Blistering agents The blistering agents are irritants that can cause damage to the eyes, skin, and lungs. Blistering agents are not easily obtainable and have no industrial uses but can be made by terrorist groups (Virginia Department of Health, 2018). Exposure is from an airborne vapor. Exposure is more harmful if released in a closed building, as open areas will result in fast dilution and dispersal of the blistering agent. Nitrogen mustard is yellowish-brown in color and smells like garlic or mustard. If someone is exposed, they should remove themselves immediately from the area and into fresh air. Symptoms may not immediately appear and usually occur within 1 to 24 hours (CDC, 2018g; Virginia Department of Health, 2018). Lewisite, another type of blistering agent, has an immediate effect on the skin, nose, eyes, and lungs. More serious symptoms appear from 1 to 24 hours later (Virginia Department of Health, 2018). It is colorless and has an odor resembling geranium oil. When inhaled in large quantities, it may cause death in as short as 10 minutes. It acts as a systemic poison causing pulmonary edema, weakness, and low blood pressure (Federation of American Scientists, 2013). Evidence-Based Practice: Mustard gasses are effective in cold and temperate climates. The eyes are most susceptible to mustard gas, which is very painful. The only protection against these agents is a full protective body covered with a respirator (Federation of American Scientists, 2013). Choking agents The third class of chemical agents is the choking agent. These attack lung tissue and cause pulmonary edema. Phosgene is the most dangerous choking agent and was used in World War I (Federation of American Scientists, 2013). The patient may present with coughing, choking, and tightness in the chest. Nausea and vomiting may ensue with a resulting headache. Victims may present with various types of symptomatology. Those presenting with severe cough may fail to develop pulmonary edema, and those with little or no symptoms may develop fatal pulmonary edema. These choking agents can be
fatal, with death occurring within several hours or up to 24 to 48 hours. The rapidity of symptoms and resulting mortality depends on the concentrations of exposure. If one survives 48 hours after exposure, there may be little or no sequelae. Infection may ensue as a result of the exposure and must be treated. Evidence-Based Practice: Because patients react differently and it can be difficult to tell the amount of inhaled substances, the healthcare provider must treat each patient aggressively for the first 24 to 48 hours. Watch for signs of rapid shallow breathing, dyspnea, and cyanosis. If pulmonary edema progresses, the patient will become apprehensive and may develop frothy sputum (Federation of American Scientists, 2013) Medical consequences The victims in a chemical terrorist attack may have a dramatic presentation. The mucous membranes, eyes, respiratory, and digestive systems can experience serious symptoms. The eyes may appear white and pupils may constrict. The victim may experience incontinence and may be drooling with convulsions ensuing that may result in a coma. There may be trauma associated with chemical poisoning, such as a chemical spill in a truck accident, a factory explosion, or if the chemical is delivered via an explosive device. Open wounds can serve as an additional port of entry for the agent. A combination of biological and chemical agents may be employed to complicate care further. Biological agents may have a delayed presentation. The clinical signs will depend on the toxicity of the dose, the route of exposure, and the time since exposure. Symptoms may vary and may manifest within minutes of an inhalation exposure or hours later with percutaneous or gastrointestinal exposure (Worek et al., 2016). Victims may present stable then quickly decompensate. The healthcare team must be cognizant of airway management. In the case of nerve agents such as Novichok, muscle contractions are blocked because of a breakdown of neurotransmitters, which leads to respiratory and cardiac arrest (Barry & Perez-Pena, 2018). The affected systems and presenting symptoms are shown in Figure 2.
Figure 2: How Nerve Agents Affect Different Organs of the Body
Not e. From “Russian spy: What are nerve agents and what do they do?” by Therrien, A. & Roxby, Copyright 2018 by the BBC News. Reprinted with permission.
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