lipner MD, PhD
    Jason Maguire MD
    Mark Malek MD, MPH
    Jere Mammino DO
    Ricardo Mandojana MD
    Lynne Margesson MD
    Thomas J. Marrie MD
    Maydel Martinez MD
    Ralph Massey MD
    Patrick McCleskey MD
    Karen McKoy MD
    Thomas McMeekin MD
    Josette McMichael MD
    Somchai Meesiri MD
    Joseph F. Merola MD
    Mary Gail Mercurio MD
    Anis Miladi MD
    Larry E. Millikan MD
    Dan Milner Jr. MD
    Zaw Min MD
    Stephanie Montero
    Alastair Moore MD
    Keith Morley MD
    Dean Morrell MD
    Samuel Moschella MD
    Taimor Nawaz MD
    Vic Newcomer MD
    John Nguyen MD
    Matilda Nicholas MD
    Thomas P. Nigra MD
    Steven Oberlender MD, PhD
    Maria Teresa Ochoa MD
    Art Papier MD
    Lawrence Parish MD
    Tanner Parrent MD
    Mukesh Patel MD
    Lauren Patty-Daskivich MD
    David Peng MD, MPH
    Robert Penne MD
    Nitipong Permpalung MD
    Doug Powell MD
    Harold S. Rabinovitz MD
    Christopher J. Rapuano MD
    Sireesha Reddy MD
    Angela Restrepo MD, PhD
    Bertrand Richert MD, PhD
    J. Martin Rodriguez, MD, FACP
    Theodore Rosen MD
    Misha Rosenbach MD
    Scott Schiffman MD
    Robert H. Schosser MD
    Glynis A. Scott MD
    Carlos Seas MD, MSc
    Deniz Seçkin MD
    Daniel Sexton MD
    Paul K. Shitabata MD
    Tor Shwayder MD, FAAP, FAAD
    Elaine Siegfried MD
    Gene Sienkiewicz MD
    Christye Sisson
    Mary J. Spencer MD, FAAP
    Sarah Stein MD
    William Van Stoecker MD
    Frances J. Storrs MD
    Erik J. Stratman MD
    Lindsay C. Strowd MD
    Erika Summers MD
    Belinda Tan MD, PhD
    Robert Tomsick MD
    Jenny Valverde MD
    Vishalakshi Viswanath MD
    Susan Voci MD
    Lisa Wallin ANP, FCCWS
    Douglas Walsh MD
    Ryan R. Walsh MD
    George Watt MD
    Clayton E. Wheeler MD
    Sally-Ann Whelan MS, NP, CWOCN
    Jan Willems MD, PhD
    James Henry Willig MD, MPH
    Karen Wiss MD
    Vivian Wong MD, PhD
    Sook-Bin Woo MS, DMD, MMSc
    Jamie Woodcock MD
    Stephen J. Xenias MD
    Lisa Zaba MD
    Vijay Zawar MD
    Bonnnie Zhang MD
    Carolyn Ziemer MD


Organizations

  • Am. Journal of Trop. Med & Hygiene
  • Armed Forces Pest Management Board
  • Blackwell Publishing
  • Bugwood Network
  • Centers For Disease Control and Prevention
  • Centro Internacional de Entrenamiento e Investigaciones Mèdicas (CIDEIM)
  • Dermatology Online Journal
  • East Carolina University (ECU), Division of Dermatology
  • International Atomic Energy Agency
  • Massachusetts Medical Society
  • Oxford University Press
  • Radiological Society of North America
  • Washington Hospital Center
  • Wikipedia
  • World Health Organization
ContentsSynopsisCodesLook ForDiagnostic PearlsDifferential Diagnosis & PitfallsBest TestsManagement PearlsTherapyReferencesView all Images (2)
Potentially life-threatening emergency
Vesicant exposure - Pulmonary
See also in: Overview
Print
Other Resources UpToDate PubMed
Potentially life-threatening emergency

Vesicant exposure - Pulmonary

See also in: Overview
Print Images (2)
Contributors: Lewis Rubinson MD, PhD, Justin S. Gatewood MD, Susan Voci MD, Sumanth Rajagopal MD, William Bonnez MD
Other Resources UpToDate PubMed

Synopsis

Vesicants, or blistering agents as they are often called, produce skin damage that resembles thermal or chemical burns. There are the mustards (sulfur mustard and nitrogen mustard), the arsenicals (lewisite), and phosgene oxime. Through their effects as cytotoxic alkylating compounds, they produce damage to tissues in which they come into contact (mucous membranes, skin, respiratory, and gastrointestinal tract). Unlike bioterrorism agents, which may have a prolonged incubation period (days to weeks) after exposure, most symptoms due to vesicants occur within minutes to hours after exposure; thus an unrecognized release is less likely with vesicants. However, mustards, which are the agents most likely to be used, may have an initial delay of several hours from exposure to presentation of symptoms.

