Are we prepared to manage patients who have suffered a terrorist attack with mustard gas?

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Are we prepared to manage patients who have suffered a terrorist attack with mustard gas?

An excellent article by Garriou et al, ” Quels enseignements peut-on tirer de l’utilisation récente de l’ypérite au Levant, ” A. Garriou, O. Dubourg, R. Doaré, H. Delacour, Médecine de Catastrophe, Urgences collectives, 2021, 5, 253-258, which has just been published, provides us with information on the state of management of patients who have just been subjected to a terrorist attack using mustard.

What is it about?

The authors have identified the different chemical attacks that have taken place since 2012 in the Levant. Based on very concrete cases they have closely studied the management of patients affected by mustard and their conclusions are very interesting.

The necessary reminders

In a 2017 article titled “The main chemical weapons: a reminder (CBRNe)” we gave a quick tour of the main molecules used as chemical weapons in the CBRNe domain. Among them, mustard gas or mustard yperite, first used in July 1917 by the German army, far more powerful than all existing gases combined (chlorine, phosgene and cyanogen chloride). Patients affected by this so-called “vesicant” are much more difficult to treat, the skin, eyes and lungs are affected. Moreover, mustard persists in the environment and creates a toxic environment.

This product penetrates textiles, including leather, which immediately led to research into the development of materials that are impermeable to the toxic product and effective respiratory masks.

The use of mustard in the Levant

Several organizations have counted the chemical attacks: they conclude that the vast majority of them are due to the Syrian regime, the others being attributed to the terrorist organization Daesh. Chlorine was used most often, sometimes sarin or mustard. Finally, mustard was involved in a very small number of cases but was only used by Daesh.

Four mustard attacks have been thoroughly investigated and published in scientific journals. The authors have dissected them in order to draw rich lessons for the future.

Lessons learned

Relationships between terrorism and yperite

Daesh has controlled large territories in Syria and Iraq, allowing them to get their hands on both abandoned stockpiles and mustard production facilities. What we already mentioned in a blog “current and future BCRNe terrorist threats” is again verified in this publication. The threat of the export of these weapons to other parts of the world is therefore real, especially as the Daesh movement resumes its activities in Afghanistan once again controlled by the Taliban.

How to respond to cases of exposure to mustard gas?

The authors note that even hospital staff did not have the necessary reflex actions to implement after extraction of the victims from the danger zone

– Undress the victim as soon as possible by removing at least a first layer of clothing and shoes;

– Perform emergency decontamination with Fuller’s earth, RSDL or Dec’pol ABS wipe;

– Perform thorough decontamination with a shower and surfactant.

Aberrant behaviors have been reported, such as the undressing of several members of a family only 16 hours after being taken care of by a medical team!

Please refer to the SGDSN data sheet on mustard

How to manage a victim combining traumatic injury and chemical contamination?

This is the case for victims injured by an Improvised Explosive Device (IED) explosion using mustard.

When the device has not fatally injured the victim, the latter combines traumatic injury and chemical contamination and is likely to be the source of a contamination transfer that could reach the caregivers for example.

Knowing the clinical symptoms and the well-known biological markers

Poisoning is insidious: the toxic substance enters the body in a painless way and the symptoms appear with more or less long delays.

Three elements deserve to be reminded:

the eye is the most sensitive organ to mustard;

the cutaneous attack is more marked where the skin is thinner and wetter (inguinal, axillary or genital regions);

the hematological damage in case of severe intoxication is lymphopenia and thrombopenia at the origin of bacterial superinfections is similar to an immunocompromised burn victim.

The lethality is low (less than 5%), remember that the vast majority of soldiers gassed with mustard during the First World War, returned to the front after receiving care in health institutions. This low lethality is not a negative element for the authors of attacks because spreading terror is also part of their objectives.

The care of target organs such as the eyes (washing…), the skin (cooling and disinfection of burns…), the respiratory system (oxygen therapy if necessary…), analgesic treatment, transfusion of red blood cells and/or platelets…) are very well described in this publication.


The authors conclude by saying that even though there are not many cases of mustard attacks, they are always committed by a terrorist movement, which is why adequate training of health care teams followed by regular drills should be maintained.

Useful links

Comment décontaminer en cas de contact chimique ?

NRBCe : la première guerre mondiale ou “guerre chimique” 


Masque OPC50


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