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Publications policy and guidance
Treatment of Poisoning by Selected Chemical Compounds - Blain Report
- 1. Executive Summary
- 2. Introduction
- 3. Use of oximes in nerve agent poisoning
- 4. Use of antidotes in cyanide poisoning
- 5. Lung damaging agents
- 6. Acute management of mustard gas injuries of the eyes
- 7. Recommendations for research
- Glossary and abbreviations
- Annex 1: General Management of Casualties contaminated by Chemical Compounds
- Annex 2: Membership of the Expert Group on Management of Chemical Casualties Caused by Terrorist Activity (EGMCCT)
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6. Acute management of mustard gas injuries of the eyes
It is acknowledged that sulphur mustard is a volatile liquid at room temperatures and thus that the term 'mustard gas' is not wholly appropriate. However, 'mustard gas' is a widely used term and we have retained it in this account.
Introduction
6.1 Among the survivors of mustard gas attacks in World War 1 (1914-18) and the Iran-Iraq conflict (1980s) skin, eye and respiratory injuries were almost universal. Mortality is, however, low - 2% in World War 1 and 3-4% in the Iran-Iraq conflict.
6.2 Eye exposures occur in 80-90% of casualties. Reactions vary from mild conjunctivitis (75% of cases) to moderate and severe keratoconjunctivitis. It is this latter group with corneal involvement that requires ophthalmological attention may have severe and long-standing ocular sequelae.
6.3 Sulphur mustard exists as a straw coloured fluid, slightly soluble in water and is aerosolised when dispersed or spread by an explosive force. It is highly toxic and has low volatility so that it may persist for more than a week in closed spaces, open spaces with little wind and in temperate climates. Sulphur mustard rapidly penetrates the skin, but 80% will evaporate, and of the remainder 10% remains on the skin and 10% is absorbed systemically. Damage is from destruction of adhesion points between cells and basement membranes. It also binds to and alkylates DNA, enzymes, structural proteins and other macromolecules.
Literature review
6.4 A review carried out for this report identified the relevant literature to consider four aspects of management. Altogether, 1717 papers were identified of which 22 appeared relevant. The reference lists of these papers were also searched and these revealed another 16 papers of interest; these, in turn, allowed a further 6 papers to be found.
Results of review
- Decontamination: There are no observational human studies, controlled trials or even case reports concerning appropriate decontamination after mustard gas exposure but it is clear that the chemical is fixed in the cornea within 15 minutes.
- Immediate general treatment: There are no controlled trials concerning appropriate immediate general treatment of mustard gas exposure. Most recommendations are based on reading the historical literature and personal experience. Eyes exposed to mustard gas should be irrigated with copious amounts of water.
- Specific treatment: There are no reported observational human studies or controlled trials concerning appropriate immediate specific treatment after mustard gas exposure. What little evidence there is, is experimental and based on experiments in rabbits. Most recommendations are based on comtempory management of other types of chemical injury.
- Pre-treatment: There are no known proven safe and effective pretreatments against mustard agent exposure of the eyes.
Recommended management
6.5 Although no clear evidence base is available from controlled studies, the following staging and intervention may be used based on present knowledge and experience.
- Immediate: there may be few initial symptoms.
- Early: (1 to 8 hours.) Lid swelling and eye closure, grittiness, lacrimation, photophobia, blepharospasm and impaired vision.
- Intermediate: (1 to 10 days.) Corneal epithelial loss, stromal opacification and thinning, secondary infection and uveitis.
- Late: (Months-Years.) Abnormalities of limbal vascular bed with ischaemia and ulceration.
Treatment
6.6 The priority is to remove the casualty from the contaminated area. Contaminated clothing should be removed as soon as possible and the skin washed with soap and water, as mustard gas penetrates the skin within a few minutes.
Immediate
Speed of decontamination is extremely important and immediate irrigation is needed to minimise damage to the cornea. While isotonic fluids such as saline might have theoretical advantage they are rarely available in quantity at the point of contamination. The need for speed is such that the use of large quantities of clean water is therefore recommended. During irrigation, the eye is held open, ideally with the aid of topical anaesthetic drops. The lids should be held away from the globe. Copious fluid should be irrigated into the eye and allowed to drain for at least 30 minutes to leach out all possible traces of active chemical from the ocular tissue. Any particulate matter should removed straight away. Patients with eyes exposed to mustard gas should be reassured, given systemic analgesics and dark glasses. Petroleum jelly can be used to prevent lid adhesion. Bandages should be avoided.
Early and Intermediate (0-10 days)
Early assessment is vital to determine the extent and severity of the injuries. This should include the features listed in Table 6.1. The extent of the corneal chemical injury can be graded (Table 6.2). Admission to hospital is advised if there are grade 3 or 4 changes. Intraocular damage, especially if accompanied by a raised intraocular pressure indicates a poor prognosis. In the mild forms, grades 1-2, epithelial healing can occur in the first few days.
