# Presentation: 094229

## Module 4Signs and Symptoms

**Notes:**
A key part of treating victims who have been exposed to a chemical warfare agent is recognizing the signs and symptoms of exposure. Signs are objective evidence of a medical condition, such as drooling. Symptoms, on the other hand, consist of subjective evidence, such as a headache. A health care worker can see or measure signs, while symptoms usually have to be expressed verbally by the patient.

## Situation Assessment

**Known information regarding the chemical release**
**Recognition of the event based on signs and symptoms**

**Notes:**
To minimize serious health effects, victims of chemical agent exposure must receive the appropriate treatment and they must receive it as soon as possible. This means that first responders must be able to determine quickly that a chemical agent exposure has occurred and how severe the exposure has been. Responders must be able to assess the situation based both on the information that has been provided about the release of chemical agent and on the recognition of the event based on signs and symptoms experienced by the victims. 

## Not All Signs and Symptoms May Appear Immediately

**Manifestation based on:**
**dose, **
**duration, and **
**route of entry**** **

**Notes:**
In this section we will talk about numerous signs and symptoms of exposure to nerve and mustard agents. It is important to recognize that any single patient is not likely to experience all of these effects. The specific signs and symptoms that do appear will depend on the dose of agent the victim received, the duration of exposure, and the route of entry.

## Nerve Agent Exposure

**Notes:**
Victims who receive a severe exposure to nerve agent will display similar signs and symptoms regardless of the route of exposure. But for lesser exposures, the effects differ depending on the agent’s route of entry into the body and the dose of agent received.

## Signs and Symptoms: Nerve Agent Vapor Exposure

**Affects organs directly contacted by agent**
**Affects other organs as agent is absorbed into body systems**
**Signs and symptoms appear in seconds to minutes**
**Peak effects within 15 to 25 minutes after exposure stops**

**Notes:**

Exposure to nerve agent vapor causes effects in the organs directly contacted by the vapor and other effects that occur as the agent is absorbed into the body’s systems. Specific signs and symptoms depend on whether the exposure was mild, moderate, or severe. 

Regardless of the severity of exposure to nerve agent vapor, signs and symptoms will appear with seconds to minutes after the beginning of exposure. The effects usually peak within 15 to 20 minutes after exposure stops.

## Signs and Symptoms:Mild Vapor Exposure

**Pinpoint pupils (w/ or w/o redness, pain)**
**Dim or blurred vision**
**Runny nose**
**Slight chest tightness**
**Slight difficulty breathing**
**Secretions (tears, nasal fluids, saliva, sweat, phlegm)**
**Nausea and vomiting**

**Notes:**
A mild exposure to nerve agent vapor mainly affects the organs directly contacted by the vapor; that is, the eyes, nose, and airways. The eyes and nose are most sensitive and show the first effects. Miosis and a runny nose are the most common signs. The patient may display red eye or experience pain in or around the eye. Vision may be dim or blurred. The patient may complain of tightness in the chest or have slight difficulty breathing. There may also be an increase in discharge from affected glands. Some patients may experience nausea and vomiting.

## Signs and Symptoms:Moderate Vapor Exposure

**Pinpoint pupils (w/ or w/o redness, pain)**
**Dim or blurred vision**
**Excessively runny nose**
**Pronounced chest tightness**
**Plentiful secretions**
**Moderate to severe breathing difficulty**
**Nausea and vomiting**
**Diarrhea**
**General muscle weakness**

**Notes:**

A moderate exposure to nerve agent vapor produces signs and symptoms that are similar to those of a mild exposure, but are more pronounced and more detrimental to the patient’s health. In the eyes, miosis may be more severe, and dim or blurred vision will be more likely. The effects of the runny nose may be much greater than normally experienced during a bad cold, and secretions from glands may be similarly increased. Abundant mucous secretions from the respiratory passages may make breathing more difficult, and the patient may be gasping for air. Gastrointestinal effects will be more common, with patients experiencing nausea, vomiting, or diarrhea. Patients may complain of a general weakness of muscles. 

Remember: Some or all of these effects will appear within seconds to minutes after the beginning of exposure.

