Vesicants

Objectives

To guide the management of patients presenting to medical facilities with suspected vesicant exposure. 
To understand the common Chemical Agents and Toxic Industrial Chemicals that can cause blistering or chemical burns to skin.

Scope

This guideline describes the management of suspected vesicant and corrosive toxic industrial chemical (TIC) exposure. Many of these have associated lung damaging properties and this guideline should be read in conjunction with Pulmonary Agents. There are separate guidelines for the management of acute lung injury (ALI)/ acute respiratory distress syndrome (ARDS) which must be applied in severe cases of ALI secondary to vesicant agent or corrosive TIC inhalation. 

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical locations or in an Emergency Department on deployed operations. 

Initial Assessment & Management

Mustard

The Mustards, Sulphur Mustard (HD) and Nitrogen Mustard (HN) are the archetypal vesicant agents. There are many more vesicant agents and corrosive TICs. Very few of these have specific antidotes and treatment is generally supportive. PPE and rapid decontamination are mandatory. The effects of H agents may be delayed for hours, particularly with HD. Tissue injury occurs rapidly before symptoms, decontamination must still be performed without delay. Onset time is quicker at higher temperature and humidity, and with tissue factors such as water/ sweat. H agents deployed in cold conditions can generate casualties later as the ground warms. Eye exposure to H agents rarely causes permanent blindness. H agents cause immunosuppression and longer-term effects such as bronchiolitis and increased cancer risk. 

Signs and Symptoms

Airway Breathing Circulation Disability Exposure
  • Burning 
  • Mucosal inflammation 
  • Laryngeal oedema
  • Coughing 
  • Dyspnoea 
  • Pulmonary oedema 
  • Bronchospasm 
  • Cyanosis 
  • Chest pain 
  • Tachycardia
  • Eye pain 
  • Blepharospasm 
  • Chemical burns to skin 
  • Erythema 
  • Blisters 

 

Initial Management

Immediate decontamination. 
Eye irrigation with crystalloid or copious amount of potable water.
Chloramphenicol ointment or sterile petroleum jelly to prevent eyelid adhesions.
Mydriatic eye drops can reduce anterior chamber scarring.
Oxygen supplementation may be required to maintain oxygen saturation above 94%. 
Bronchospasm can be treated conventionally with bronchodilators. 
Nebulised N-acetylcysteine (NAC) has been shown to be of benefit following HD exposure1. 
Extensive burns may require iv fluid resuscitation. 
Patients who are asymptomatic 24h post exposure can be considered for discharge. 

 

🪗Management of H Agent Blisters

  • Small (1-2cm) blisters can be left intact. 
  • Larger blisters can be drained or deroofed aseptically. 
  • Blister fluid is not corrosive but remains a biohazard. 
  • Blister fluid can be kept for Forensic analysis.

 

🪗Features of Lewisite exposure

  • Rapid onset painful blisters.
  • Pulmonary effects. 
  • Multiple systemic effects.
  • Antidote is IV Dimercaprol

 

🪗Management of Suspected Hydrofluoric Acid Exposure

Hydrogen fluoride (HF), or hydrofluoric acid causes rapid damage to skin and development of systemic toxicity. 

  • Local application of calcium gluconate gel. 
  • Profound hypocalcaemia accompanies HF exposure and should be aggressively corrected with IV calcium chloride.
  • 12 lead ECG for QTc and QRS duration should be performed. 
  • Keep K+, Mg2+ and Ca2+ in the high normal range.
  • For management of inhaled HF, consult Pulmonary Agents 

Advanced Assessment & Management

Severe respiratory distress is an indication for invasive ventilation using established ARDSNet strategies. Patients with stridor or other concerning upper airway signs warrant careful assessment and consideration before tracheal intubation. Emergency tracheal intubation prior to airway obstruction is preferred. Nebulised NAC can be continued, acting also as a mucolytic agent. Hypoxaemia refractory to the above measures is an indication for referral for extracorporeal membrane oxygenation (ECMO). 

Prolonged Casualty Care

Dress blisters. 
Fastidious attention to preventing infection. 
Avoid deroofing blisters in case of introducing infection. 

Last reviewed: 18/09/2026

Next review date: 18/09/2027

References

1. Jugg B, Fairhall S, Smith A, Rutter S, Mann T, Perrott R, Jenner J, Salguero J, Shute J, Sciuto AM. N-acetyl-L-cysteine protects against inhaled sulfur mustard poisoning in the large swine. Clinical Toxicology. 2013 May 1;51(4):216-24.