Sulfur Mustard: Blister Agent

Oily liquid ranging in color from colorless to yellow or brown. Also can be a colorless vapor.

Sulfur mustard (military designation HD or H) is a blister agent (vesicant) that causes severe, delayed burns to the eyes, skin, and respiratory tract. Sulfur mustard damages cells within minutes of contact; however, the onset of pain and other health effects is delayed until hours after exposure. Large exposures to sulfur mustard may be fatal. Sulfur mustard is also an alkylating agent that damages the cells within the bone marrow that are necessary for making blood cells; this affects the body’s immune system. Finally, sulfur mustard also affects a part of the nervous system responsible for everyday bodily function, causing “cholinergic toxicity,” marked by excessive saliva, tears and urine; gastrointestinal (GI) cramping and diarrhea; vomiting (emesis); and constricted or pinpoint pupils (miosis). Sulfur mustard has been used as a chemical warfare agent to cause delayed casualties. It has an odor of garlic, onion, horseradish, or mustard. However, odor is not a reliable indicator of sulfur mustard and should not be depended on to warn of sulfur mustard exposure.

• Indoor Air: Sulfur mustard can be released into indoor air as a liquid spray (aerosol) or as a vapor.
• Water: Sulfur mustard liquid can contaminate water.
• Food: Sulfur mustard liquid can contaminate food.
• Outdoor Air: Sulfur mustard can be released into outdoor air as a liquid spray (aerosol) or as a vapor.
• Agricultural: If sulfur mustard is released into the air as a liquid spray (aerosol), it has the potential to contaminate agricultural products. If sulfur mustard is released as a vapor, it is highly unlikely to contaminate agricultural products.

Sulfur mustard can be absorbed into the body by inhalation, ingestion, skin contact, and eye contact. Inhalation is an important route of exposure. Ingestion is an uncommon route of exposure. Warm, moist areas with thin skin, the moist linings of body passages and cavities (mucous membranes), and perspiration-covered skin are more sensitive to the blistering (vesicant) effects of sulfur mustard.

First Responders should use a NIOSH-certified Chemical, Biological, Radiological, Nuclear (CBRN) Self Contained Breathing Apparatus (SCBA) with a Level A protective suit when entering an area with an unknown contaminant or when entering an area where the concentration of the contaminant is unknown. Level A protection should be used until monitoring results confirm the contaminant and the concentration of the contaminant.
NOTE: Safe use of protective clothing and equipment requires specific skills developed through training and experience.

Select when the greatest level of skin, respiratory, and eye protection is required. This is the maximum protection for workers in danger of exposure to unknown chemical hazards or levels above the IDLH or greater than the AEGL-2.

• A NIOSH-certified CBRN full-face-piece SCBA operated in a pressure-demand mode or a pressure-demand supplied air hose respirator with an auxiliary escape bottle.
• A Totally-Encapsulating Chemical Protective (TECP) suit that provides protection against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Coveralls, long underwear, and a hard hat worn under the TECP suit are optional items.

Select when the highest level of respiratory protection is necessary but a lesser level of skin protection is required. This is the minimum protection for workers in danger of exposure to unknown chemical hazards or levels above the IDLH or greater than AEGL-2. It differs from Level A in that it incorporates a non-encapsulating, splash-protective, chemical-resistant splash suit that provides Level A protection against liquids but is not airtight.

• A NIOSH-certified CBRN full-face-piece SCBA operated in a pressure-demand mode or a pressure-demand supplied air hose respirator with an auxiliary escape bottle.
• A hooded chemical-resistant suit that provides protection against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Coveralls, long underwear, a hard hat worn under the chemical-resistant suit, and chemical-resistant disposable boot-covers worn over the chemical-resistant suit are optional items.

Select when the contaminant and concentration of the contaminant are known and the respiratory protection criteria factors for using Air Purifying Respirators (APR) or Powered Air Purifying Respirators (PAPR) are met. This level is appropriate when decontaminating patient/victims.