Prehospital agent identification may be achieved prior to casualty arrival at the hospital, but in some jurisdictions, all that will be known is that an exposure occurred. Decontamination must occur almost immediately (usually at the scene, and needs to occur nearly immediately after exposure for maximal benefit).

If agent identification has not been achieved prior to casualty arrival at the hospital, and there is some uncertainty regarding exposures due to nonspecific symptoms or concern for use of multiple agents, clinical staff should get expert consultation (institutional, local, or state toxicology services) regarding the risks / benefits of empiric use of various chemical agent antidotes.

Of the vesicants, sulfur mustard has been used the most frequently. Tens of thousands of soldiers and civilians were exposed during the Iraq-Iran conflict in the 1980s. Sulfur mustard can cause delayed symptoms and signs (hours) and can also suppress hematologic cell lines.

Organ involvement, severity of presenting symptoms, and time of symptom onset postexposure will depend on ambient conditions, agent involved, exposure dose, and preexposure comorbidities.

Sulfur Mustard:
  • Sulfur mustard, also known as mustard gas, HD, yellow cross, and yperite, was named for its mustard-like odor and taste and its yellow-to-dark brown color. (Note: It can also have an onion or garlic odor and taste.) There is no antidote for mustard gas.
  • The freezing point for mustard is 57°F (13.9°C). This freezing point can be lowered if it is mixed with another agent such as lewisite. Mustard is not very volatile and relies on heat to be vaporized. However, release would probably be as an aerosol or droplets, making vaporization unnecessary. The LD50* of mustard is 100 mg/kg. This amount would be about 1-1.5 teaspoons for an average adult or enough to cover 25%-50% of the total body surface.
Lewisite:
  • Lewisite, also known as L, is an arsenical. Lewisite is a colorless, oily liquid in its pure form that may smell like geraniums, and it has an amber-to-black color in less pure forms. Dimercaprol (British anti-lewisite) is a chelating antidote and should be administered as soon as possible after exposure.
  • Vesication from percutaneous exposure is caused by 14 μg of liquid lewisite. The blister fluid is not harmful, but it does contain arsenic. Lewisite's LCt50** by inhalation is 1500 mg × min/m3.
Phosgene Oxime:
  • There is little documentation regarding the effects of phosgene oxime, also known as CX, on humans. Although it is frequently classified as a vesicant, it does not produce blisters. Instead it is really an urticant, producing skin wheals similar to a nettle sting. There is no antidote for phosgene oxime.
  • Phosgene oxime is a colorless, crystalline solid or, more typically, a yellow to brown liquid that can penetrate clothing and rubber. Phosgene oxime can be mixed with nerve agents to promote faster absorption of the nerve agent.
  • LCt50** by inhalation is 1500-2000 mg × min/m3, and the LD50* for skin exposure is about 25 mg/kg.
*LD50 (LD = lethal dose) is the amount of a material, given all at once, that causes death in 50% of people.

**LCt50 (L = lethal, C = concentration of vapor [mg/m3], t = exposure time [minutes]) is the concentration of a chemical agent exposure by inhalation that causes death in 50% of unprotected people.

Codes

ICD10CM:
Y38.7X2A – Terrorism involving chemical weapons, civilian injured, initial encounter

SNOMEDCT:
243057007 – Poisoning due to vesicant gas

Look For

Subscription Required

Diagnostic Pearls

Subscription Required

Differential Diagnosis & Pitfalls

Best Tests

Subscription Required

Management Pearls

Subscription Required

Therapy

Subscription Required

References

Subscription Required

Last Updated: 10/24/2016
Copyright © 2018 VisualDx®. All rights reserved.
Potentially life-threatening emergency
Vesicant exposure - Pulmonary
See also in: Overview
Print 2 Images
View all Images (2)
(with subscription)
Vesicant exposure : Cough, Bullae, Eye burning, Rhinorrhea, Epistaxis
Clinical image of Vesicant exposure
Copyright © 2018 VisualDx®. All rights reserved.