## Signs and Symptoms:Severe Vapor Exposure

**Same as for moderate exposure, plus**
**Loss of consciousness**
**Convulsions**
**Generalized rippling of muscles under skin**
**Flaccid paralysis**
**Cessation of breathing**
**Involuntary urination or defecation**

**Notes:**

Severe exposure to nerve agent vapor will set off a rapid chain of reactions resulting in loss of consciousness and convulsions within one to two minutes. After a few more minutes, breathing may stop and muscles may become limp and flaccid. Muscles may appear to be rippling under the skin over different parts of the body, and limbs may jerk or flail. Soon the affected muscles become fatigued and flaccid paralysis sets in. The loss of muscle control may lead to involuntary urination or defecation. 

Because these effects progress so rapidly, victims of severe nerve agent exposure are likely to be unconscious, convulsing, and/or not breathing by the time first responders arrive on the scene.

## Signs and Symptoms:Liquid Nerve Agent on Skin

**Effects differ from vapor exposure**
**Different signs and symptoms**
**Different timing of appearance**
**General rule: the more severe the exposure, the quicker effects appear**

**Notes:**
Exposure to liquid nerve agent on the skin produces signs and symptoms different from those occurring with vapor exposure. The signs and symptoms themselves are different as are the times at which they appear. In general, the more severe the exposure, the quicker the effects appear.

## Signs and Symptoms:Mild Liquid on Skin Exposure

**Sweating at site of exposure**
**Rippling of muscles under skin at site of exposure**
**Effects appear in 10 min to 18 hrs, depending on dose**

**Notes:**

Mild skin exposure to nerve agent liquid typically causes local effects at the site of exposure. Sweating at the site is common, and rippling of muscles may also occur at the site. In some case, nausea and vomiting may occur. 

Depending of the amount of agent absorbed, these effects may appear as soon as 10 minutes after exposure or be delayed up to 18 hours. Once signs and symptoms begin to appear, they tend to develop rapidly.

## Signs and Symptoms:Moderate Liquid/Skin Exposure

**Same as for Mild exposure, plus**
**Nausea, vomiting, and diarrhea**
**Generalized sweating**
**Generalized weakness, tiredness, or ill feeling**
**Effects appear in 10 min to 18 hrs, depending on dose**

**Notes:**

Following a moderate skin exposure the nerve agent liquid, the signs and symptoms of mild exposure are likely to be accompanied by nausea and vomiting and, less commonly, diarrhea. The patient may also exhibit generalized sweating over the whole body and report feeling tired and generally unwell. 

As with Mild exposures, these signs and symptoms may not show up for as much as 18 hours after exposure. In the meantime, the patient will appear to be unaffected by the exposure.

## Signs and Symptoms:Severe Liquid on Skin Exposure

**Same as for Moderate exposure, plus**
**Collapse**
**Loss of consciousness**
**Convulsions**
**Severe respiratory difficulty**
**Flaccid paralysis**
**Cessation of breathing**
**Involuntary urination or defecation**
**Effects appear suddenly in 2-30 min**

**Notes:**
Signs and symptoms will appear suddenly within minutes of the beginning of a severe skin exposure to liquid nerve agent. The effects are quite similar to those associated with severe vapor exposure. Once the effects begin, they progress rapidly. Within a very few minutes, the victim will collapse, lose consciousness, experience convulsions, become flaccidly paralyzed, and stop breathing.

## Differential Diagnosis

**Refers to distinguishing one disease from another when they produce similar signs and symptoms**

**Notes:**
Many of the signs and symptoms we’ve talked about could be caused by health problems other than exposure to a nerve agent. Before administering medical treatment, responders will need to perform a “differential diagnosis” to be sure the patient is, indeed, suffering from nerve agent exposure. The situation is simplified if, before arriving at the scene, you have been notified that a nerve agent release has occurred.

## Diseases Producing Symptoms Similar to Nerve Agent Exposure

**Epilepsy**
**Gastroenteritis**
**Exposure to agricultural insecticides (organophosphates and carbamates)**

**Heat illness**
**Emphysema**
**Stroke**
**Head trauma**
**Drug overdose**

**Notes:**
The patient should be examined and questioned for other signs and symptoms that may help determine whether a nerve agent exposure has occurred. Asking for the patient’s medical history or, if the patient is unconscious, looking for medic-alert bracelets or cards may assist in making the correct diagnosis.

