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Nitrogen Mustard Gas: First Aid Measures and TreatmentAuthor(s): Alden H. WaittSource: The American Journal of Nursing, Vol. 43, No. 7 (Jul., 1943), pp. 641-643Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3456160 .

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Nitrogen Mustard Gas First aid measures and treatment

By ALDEN H. WAITT

Brigadier General, Chemical Warfare Service, United States Army

WHAT NEW GASES must we be prepared against in a chemical war? Mustard gas has been the

king of the war chemicals since its introduction in 1917 in World War I. There is much evi- dence now, however, that the Germans have a new agent which could prove a serious rival to mustard.

For many years the chemical warfare re- search experts of the armies of the world have

sought a blister gas that would have little or no odor, that would volatilize rapidly, and that, in- stead of lasting on the ground for days as in the case of mustard gas, would dissipate in a few minutes or a few hours. It now appears that the Germans have a new class of blister gases which is important especially because of these proper- ties. These new agents have been known for a

long time from a technical standpoint, but un- til recently had not been given serious consid- eration as war gases. They are all grouped un- der the general name of nitrogen mustard gases.

The compounds of the nitrogen mustard

group range from liquids to solids which melt at low temperature and which vary in color from almost colorless compounds to a pale yel- low. One of the most important facts about them is that they have very little odor, or at the most, possess a slight fishy odor typical of the amines and their derivatives. The signifi- cance of lack of odor is immediately apparent to the person who is engaged in devising pro- tection and in training men in gas defense. De- tection is difficult and there is great danger that a man may be gassed before he recognizes the fact that he is breathing a toxic compound.

The nitrogen mustards have low freezing points which make the liquids especially valu- able for spraying from airplanes at high alti- tudes. One of the disadvantages of ordinary mustard gas is that it solidifies and therefore cannot be sprayed at temperatures generally ex

isting at altitudes of Io,ooo feet and above. The more volatile members of the group make it

possible to produce high gas concentrations in

the air. Since these agents have a much less noticeable odor than other war gases, concen- trations which are toxic are not easily detect- able by smell, especially in battle when gas shells are used at the same time as high explo- sive shell.

The nitrogen mustards are more dangerous than ordinary mustard to the eyes, but have less blister effect on the skin. Almost all results of the gas, even the eye effects and the blister- ing, are delayed. Blindness may result in from one to six hours, while blistering action may be delayed twenty-four hours. Fatal casualties from breathing the gas may be delayed for sev- eral days.

As with mustard, the gas mask affords excel- lent protection. Permeable protective clothing gives somewhat less protection than against mustard gas, but the skin effects are not as se- vere generally. Impermeable clothing made of alligator raincoat material or cloth treated with a drying oil gives protection more nearly like that for mustard. Soap and water are useful for the removal of nitrogen mustards and ordinary or permeable protective clothing may be de- contaminated by airing or washing. For decon- tamination of ground and equipment the stand- ard methods, such as bleach, and hydrocarbon solvents may be used.

Because of the difficulty of detection by odor, chemical detection is necessary and this can be done readily by use of detector paint M5, and by detector paper M6. These detec- tors which are issued to our troops in active operations do not distinguish the nitrogen mustards from other blister gases such as mustard and lewisite. The detector crayon M7 will de- tect the agents in liquid form and its reaction with the nitrogen mustards is distinctive. With a liquid nitrogen mustard it gives a yellow color, but the reaction is very slow, whereas it reacts rapidly with other vesicants to give a blue color. The vapor detector kit M4, which is now being supplied chemical officers and gas spe-

JULY 1943 641

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64+ The American Journal of Nursing cialists, will indicate the presence of small amounts of vapor, and where available, gives the surest means of identifying these agents.

The gas mask should be put on as soon as the

gas is detected, and should not be removed until tests show that gas is no longer present in the air. Liquid-splashed clothing should, of course, be removed as soon as possible. The man af- fected should not remain in a contaminated area unless the situation requires it.

