Textbook of Disaster Psychiatry

Edited by Robert J. Ursano Carol S. Fullerton Uniformed Services University of the Health Sciences

Lars Weisaeth University of Oslo

Beverley Raphael University of Western Sydney

CAMBRIDGE UNIVERSITY PRESS I Assessment and management of medical-surgical disaster· casualties

James R. Rundell

Introduction identify how postdisaster patient triage and manage­ ment can incorporate behavioral/psychiatric assess­ Having medical or surgical injuries or conditions ment and treatment, merging behavioral and following a disaster or terrorist attack increases the medical approaches in the differential diagnosis likelihood a psychiatric condition is also present. and early management of common psychiatric syn­ Fear of exposure to toxic agents can drive many dromes among medical-surgical disaster or terrorism times more patients to medical facilities than actual casualties. terrorism-related toxic exposures. Existing post­ disaster and post-terrorism algorithms consider pre­ dominantly medical and surgical triage and patient Phases of individual and community management. There are few specific empirical data responses to terrorism and disasters: about the potential effectiveness of neuropsychiatric integrating psychiatric management triage and treatment integrated into the medical­ into disaster victim medical-surgical surgical triage and management processes (Burkle, triage and treatment 1991). This is unfortunate, since there are lines of evidence to suggest that early identification of Disasters include natural disasters as well as human­ psychiatric casualties can help decrease medical­ made disasters such as terrorist attacks with explo­ surgical treatment burden, decrease inappropriate sives, chemicals, and biological agents. In cases of treatments of patients, and possibly decrease long­ disaster or terrorism, particularly when the scope of term psychological sequelae in some patients potential casualties could overwhelm local response (Rundell, 2000). Physicians and mental health pro­ capabilities, the ability to separate medical-surgical fessionals involved in disaster/terrorism response casualties, psychiatric casualties, mixed casualties, planning should understand the importance of con­ and the worried well becomes crucial to targeting aid sidering behavioral symptoms within the context of to the correct patients. The principles of differential concurrent medical-surgical assessment and treat­ diagnosis discussed in this chapter are aimed to be ment (Rundell, 2003). Effective medical-psychiatric clinically useful across the range ofdisaster etiologies. differential diagnosis and adequate attention to Following a potential terrorism or disaster-related .1 ;1 public risk communication lessen the risk of medical toxic (biological, chemical or nuclear) exposure, or a ""I or psychiatric misdiagnoses, and decrease the odds possible toxic exposure, three types of patients pre­ that healthcare systems may be overwhelmed sent themselves for medical evaluation, (1) people (Rundell & Christopher, 2004). This chapter will with disease or injuries due to the toxic agent,

© Cambridge University Press 2007

164 Management of medical and surgical disaster casualties 165

(2) people who have organic disease plus a con­ begin to present to medical facilities for evaluation ­ current psychiatric condition that may confuse the some will contract illness and some won't. The clinical picture, and (3) people who have not been experience in the United States following the anthrax exposed but fear they have. Anxiety and fear pro­ terrorism of October 2001 was that the number of voked by concerns about having been potentially people who feared exposure, or were exposed but exposed can complicate the medical picture; phy­ never developed disease, was over a thousand times siological signs of autonomic nervous system arou­ greater than the number of people who actually sal, along with normal somatizing behaviors and developed anthrax (CDC, 2001a). The ratio will dysphoria, can mimic symptoms and signs of dis­ depend on the virulence of the agent, the mode of eases due to biological and chemical agents. delivery, and the effectiveness ofrisk communication The numbers ofpeoplewho presentfor healthcare to the general public. After the clinical illnesses have in each of the three categories above are neither run their courses, there will continue to be patients proportional nor linear across the life of a bio­ presenting for health evaluations who fear they have terrorism epidemic. When there is an explosive been exposed and displaying anxiety, fear, or idio­ event, such as a suicide bombing or a building syncratic manifestations of psychiatric illnesses. bombing, physical injuries are often clear, definable, The principles presented in this discussion and in and obvious. If exposure is covert, as in potential Figure 8.1 may occur serially or continuously if release of a chemical or biological agent, patients there is an ongoing bioterrorism event (e.g., anthrax­ with organic disease will present before any wave of tainted letters mailed over several months), produ­ patients who present with fear, anxiety, or psychia­ cing waves of exposures and fear. tric illness. If a biological or chemical attack is announced by the perpetrators, the first wave of Announced exposure people presenting for health evaluation is more likely to feature behavioral manifestations, given the Some terrorists may estimate that the greatestimpact incubation periods of potential biological agents. on a population will occur if they announce they Figure 8.1 summarizes the differences between have perpetrated a bioterrorist act. An actual attack these two types of individual and community mayor may not follow. If an attack does not responses to toxic agent exposure. follow, all presentations will represent behavioral and physical manifestations of fear, anxiety, and idiosyncratic presentations of psychiatric illness. If (overt exposure an actual exposure occurs in the context of an If a terrorist group unleashes a biological agent cov­ announcement, the lengm of time for actual clinical ertly, organic disease will emerge before the general prodromes or illnesses to appear that are attributable public is aware of the terrorist event. The duration of to the agent will depend on the incubation period of the period when illnesses attributable to the agent the disease produced by the agent. Prior to the onset comprise all ofthe patients presenting or referred for cif the organic infectious disease, all patients pre­ medical evaluation depends on three variables: (1) senting to medical facilities will be people who fear the incubation period, the duration of the prodrome, exposure and might be misinterpreting signs and and the time to definitive diagnosis, (2) the length of symptoms of other physical illnesses, psychiatric time it takes public health authorities to identify a illnesses, or autonomic hyperactivity. After patients bioterrorist event, and (3) the length of time it takes stop presenting with clinical illnesses attributable to the public to be informed about the event. Once there the biological agent there will be a period during is general public awareness there has been a terrorist which the worried well or the medically ill who fear event or disaster-related release of toxic substances, their symptoms may be due to the biological agent i l people who fear they may have been exposed will continue to present, often with symptoms of fear, 166 J. R. Rundell

COVERT EXPOSURE

~.------­Time------+ Clinicall1lness Behavioral Manifestations

• Clinical illness: first wave of people who present with clinical symptoms and signs of agent before the general public becomes aware of the bioterrorism event

• Behavioral symptoms and signs: as the outbreak becomes defined and publicized, patients present with a mixture of clinical illness attributable to the agent, behavioral manifestations attributable to fears of having been exposed, and psychiatric disorders. After the exposures attributable to the biological agent illnesses have run their course, fears of having been exposed remain and result in continued presentations to medical facilities

ANNOUNCED EXPOSURE

~------Time------+ Behavioral Manifestations Clinicall1lness

Behavioral manifestations: initially, the latency period and clinical course of the biological agent dictate that there has not been time yet for actual illnesses attributable to the • biological agent to have occurred. Behavioral manifestations will remain after clinical A, cases have run their course among those worried they may have been exposed fo Clinical illness: it is important to address anxiety and concurrent psychiatric disorders in • the overall medical management of patients with confirmed illness due to biological pr agents ac co Figure 8.1 Phases of individual and community responses to chemical or biological agent exposure. Adapted with eVI permission from Rundell & Christopher (2004) thl pal anxiety, or psychiatric illness: If there are ongoing or will be determined by a number of factors, listed in bel . serial bioterrorism events,. the simple curves and Table 8.1. These are a combination of individual the phases presented in Figure 8.1 may become co~Pli­ medical factors (risk factors and nature of the ill­ nUl cated, serial, and merge together into an ongoing nesses produced by the agent as delivered) and sun need to attend to medical-behavioral differential public health/education factors. Explosive events foll. diagnosis issues. will produce initial injuries, and then those casual­ natl ties due to secondary or delayed effects of the initial mel injuries, such as those related to infection, blood FI Factors determining presentations loss, head injury, etc. The nature ofvarious biologi­ initi to healthcare providers and facilities cal and chemical agents likely to be used in terrorist prol The number and types of patient presentations to activities is presented later in this chapter. It is becI healthcare providers following a bioterrorism event important, however, to emphasize how crucial it is pub] Management of medi(al and surgi(al disaster (asualties 167