• A NIOSH-certified CBRN tight-fitting APR with a canister-type gas mask or CBRN PAPR for air levels greater than AEGL-2.
• A NIOSH-certified CBRN PAPR with a loose-fitting face-piece, hood, or helmet and a filter or a combination organic vapor, acid gas, and particulate cartridge/filter combination or a continuous flow respirator for air levels greater than AEGL-1.
• A hooded chemical-resistant suit that provides protection against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Escape mask, face shield, coveralls, long underwear, a hard hat worn under the chemical-resistant suit, and chemical-resistant disposable boot-covers worn over the chemical-resistant suit are optional items.

Select when the contaminant and concentration of the contaminant are known and the concentration is below the appropriate occupational exposure limit or less than AEGL-1 for the stated duration times.

• Limited to coveralls or other work clothes, boots, and gloves.

• Sulfur mustard is stable at ambient temperatures.
• When heated to decomposition between 300°F and 350°F (149°C to 177°C), sulfur mustard emits highly toxic fumes of sulfur oxides and hydrochloric acid. See the emergency response card for hydrochloric acid.
• At 149°F (65°C), sulfur mustard is rapidly corrosive to brass and will corrode steel at .001 inch per month.
• Hydrolysis of sulfur mustard yields hydrochloric acid and thiodiglycol. See the emergency response cards for hydrochloric acid and thiodyglycol.
• Sulfur mustard reacts vigorously with oxidants.
• Sulfur mustard is incompatible with bleaching powder.
• On contact with acid or acid fumes, sulfur mustard emits highly toxic fumes (sulfur oxides and chlorides).
• Sulfur mustard reacts with water or steam to produce toxic and corrosive fumes.
• Contact with metals may evolve flammable hydrogen gas.

• When heated, vapors may form explosive mixtures with air, presenting an explosion hazard indoors, outdoors, and in sewers.
• Containers may explode when heated.

• Sulfur mustard is combustible.
• The agent may burn but does not ignite readily.
• Fire may produce irritating, corrosive, and/or toxic gases.
• For small fires, use dry chemical, carbon dioxide, or water spray.
• For large fires, use dry chemical, carbon dioxide, alcohol-resistant foam, or water spray. Move containers from the fire area if it is possible to do so without risk to personnel. Dike fire control water for later disposal; do not scatter the material.
• Avoid methods that will cause splashing or spreading.
• For fire involving tanks or car/trailer loads, fight the fire from maximum distance or use unmanned hose holders or monitor nozzles. Do not get water inside containers. Cool containers with flooding quantities of water until well after the fire is out. Withdraw immediately in case of rising sound from venting safety devices or discoloration of tanks. Always stay away from tanks engulfed in fire.
• Runoff from fire control or dilution water may be corrosive and/or toxic, and it may cause pollution.
• If the situation allows, control and properly dispose of run-off (effluent).

• If a tank, rail car, or tank truck is involved in a fire, isolate it for 0.5 mi (800 m) in all directions; also, consider initial evacuation for 0.5 mi (800 m) in all directions.
• Small spills (involving the release of approximately 52.83 gallons (200 liters) or less), when H/HD is used as a weapon
• First isolate in all directions: 100 ft (30 m).
• Then protect persons downwind during the day: 0.1 mi (0.2 km).
• Then protect persons downwind during the night: 0.1 mi (0.2 km).
• Large spills (involving quantities greater than 52.83 gallons (200 liters)), when H/HD used as a weapon
• First isolate in all directions: 200 ft (60 m).
• Then protect persons downwind during the day: 0.4 mi (0.7 km).
• Then protect persons downwind during the night: 0.7 mi (1.2 km).
• Small spills (involving the release of approximately 52.83 gallons (200 liters) or less), when Mustard is used as a weapon
• First isolate in all directions: 100 ft (30 m).
• Then protect persons downwind during the day: 0.1 mi (0.2 km).
• Then protect persons downwind during the night: 0.1 mi (0.2 km).
• Large spills (involving quantities greater than 52.83 gallons (200 liters)), when Mustard used as a weapon
• First isolate in all directions: 100 ft (30 m).
• Then protect persons downwind during the day: 0.1 mi (0.2 km).
• Then protect persons downwind during the night: 0.2 mi (0.4 km).

