Rosen & Barkin's 5-Minute Emergency Medicine Consult (101 page)

• Anthrax:
  
  • Influenza
    
  • Bacterial pneumonia, bacterial meningitis
    
  • Brown recluse spider bite
    
  • Tularemia
    
  • Streptococcal/staphylococcal skin infection
    
• Plague:
  
  • Tularemia, catscratch disease
    
  • Lymphogranuloma venereum, chancroid
    
  • Tuberculosis
    
  • Streptococcal adenitis
    
  • Meningitis, encephalitis, sepsis
    
• Smallpox:
  
  • Varicella
    
  • Rash starts centrally on trunk and spreads outward:
    
    • Lesions in different stages of development
      
    • Rarely involves palms or soles
      
    • Disseminated molluscum contagiosum
      
  • Monkeypox, drug eruptions
    
• Toxins:
  
  • Staphylococcal enterotoxin B:
    
    • Most common cause of food poisoning
      
    • Can be aerosolized in addition to being placed in food or water reservoir
      
    • When inhaled, produces febrile type of illness that can progress to septic shock picture
      
  • Ricin:
    
    • Plant protein derived from castor beans
      
    • Causes rapid progression from upper respiratory congestion to cardiopulmonary collapse
      
    • Ingestion is less toxic because GI tract does not absorb it well, but it can lead to local cytotoxic death, shock, and death.
      
  • Botulinum toxin:
    
    • Initially symptoms include cranial nerve dysfunction with descending paralysis that leads to respiratory failure.
      
  • Mycotoxins:
    
    • Highly toxic compounds produced by certain species of fungus
      
    • Dermal, respiratory, or GI contact can rapidly lead to multiorgan system failure and death.
      

TREATMENT

Universal precautions with N-95 mask

• ABCs
  
• 0.9% NS fluid bolus for hypotension
  
• Supplemental oxygen for hypoxemia
  
• Vasopressors for persistent hypotension
  
• Respiratory and contact isolation for suspected cases
  

• All treatments include:
  
  • Control fever with acetaminophen.
    
  • Initiate therapy for specific disease.
    
• Anthrax:
  
  • Initiate antibiotics:
    
    • IV for inhalational or severe cutaneous
      
    • Antibiotic choice depends on susceptibility.
      
  • Antibiotic options:
    
    • Ciprofloxacin: 1st line
      
    • Doxycycline
      
    • Rifampin
      
    • Clindamycin
      
    • Vancomycin
      
• Plague:
  
  • Antibiotics initiated within 24 hr minimizes mortality.
    
  • 1st-line agents: Streptomycin or gentamicin
    
  • Add chloramphenicol if signs of meningitis or unstable patient
    
  • Prophylaxis: Doxycycline or ciprofloxacin
    
• Brucellosis:
  
  • Supportive therapy
    
  • Start doxycycline 100 mg PO BID for 6 wk with the addition of streptomycin 1 g per day IM for the 1st 2–3 wk or rifampin 900 mg per day for 6 wk.
    
• Q fever:
  
  • Recovery occurs within 2 wk without treatment.
    
  • Doxycycline shortens duration of illness.
    
• Smallpox:
  
  • Supportive therapy
    
  • Vaccine given within 4 days of initial exposure decreases chances of contracting smallpox or developing severe symptoms.
    
  • Vaccinate medical staff caring for patient.
    
  • Treat secondary bacterial infection.
    
• Tularemia:
  
  • See “Tularemia.”
    
• Hemorrhagic fevers:
  
  • See “Hemorrhagic Fever.”
    

• Chloramphenicol: 25 mg/kg IV q6h
  
• Ciprofloxacin: 400 mg IV q12h or 500 mg PO BID (peds: 15 mg/kg BID PO)
  
• Clindamycin: 900 mg IV q12h
  
• Doxycycline: 100 mg (peds: ≥45 kg, 100 mg; if weight ≤45 kg, 2.2 mg/kg IV) PO/IV q12h
  
• Gentamicin: 5 mg/kg IM or IV q24h (peds: 2.5 mg/kg IV/IM q8h)
  
• Rifampin: 10 mg/kg IV not to exceed 600 mg/d
  
• Streptomycin: 1 g (peds: 20–40 mg/kg) IM q12h
  
• Vancomycin: 1 g IV q12h
  

FOLLOW-UP

• Decision to treat patient as inpatient vs. outpatient will have to be made in context of overall disaster.
  
• Toxic or hypoxic patients require admission.
  
• Respiratory isolation
  

Mild, noncontagious illness

• Contact local and state health departments for suspected or confirmed illness related to biologic weapons.
  
• Infectious disease and toxicology consult for suspected illness
  

• Postexposure prophylaxis and vaccinations should be continued based on the causative agent.
  
• Exposed staff should have follow-up with employee health and infection control prior to returning to work.
  

• Early diagnosis is difficult, and a high index of suspicion is required.
  
• Failing to use personal protective equipment to protect self and staff is a pitfall.
  
• Suspect biologic weapons etiology when there is geographic clustering of patients who live, work, or attended an event in close proximity.
  
• Initiate therapy or prophylaxis early in suspected illness.
  

• Centers for Disease Control and Prevention (CDC). Recognition of illness associated with the intentional release of a biologic agent.
  MMWR Morb Mortal Wkly Rep.
  2001;50:893–897.
  
• Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and management of patients exposed to biological warfare agents.
  JAMA
  . 1997;278(5):399–411.
  
• US Army Medical Research Institute of Infectious Diseases.
  Medical Management of Biological Casualties Handbook
  . 6th ed. Fort Detrick, Frederick, MD, April 2005.
  

• emergency.cdc.gov/bioterrorism/
  
• sis.nlm.nih.gov/enviro/biologicalwarfare.html
  

See Also (Topic, Algorithm, Electronic Media Element)

• Botulism
  
• Hemorrhagic Fever
  
• Tularemia
  

CODES

• V01.0 Contact with or exposure to cholera
  
• V71.82 Observation and evaluation for suspected exposure to anthrax
  
• V71.83 Observation and evaluation for suspected exposure to other biological agent
  

BASICS

• Mania:
  
  • Presentation is diverse and may be difficult to recognize as mania:
    
    • Simple irritability
      
    • Cheerfulness
      
    • Psychosis
      
    • Delirium
      
    • Agitation
      
  • Full extent of pathology often revealed only by outside informants
    
  • Onset gradual or acute, duration several weeks or months; rarely may be chronic
    
• Hypomania:
  
  • Milder symptoms without marked impairment
    
• Mixed mood:
  
  • Simultaneous symptoms of mania and depression
    
  • Treat in ED as for mania
    
• Bipolar disorder:
  
  • Formerly manic depressive disorder
    
  • Defined as one or more episodes of hypomanic, manic, or mixed mood
    
  • Possibly with episodes of depressed mood
    
  • Bipolar II is used to denote cases where hypomania has occurred in the course of the disorder but never mania.
    
  • Typically begins in the teens or 20s
    
  • Episodes of abnormal mood may be mild or severe, brief or prolonged, infrequent or chronic, chiefly elevated or chiefly depressed in character.
    
  • Bipolar disorder may be readily responsive to treatment or nearly intractable.
    
• Schizoaffective disorder:
  
  • Characterized by episodes of altered mood, but psychotic features present even when mood is normal