Blister Agents Guide

NOTE:

The Occupational Safety and Health Act (OSH Act) requires employers to comply with hazard-specific safety and health standards. In addition, pursuant to Section 5(a)(1) of the OSH Act, employers must provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. Emergency Preparedness Guides do not and cannot enlarge or diminish an employer's obligations under the OSH Act.

Emergency Preparedness Guides are based on presently available information, as well as current occupational safety and health provisions and standards. The procedures and practices discussed in Emergency Preparedness Guides may need to be modified when additional, relevant information becomes available or when OSH Act standards are promulgated or modified.

Because of recent terrorist events many workers have expressed concern about the possibility of a terrorist attack involving blister agents. Blister agents have been used as chemical warfare agents, in World War I (1914-1918) and the Iran-Iraq war (1980-1988). The following frequently asked questions will help workers understand what blister agents are and how they may affect their health and safety.

General Information

What are blister agents?

Blister agents or "vesicants" are chemicals which have severely irritating properties that produce fluid filled pockets on the skin and damage to the eyes, lungs and other mucous membranes. Symptoms of exposure may be immediate or delayed until several hours after exposure.

What are the different forms of blister agents and their properties?

The three major categories of blister agents are: sulfur mustard (H,HD,HT), nitrogen mustard (HN-1, HN-2, HN-3), Lewisite (L), and halogenated oximes (CX). Sulfur mustards are clear to yellow or brown oily liquids with a slight garlic or mustard odor. Although volatility is low, vapors can reach hazardous levels during warm weather. Nitrogen mustards are colorless to yellow, oily liquids with variable odors. Lewisite contains arsenic and is a dark oily liquid with a slight odor of geraniums. Phosgene oxime, one of the most common halogenated oximes, is a colorless solid or liquid, with an intense irritating odor.

Why are we concerned about blister agents as a terrorist's weapon?

There are large stockpiles of blister agents which, if obtained by terrorists, could be released using bombs, explosives, spray tanks, or rockets.

How long will blister agents persist in the environment?

When exposed to air, blister agents will break down but this may take several days. Nitrogen mustards and Lewisite should break down quickly in soil and water. Sulfur mustards, however, may persist for several days in soil and water. When exposed to air, phosgene oxime is broken down slowly, but in water or soil it is broken down more quickly. See the following table for more information:

Types and Characteristics Chemical Agents

		PERSISTENCE	PERSISTENCE		ENTRANCE
TYPE OF AGENT	SYMBOL	SUMMER	WINTER	RATE OF ACTION	VAPOR/AEROSOL	LIQUID
BLISTER	HD, HN	3 days-1 wk	Weeks	Slow	Eyes, Skin, Lungs	Eyes, Skin
	L, HL	1-3 days	Weeks	Quick	Eyes, Skin, Lungs	Eyes, Skin, Mouth
	CX	Days	Days	Very Quick	Eyes, Lungs, Skin	Eyes, Skin, Mouth

*ARMY FIELD MANUAL NO. 8-10-7. Health Service Support in a Nuclear, Biological, and Chemical Environment.

Health Effects

How do blister agents affect people?

Blister agents burn and blister the skin or any other part of the body they contact. Blister agents (whether as a gas, aerosol, or liquid) enter the body primarily through inhalation and dermal contact. They may act on the eyes, mucous membranes, lungs, and skin. Mustard agent symptoms are delayed - with little or no pain at the time of exposure. In some cases, signs of injury may not appear for several hours or days depending on the concentration. Mustard agents are also suspected carcinogens. Lewisite and phosgene oxime cause immediate, severe pain.

For additional information, see

Emergency Preparedness and Response: A-Z Index. Centers for Disease Control and Prevention (CDC).

Controls

How do I protect myself from blister agents?

If you are exposed to a blister agent attack, get away from the impacted area quickly without passing through the contaminated area, if possible. It may be necessary to "shelter-in-place" if you can't get out of a building or if the nearest place with clean air is indoors.

