Because mustard penetrates tissue rapidly and binds to cellular components within the first to minutes, the most important early intervention is immediate decontamination, ideally within the first minutes Decontamination after a half hour is unlikely to affect the eventual development of local effects, but even late removal of agent can stop continuing absorption and limit the total internal dose As with nerve agents, RSDL is particularly effective for skin decontamination In contrast, soap and water often ends up simply smearing agent and increasing the area for absorption No specific antidotes to mustard poisoning are available Supportive care for skin lesions is analogous to that provided for burn injury, although fluid requirements are usually far less than with comparable thermal burns Additional treatment of respiratory tract inflammation, ocular injury, and immunosuppression associated with leukopenia may be required (see Chapters 93 Hematologic Emergencies , 99 Pulmonary Emergencies , 123 Ophthalmic Emergencies ) and bone marrow stimulating factors may be needed Pulmonary Agents Toxic inhalant agents, including chlorine and phosgene, may cause injury in several ways, including simple asphyxia by displacing oxygen, topical damage to airways or alveoli, systemic absorption through the pulmonary capillary bed, and allergic hypersensitivity reactions Both chlorine and phosgene were used in battle in World War I, are commonly used for industrial purposes today, and are reviewed briefly in this section Chlorine is a dense, acrid, yellow-green gas with intermediate water solubility and chemical reactivity, whereas phosgene has low solubility and reactivity Because the initial irritant symptoms of gas exposure tend to correlate directly with water solubility and chemical reactivity, low-dose exposures to chlorine and even moderate exposures to phosgene might cause either no symptoms at all or only mild irritation of mucous membranes Victims could easily dismiss these effects, thus prolonging exposure and the severity of the ultimate lung injury Phosgene (carbonyl chloride) also generates hydrochloric acid, contributing particularly to upper airway, nasal, and conjunctival irritation at higher doses Also generated is a carbonyl group that participates in acylation reactions at the pulmonary alveolocapillary membranes; the resulting leakage of fluid across damaged membranes eventually leads pathologically to pulmonary edema and clinically to acute lung injury (ALI), including its most severe form, acute respiratory distress syndrome (ARDS) Phosgene lung injury may also be mediated in part by an inflammatory reaction associated with leukotriene production