## VESICANT AGENT EXPOSURE

**Notes:**
The signs and symptoms of mustard agent exposure are very different from those resulting from exposure to a nerve agent. The timing of effects is also different. Signs and symptoms of mustard agent exposure seldom appear until hours after the exposure has occurred. This means that emergency medical personnel may find themselves treating patients who are not yet showing the effects of exposure. 

In spite of the delay in signs and symptoms, mustard agent binds itself irreversibly to human tissue within minutes. People suspected of mustard agent exposure should be immediately decontaminated and observed for the possible onset of signs and symptoms.

## Signs and Symptoms by Route of Exposure

**Agent vapor affects eyes, skin, and airways**
**Agent liquid on skin or eyes**
**Produces more severe effects than vapor**
**Does not normally affect airways**
**Large exposures via either route can affect internal body systems**

**Notes:**
The areas most commonly affected by exposure to mustard agent vapor are the eyes, skin, and airways that are contacted by the vapor. Exposure to liquid agent on the skin or in the eyes has more severe effects on these organs, but does not normally produce signs and symptoms in the airways. Heavier exposures via either route can damage the body’s blood making system along with the gastrointestinal tract and the central nervous system. These systemic effects occur later.

## Signs and Symptoms of Exposure to Mustard Agent Vapor

**Agent contacts skin and eyes**
**Causes surface damage**
**Absorbed into body**
**Agent is inhaled into respiratory tract**
**Damages mucous membranes**
**Absorbed into body**

**Notes:**
People exposed to an airborne plume containing mustard agent vapor would be affected in two ways. First, the agent would contact the skin and eyes, injuring them before being absorbed into the body. Second, the agent would be inhaled into the respiratory tract, contacting mucous membranes and being absorbed into the body.

## Signs and Symptoms ofVapor Exposure on Eyes

**Mild exposure**
**Tearing, itching, burning, gritty feeling, sensitivity to light**
**Effects appear in 4-12 hrs**
**Moderate exposure**
**Same as for Mild exposure, plus reddening, swelling of lids, moderate pain**
**Effects appear in 3-6 hrs**
**Severe exposure**
**Same as for Moderate, plus marked swelling of lids, possible damage to cornea, severe pain**
**Effects appear in 1-2 hrs**

**Notes:**
The eye is the organ that is most sensitive to mustard agent and is usually the first one to show signs and symptoms. The seriousness of the effects and the speed with which they appear depend on the degree of exposure, but even with severe exposure, at least an hour will pass before any effects appear. If the vapor exposure is large, the eyelids may swell until they are completely closed. Patients may be alarmed and think they are blind. They should be reassured that it is only the swelling that is temporarily blocking their vision.

## Signs and Symptoms of Vapor Exposure on Skin

**Mild exposure**
**Reddening of skin with itching, burning, and stinging**
**Severe exposure**
**Same as for Mild exposure, plus blisters**
**Effects appear in 2-24 hrs**

**Notes:**
Skin injuries caused by exposure to mustard agent vapor are usually comparable to first- or second-degree burns. Generally, the first skin effect to appear is reddening resembling sunburn, with itching, burning and stinging. For mild exposures this may be the only effect, but after larger exposures, blisters will begin to form hours later. The most sensitive skin areas are warm moist locations such as the anal-genital area, armpits, insides of elbows and knees, and the folds of the neck.

## Signs and Symptoms of Vapor Exposure on Airways

**Mild exposure**
**Runny nose; pain in throat, nostrils, sinus; sneezing; nose bleed; hoarseness; hacking cough**
**Effects appear in 6-24 hrs**
**Moderate exposure**
**Same as for Mild exposure, plus, loss of voice, productive cough**
**Severe exposure**
**Same as for Moderate exposure, plus mild-to-severe breathing difficulty**
**Effects appear in 2-6 hrs**

**Notes:**
Inhalation of mustard agent vapor damages the mucous membranes of the respiratory tract. A mild exposure may affect only the nose and throat, but a more severe exposure can injure the lower airways. Signs and symptoms of mild exposure usually appear in 6 to 24 hours and include runny nose, a burning sensation in the nostrils, sinus pain, sneezing, nose bleed, and sore throat. Almost all patients are hoarse, and many have a hacking or barking cough. After a severe exposure, these effects may appear in as little as two hours and gradually progress to loss of voice, productive cough, and breathing difficulty.