If the liquid agent has entered the eye, it must be washed out as quickly as possible. Wa- ter from the canteen may be used for this pur- pose. The eye can be better irrigated by an- other man, but when no one is around to

help, the individual must attempt to flush his own eye without delay. This is best done with the victim lying on his back, face up. The lower lid of the injured eye is pulled open and water is slowly poured into the eye from the canteen held close to the eye. The eye should be moved from side to side, and up and down, during the

washing, which should be continued for about five minutes, if enough water is available.

If the liquid has contaminated the skin, it should be removed with protective ointment which should be used as for other blister gases. Since the ointment merely dilutes and does not

destroy nitrogen mustard, it is necessary as a final step to wash off the film of ointment with water, or preferably with soap and water. If the contamination is positively known to be due to

nitrogen mustard, soap and water alone may be used for decontamination, but it is safer where doubt exists to use first the ointment, followed

by soap and water, or plain water. If redness has appeared, the use of the ointment should be omitted, and soap and water alone used. Blis- ters should not be opened until medical treat- ment is available.

In vapor contaminations of the skin, eyes, or breathing apparatus the damage has already been done, and it is too late for effective pre- ventive measures. However, if a U. S. Army Medical Department first aid gas casualty kit is available (on a combat or motor vehicle), item No. 4, eye and nose drops, may be used for the relief of eye or nasal pain, and irritation and itching of the skin may be allayed by the use of item No. 8, pontocaine compound ointment.

The following treatment has been recom- mended by the U. S. Army Medical Depart- ment and is included in Training Circular 86 issued by the War Department:

TREATMENT

Eye.-The treatment of eye injuries is identical with that for eye injuries due to mustard. Irrigation is used only for contaminations with the liquid agents, and then only if the irrigation can be per- formed during the first five minutes after contami- nation. Thereafter irrigation is useless and may be harmful. A 2 per cent solution of sodium bicarbon- ate is the best irrigating fluid, but the nature of the fluid is of minor importance compared to the urg- ency of speed in initiating the procedure. Normal saline or plain water will serve practically as well in an emergency.

Eye and nose drops (Medical Department item 9Io9o) may be used for the relief of local pain and irritation. Atropine sulfate, i per cent, must be started early and instilled every hour until effective mydriasis is induced. The headache and deep eye pain are relieved following dilatation of the pupil. Thereafter mydriasis is to be maintained by the daily instillation of I per cent atropine sulfate until the eye has recovered. A solution (I gram per 30 cubic centimeters) of sodium sulamyd (Medical Department item IK76525) is instilled every two hours for the first forty-eight hours, and thereafter four times daily to prevent infection. If infection has already developed, a double or triple strength (2 to 3 gram per 30 cubic centimeters) of solution of sodium sulamyd is instilled with increased fre- quency, as indicated. An eye shade is used to relieve the photophobia, and sterile solid or liquid pet- rolatum is used to keep the lids from sticking. Severe cases should be under the care of an ophthal- mologist.

Skin.-Irritation and itching of the skin may be allayed by the use of pontocaine compound oint- ment (Medical Department item IK6i ioo). Unless the blisters are tense, they should not be opened or drained, because of the difficulty of avoiding second- ary infection. If necessary or advisable in certain in- stances to drain the blisters, strict aseptic technic must be followed. The blisters are drained with the minimum number of punctures, and the drainage is preferably performed with a sterile hypodermic syringe and needle. The tops of the blisters must not be removed, but collapsed flat to the skin surface and left intact. The application of a sterile dressing dampened with amyl salicylate (Medical Depart- ment item 91026) w ill act as an analgesic and help reduce the local edema. This should be discontinued after local edema subsides. Thereafter the lesion is treated as an ordinary heat burn. Aseptic technic should be used throughout the treatment, since these burns are prone to become secondarily in- fected, in which event healing is greatly delayed.