Table 8.1 Factors that determine the timing, number the epidemic is defined depends on the complexity and types of presentations to healthcare providers of the presentations and how much warning there following a biological or chemical terrorism event was, either through intelligence or announcement of the' event by the perpetrators. For obvious rea­ 1. Whether the event is covert or announced sons, there will be very little specific public fear or 2. The toxicity of the agent employed anxiety driving referrals to healthcare providers or 3. The duration and magnitude of the exposure 4. The effectiveness of the delivery mechanism facilities during the initial phases of a covert bio­ 5. The incubation period and duration of prodromal terrorism event. However, as the nature ofthe threat syndromes and illnesses caused by the agent becomes defined and publicized, there will be a 6. The duration of time it takes public health authorities period of uncertainty that will increase public anxi­ to identify and characterize the threat ety and fear, lowering individuals' thresholds for 7. Effectiveness of public education and risk commu­ seeking medical attention for unexplained physical nication efforts symptoms or physiological sensations. Fear and 8. Individual behavioral and medical risk factors of those anxiety itselfleads to autonomic arousal, which may potentially exposed cause people to experience signs and symptoms a. General health leading to medical referrals. This intermediate phase b. Concurrent medical illnesses of uncertainty (Figure 8.2) is associated with the c. Concurrent psychiatric illnesses d. Psychiatric predispositions highest degree of public fear and anxiety. The risk of e. Underlying degree of anxiety regarding terrorism behavioral contagion overwhelming a healthcare threat system is greatest during this phase, and can be f. Individual social supports and overall sense of minimized by truthful, thoughtful, and reassuring community information from governmental and public health g. General sense of efficacy of and confidence in authorities. As the illnesses attributable to the bio­ governmental and public health officials logical agent become defined, and risk commu­ nication to the general public has occurred, there is a Adapted with permission: Rundell & Christopher (2004). third (consolidation) phase. As the illnesses caused for competent, credible public health authorities to by the agent decrease in frequency, and public provide the general public with timely, truthful, and knowledge about risks increases, public fear and accurate information. The degree of behavioral anxiety decrease to more moderate and realistic contagion possible in the context of a bioterrorism levels. Multiple, serial, or ongoing bioterrorism event is inversely associated with the efficacy of events will result in overlapping curves ofthe graphs the public information campaign. Bioterrorism is a in Figures 8.1 and 8.2, which translate into the need particularly challenging public health problem for healthcare providers and systems to be as effect­ din because of the different agents' latency periods and ive as possible with differential diagnosis and patient jual the large number of variables that can affect the education. ~ ill­ number, nature, and severity ofcasualties. Figure 8.2 and summarizes the phases of public understanding The ATLS® primary and secondary surveys ents following a bioterrorism event that will drive the ual­ nature of presentations to healthcare providers and Since 1980 the American College of Surgeons .itial medical facilities. has taught Advanced Trauma Life Support®, an .ood Following a bioterrorism event, there will be an approach for providing care to people suffering ogi­ initial period during which patients present with major. life-threatening physical injury. The under­ Jrist prodromes and clinical illnesses that eventually lying concept ofATLS® is simple: the greatest threats [t is become part of a pattern recognized and defined by to life are treated first - loss of airway, loss of it is public health officials. The duration of time before breathing ability, loss of circulating blood volume, 168 J. R. Rundell

Degree of Fear and Anxiety

Time "------,=---===-­

Initial Phase Uncertainty Phase Consolidation Phase

Initial phase: initial presentations of cases as they develop prodromes and illnesses prior to general public awareness - little if any public fear or anxiety

Uncertainty phase: "There's something going on but we're not sure what" period of general public knowledge and perception - highest amount of public fear and anxiety. Requires thoughful public education and risk communication

Consolidation phase: the outbreak and risks to individuals and the community become • defined and publicized - moderate and manageable public fear and anxiety Figure 8.2 Phases of public understanding following a disaster or terrorism event that will drive nature of presentations to medical facilities. Adapted with permission from Rundell & Christopher (2004).

and effects of an expanding intracerebral mass more alertthe patient, the more reassured the triager (American College of Surgeons, 2004). ATLS® prin­ is that the individual is stable for the moment. The ciples are sure to be applied when there are explosive final step of the primary survey is to completely injuries to large numbers of patients. The rapid, undress a patient and observe for obvious injury, targeted examination of the patient necessary to taking care to prevent hypothermia. identify these life-threatening injuries is called the Once the primary survey aLa trauma victim is "primary suivey." The ~ctim's'aiIW~yis ch~cked for completed, resuscitative efforts are well established, obstruction, while taking care to protect the spine and the patient has stable vital signs, the "secondary and spinal cord. Next, adequate air flow to the lungs survey" is initiated. The secondary survey (American is ensured, and provided to the patient by artificial College of Surgeons, 2004) is a "head to toe" evalua­ means ifneeded. Next, blood circulation is assessed, tion ofthe trauma patient - each region ofthe body is points of hemorrhage addressed, fluids replaced, systematically examined. Available and relevant and cardiac compressions administered ifindicated. aspects of medical history are reviewed at this junc­ A brief alertness assessment is made; the patient is ture as well: especially allergies, current medications, described as alert/responsive to verbal stimuli, significant past illnesses, and events related to the responsive to painful stimuli, or unresponsive. The injury. Management of medical and surgical disaster casualties 169

The "tertiary" psychiatric survey: early be difficult, and multiple disorders may be present. identification of psychiatric casualties Table 8.2 summarizes key principles of psychiatric screening of medical-surgical disaster victims fol­ There are many advantages if psychiatrists likely lowing primary and secondary surveys and medical to participate in disaster or terrorism response stabilization. have training, and ideally current certification, in ATLS® and Advanced Cardiac Life Support (ACLS) (American Heart Association, 2002). The history The mental status examination in critically and physical examination findings collected during injured patients the primary and secondary surveys are the very Conducting a good mental status examination in a data needed for the differential diagnosis of psy­ critically injured patient is a challenge, but it is chiatric symptoms in the medical-surgical and indispensable for differential diagnosis. Following trauma settings. Psychiatrists who are skilled in or at explosive and exposure events, many patients will least understand ATLS® and ACLS principles can be have altered mental status examinations. First, note higWy effective in the disaster or emergency room the patient's level ofconsciousness. Next, establish a setting when the time comes to evaluate potential method of communication. If the patient cannot victims. First, they have credibility with medical­ communicate verbally, have him or her write surgical colleagues because they speak the language answers on a tablet. Writing may show spatial dis­ inherent in ACLS and ATLS® algorithms and under­ orientation, misspellings, inappropriate repetition stand the concepts of clinical management defined of letters (perseveration), and linguistic errors. If a by those two approaches. Credibility with disaster patient is unable to speak or write, use either an eye leaders is key to influencing their leadership beha­ blink method of communication (one blink for yes, viors (Bartone et aI., 1994). Second, they can apply two blinks for no), or have the patient squeeze your the triage philosophies behind ATLS® and ACLS finger with his or her hand (one squeeze for yes, two to the differential diagnosis of neuropsychiatric squeezes for no). Phrase questions to allow for a yes symptoms and to early identification of psychiatric or no response (e.g., "are you feeling frightened?"). disaster casualties. To determine whether a patient is confused, insert A postdisaster or post-terrorism psychiatric nonsense questions such as "Do catfish fly" or screening examination to triage and identify early "Do beagles yodel?" (Wise & Rundell, 2005). If the psychiatric casualties canbe thoughtofas a "tertiary" patient looks surprised or amused and properly survey that focuses on the most common psychiatric answers the question, a secondary psychiatric dis­ sequelae (Holloway et aI., 1997; Rundell & Ursano, order (medical or toxic etiology) is less likely. 1996; Ursano & Rundell, 1994) and those most likely to adversely affect medical-sUJ:,gical outcomes. There will be time for a more comprehensive mental health . M.edical-psychiatric differential diagnosis evaluation later, along with psyc;;hotherapy', pie~ca ~: tion evaluations, and debriefings when frldicated. Unique attributes of biological The screening psychiatric examination of the dis­ and chemical terrorist attacks aster, terrorism, or trauma victim is easy if the pri­ mary and secondary surveys are unremarkable. While there is ample recent evidence that natural Psychiatric examination findings in that instance disasters and explosive devices can cause consider­ are likely to represent the warning signs of primary able death and destruction, an incident of chemical psychiatric disorders. However, when there are or biological terrorism has the potential to generate behavioral signs as well as significant primary and tens of thousands of casualties requiring prompt secondary survey findings, differential diagnosis can medical attention. Chemical and biological terrorism 170 J. R. Rundell