• Sulfur mustard evaporates slowly and is primarily a liquid hazard under temperate conditions.
• The vapor hazard of sulfur mustard increases with increasing temperature; it is a definite vapor hazard at 100°F (38°C).
• Vapors are heavier than air. They will spread along the ground and collect and stay in poorly-ventilated, low-lying, or confined areas (e.g., sewers, basements, and tanks).
• Hazardous concentrations may develop quickly in enclosed, poorly-ventilated, or low-lying areas. Keep out of these areas. Stay upwind.
• Although sulfur mustard is heavier than water, small droplets float on water surfaces and present a hazard in contaminated areas.
• Sulfur mustard is 2 to 5 times more persistent in winter than in summer.

• OSHA: Not established/determined
• NIOSH: Not established/determined

• AIR MATRIX
  Carrick WA, Cooper DB, Muir B [2001]. Retrospective identification of chemical warfare agents by high-temperature automatic thermal desorption-gas chromatography-mass spectrometry. J Chromatogr A 925(1-2):241-249.Suryanarayana MVS, Shrivastava RK, Pandey D, Vaidyanathaswamy R, Mahajan S, Bhoumik D [2001]. Simple time weighted average level air-monitoring method for sulfur mustard in work places. J Chromatogr A 907(1-2):229-234.Trap HC, Langenberg JP [1999]. Semi-continuous high speed gas analysis of generated vapors of chemical warfare agents. HRC-J High Resol Chromogr 22(3):153-158.
• OTHER
  No references were identified for this sampling matrix for this agent.
• SOIL MATRIX
  Beck NV, Carrick WA, Cooper DB, Muir B [2001]. Extraction of thiodiglycol from soil using pressurized liquid extraction. J Chromatogr A 907(1-2)221-227.Black RM, Clarke RJ, Cooper DB, Read RW, Utley D [1993]. Application of headspace analysis, solvent extraction, thermal desorption and gas chromatography––mass spectrometry to the analysis of chemical warfare samples containing sulphur mustard and related compounds. J Chromatogr A 637(1):71-80.Gresham GL, Groenewold GS, Appelhans AD, Olson JE, Benson MT, Jeffery MT, Rowland B, Weibel MA [2001]. Static secondary ionization mass spectrometry and mass spectrometry/mass spectrometry (MS2) characterization of the chemical warfare agent HD on soil particle surfaces. Int J Mass Spectrom 208(1-3):135-145.

  Hooijschuur EWJ, Kientz CE, Brinkman UAT [1999]. Determination of the sulfur mustard hydrolysis product thiodiglycol by microcolumn liquid chromatography coupled on-line with sulfur flame photometric detection using large-volume injections and peak compression. J Chromatogr A 849(2):433-444.

  Kimm GL, Hook GL, Smith PA [2002]. Application of headspace solid-phase microextraction and gas chromatography–mass spectrometry for detection of the chemical warfare agent bis(2-chloroethyl) sulfide in soil. J Chromatogr A 971(1-2):185-191.

• SURFACES
  Mazurek M, Witkiewicz Z, Popiel S, Śliwakowski M [2001]. Capillary gas chromatography–atomic emission spectroscopy–mass spectrometry analysis of sulphur mustard and transformation products in a block recovered from the Baltic Sea.
  J Chromatogr A 919(1):133-145.
• WATER
  Buchanan MV, Hettich RL, Hai XJ, Waters LC, Watson A [1995]. Low level detection of chemical agent simulants in meat and milk by ion trap mass spectrometry. J Hazard Mater 42(1):49-59.Creasy WR, Stuff JR, Williams B, Morrissey K, Mays J, Duevel R, Durst HD [1997]. Identification of chemical-weapons-related compounds in decontamination solutions and other matrices by multiple chromatographic techniques. J Chromatogr A 774(1-2):253-263.Hooijschuur EWJ, Kientz CE, Brinkman UAT [2001]. Application of microcolumn liquid chromatography and capillary electrophoresis with flame photometric detection for the screening of degradation products of chemical warfare agents in water and soil.
  J Chromatogr A 928(2):187-199.