If available, a good way to protect yourself from a from blister agents is to wear appropriate chemical protective clothing and respiratory protection. However, protective equipment does not always work against blister agents. The effectiveness is determined by the materials of construction, the type and level of exposure, and duration of exposure.

What does it mean to "shelter in place"?

"Shelter in place" means to go indoors, close up the building, and wait for the danger to pass. If you are advised to shelter in place, close all doors and windows; turn off fans, air conditioners, and forced-air heating units that bring in fresh air from the outside; only re-circulate air that is already in the building; move to an inner room or basement; and keep your radio turned to the emergency response network or local news to find out what else you need to do.

What should I do if I have been exposed to a blister agent?

If you have been exposed to a blister agent, remove all clothing immediately and wash with copious amounts of soap and water. Seek emergency medical attention.

Is there any treatment for persons exposed to blister agents?

The military has many publications covering the treatment of personnel who have been exposed to blister agents. Examples are the US Army Medical Research Institute of Chemical Defense (USAMRICD) Medical Management of Chemical Casualties Handbook, Chapter 4, Vesicants and Field Manual 8-285, Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries, Chapter 4, Blister Agents (Vesicants).

Has the federal government made recommendations to protect worker health?

OSHA has not set occupational exposure levels for exposure to blister agents. However, other government departments and agencies have published existing and proposed standards.

Summary of Chemical Agent Air Exposure Values Table 1. (August 3, 2004).
Summary of Multi-Media Chemical Agent Toxicity and Exposure Values Table 2. (August 3, 2004).
Lewisite. Centers for Disease Control and Prevention (CDC) Emergency Preparedness and Response, (December 22, 2003). Includes Fact Sheets, an Emergency Response Card, Medical Management Guidelines, and FAQ's about Lewisite.
Sulfur Mustard (Mustard Gas). Centers for Disease Control and Prevention (CDC) Emergency Preparedness and Response, (December 22, 2003). Includes Fact Sheets, an Emergency Response Card, Medical Management Guidelines, and FAQ's about Sulfur Mustard.
Nitrogen Mustard. Centers for Disease Control and Prevention (CDC) Emergency Preparedness and Response, (December 22, 2003). Includes Fact Sheets, Emergency Response Card, Medical Management Guidelines, and FAQ's about Nitrogen Mustard.
Phosgene Oxime. Centers for Disease Control and Prevention (CDC) Emergency Preparedness and Response, (December 22, 2003). Includes Fact Sheets, Emergency Response Card, Medical Management Guidelines, and FAQ's about Phosgene Oxime.

First Responders

How should first responders prepare for a release of blister agents?

First responders should consider the possible impact of a release and potential exposure to blister agents and address this in their health and safety plan (HASP). The health and safety plan should include guidelines such as: monitoring, detection, awareness training, personal protective equipment, decontamination, and medical surveillance of acutely exposed workers.

What equipment can first responders use to detect if a blister agent is present?

There are a variety of devices available to detect blister agent vapor and liquid. The most portable of the vapor detectors are the M256A1 card or ticket and the Chemical Agent Monitor (CAM). The simplest liquid detectors are the M8 and M9 papers. Direct reading instruments that are available include specialized gas chromatographs (Minicams) and ion mobility spectrometers such as the APD 2000. Since some of these detectors cannot adequately detect the agents at safe airborne levels, users should be trained in regards to the use and limitations of the detectors. Listed below is a table of military detection and monitoring equipment:

