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MUSTARD GAS
GUIDELINES FOR ACTION IN THE EVENT OF A SUSPECTED
DELIBERATE RELEASE
Contents:
1 Background
2
1.1 Introduction
2
1.2 Physical and Chemical Properties
2
1.3 Summary of Human Toxicology
2
1.4 Clinical Features
3
1.4.1 Acute
3
1.4.2 Chronic
6
2 Clinical Procedures
6
2.1 Triage
6
2.2 Decontamination
6
2.3 Sample Collection and Monitoring
7
2.4 Treatment
7
2.5 Management
7
2.5.1 Dermal
7
2.5.2 Eye
7
2.5.3 Oral
7
2.5.4 Inhalational
8
2.6 Admission Criteria
8
3 Public Health Procedures
9
3.1 Surveillance and Detection of Deliberate Release
9
3.2 Case Definition
9
3.2.1 Possible Case
9
3.2.2 Probable Case
9
3.2.3 Confirmed Case
10
3.3 Public Health Action
10
3.3.1 Removal from Exposure
10
3.3.2 Epidemiological Investigation
10
3.4 Environmental Hazard Summary
10
4 National Specialists
11
5 References
12
Version 1.1, amended 12 th December 2002
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1 Background
1.1 Introduction
Mustard gas is a vesicant i.e. it is a blister- forming agent and may cause damage to
skin, eyes and the respiratory system. Sulphur mustard is the chemical warfare agent
that is normally referred to as mustard gas. There are several other toxic mustard
compounds, including nitrogen and sesqui mustard. Of this group, only sulphur
mustard has been extensively used as a chemical warfare agent.
The development of sulphur mustard as a chemical warfare agent was undertaken
during world war I and used for the first time at Ypres on the 12 th .July, 1917. It was
generally recognised as the most effective of chemical warfare agents in World War
I. This related to its incapacitating ability, as death rates following exposure were in
the region of 2-3% 1 . It has also been reported to have been used in the Italian-
Ethiopian conflict of 1936, the Sino-Japanese conflict during World War II and in the
Iraqi-Iranian conflict during 1984-1986.
1.2 Physical and Chemical Properties
Although often referred to as mustard gas, sulphur mustard is a volatile liquid at
room temperature. Being denser than air, it accumulates at ground level.It is oily in
appearance, its colour ranging from colourless to dark brown, with the odour of
mustard, horse radish, garlic or leeks. Toxicity is greater at higher tempertaures,
whilst at low temperature, mustard freezes, thus increasing its persistence. The
vapour given off by sulphur mustard has considerable penetrating powers and rapidly
passes through clothing, affecting skin beneath. It also penetrates substances such
as wood and leather. Metal, glass and glazed tiles are generally impervious.
Mustard gas is only slightly soluble in water, but is soluble in fat and other common
organic solvents 2 . Oxidising agents react with mustard gas to produce the
corresponding sulphone and sulphoxide. The sulphone is produced by stronger
oxidising agents e.g. hypochlorite and may produce lacrimation and sneezing; the
sulphoxide is not a vesicant 3 .
1.3 Summary of Human Toxicology
• Vesicant chemical warfare agents incapacitate more people than they kill 4 . The
toxic effect of mustard gas is primarily due to its alkylating ability i.e. the ability to
cross link to strands of DNA. This is a key factor in the cell injury producing
mechanisms of mustard.
• Following skin exposure, 80% of liquid mustard gas placed on the skin
evaporates, 10% becomes fixed to the skin and the remainder absorbed
systemically.
The table overleaf illustrates the correlation between exposure (product of
concentration and time) and observed clinical effects:
Version 1.1, amended 12 th December 2002
2
Estimated Concentrations and Clinical Effects of Mustard Gas
Type
of
Concentration
Clinical effects
exposure
Vapour in eyes
50 mg.min.m -3
Maximum safe exposure
70 mg.min.m -3
Mild reddening of the eyes
100 mg.min.m -3
Partial incapacitation due to
eye effects
200 mg.min.m -3
Complete incapacitation due
to eye effects
Liquid on skin
50 µ g.cm -2 for 5 min
Slight erythema
250-500 µ g.cm -2 for 5 min
Blistering
Vapour on skin
100-400 mg.min.m -3
Erythema of skin
200-1000 mg.min.m -3
Blistering
750-1000 mg.min.m -3
Severe, incapacitating skin
burns
Accident and Emergency Guidelines (AEGLs) for mustard gas are available. The
table gives values in ppm [mg/m 3 ]:
10 MIN
30min
1h
4h
8h
AEGL 1
0.060
[0.40]
0.020
[013]
0.010
[0.067]
0.0026
[0.017]
0.0012
[0.0083]
AEGL 2
0.090
[0.60]
0.030
[0.20]
0.015
[0.10]
0.0038
[0.0025]
0.0020
[0.013]
AEGL 3
0.59
[3.9]
0.41
[2.7]
0.32
[2.1]
0.080
[0.53]
0.041
[0.27]
1.4 ClinicalFeatures
1.4.1 Acute
Mustard gas does not usually cause pain at the time of exposure; symptoms may be
delayed for 4 to 6 hours 5 . Keratitis can be delayed for years following ocular
exposure, although this is unusual.