Table 6.1. Initial clinical assessment of chemical eye injury
| Visual acuity | unaided and with pinhole |
|---|---|
| Pupil | reactivity and presence of afferent pupil defect |
| Lids | extent of burns, necrosis |
| Conjunctiva and Limbus | epithelial loss, necrosis, ischaemia, symblepharon formation |
| Cornea | epithelial loss, oedema, stromal opacity |
| Anterior chamber | fibrin, uveitis, lens debris |
| Iris | atonicity, haemorrhage |
| Lens | opacity, leakage |
| Intraocular pressure | low, normal, raised |
Table 6.2. Grading for severity of chemical burns
| GRADE | PROGNOSIS | SIGNS | ISCHAEMIA |
|---|---|---|---|
| 1 | Good | Epithelial damage | none |
| 2 | Good | Cornea hazy Iris details visible | >1/3 limbus |
| 3 | Guarded | Total epithelial loss Iris details obscured | 1/3--1/2 limbus |
| 4 | Poor | Cornea opaque Iris and pupil not visible | >1/2 limbus |
Some or all of the following may be used by ophthalmologists. Ideally, preservative free topical drops should be used where available.
1. Steroids - up to hourly for the first week and then gradually tapered off. In the early phase, the anti-inflammatory leucocytic inhibitory action of steroids is valuable to prevent secondary tissue damage by invading polymorphs. In the longer term, their use may impair epithelial regeneration and collagen repair, together with corneal melt. Therefore their use ought to be reduced after the first week.
2. Vitamin C or potassium ascorbate drops - up to every hour. Vitamin C acts as a cofactor in collagen synthesis, and as an antioxidant, and may prevent damage by chemically active free radicals, released at the time of injury. Intraocular vitamin C is rapidly depleted in severe chemical burns and anterior segmented ischaemia prevents its transport into the eye. The use of topical vitamin C has been shown to be effective in experimental chemical burns. Use G Ascorbic 10%, or sodium citrate 10% (eye drops) hourly, and discontinue when the epithelium has healed.
3. Acetylcysteine four times a day for up to two weeks. This donates sulfhydryl groups, which contribute to the cross linkage and maturation of new collagen and inhibits collagenase enzymes, which are released at the time of tissue damage.
4. Antibiotics. If there is loss of corneal epithelium, their use prevents secondary infection. Chloramphenicol drops or Fluoroquinolones 4 times a day.
5. Pupil Dilation with atropine 1% or cyclopentolate 1% drops twice daily, until the acute phase is over.
6. Corneal Protection If there is significant damage to the lid or corneal exposure, in any form, remedial treatment is a moist protective chamber, constant lubrication with preservative free drops, such as Hypromellose or Celluvisc hourly or Lacri-Lube ointment 6 times a day.
7. Lids Topical steroid and antibiotic treatment as required. Check that no symblepharon has formed, and rod or use a contact lens as required.
8. Analgesics. Nerve endings will be damaged and pain may be severe. Adequate analgesics are required.
Late Management
6.7 Long -term treatment should be by a corneal specialist. The initial treatment is to allow the epithelium to heal. Further management may include removal of necrotic tissue, a bandage contact lens, a penetrating corneal graft, amniotic membrane graft, limbal cell transplantation for the cornea, and mucus membrane and amniotic membrane grafts for the lids. The techniques used will depend on the severity of the injury and are outside the role of these guidelines, which are for the acute treatment only.
Recommendation Regarding Monitoring of Efficacy of Treatment
6.8 We recommend that a particularly careful record should be kept of the outcome of treatment using the various methods listed above. Experience in this field is limited in the UK and the identification of approaches that are demonstrably valuable would be helpful.
Summary
6.9 This review was prepared with the aid of the Royal College of Ophthalmologists. The opportunity to consult a group of specialists in diseases of the cornea (the Bowman Group) was also taken.
6.10 All ocular injuries, which are likely to be bilateral and symmetrical, should be managed by vigorous and copious irrigation with water as soon as possible which can be aided by the use of topical anaesthetic drops. Although initially distressing the majority of ocular injuries from mustard gas make a full recovery.
6.11 Injuries that are persistent in signs or symptoms should be referred for specialist opinion.
6.12 Although there is no evidence base for specific ocular treatment, ophthalmologists are likely to use at their discretion; topical mydriatics, antibiotics, and steroids plus membrane removal and insertion of symblepharon rings (to separate the bulbar from the palpebral conjunctiva).
6.13 Other agents that may have a part to play in early management include; topical vitamin C, acetyl cysteine, and systemic nonsteroidal anti- inflammatory /analgesic agents.
6.14 Other treatments in the longer term for severe cases may include; therapeutic bandage, contact lenses, amniotic membrane transplantation and limbal stem-cell allografts.
References
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Pellathy B. Experiments to lessen the action of mustard gas. Szemesz 1938; 1-48.
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Berens C, Hartmann E. The effect of war gases and other chemicals on the eyes of the civilian population. Bull NY Acad Med 1943;19: 356-367.
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Jampol LM, Axelrod A, Tessler Hl. Pathways of the eyes response to topical nitrogen mustard. Invest Ophthalmol 1976;15:486-489.
Gonzalez GG, Gallar J, Belmonte C. Influence of diltiazem on the ocular irritative response to nitrogen Mustard. Exp Eye Res 1995; 61: 205-212.
Varma SD, Devamanoharan PS, Ali AH, Brozetti J, Petrali J, Lehnert E, Weir A. Half mustard (CEES) induced damage to rabbit cornea: attenuating effect of taurine-pyruvate-alpha ketoglutarate pantothenate mixture. J Ocul Pharmacol Ther 1998;14:423-428.
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