  Kientz CE, Verweij A, Dejong GJ, et al. [1992]. Verification of nonproduction of chemical warfare agents. 2. Large volume injections in microcolumn liquid-chromatography using flame photometric detection. J Microcolumn 4(6):477 483.

  Maisonneuve A, Callebat I, Debordes L, Coppet L [1992]. Specific and sensitive quantitation of 2,2′-dichlorodiethyl sulphide (sulphur mustard) in water, plasma and blood: application to toxicokinetic study in the rat after intravenous intoxication. J Chromatogr 583(2):155-165.

  Tomkins BA, Sega GA [2001]. Determination of thiodiglycol in groundwater using solid-phase extraction followed by gas chromatography with mass spectrometric detection in the selected-ion mode. J Chromatogr A 911(1):85-96.

Clinical effects do not appear until hours after sulfur mustard exposure. Sulfur mustard penetrates and binds quickly to cells of the body, but its health effects develop slowly. The full extent of cellular injury may not be known for days. The sooner after exposure that health effects occur, the more likely it is that the patient/victim was exposed to a high concentration of mustard. Similarly, the sooner that health effects occur, the more likely it is that they will progress and become severe. Eye exposure: The eyes are the organs that are most sensitive to mustard vapor; eye injury may occur within 1 to 2 hours after severe exposure, or 3 to 12 hours after a mild to moderate exposure. Inhalation exposure: Airway injury may occur within 2 to 6 hours after severe exposure, and within 12 to 24 hours after mild exposure. Skin exposure: The symptom-free (latent) period is 6 to 12 hours in temperate conditions; hot, humid weather strikingly increases the action of sulfur mustard. Some skin injury may appear as late as 48 hours after exposure.

Sulfur mustard damages the tissues of the eyes, skin, and respiratory tract. The skin healing process following mustard exposure is very slow. In addition to being a blister agent (vesicant), sulfur mustard is an alkylating agent: when absorbed into the body, it can injure the bone marrow, lymph nodes, and spleen, causing a drop in white blood cell counts and increasing the risk of developing infections. Sulfur mustard also affects the central nervous system (CNS). Sulfur mustard exposure may be fatal; the cause of death is usually respiratory failure.

• Mild (onset within 4 to 12 hours): Tear production (lacrimation), irritation, itching, burning, spasmodic blinking (blepharospasm), dryness or gritty feeling, and possible pinpoint pupils (miosis).
• Moderate (onset within 3 to 6 hours): Above plus increased redness, fluid accumulation (edema) in the eyelids, and moderate pain.
• Severe (usually from liquid agent; onset within 1 to 2 hours): Increased fluid accumulation (edema) in eyelids, painful sensitivity to light (photophobia), damage to the cornea (ulceration), blindness, and severe pain.

• Nausea, vomiting (emesis), pain, diarrhea, possible chemical burns of the gastrointestinal (GI) tract, and complete exhaustion (prostration).

• Mild (onset within 2 to 24 hours): Runny nose (rhinorrhea), sneezing, nosebleed (epistaxis), hoarseness progressing to “toneless” voice, barking cough, loss of taste and smell, wheezing and difficulty breathing or shortness of breath (dyspnea) in smokers and asthmatics, and nasal and sinus pain (occurring later).
• Severe (onset within 2 to 6 hours): Same as above, plus acute inflammation of the upper and lower airways; tissue death (necrosis) of the airway lining (respiratory epithelium); possible obstruction of both upper and lower airways due to formation of a false membrane or fibrous deposit (pseudomembrane); airway blockage (occlusion) from inflamed and dead (necrotic) cells; and death, due to inflammatory lung disease (pneumonia).
• Exposures to higher concentrations of vapor result in health effects that occur sooner and are more severe.
• Damage to the airways (and to tissues immediately surrounding the airways) begins with the upper airways and descends to the lower airways. The severity of damage increases as the concentration of sulfur mustard increases.