VOL. 43, No. 7

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Nitrogen Mustard Gas 643

Respiratory tract.-Eye and nose drops (Medical Department item 9io9o) may be used to allay the irritation in the nose and to shrink the swollen mu- cous membranes. The inhalation of steam may help soothe the irritated larynx and trachea. Codeine sulfate is indicated to control the cough. Expecto- rants are not indicated until the acute stages have passed and convalescence has begun. Lung edema may require the administration of oxygen. A rise in temperature on the second day or later may indicate the onset of bronchopneumonia, which must be treated as bronchopneumonia from other causes.

Gastro-intestinal.-Nausea and vomiting, if pres- ent, will probably be temporary and may be treated by the oral administration of weak sodium bicarbonate solution. If the symptoms are severe, accompanied by blood-stained vomitus, diarrhea, or

considerable abdominal pain, the use of sedatives and antispasmodics (for example, barbiturates and atropine) may be required.

Nervous symptoms.-The cholinergic effects (sali- vation, contracted intestine, and diarrhea) may be relieved by the administration of atropine sulfate, i/ioo grain subcutaneously. There is no known treatment at present to relieve the flaccid paralysis; if the animal survives,' it gradually disappears with- out treatment. Prolonged artificial respiration may be required if the muscles of respiration are para- lyzed, but such cases are usually fatal in animals.2

1 The neurological symptoms are known only from animal experiments according to Training Circular 86.-EDITOR. 2 Training Circular 86, War Department, Washington, D. C., November 13, 1942, pp. 5-6.

How To Protect Yourself Against War Gas

I. STAY INDOORS. A tightly closed room affords protection against war gas. All windows and doors should be tightly shut, and blankets (to be soaked with water) or cardboard should be kept in readi- ness to cover and seal shattered windows. Choose a room on an upper floor if possible; most war gases are heavier than air, although they may be carried

up with air currents. 2. If caught outdoors in a gas attack, get out of

the area at once. Look down and shield your eyes with your arm. Do not worry about any brief vapor exposure to which you may be subjected. The dan-

ger from this source is not great. 3. Prompt action will avoid serious effects. If

you know or suspect that you have gotten any of the

gas on your person or clothing, do not go hunting for a casualty station or gas cleansing station and

expect someone else to help you. Knock on the first door you come to, and take whatever steps are

necessary. Self-aid is the quickest and safest way. 4. This is what you should do. This routine

should be memorized so it will be done automati- cally in an emergency:

(a) Remove shoes and outer clothing and drop them outside the house, in a covered can if available. Do not touch this clothing again except with sticks or gas-proof gloves. Do not cling to false modesty. To enter a house with contaminated clothing en-

dangers everyone in it. (b) Get to a bathroom, kitchen, or laundry room as

fast as possible.

(c) If your eyes have been exposed to liquid gas or spray, flush them immediately. Plain water out of a faucet, shower-head, canteen, or douche bag will do, but a lukewarm dilute solution of bicarbonate of soda (heaping tablespoonful in a quart of water) is even better, if it is handy. Let anyone nearby help you.

(d) If drops of liquid blister gas have splashed the skin, you can prevent serious burns by adequate cleansing. Promptly blot up the liquid with pieces of cleansing tissue, cloth, or a handkerchief, which should be disposed of carefully in order that it can- not contaminate anyone else. Then sponge the skin briskly with laundry bleach containing sodium hypochlorite, if it is at hand, and rinse off under the shower or in a tub. A thorough bath with a vigorous lathering is the final step, which should never be omitted. Dry the skin by patting. Do not rub. Dress in whatever clean clothing you can get. If blisters develop, you should seek medical advice.

(e) If your nose and throat feel irritated, snuff and gargle with a dilute solution of bicarbonate of soda. If your chest feels heavy and oppressed, if you have any trouble breathing, or if smoking becomes dis- tasteful, lie down immediately and stay perfectly still until you can be taken to a doctor. Do this even if you feel fine otherwise.

5. Remember: Cleanse yourself quickly and calmly. Follow the instructions of your air-raid warden.-OFFICE OF CIVILIAN DEFENSE Washing- ton, Operations Letter No. 128, May j5, 1943-

JULY 1943

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