Table 8.2 Screening psychiatric examination of medical-surgical disaster casualties: the "tertiary" survey

Examination parameter Finding increases likelihood of:

History Physical injuries during traumatic event Secondary psychiatric disorder,a ASD,b PTSD, dissociation Past history of psychiatric disorder That psychiatric disorder Patient is on routine, ongoing medication Substance intoxication, substance withdrawal, secondary psychiatric disorder Received ATLS® or ACLS medications Secondary psychiatric disorde~ Physical findings Elevated heart rate, blood pressure Substance withdrawal, generalized anxiety disorder, panic disorder ASD,b a PTSD, C secondary psychiatric disorder Easy startle ASD,b PTSD,c generalized anxiety disorder Lateralizing neurological signs Head or vertebral column injury, secondary psychiatric disordera Physical complaints out of proportion to Conversion disorder, hypochondriasis, factitious disorder, malingering,d objective findings undiagnosed physical condition Mental status examination Disoriented Delirium, secondary psychiatric disordera Clouded consciousness Delirium, secondary psychiatric disorder,a dissociation Dysarthria Substance intoxication, head injury Dysgraphia, dyscalculia Head injury, delirium Impaired short-term memory Head injury, substance intoxication, delirium, generalized anxiety disorder, panic attack Hallucinations or delusions Substance intoxication, secondary psychiatric disorder,a substance withdrawal, primary psychotic disorder

a Psychiatric disorders due to general medical conditions or due to toxins/psychoactive substances. b Acute stress disorder.

C Post-traumatic stress disorder. d Malingering is not a psychiatric disorder; it is a legal accusation. Adapted with permission from Rundell (2003).

is of particular interest to mental health professionals national-level response effectiveness to chemical because the news orrumor ofa chemicalor biological and biological potential threats depends as much attack could also cause tens of thousands of people or more on effective public education and public to fear they have been exposed who could rapidly health efforts as on individual medical treatments. overwhelm local medical resources. Biological and Because the signs and symptoms of chemical and chemical warfare are not new. Since antiquity bio­ biological attacks can be nonspecific and mimic logical and chemical agents have been used to neuropsychiatric syndromes, differential diagnosis contaminate sources of water and food, or to by skilled clinicians is crucial to effectively triage large cause uncontrollable diseases among populations populations. In many cases the presence or absence (Christoper etai., 1997). In recent years, the technical of fever may be the only reliable early differentiator capabilities of those who would use biological or between those exposed to a biological agent and chemical agents of terror have surged (Franz et ai., those not exposed but fearful they may have been. 1997). Because ofthe potential impacts of large-scale When a patient presents to a health provider with exposure and psychological contagion, local- and signs or symptoms suggesting disease caused by a Management of medical and surgical disaster casualties 171

chemical or biological agent, or fears he or she may ing stimulation (Heath, 1961). Resulting symptoms have been exposed, a number ofinfectious diseases, include cholinergic signs such as lacrimation, sali­ psychiatric syndromes, or behavioral contagion vation, nausea, hyperpnea, rhinorrhea, broncho­ issues may account for the presentation. There may consmction, vomiting, muscle twitching, progressive be multiple simultaneous presentations; having an respiratory paralysis, and death. The usual cause of illness due to a biological agent does not exclude death is respiratory paralysis. psychiatric disorders or fear/anxiety, it makes these Nerve agents have the greatest potential among behavioral manifestations more likely. In addition, toxic agents for causing diagnostic confusion. Psy­ patients with pre-existing medical or psychiatric chological findings may be more prevalent than illnesses are at risk for exaggerated responses physical findings, especially in early stages of expo­ to potential exposure, including idiosyncratic or sure (DiGiovanni, 1999). Persistent long-term neu­ unusual presentations. This is particularly true of ropsychiatric effects can be seen as well, including the chronically and persistently mentally ill with drowsiness, memory impairment, depression, fati­ severe psychiatric disorders, such as schizophrenia gue, and increased irritability. These effects can last and bipolar disorder. Other predictors of having weeks to years after the exposure. a maladaptive psychological response to the chem­ Acute treatment is atropine. As much as 10-40 mg ical and biological warfare or terrorist event of atropine may be necessary within 24 h, and atro­ environment include anticipatory anxiety, low per­ pinization is usually maintained for at least 24-48 h ceived social support (especially when stress is (Grob & Harvey, 1953). Treatment protocols also high), lack of effective preparatory training, and include pralidoxime (2-PAM cWoride), which acts order, fatigue (Fullerton et ai., 1996). by removing bound agent from the enzyme, reacti­ Table 8.3 summarizes the medical, psychiatric, vating the enzyme. Atropine causes neuropsychia­ and behavioral conditions important in the after­ tric effects which may be worse than the nerve math of a terrorist event related to possible biolo­ agent itself in some cases. Doses necessary for gical or chemical agents. These will be discussed treatment may cause significant drowsiness, con­ individually in the remainder of this section of the centration disturbance, hyperactivity, hallucina­ chapter. tions, and stupor or coma (DiGiovanni, 1999). Time is of the essence in treating nerve agent poisoning, and symptoms should not be mistaken Nerve agents for anxiety or panic attacks. Key in the differential The nerve agents are derived from organophos­ diagnosis is history of nerve agent use and presence mical phorus compounds related to insecticides such as of early cholinergic symptoms, such as lacrima­ nuch diazinon and parathion. They can be very toxic; for tion, salivation, and rhinorrhea. Poisoning with nerve mblic example, 0.4 mg of agent VX or 0.8 mg of Soman can agents at a sublethal level may cause or mimic lents. be lethal to humans (Jones, 1995). Other nerve agents, psychiatric disturbances such as anxiety disorders, I and such as SilIin, can penetrate ordinary clothes with mood disorders, and delirium (Jones, 1995). Atropine !limic ease. Nerve agents in the liquid state can penetrate itself can cause psychosis. These should not be trea­ :nosis unbroken skin. Nerve agents are irreversible inhibi­ ted with highly anticholinergic antipsychotic agents, .large tors of acetylcholinesterase, an enzyme present in as they may worsen the syndrome. ,ence the central nervous system, skeletal muscle, several tiator endocrine glands, and other cholinergically inner­ Cyanide t and vated organs. Poisoning with these agents results in

~en. an inability to break down acetycholine, leading to a Cyanide is a nonpersistent gas, especially danger­ .with functional denervation state or subsensitivity of the ous because it may saturate the active material in by a postsynaptic receptor in response to overwhelm­ gas masks, rendering them useless (Jones, 1995). .... -..,J '" Table 8.3 Medical-psychiatric differential diagnosis of patients in the aftermath of a chemical or biological terrorism event

Time to Time for lab Latency onset of to identify Key elements of to initial full specimen or prodrome or Key elements of prodrome illness agent mild exposure lIIness Treatment Comments

Nerve agents Minutes Minutes Rapid Lacrimation, Progressive Atropine, Avoid anticholinergic to hours to hours presumptive salivation, respiratory paralysis, pralidoxime antipsychotics if treating ID can be nausea, muscle twitching, anticholinergic psychosis due to made in field hyperpnea, and death atropine rhinorrhea, broncho­ constriction, vomiting Cyanide Minutes Minutes No rapid lab Anxiety, Anxiety, confusion, Symptomatic Exposure symptoms are difficult to hours to hours diagnosis confusion, giddiness, and to distinguish from situational giddiness, and hyperventilation anxiety hyperventilation Incapacitating Instant Instant No lab Lacrimation, Lacrimation, pain Symptomatic May be confused with nerve agents diagnosis pain agent exposure; avoid premature atropine use Mustard Several Several Rapid Conjunctivitis Higher doses burn Symptomatic and Conjunctivitis and blindness can hours hours presumptive the eyes and cause supportive be permanent or last for several 10 can be blindness, days or weeks made in field pulmonary injury if inhaled, and disfiguring facial and other skin Cutaneous 2-5 days 2-5 days 1-2 days Pruritic macules Ulcerated lesions Doxycycline anthrax or papules turning into eschars Penicillin Ciprofloxacin Inhalation 1-5 days 2-60 days 1-2 days Malaise, fatigue, Hemorrhage, Ciprofloxacin Key differentiating feature anthrax cough, headache, edema, dyspnea, or Doxycycline between prodrome and vomiting, fever stridor, plus one or depressive disorders or diaphoresis, two additional hypochondriacal concern is cyanosis. agents presence or absence of fever Smallpox 12-14 13-15 Days-weeks Fever, Maculopapular rash Postexposure Key differentiating feature days days malaise, in mouth, pharynx, vaccination; between prodrome and prostration, face, and supportive care depressive disorders or headache, forearms ~ spreads (cidofovir, effective hypochondriacal concern is backache to trunk and legs, in vitro) presence or absence of fever. progresses through Vaccine as postexposure vesicles, pustules, prophylaxis and scabs Tularemia 3-5 days Days­ 2-10 days Fever, chills, Pneumonitis, Streptomycin, Key differentiating feature weeks headache, pharyngitis, gentamicin, between prodrome and bodyache bronchiolitis, doxycycline, depressive disorders or lymphadenopathy ciprofloxacin hypochondriacal concern is presence or absence of fever and chills