Military Detection and Monitoring Equipment

Equipment	Agent	Sensitivity	Time	Cost	Operations/ Maintenance/ Limits	Notes
M-8 Paper	Nerve-G Nerve-VX Mustard-H Liquids only	100-µ drops 100-µ drops 100-µ drops	<=30 sec	$1 per book of 25 sheets	Disposable/ hand-held Dry, undamaged paper has indefinite shelf life	Chemical agent detector paper; 25 sheets/book and 50 booklets/box; potential for false positives.
M-9 Paper	Nerve-G Nerve-VX Mustard-H Liquids only	100-µ drops 100-µ drops 100-µ drops	<=20 sec	$5 per 10-m roll	Disposable/ hand-held 3-year shelf life Carcinogen	Adhesive-backed dispenser roll or books.
M-18A2 Detector Kit	Nerve-GB Nerve-VX Mustard-H, HN, HD, HT Lewisite-L, ED, MD Phosgene-CG Blood-AC Liquid, vapor, aerosol	0.1 mg/m³ 0.1 mg/m³ 0.5 mg/m³ 10.0 mg/m³ 12.0 mg/m³ 8.0 mg/m³	2-3 min	$360	Disposable tubes Hand-held	25 tests per kit; Detector tubes, detector tickets, and M-8.
M-256A1 Detector Kit	Nerve-G and VX Mustard-HD Lewisite-L Phosgene oxime-CX Blood-AC, CK Vapor or liquid	0.005 mg/m³ 0.02 mg/m³ 2.0 mg/m³ 9.0 mg/m³ 3.0 mg/m³ 8.0 mg/m³	15 min Series is longer AC--25 min	$140	Disposable/ Hand-held 5-year shelf life	Each kit contains 12 disposable plastic sampler-detectors and M-8 paper.
M-272 Water Test Kit	Nerve-G and VX Mustard-HD Lewisite Hydrogen cyanide	0.02 mg/l 2.0 mg/l 2.0 mg/l 20.0 mg/l	7 min 7 min 7 min 6 min	$189	Portable/ lightweight 5-year shelf life USN, USMC	Used to test raw or treated water; Type I and II detector tubes, eel enzyme detector tickets; Kit conducts 25 tests for each agent.
CAM Chemical Agent Monitor	Nerve-GA, GB, VX Blister-HD and HN Vapor only	0.03 mg/m³ 0.1 mg/m³	30 sec <=1 min	$7,500	Hand-held/portable battery operated 6—8 hours continuous use. Maintenance required.	Radioactive source. False alarms to perfume, exhaust paint, additives to diesel fuel.
ICAM Improved Chemical Agent Detector	Nerve-G and V Mustard-HD	0.03 mg/m³ 0.1 mg/m³	10 sec 10 sec	$7,500	4.5 pounds Minimal training	Alarm only; False positives common.
ICAM-APD Improved Chemical Agent Detector--Advanced Point Detector	Nerve-G Nerve-V Mustard-H Lewisite-L	0.1 mg/m³ 0.04 mg/m³ 2.0 mg/m³ 2.0 mg/m³	30 sec 30 sec 10 sec 10 sec	$15,000	12 pounds including batteries Low maintenance Minimal training	Audible and visual alarm.
ICAD Miniature Chemical Agent Detector	Nerve-G Mustard-HD Lewisite-C Cyanide-AC, CK Phosgene-CG	0.2—0.5 mg/m³ 10 mg/m³ 10 mg/m³ 50 mg/m³ 25 mg/m³	2 min (30 sec for high levels) 2 min 15 sec	$2,800	8 oz pocket-mounted 4 months service No maintenance Minimal training	Audible and visual alarm; Marines; No radioactivity.
M-90 D1A Chemical Agent Detector	Nerve-G, V Mustard Lewisite Blood Vapor only	0.02 mg/m³ 0.2 mg/m³ 0.8 mg/m³ N/A	10 sec 10 sec 80 sec	$16,000	15 lb. with battery Radioactive source exempt from licensing. Minimal training	Ion mobility spectroscopy and metal conductivity technology can monitor up to 30 chemicals in parallel. Alarm only.
M-8A1 Alarm Automatic Chemical Agent Alarm	Nerve-GA, GB, GD Nerve-VX Mustard-HD Vapor only	0.2 mg/m³ 0.4 mg/m³ 10 mg/m³	<=2 min <=2 min <=2 min	$2,555	Vehicle battery operated Maintenance required	Radioactive source (license required); Automatic unattended operation; Remote placement.
MM-1 Mobile Mass Spectrometry Gas Chromatograph	20-30 CWA Vapor	<10 mg/m² of surface area	<=45 sec	$300,000 military $100,000 civilian	Heater volatizes surface contaminants.	German "Fuchs" (FOX Recon System/Vehicle)
RSCAAL M-21	Nerve-G Mustard-H Lewisite-L Vapor	90 mg/m³ 2,300 mg/m³ 500 mg/m³		$110,000	Line-of-sight dependent 10 year shelf life 2-person portable tripod	Passive infrared energy detector 3 miles; Visual/ audible warning from 400 meters
SAW Mini-CAD	Nerve-GB Nerve-GD Mustard-HD Vapor	1.0 mg/m³ 0.12 mg/m³ 0.6 mg/m³	1 min 1 min 1 min 1 pound No calibration	$5,500	Minimal training Field use	Alarm only; False alarms from gasoline vapor, glass cleaner.
ACADA (XM22)	Nerve-G Mustard-HD Lewisite Vapor	0.1 mg/m³ 2 mg/m³ --	30 sec 30 sec --	$8,000	Vehicle mounted, battery powered Radioactive source (license required) Minimal training	Audible alarm; Bargraph display--low, high, very high.
Field Mini-CAMs	Nerve-G, V Mustard-H Lewisite-L	<0.0001 mg/m³ <0.003 mg/m³ <0.003 mg/m³	<5 min <5 min <5 min	$34,000	Designed for field industry monitoring (10 lb.) 8 hours training 24 hour/7 day operations	Plug-in modules increase versatility; Threshold lower than AEL.
Viking Spectratrak GC/MS	Nerve-G, V Mustard-HD Many others	<0.0001 mg/m³ <0.003 mg/m³	<10 min <10 min	$100,000	Field use, but 85 pounds Needs 120v AC, helium 40 hours training	Lab quality analysis; Library of 62,000 chemical signatures.
HP 6890 GC with flame photometric detector	Nerve-G, V Mustard-HD Many others	<0.0001 mg/m³ <0.0006 mg/m³	<10 min <10 min	$50,000	Not designed for field use Gas, air, 220v AC 40 hours training	State-of- the-art gas chromatograph; Used by CWC treaty lab.