• Tender skin, the moist lining of body passages and cavities (mucous membranes), and perspiration-covered skin are more sensitive to the effects of sulfur mustard.
• Skin effects of liquid mustard occur sooner than do the effects of mustard vapor.
• Mild to moderate: Erythema (redness) begins to appear 1 to 24 hours after exposure (typically within 4 to 8 hours); blistering (vesication) begins 2 to 18 hours after onset of redness; possible intense itching (pruritus), and burning pain.
• Severe: As above, with more severe blistering (vesication) with areas of central tissue death (necrosis), plus whole-body (systemic) health effects including weakness (malaise), vomiting (emesis), fever, and complete exhaustion (prostration).
• Skin exposure to sulfur mustard can be fatal. An area of redness (erythema), with or without blistering (vesication), which covers 25% or more of the body’s surface area, suggests a lethal exposure.

The purpose of decontamination is to make an individual and/or their equipment safe by physically removing toxic substances quickly and effectively. Care should be taken during decontamination, because absorbed agent can be released from clothing and skin as a gas. Your Incident Commander will provide you with decontaminants specific for the agent released or the agent believed to have been released.

The following are recommendations to protect the first responders from the release area:

• Position the decontamination corridor upwind and uphill of the hot zone.
• The warm zone should include two decontamination corridors. One decontamination corridor is used to enter the warm zone and the other for exiting the warm zone into the cold zone. The decontamination zone for exiting should be upwind and uphill from the zone used to enter.
• Decontamination area workers should wear appropriate PPE. See the PPE section of this card for detailed information.
• A solution of detergent and water (which should have a pH value of at least 8 but should not exceed a pH value of 10.5) should be available for use in decontamination procedures. Soft brushes should be available to remove contamination from the PPE.
• Labeled, durable 6-mil polyethylene bags should be available for disposal of contaminated PPE.

The following methods can be used to decontaminate an individual:

• Decontamination of First Responder:
  • Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
  • Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE has been removed.
  • Place all PPE in labeled durable 6-mil polyethylene bags.
• Decontamination of Patient/Victim:
  • Remove the patient/victim from the contaminated area and into the decontamination corridor.
  • Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag.
  • Thoroughly wash and rinse (using cold or warm water) the contaminated skin of the patient/victim using a soap and water solution. Be careful not to break the patient/victim’s skin during the decontamination process, and cover all open wounds.
  • Cover the patient/victim to prevent shock and loss of body heat.
  • Move the patient/victim to an area where emergency medical treatment can be provided.

Sulfur mustard is extremely toxic and may damage the eyes, skin, and respiratory tract and suppress the immune system. Although sulfur mustard causes cellular changes within minutes of contact, the onset of pain and other symptoms is delayed. Thus, patients/victims arriving immediately from the scene of sulfur mustard exposure are not likely to have signs and symptoms. The sooner after exposure that symptoms occur, the more likely they are to progress and become severe. Initial treatment is primarily supportive.

There is no antidote for sulfur mustard toxicity. Decontamination of all potentially exposed areas within minutes after exposure is the only effective means of decreasing tissue damage.