Plague xl-6 days 3-10 days 1~2 days Fever, cough, Pneumonia, Streptomycin, Droplet isolation pending chest pain, progressing to septic gentamicin, negative cultures, postexposure hemoptysis shock tetracycline prophylaxis Botulism 1-3 days 1-3 days 3-5 days Diplopia, Descending flaccid Antitoxin, supportive Key differentiating feature dysphonia, paralysis with bulbar care between prodrome and anxiety dysarthria signs and autonomic disorders or hypochondriacal dysfunction concerns is presence or absence of viscous secretions, especially in throat Delirium Variable Variable No lab Confusion, Short-term memory Symptomatic Medications used in diagnosis insomnia, deficit, management with resuscitation or life support may restlessness, disorientation, sedating or cause delirium irritabiiity disorganized antipsychotic thinking, sleep-wake medication; remove cycle disturbance, etiology visual hallucinations, hypoactivity or hyperactivity

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Table 8.3 (cont.)

Time to Time for lab Latency onset of to identify Key elements of to initial full specimen or prodrome or Key elements of prodrome illness agent mild exposure illness Treatment Comments

Depression and Variable Variable No lab Malaise, Two or more weeks: Antidepressant Depressed mood or resignation mood diagnosis lassitude, sleep disturbance, medications in the aftermath of bioterrorism disorders dysphoria, low loss of interest and Cognitive- or other traumatic event may be energy pleasure, depressed behavioral difficult to distinguish from the mood, low energy, psychotherapy malaise and lassitude common low concentration, among the prodromes of appetite infectious diseases. Look for disturbance, presence of fever as a psychomotor discriminator disturbance, guilt, suicidality

Acute stress 1-2 days 2~28 days No lab Sleep Dissociation, Antidepressant Not everyone who has disorder (ASDj diagnosis disturbance, re-experiencing medication re-experiencing and arousal goes arousal, anxiety, phenomena, Psychotherapy on to develop ASD - focus on dissociation avoidance of social and occupational associated stimuli, functioning to guide diagnosis increased arousal, disrupted social! occupational functioning Post-traumatic 2-28 days >30 days No lab ASD or arousal, Dissociation, Antidepressant Half of patients with ASD go on stress disorder diagnosis anxiety, or re-experiencing medication to develop PTSD (PTSDl dissociation phenomena, Psychotherapy avoidance of associated stimuli, increased arousal, disrupted social! occupational functioning Generalized Variable Variable No lab Worry, Incessant worry, Benzodiazepine or Look for mucous secretions to anxiety disorder diagnosis restlessness, restlessness, fatigue, antidepressant help differentiate botulism (GAD) fatigue, autonomic arousal, medication prodrome from GAD. Situational irritability irritability, muscle Cognitive anxiety is differentiated from tension, sleep psychotherapy GAD by degree of worry and disturbance impact on social and occupational functioning Panic disorder Variable Variable No lab No prodrome Recurrent attacks Antidepressant or diagnosis characterized by benzodiazepine massive autonomic medication discharge for several Cognitive and minutes, followed by behavioral worry and behavior psychotherapy changes related to techniques attack Hypochondriasis Variable Chronic No lab No prodrome Fear and belief that Reassurance. high Six full months of symptoms disorder diagnosis one has a disease, tolerance for necessary to make diagnosis. based on patients' requests for Mild hypochondriacal concerns misinterpretation of appointments and may be common among general body symptoms. examinations population following disasters or Reassurance terrorist events exceedingly difficult Conversion Variable Variable No lab Variable Physical symptoms Sometimes Prevention enhanced by effective symptoms diagnosis without medical suggestive; training in prevention of basis or etiology reassurance. exposure to chemical/biological education agent Dissociative Variable Variable No lab No prodrome Depersonalization or Psychotherapy Dissociative disorder can disorder diagnosis environmental resemble organic or traumatic perception central nervous system disorders disturbance that is (e.g., consequences of head persistent or trauma) recurrent, and results in a feeling of detachment or unreality. Must cause socialloccupational dysfunction

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Table 8.3 (cont.)

Time to Time for lab Latency onset of to identify Key elements of to initial fuU specimen or prodrome or Key elements of prodrome illness agent mild exposure Illness Treatment Comments

Situational Variable Variable No lab No prodrome Depersonalization or Do not Can be confused with dissociation diagnosis derealization in the overstimulate. May neuropsychiatric disorder context of a be a normal, secondary to disaster or terrorist traumatic event not expectable response event, especially head trauma or rising to threshold of smoke inhalation. Important to dissociative disorder recognize, and manage conservatively Situational Variable Variable No lab No prodrome Worry, insomnia, Benzodiazepine Unrecognized anxiety symptoms anxiety diagnosis restlessness, fatigue, medication can resemble prodrome of irritability,

Early symptoms of cyanide exposure are anxiety, Inhalation anthrax confusion, giddiness, and hyperventilation. These Inhalation anthrax results when aerosolized spore­ symptoms are difficult to distinguish from situa­ bearing particles of 1-5 ~m are deposited into the tional anxiety, sure to be common in the disaster or alveoli. Macrophages phagocytize the spores, which terror setting. resist intracellular lysis due to the presence of a pro­ tective capsule. Surviving spores are transported to Incapacitating agents mediastinal lymph nodes, where germination occurs 2-60 days later. Once germination occurs, disease Tear gas has long been used as a harassing agent, as follows rapidly. Replicating bacteria release toxins it is rarely lethal. It is intended to cause temporary leading to mediastinal hemorrhage, edema and unconsciousness or immobilization. Tear gas may necrosis, followed by bacteremia and sepsis. Inhala­ produce inappropriate responses by mimicking the tion anthrax features a nonspecific prodrome of early symptoms of more lethal agents. For example, malaise, fatigue, myalgia, headache, abdominal pain, tear gas effects may be confused with lacrimation nausea, vomiting, dry cough, chest tightness, and produced by nerve gases and lead to inappropriate fever (Franzetai., 1997; Henderson etai., 1999). There treatment with anticholinergic medication. may be a brief 2- to 3-day period of improvement, followed by an abrupt onset of severe respiratory Blister agents distress with dyspnea, stridor, diaphoresis, and cya­ nosis (Franz et ai., 1997). Septic shock portends death Mustard gas is insidious and several hours may pass within 24-36 h. During the 1979 Sverdlovsk anthrax before characteristic burns and blisters appear. Low epidemic, there were reportedly only 2 patients doses of mustard produce painful conjunctivitis, and with cutaneous lesions among 77 cases of inhalation are disabling and anxiety-producing. Higher doses anthrax (Meselson et ai., 1994), and no cutaneous burn the eyes and cause blindness, pulmonary injury lesions reported among the 42 patients who under­ if inhaled, and disfiguring facial and other skin went autopsy (Abramova et ai., 1993). Preliminary burns (Jones, 1995). Blister agents such as mustard diagnosis may be made via culture within 6-24 h. and Lewisite have been reported to produce long­ Laboratory confirmation requires an additional term psychological symptoms such as apathy and 1-2 days of testing in laboratories with additional depression (Grinstad, 1964). Acutely, blister agents technical capability (Papaparaskevas et ai., 2004). can also cause delirium, and psychological distress Recommended therapy for inhalation anthrax uti­ resulting from the disfiguring lesions, most com­ lizes combinations of two or three parenteral anti­ monly in the face and genitalia (DiGiovanni, 1999). biotics, to include either ciprofloxacin or doxycycline (CDC, 200Ib). Early treatrnentis importantto prevent Cutaneous anthrax progression to septic shock, meningitis, and death.