## Signs and Symptoms ofVapor Exposure on GI Tract

**Nausea and vomiting**
**Effects appear a few hrs to 24 hrs after exposure**

**Notes:**
Nausea and vomiting are frequent signs and symptoms of victims of mustard agent exposure, regardless of the amount of agent involved. These signs and symptoms usually appear about the same time as the first skin effects appear, but they may also be delayed for up to 24 hours after exposure.

## Signs and Symptoms of Liquid Exposure on Skin or Eye

**Effects similar to those for vapor exposure but more severe and appear sooner**
**Eyes—tearing, itching, burning, gritty feeling, sensitivity to light, swelling of lids, damage to cornea, pain**
**Skin—reddening, itching, burning, stinging, blisters**
**Effects most apparent at exposure site**

**Notes:**
As we said earlier, exposure to liquid mustard agent on the skin or in the eyes affects those organs more severely than an exposure to mustard vapor. The signs and symptoms also occur more quickly, and they are most evident in the area of the body that was exposed to the agent. The airways are not normally affected by exposure to liquid mustard agent.

## Signs and Symptoms of Liquid Exposure on Eyes

**Effects same as for vapor exposure, but more severe**
**For severe exposure**
**Symptoms can appear within minutes**
**Can result in severe damage to cornea, loss of vision, or loss of eye**

**Notes:**
Direct contact with liquid mustard agent is highly damaging to the eye. Tearing, pain, and swelling of eyelids occur more quickly than for vapor exposure. If the exposure is severe these symptoms may appear within minutes and be followed eventually by severe corneal damage and possibly by loss of vision or loss of the eye. Immediate decontamination is the only way to minimize the injury.

## Signs and Symptoms of Liquid Exposure on Skin

**Effects similar to those for vapor exposure, but more severe**
**Tissue damage is deeper**
**Tissue death may occur at exposure site**
**Injury comparable to third-degree burn**

**Notes:**
The skin is damaged more severely by direct contact with liquid mustard agent than by contact with agent vapors. The tissue damage extends to a deeper level, and tissue at the site of exposure may be killed. The injury is comparable to a third-degree burn.

## How Sulfur Mustard Agent Blisters Skin

**Normal skin**

**Reddened skin**

**Blistered skin**

**Notes:**
When the skin is exposed to sulfur mustard, no effects are apparent at first, even though the agent quickly penetrates the skin and binds to tissue. Then hours later the skin in the area of the exposure reddens and itches or stings. After more hours go by, blisters form at the site.

## Sulfur Mustard Blisters

**Notes:**
The blisters are small at first, but they may later combine to form large, dome-shaped, thin-walled, translucent, yellow blisters surrounded by reddened skin. The fluid in the blisters is clear and does not contain mustard agent.

## Other Possible Causes of Signs and Symptoms

**Blister agent signs and symptoms could also apply to:**
**hay fever**
**chemical or thermal burns**
**heavy tear gas exposure**
**poison ivy, poison oak, and other contact allergies**

**Notes:**
Many of the signs and symptoms of mustard agent exposure could be caused by other illnesses or injuries. To determine whether the patient has been exposed to mustard agent, health care providers should ask the patient about other signs and symptoms and should try to obtain the patient’s medical history.

## Summary: Pop QuizMatch signs & symptoms on the left with the correct cause on the right

**Miosis**
**Blisters on skin**
**Breathing difficulty**
**Extreme sore throat**
**Runny nose**
**Hearing loss**
**Rippling muscles**
**Swollen eyelids**

**Nerve Agent**
**Mustard Agent**
**Either**
**Neither**

## Summary: Pop QuizAnswers

**Miosis—Nerve agent**
**Blisters on skin—Mustard agent**
**Breathing difficulty—Either**
**Extreme sore throat—Mustard agent **
**Runny nose—Nerve agent**
**Hearing loss—Neither**
**Rippling muscles—Nerve agent**
**Swollen eyelids—Mustard agent**