The table overleaf shows the evolution of symptoms and signs that might be
expected following severe exposure to sulphur mustard vapour.
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Time after vapour
exposure
Signs and Symptoms
20-60 min
Nausea, retching, vomiting and eye smarting
occasionally reported, sometimes no initial symptoms
1 h
First appearance of erythema
2-6 h
Nausea, fatigue, headache, inflammation of eyes with
intense pain, lacrimation, blepharospasm, photophobia
and rhinorrhoea; erythema of face and neck; sore
throat, hoarse voice or total loss; tachycardia and
increased respiration; definite erythema
8-12 h
Raised erythema (oedema)
13-22 h
Inflammation in areas where tight clothing was worn
and inner thighs, genitalia, perineum, buttocks and
axillae followed by blister formation which may be
pendulous and filled with clear, yellow fluid; death
within 24 hours is rare and extremely unlikely under
civilian conditions
42-72 h
Maximum blisters or necrosis; coughing appears: muco
pus and necrotic slough may be expectorated; intense
itching of skin; increase in skin pigmentation
6-9 days
Possible complete skin surface denudation
20-28 days
Removal of scab
22-29 days
Usually complete skin healing
Inhalation
• Coughing (which may be worse at night and become productive), wheezing,
dyspnoea, paroxysmal coughing, and pulmonary oedema may be delayed for 1 to
12 hours.
• Fever, headache, hoarseness or loss of voice may be delayed for 24 hours.
• Adult Respiratory Distress Syndrome
• Broncho-pneumonia, complicated by bone marrow suppression
• Symptoms may persist for 1 or more years 4 .
Dermal
• Erythema - This typically occurs within 2-48 hours post exposure. It may be very
striking and reminiscent of scarlet fever. Slight oedema of the skin may occur,
whilst itching may be common and intense. As the erythema fades, areas of
increased pigmentation are left.
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• Blistering - Blisters are not generally painfull but may feel uncomfortable and
tense. The blisters are delicate and are easily de-roofed by contact with bed
linen, bandages or during transportation of casualties. Crops of new blisters may
appear as late as the second week post exposure. Blister fluid does not produce
secondary blisters if applied to skin of patient or carer.
• Deep Burning - Full thickness loss is likely if mustard gas is applied to the penis
and scrotum.
Lesions tend to be painful and heal slowly. Previously erythematous areas darken
and become hyperpigmented. These areas tend to disappear over several weeks with
desquamation leading to hypopigmentation.
Ocular
The eyes are the organs most sensitive to mustard gas, although no clinical
indication of injury may become evident until several hours later.
The corneal epithelium may become oedematous; lids and conjunctiva become red
and swollen. Burning, discomfort, photophobia, lacrimation, blepharospasm
Exposure to vapour induces extreme discomfort and temporary disablement, but in
most cases recovery is complete.
In more severe cases, injuries have involved not only the epithelium but also deeper
layers; corneas may become cloudy and infiltrated, and in extreme cases eyes may
become totally opaque
Long term effects include corneal opacities and chronic conjunctivitis.
Oral
Ingestion of food or water contaminated with mustard gas may cause nausea and
vomiting, pain, bloody diarrhoea and, in severe cases, dehydration
Systemic
Dizziness, generalised malaise, anorexia and lethargy can occur after acute exposure
CNS excitation with convulsions may occur, followed by CNS depression; AV-block
and cardiac arrhythmias
• Irreversible bone marrow depression may occur. Anaemia occurs within 4 days.
1.4.2 Chronic
Chronic exposure has been associated with an increased risk of respiratory tract
cancer (nasopharyngeal, laryngeal and lung), and skin cancer especially in
ammunition factory workers; also chronic bronchitis, pigmentation abnormalities,
Version 1.1, amended 12 th December 2002
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