Cutaneous anthraX occurs when spores of Bacillus Smallpox anthracis are'introduced into superficial, and often unapparent cuts or abrasions. After a brief incu­ A global campaign, begun in 1967 under the auspices bation period of a few days, a small pruritic macule of the World Health Organization, succeeded in era­ will develop. This lesion will evolve into a round dicating smallpox in 1977. In 1980, vaccination ofthe ulcer, with a black, depressed, painless eschar that general population ceased worldwide. The terrorist will dry and falloff within 2 weeks. Cutaneous reintroduction of smallpox would be an unprece­ anthrax carries a very narrow differential diagnosis, dented public health catastrophe, due to the lack of possibly including spider bites (Franz et ai., 1997; herd immunity, the virulence and contagiousness of Inglesby et ai., 2000). the organism, and a relatively long incubation period -...I 0>­

Table 8.3 (cont.)

Time to Time for lab Latency onset of to Identify Key elements of to Initial full specimen or prodrome or Key elements of prodrome illness agent mild exposure illness Treatment Comments

Situational Variable Variable Nu lab No prodrome Depersonalization or Do not Can be confused with dissociation diagnosis derealization in the overstimulate. May neuropsychiatrk disorder context of a be a normal, secondary to disaster or terrorist traumatic event not expectable response event, especially head trauma or rising to threshold of smoke inhalation. Important to dissociative disorder recognize, and manage conservatively

Situational Variable Variable No lab No prodrome Worry, insomnia, Benzodiazepine Unrecognized anxiety ~ymptoms anxiety diagnosis restlessness, fatigue, medication can resemble prodrome of irritability, (short-term) botulism and be an adverse autonomic signs Behavioral and effect of medications used in cognitive therapies disaster/mass violence settings Substance- Variable Variable Alcohol and Intoxication Toxicity state Supportive Toxicity and withdrawal states related drug screens seconds to depends OIl management for can mimic effects of chemical! disorders can take minutes. substance. toxicity states; biological agents, metabolic minutes to Withdrawal Withdrawal! standard algorithms derangements, and medications hours hours to days abstinence states exist for managing used to treat medical-surgical characterized by withdrawal Slates conditions in the disaster/ autonomic terrorism setting hyperactivity Management of medical and surgical disaster casualties 177

Early symptoms of cyanide exposure are anxiety, Inhalation anthrax confusion, giddiness, and hyperventilation. These Inhalation anthrax results when aerosolized spore­ symptoms are difficult to distinguish from situa­ bearing particles of 1-5 /lm are deposited into the tional anxiety, sure to be common in the disaster or alveoli. Macrophages phagocytize the spores, which terror setting. resist intracellular lysis due to the presence of a pro­ tective capsule. Surviving spores are transported to Incapacitating agents mediastinal lymph nodes, where germination occurs 2--60 days later. Once germination occurs, disease Tear gas has long been used as a harassing agent, as follows rapidly. Replicating bacteria release toxins it is rarely lethal. It is intended to cause temporary leading to mediastinal hemorrhage, edema and unconsciousness or immobilization. Tear gas may necrosis, followed by bacteremia and sepsis. Inhala­ produce inappropriate responses by mimicking the tion anthrax features a nonspecific prodrome of early symptoms of more lethal agents. For example, malaise, fatigue, myalgia, headache, abdominal pain, tear gas effects may be confused with lacrimation nausea, vomiting, dry cough, chest tightness, and produced by nerve gases and lead to inappropriate fever (Franzetal., 1997; Hendersonetal., 1999). There treatment with anticholinergic medication. may be a brief 2- to 3-day period of improvement, followed by an abrupt onset of severe respiratory Blister agents distress with dyspnea, stridor, diaphoresis, and cya­ nosis (Franz etaL, 1997). Septic shock portends death Mustard gas is insidious and several hours may pass within 24-36 h. During the 1979 Sverdlovsk anthrax before characteristic burns and blisters appear. Low epidemic, there were reportedly only 2 patients doses ofmustard produce painful conjunctivitis, and with cutaneous lesions among 77 cases of inhalation are disabling and anxiety-producing. Higher doses anthrax (Meselson et al., 1994), and no cutaneous burn the eyes and cause blindness, pulmonary injury lesions reported among the 42 patients who under­ if inhaled, and disfiguring facial and other skin went autopsy (Abramova et aI., 1993). Preliminary burns aones, 1995). Blister agents such as mustard diagnosis may be made via culture within 6-24 h. and Lewisite have been reported to produce long­ Laboratory confirmation requires an additional term psychological symptoms such as apathy and 1-2 days of testing in laboratories with additional depression (Grinstad, 1964). Acutely, blister agents technical capability (Papaparaskevas et al., 2004). can also cause delirium, and psychological distress Recommended therapy for inhalation anthrax uti­ resulting from the disfiguring lesions, most com­ lizes combinations of two or three parenteral anti­ monly in the face and genitalia (DiGiovanni, 1999). biotics, to include either ciprofloxacin or doxycycline (CDC, 2001b). Earlytreatrnent is important to prevent Cutaneous anthrax progression to septic shock, meningitis, and death.

Cutaneous anthrax occurs when spores of Bacillus Smallpox anthracis are introduced into superficial, and often unapparent cuts or abrasions. After a brief incu­ Aglobal campaign, begun in 1967 under the auspices bation period of a few days, a small pruritic macule of the World Health Organization, succeeded in era­ will develop. This lesion will evolve into a round dicating smallpox in 1977. In 1980, vaccination of the ulcer, with a black, depressed, painless eschar that general population ceased worldwide. The terrorist will dry and fall off within 2 weeks. Cutaneous reintroduction of smallpox would be an unprece­ anthrax carries a very narrow differential diagnosis, dented public health catastrophe, due to the lack of possibly including spider bites (Franz et al., 1997; herd immunity, the virulence and contagiousness of Inglesby et al., 2000). the organism, and a relatively long incubation period 178 J. R. Rundell

of 7-17 days. Each index case may produce as many evolution of disease would occur during the first 2-4 as 10-20 second-generation cases, raising human days of illness, with septic shock with high mortality rights and public panic issues associared with the without early treatment (Butler, 1995; Perry & inevitable need for isolation or quarantine of poten­ Fetherston, 1997). There are no widely available rapid tially exposed populations. Postexposure vaccination diagnostic tests for plague. Since the diagnosis may within 4 days of exposure has been shown to reduce be missed with laboratory methods, case reports will morbidity and mortality, and to potentially prevent be a primary source of information for public health disease (Fenner, 1988). Postexposure vaccination authorities and clinicians. Prompt treatment is would be indicated for those potentially exposed essential. Plague is an internationally quarantinable during the initial release, healthcare providers treat­ disease (Franz et aI., 1997; Inglesby et aI., 2000). ing cases, andothercontacts ofcases (CDC, 2001c). At this time, the mainstay of therapy of cases would Botulism be supportive care by vaccinated caregivers. Patients must be isolated, and contacts must be placed Clostridium botulinum is a spore-forming, obligate under epidemiologic surveillance (Franz et al., 1997; anaerobe that produces botulinum toxin. Botulinum Henderson et aI., 1999). In some cases quarantine toxin binds to the neuronal cell membrane at will be necessary, for example when there is uncon­ the nerve terminus and enters the neuron by endo­ trolled contagion or where individuals are unco­ cytosis. The toxin cleaves specific sites on neuronal operative with isolation and surveillance procedures. proteins, preventing complete assembly of synaptic fusion complexes and thereby blocking acetylcholine Tularemia release. The absence of acetylcholine results in neu­ romuscular paralysis and autonomic dysfunction, Francisella tularensis has long been considered a producing the signs of botulism. An aerosolized potential biological weapon. In 1969, a World Health or foodbome botulinum weapon would cause Organization committee estimated that an aerosol acute, symmetric, descending flaccid paralysis with dispersal of 50 kg of virulent F. tularensis over a prominent bulbar palsies, manifested 12-72 h after metropolitan area with 500 000 people would result exposure as diplopia, dysarthria, dysphonia, and in 125000 cases, including 30 000 deaths (World dysphagia (Arnon et al., 200l). Autonomic compli­ Health Organization, 1970). Within 3-5 days of cations may include dry mouth, ileus, and urinary exposure, pneumonic tularemia will begin with an retention. Patients who may fear they have been acute and nonspecific febrile prodrome with chills, exposed, but haven't, could report similar symptoms headache, and bodyache. Within days to weeks, a due to anxiety andworry. By the secondday ofclinical pneumonitis, pharyngitis, or bronchiolitis, possibly illness, however, difficulty moving eyes, indistinct with hilar or mediastinal lymphadenopathy, or a speech, unsteady gait, apd extreme weakness will prolonged typhoidal illness would follow (Dennis leave little doubt as to the' presence of a severe neu­ et al., 2001; Franz et al.. 1997). The presence of the rological disturbance. febrile prodrome is key to differentiating tularemia from any psychiatric conditions. Delirium Plague In the disaster or terrorism victim with major illness Plague, caused by Yersinia pestis, occurs naturally or injuries due to explosive devices, volume depletion in bubonic and pneumonic forms. An aerosolized and metabolic derangements can cause delirium: plague weapon could cause pneumonic plague, with clouded consciousness, agitation or diminished fever, cough, chest pain, and hemoptysis due to responsiveness, and disorientation (American Psy­ severe pneumonia 1--6 days after exposure. Rapid chiatric Association, 2000). Aprodrome ofconfusion, Management of medical and surgical disaster casualties 179