• Immediately remove the patient/victim from the source of exposure.
• Immediately wash eyes with large amounts of tepid water for at least 15 minutes.
• Eyes must be decontaminated within minutes after exposure to limit injury.
• Do not cover eyes with bandages.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• Ensure that the patient/victim has an unobstructed airway.
• Do not induce vomiting (emesis).
• Administer nothing by mouth (NPO).
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• Evaluate respiratory function and pulse.
• Ensure that the patient/victim has an unobstructed airway.
• If shortness of breath occurs or breathing is difficult (dyspnea), administer oxygen.
• Assist ventilation as required. Always use a barrier or bag-valve-mask device.
• If breathing has ceased (apnea), provide artificial respiration.
• Monitor for and treat spasmodic narrowing of the large airways (bronchospasm), if it occurs.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• See the decontamination section for patient/victim decontamination procedures.
• Skin must be decontaminated within minutes after exposure to limit injury.
• Persons exposed to sulfur mustard will seldom be received for medical treatment in time to prevent tissue damage.
• Seek medical attention immediately.

Because health effects due to sulfur mustard may not occur until several hours after exposure, patients/victims should be observed in a hospital setting for at least 24 hours. Gastric lavage is contraindicated following ingestion of this agent due to the risk of perforation of the esophagus or upper airway. Fluid and electrolyte balance should be monitored and restored if abnormal. Following significant whole-body (systemic) absorption of sulfur mustard, injury to the bone marrow, lymph nodes, and spleen may cause a drop in white blood cell counts (beginning on days 3 to 5), which can result in an increased risk for developing (life-threatening) infections. Counts of red blood cells and platelets may also fall due to bone marrow damage.

Following eye exposure, visual loss may return within days to months depending on the severity of exposure; however, permanent visual loss is rare. Chronic eye infections are possible. After-effects (sequelae) of inhalation exposure may include loss of taste and smell; chronic respiratory illness, including asthmatic inflammation of the large airways (bronchitis), recurrent respiratory infections, and increased fibrous tissue in the lung (fibrosis); and cancer of the airways (following repeated exposures). Skin scarring and pigment changes may follow a severe skin lesion from sulfur mustard exposure; cancer sometimes develops in scarred skin. Sulfur mustard exposures may produce lasting central nervous system effects; minor psychological problems can last for a year or more after exposure.

Sulfur mustard is a known carcinogen. Information is inconclusive whether chronic or repeated exposure to sulfur mustard increases the risk of reproductive toxicity, or developmental toxicity. Chronic or repeated exposure to sulfur mustard may cause cancer in any part of the respiratory system, cancer of the skin, or leukemia. Chronic or repeated exposure to sulfur mustard may cause birth defects. Chronic or repeated exposure to sulfur mustard may cause genotoxicity.

• Consult with the Incident Commander regarding the agent dispersed, dissemination method, level of PPE required, location, geographic complications (if any), and the approximate number of remains.
• Coordinate responsibilities and prepare to enter the scene as part of the evaluation team along with the FBI HazMat Technician, local law enforcement evidence technician, and other relevant personnel.
• Begin tracking remains using waterproof tags.

• Wear PPE until all remains are deemed free of contamination.
• Establish a preliminary (holding) morgue.
• Gather evidence, and place it in a clearly labeled impervious container. Hand any evidence over to the FBI.
• Remove and tag personal effects.
• Perform a thorough external evaluation and a preliminary identification check.
• See the Decontamination section for decontamination procedures.
• Decontaminate remains before they are removed from the incident site.

The following methods can be used to decontaminate the environment/spillage disposal:

• Do not touch or walk through the spilled agent if at all possible. However, if you must, personnel should wear the appropriate PPE during environmental decontamination. See the PPE section of this card for detailed information.
• Keep combustibles (e.g., wood, paper, and oil) away from the spilled agent.
• Use water spray to reduce vapors or divert vapor cloud drift. Avoid allowing water runoff to contact the spilled agent.
• Do not direct water at the spill or the source of the leak.
• Stop the leak if it is possible to do so without risk to personnel, and turn leaking containers so that gas rather than liquid escapes.
• Prevent entry into waterways, sewers, basements, or confined areas.
• Isolate the area until gas has dispersed.
• Ventilate the area.

Agents can seep into the crevices of equipment making it dangerous to handle. The following methods can be used to decontaminate equipment:

• Not established/determined