Reference from National Research Council's Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response.

Guide for the Selection of Chemical Agent and Toxic Industrial Material Detection Equipment for Emergency First Responders. National Institute of Justice Guide 100-00 (Volume II), (June 2000). Provides information about detecting chemical agents and toxic industrial materials and selecting equipment for different applications. Volume II Appendices B, C, D, E have specific equipment information including manufacturers.
Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. Institute of Medicine, National Research Councils, (1999).

What personal protective equipment (PPE) should first responders use?

When an active release is occurring, or the release has stopped but there is no information about the duration of the release or the airborne concentration of nerve agents, don Level A protection. The requirement of OSHA's Hazardous Waste Operations and Emergency Response (HAZWOPER) standard (29 CFR 1910.120(q)) provides additional information for responding to hazardous substance releases, including blister agents.

For additional information, see CBRN Personal Protective Equipment Selection Matrix for Emergency Responders - Blister Agents.

Healthcare Workers

How should healthcare workers prepare to respond to a blister agent release?

Healthcare facilities should have a health and safety plan in place that addresses the possibility of receiving patients exposed to blister agents from a terrorism event. The document "OSHA Best Practices for Hospital-Based First Receivers of Victims" contains practical information for developing an emergency management plan and includes victim decontamination, personal protective equipment, and employee training.

How do I decontaminate a patient?

Healthcare professionals should don appropriate gloves and respiratory protection and then remove contaminated clothing from victim and thoroughly wash exposed area with soap and water. Healthcare professionals should also wash hands after removing any protective gloves and any other potentially exposed body surfaces.