restlessness, irritability and insomnia may portend a event. Among 1008 adults interviewed in New York full syndrome which includes short-term memory City between 1 and 2 months after the attacks on the deficit, distractibility, difficulty abstracting, dis­ World Trade Center, 7.5% reported symptoms con­ organized thinking, dysarthria, reduced comprehen­ sistent with a diagnosis of current PTSD and 9.7% sion, illusions, visual hallucinations, sleep-wake cycle reported symptoms consistent with current depres­ disturbance ("sundowning"), and either hypoactivity sion (Galea et aI., 2002). ASD and PTSD do not occur or hyperactivity. While medication treatment of the in vacuums. When one of these disorders exists, it is delirious patient can help decrease agitation and higWy probable that other psychiatric conditions mitigate a safety problem, this is not the ideal man­ exist as well, especially major depressive disorder, agement. The medications used to manage agitation panic disorder, substance use disorder, and general­ can further complicate both medical assessment and ized anxiety disorder (Drsano et ai., 1995). Having a an already difficult clinical course. Onset ofsigns and physical injury increases the risk of ASD and PTSD. symptoms can occur within hours of exposure to the Treatment involves antidepressant medication and offending agent. Symptomatic management of the psychotherapy. patient's behavioral problems with sedating medi­ cationshould beinitially reserved to protect thelife or Generalized anxiety disorder safety of the patient and other patients or staff. Resolution of the delirium itself should be the pri­ Excessive anxiety plus apprehensive expectations mary goal, and requires resolving the metabolic about events or activities (American Psychiatric sequelae of the injury. Common causes ofdelirium in Association, 2000) characterize generalized anxiety disaster settings include hypovolemia, hypoxemia, disorder (GAD). Apatient's incessantworryis difficult central nervous system mass effect, infection, and to control and commonly evokes restlessness, fati­ adverse effects of ATLS® and ACLS medications. gue, irritability, muscle tension, and sleep disturb­ ance. Motor tension is prominent, and may include trembling and twitching. Treatment is with benzo­ Depression diazepine medications, antidepressant medications, Depressed mood or resignation in the aftermath of beta-blockers, and/or cognitive psychotherapy. a disaster or terrorist event may be difficult to dis­ tinguish from the malaise and lassitude common Panic disorder among the prodromes of many chemical and bio­ terrorism exposures (Table 8.3). When depressed Panic disorder (American Psychiatric Association, mood and associated depressive symptoms disrupt 2000) entails recurrent, unexpected panic attacks social and occupational functioning, major depres­ followed by worry, concern, and behavior changes sive disorder is diagnosed. Antidepressant medica­ related to the attacks. The attacks are not due to a tions and cognitive-behavioral psychotherapy are general medical condition or the direct effects of a the mainstays oftreatment for major depressive dis­ substance. Panic attacks are characterized by massive order, and may assist with managing subsyndromal autonomic discharge for several minutes. Treatment depression. is with antidepressant medication, benzodiazepines, and/or psychotherapy (behavioral, relaxation, and cognitive). Acute stress disorder and post-traumatic stress disorder Hypochondriasis There can be a substantial burden of acute stress disorder (ASDJ, acute post-traumatic stress disorder Hypochondriasis is the fear or belief that one has (PTSD) and depression following a major terrorist a serious disease based on the misinterpretation

I 180 J. R. Rundell

of bodily symptoms. Anxiety and fear about the War I "gas hysteria" was common and threatened disease persist despite normal medical evaluations the integrity of entire military units (Miller, 1944). and reassurance (American Psychiatric Association, Psychological casualties in chemical and biological 2000). In the generally anxious atmosphere and threat scenarios may outnumber and prove more uncertainty following disasters and terrorist events, costly in personnel losses than physical casualties, patients with hypochondriasis may have particular as occurred in World War I (Cadigan, 1982). Acute problems managing their anxiety and beliefs, and symptoms of gas hysteria often mimicked some of people without a history of hypochondriasis may the symptoms of gas poisoning (dyspnea, coughing, present with it for the first time. There is bodily pre­ aphonia, burning of the skin). The degree of exact occupation and vigilance regarding body sensations. exposure was unrelated to the symptoms presented. Concern about the feared illness is a central feature of Patients frequently presented with air hunger and the individual's self-image, and a topic of social dis­ other symptoms consistent with anxiety and panic. courses. Because of the generally increased anxiety Factors that predispose to psychiatric casualties following a stressful event, six full months of symp­ related to psychological contagion include rates of toms are required before making this diagnosis. wounding/exposure in the unit, lack of sleep, and Hypochondriasis is a chronic condition with a poor lack of prior experience with these phenomenal prognosis. Subsyndromal hypochondriacal fears, on attacks (Jones, 1995). the other hand, may be widespread among the gen­ eral population following a bioterrorist event, and Dissociative disorders should be managed with reassurance and a degree of tolerance for patients' requests for appointments and The essential feature of dissociative disorders is a examinations by their primary care providers. disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The onset may be sudden, gradual, Unexplained physical symptoms transient, or chronic (American Psychiatric Associa­ and conversion symptoms tion, 2000). There are several subtypes of dissociative Unexplained physical symptoms are common after disorder, including amnesia, fugue, depersonaliza­ terrorism and war. Not all unexplained physical tion, and derealization. The centerpiece of the diag­ symptoms are conversion symptoms, though con­ nosis, to discriminate it from situational dissociation, version is well documented anecdotally after ter­ is the presence of significant distress, or significant rorist and combat events. Unfortunately, there is disruption in social or occupational functioning. at present little scientific basis for future preven­ People who have been exposed to traumatic events tion and care of unexplained physical symptoms are at increased risk for developing dissociative (Clauw et al., 2003). However, it is important that disorder. Differential diagnosis of head injury and persons with unexplained symptoms be identified dissociation is one of the most important roles in the triage process so that inappropri~te and of psychiatrists participating in large-scale triage potentially harmful treatments are not conducted operations following explosive terrorist events. that could also draw resources away from victims needing them. Situational dissociation Use of biological or chemical agents presents a challenging differential diagnosis and contagion Dissociation which falls short of diagnostic criteria problem. People may not be easily talked out of the for dissociative disorder is common in the context of notion they have been exposed, even in the face of any traumatic or terrorist event. Dissociation is information certifying their risk to be nonexistent or generally under-recognized in the immediate after­ exceedingly low (Stuart et aI., 2003). During World math of a traumatic event or terrorist event. Among Management of medical and surgical disaster casualties 181

the USS Cole casualties evacuated to Landstuhl tioning and can complicate the overall differential Regional Medical Center in October 2000, dissocia­ diagnosis. While not rising to the threshold for tion was the most common behavioral response diagnosis of an anxiety disorder per se, the anxiety observed (author, personal communication). There signs and symptoms can be managed to the benefit was a fatal train crash in Silver Spring, Maryland, of the patient. A number of techniques and inter­ in February 1996, and the author lived nearby ventions are employed, including relaxation tech­ and was a first responder. At least 4 of the first 12 niques, systematic desensitization, biofeedback, initial casualties brought to a hastily arranged meditation, and short-term use of anti-anxiety or medical triage area initially labeled as "urgent" antidepressant medications. Behavior and cognitive casualties because of apparent unresponsiveness psychotherapies provide an opportunity for reduc­ were later found to simply be dissociating. Their tion of acute anxiety, enhancement of the patient's r misidentification as potential head injury patients sense of mastery, and clarification of measurable .~ resulted in misdirected rescue resources early in a goals. Israeli studies onhowterroristvictims and their mass casualty situation with heavy demands on families cope in the early post-terrorism period is local rescue resources. instructive; the most prevalent coping mechanisms Dissociation may be adaptive in the immediate are active information search about loved ones aftermath ofa trauma- dissociating may prevent the and seeking out social support (Bleich et ai., 2003). eruption of intolerable affects or the unleashing of potentially dangerous impulses or behaviors (e.g., to Substance use disorders flee the scene). It is easy to confuse dissociation and diminished neurological responsiveness. A key role Following a disaster or terrorism event, people may of a psychiatrist in the immediate aftermath of a increase their use of alcohol or drugs as a way to disaster, while primary and secondary surveys are decrease the acute despair or anxiety associatedwith occurring, can be to help identify dissociation. the event. The substance use can then evolve into a Gently tap the patient on the shoulder and ask if problematic condition in its own right and should be there is anything they need and do they know where screened for. Rescue and healthcare workers are at they are/what day it is. Watch for a muted but risk because of the types of scenes they may be appropriate response in a dissociating person; this participating in and exposed to. Disaster response indicates his or her level of consciousness and leaders must educate and model for their workers orientation is grossly intact. Identifying otherwise the avoidance of alcohol and drugs during the dis­ uninjured disaster victims who are simply dis­ astermanagement period and its aftermath. Patients sociating frees up scarce evaluation and treatment who have substance-related disorders may present resources for other emergency patients. If dissocia­ at a triage or patient management area intoxicated tion subsequently becomes frequent, ongoing, and or in withdrawal. Either can be confused with toxi­ disabling, it may then be formally diagnosed as a cities associated with chemical agents, biological psychiatric disorder - dissociative disorder. Serial agents, metabolic deranBements, or medications examinations of the patient can help differentiate used to treat patients' medical-surgical conditions. adaptive dissociation from dissociative disorder. Effects of disaster medications Situational anxiety and worry :i' A mainstay of managing patients under ATLS® and !i il Sometimes anxiety associated with potential expo­ ACLS paradigms is medication, many of which can sure to bioterrorism agents and worrythat one might cause neuropsychiatric or autonomic symptoms. It have been exposed can cause troublesome anxiety is important to find out what medications an injured symptoms that cause disruption of normal func­ patient has received, in what amounts, and over 182 J. R. Rundell

what time period. Agents such as intravenous fluids not need medical-surgical treatments (e.g., atro­ (water), epinephrine, lidocaine, atropine, sedatives, pinel. help differentiate dissociation from delirium, nitroglycerin, and morphine are commonly used and help identify patients who have mental status and have significant psychiatric or autonomic findings consistent with delirium instead of anxiety. effects. These can resemble primary psychiatric dis­ Psychiatrists can also conduct brief interventions orders. For example, atropine causes significant with individuals convinced they have been exposed anxiety and anticholinergic effects. Epinephrine to a toxic or biological agent but who are judged by causes blood pressure and heart rate elevations, disaster managers to be at no or extremely low risk and causes patients to feel anxious or panicky. (Stuart et at., 2003; Ursano et at., 2003, 2004). Morphine causes sedation and impairs orientation and responsiveness. Key elements in the differential diagnosis It is also important to know what substances a patient has not been exposed to. Following a faked When triage and evaluation occur for people who chemical or biological agent threat, there may be a have potentially been exposed to a chemical or bio­ large number ofindividuals who fear theyhave been terrorism agent, including behavioral and psychiatric exposed and will present with realistic symptoms considerations in the medical differential diagnosis based on their knowledge of the alleged agent and increases the efficacy of overall management. This is vital sign abnormalities produced by anxiety!fear particularly important because behavioral responses (Fullerton et at., 1996). To minimize the effects of to bioterrorism may exceed in number and magni­ mass hysteria, disaster leaders need accurate infor­ tude the medical and surgical consequences. In mation from investigating authorities, as soon as it addition, the signs of psychiatric illness and beha­ can be provided, along with a preplanned public vioral contagion can overlap with medical signs of information campaign. injury, toxicity or infection. Table 8.3 summarizes the medical-psychiatric differential diagnosis of history and examination findings that may present in Effective medical-psychiatric differential patients coming in for healthcare in the aftermath ofa diagnosis bioterrorism event. There are three critically import­ ant elements that point the examiner in the direction Initial presentation of patients in the of a higher likelihood of underlying psychiatric dis­ emergency department or triage setting order: past history of similar psychiatric symptoms! A terrorist attack is psychological warfare, intended diagnosis, family history of similar psychiatric to disrupt normal societal and individual function­ symptoms!diagnosis, and having a clinical pre­ ing. Following a terrorist attack, whether explosive, sentation which is more consistent with a psychiatric chemical, or biological, there will be patients, disorder than with the feared injury, chemical expo­ exposed and not exposed, who will have anxiety, sure, or infectious disease. tachycardia, tachypnea, shakiness, and other auto­ There is a need for research on gender- and age­ nomic signs and symptoms that could be due to a related differences in the aftermath of terrorist, toxic agent or to anxiety or fear associated with the combat, or disaster events. Data from Operation incident. When there are not pathognomonic signs Enduring Freedom and Operation Iraqi Freedom of a toxic agent, or when differential assessment is patients seen at Landstuhl Regional Medical Center, not conducted, patients may receive inappropriate where women are serving in danger settings in treatments that could worsen their condition, or unprecedented numbers, suggest that there are gen­ have a delay in appropriate treatment. Psychiatrists der differences in types of injuries and return to assisting with a focused mental status examination dutyrates (Rundell &Baine, 2002) .For children, there and a brief history can help identify patients who do is a need for appropriate management protocols Management of medical and surgical disaster casualties 183

unique to different age groups of children, tailored to update their infection control procedures to to their specific needs and abilities (Committee on increase responders' confidence that the level of Environmental Health and Committee on Infectious risk can be managed for aerosolized biological Diseases, 2000). threat agents (Keirn & Kaufmann, 1999).

Effective community prevention and response to disasters and terrorist Clinical issues in medical-surgical attacks as tools to mitigate psychiatric disaster/terrorism casualties casualties Clinical treatments that aim to prevent Government and organizational responses may psychiatric sequelae play an important role in limiting psychological contagion and may help to lessen overburdening It is natural and proper that mental health profes­ of the healthcare system after a terrorist event sionals strive to prevent long-term psychiatric or disaster. A well-designed, well-coordinated and sequelae of exposure to traumatic events by inter­ rehearsed community management strategy based vening early. Unfortunately, some well-intentioned on empirical evidence will do much to reduce public attempts prove in the end to be either not beneficial anxiety and increase the confidence of healthcare or even potentiallyharmful for some people (Wessely workers (Alexander & Klein, 2003; CDC, 2000; Everly & et ai., 1999). There are, however, anecdotal, and case Mitchell, 2001; Stem, 1999; Tucker, 1997). There are series that describe potentially effective interventions mass trauma casualty predictors which can help for well-defined groups of people (Benedek et ai., leaders in planning community responses (CDC, 2002; Bryant et ai., 1999; Cloak & Edwards, 2004; 2003b). Communities must work together to coordi­ Holloway et ai., 1997; Yori, 2002). Evidence-based nate the disaster response so that triage systems are approaches exist to treat patients with identified consistent, clear, simple, and implementable in psychiatric disorders. This makes psychiatric triage a short period of time (Ihlenfeld, 2003; Nocera & and case identification important in the early post­ Garner, 1999). After a terrorist attack or disaster, terrorism management scenario. The efficacy of communicating health information to an alarmed group interventions aimed at preventing later public is crucial to limiting psychological contagion; sequelae needs further research. effective use of the internet for risk communication will be increasingly important (Hobbs et ai., 2004). Burns patients Training and confidence in containment proce­ dures may be important factors in limiting psy­ During the first 24-72 h after a severe bum, there is chological contagion and unexplained physical typicallya briefperiod ofinitial lucidity, during which symptoms. Military experience is that the risk of patients usually are told their prognosis. After that, psychiatric casualties such as conversion disorder between 30% and 70% of hospitalized severe bums is lessened when potentially exposed personnel patients develop delirium, presumably caused by receive good training to allow them to feel con­ biologic stress and burn-induced metabolic dis­ fident in their odds of survival in the chemical or turbances (Rundell & Wise, 2000). Watch closely for biological threat scenario (Marshall, 1979). In substance withdrawal syndromes; unfortunately, the addition to training, there is focus on vaccinating time courses for most withdrawal syndromes coin­ groups at highest risk of coming into contact with cide with the critical periods of bums patients' biological agents or with persons exposed to them, medical courses. Substance withdrawal can greatly including healthcare workers (CDC, 2002, 2003a; complicate medical care if not managed early and Wharton et ai., 2003). Hospitals are being urged aggressively. 184 J. R. Rundell

Strongly consider the possibility of a medically screen for suspected agents of exposure. Ifpatients induced secondary mood syndrome when bums cannot be reassured and remain uncooperative and patients appear depressed (Raison et ai., 20Q2). a risk to self or others, chemical restraint is appro­ Burns patients lose water at a rate several times priate. If the patient can take oral medication, oral faster than normal; hypovolemic shock is common. risperidone (2 mg), orallorazepam (2 mg), or orally Following the shock phase is a period of intense disintegrating olanzapine (5-10mg) are first line. catabolism and negative nitrogen balance. The usual Often risperidone and lorazepam are given together. anorexia, weight loss, exhaustion, and lassitude of Iforal medications are not appropriate because the this period may lead unsuspecting clinicians to patient is uncooperative or not fully alert, the first­ diagnose primary depression. line parenteral medication is ziprasidone 20 mg Pain is a continuing and critical issue for burns intramuscularly, supplemented as needed with lor­ patients; it becomes especially important during azepam 20 mg intramuscularly. Intramuscular or dressing changes and debridement. Narcotics are intravenous haloperidol is considered second line in the drugs of choice for treating acute burn pains ­ these scenarios because of the higher risk for extra­ this is not the time to worry about addiction. Dres­ pyramidal symptoms, potentially disabling and sing changes often require pre-emptive analgesia. confusing in the bioterrorism or chemical terrorism settings. Agitated patients Losses of body parts and functions Patients who are agitated in the emergency or triage setting can present the potential for considerable The larger the disaster or terrorist event, the higher harm to self, to others, and to the effectiveness of the probability that medical-surgical needs will the medical management scenario. Clinicians must outstrip available resources, particularly in the cru­ balance patients' rights, rights ofothers to be treated cial "golden hour" following an event. This means or work safely, the potential for complicating an that there will be a number of victims who have already uncertain diagnostic situation by adding lost body parts and functions that might have been another medication, the patient's degree of suffer­ salvaged if the disaster had been on a smaller scale. ing, and the potential for drug/drug or chemical For example, victims who might have received early agent/drug interactions when deciding whether to comprehensive intervention at a trauma center control a patient's agitation with medication in the following a car accident might be triaged into a less disaster or terrorism setting. emergent category and attended to much later A recently developed algorithm for treating following a large train accident. This can become an patients who present to the Emergency Department important psychotherapy issue after the original with acute psychotic agitation and require control survival crisis, when inevitable "what if' and "if for safety is potentially helpful in the postd,isaster or only". though~s emerge. When there is acute vision post-terrorism setting since it focuses on medica­ loss, there is a high risk for delirium, psychosis, and tions less likely than in previous years to worsen or dissociation. complicate the mental status examination. The algorithm was developed by experts in Emergency Disfigurement and body image Medicine and Psychiatry from a number of aca­ demic centers (Currier et ai., 2004). An agitated Facial disfigurement and facial burns usually cause patient must first of all be assessed for potentially more psychological difficulty than injuries and burns reversible causes of agitation, using vital signs, to other body areas. Give patients honest explana­ physical examination, finger-stick glucose, history, tions and prognoses, but do not force a patientto view and if indicated drug and alcohol screens, and a a deformity until ready; he or she may choose to wait Management of medical and surgical disaster casualties 185

s several days or even weeks before looking in a mirror. medications is limited by the several weeks needed d l Longer-term individual or group psychotherapy is for the agents to be effective. The threat of I- ii sometimes required to help severely injured or impending death can also obviously cause a great burned patients adjust to permanent disfigurement 11 ~ deal of 'anxiety. If an individual does not mention 11 Y t and changes in body image. In one study, 35.3% fears of dying, inquire either indirectly (e.g., "You '~ of burns patients met criteria for PTSD at 2 months, look scared; how are you doing?") or inquire directly " .i; r. " 40% met the criteria at 6 months, and 45.2% met the (e.g., "Are you worried you may die?"). If death is ,of....": e criteria at 12 months (Perry et ai., 1992). imminent and the patient is lucid, ask "What f < frightens you most about dying?" Three common fears are abandonment, uncontrollable pain, and g Guilt and grief shortness of breath (Cassem, 2004). Therapists Ir It is a rare disaster or terrorist event where bereaved should not be afraid to speak the unspeakable or n families are not offered grief counseling or therapy. confirm reality (BIacher, 1987). Anti-anxiety medi­ L- However, survivors and their families will also have cations are very effective for dying patients if d to face important grief and guilt issues - particularly symptomatic or disabling anxiety persists after n over losses of body parts and functions. Having a psychological support and the opportunity for serious injury does not make a survivor immune abreaction is provided (Rundell & Wise, 2000). from the survivor guilt experienced by those disaster victims who walk away uninjured. Unassuaged Heroes in hospitals survivor guilt may complicate and slow psycho­

~r therapy aimed at body image and disfigurement Being a hero presents unique psychological chal­ 11 issues. There also may be secondary effects among lenges. Released prisoners of war, disaster victims

L­ surviving children of victims of terrorist events or who saved others' lives, and rescue personnel who lS other disasters. went beyond the efforts of their peers frequently 'e become public heroes. The hero must meet expec­ tations ofadoringaudiences andcommunities. They n The dead and dying must grin when they might want to cry. They must y It is often easy in a busy postdisaster setting to avoid or be extremely cautious in how they publicly

~r ignore those individuals who are "expectant." It is a discuss their own survivor guilt and grief. Heroes' ;s fact that people die in disasters, and sometimes not families may insist on special treatment for them­

~r instantly - avoid avoiding them. The dead deserve a selves and their hero relatives. Medical personnel, n respectful transition from disaster scene to family with the best of intentions, may set up scenarios II funeral director. When resources are available, a which make heroes' own postdisaster recoveries if great deal can be done to ease the suffering of dis­ more problematic, particularly when the expres­ n aster victims who are dying (Breitbart & Lintz 2002; sions of community support and adoration fade d Shuster et ai., 1999). The dying patient is generally away. For example, heroes with relatively minor comfortable talking about death. It is usually the physical injuries may be offered ongoing narcotic family, and sometimes the disaster management analgesic "pm" medication even in the absence of team, who are reluctant to engage in such con­ nocioceptive pain. The hero may accept these versations. Don't underestimate the importance of medications because it may help temporarily relieve ,e religious belief and the belief in an afterlife in dying psychological pain, guilt, and anxiety.

LS patients. Discuss "do not resuscitate" orders, wills, Hospitalized heroes become the centers of poli­

i­ and comfort measures early. tician, press, and community attention. Then when

N In a postdisaster hospital or hospice setting, the public's short attention span wanders to other it depression is common. The utility ofantidepressant topics, heroes have to become regular people again. 186 J. R. Rundell

This dizzying rise and steep fall need to be addressed and terrorism has multiplier effects in terms of in psychotherapy. Preventing post-traumatic psy­ preventing inappropriate and costly utilization of chiatric syndromes in these unique individuals healthcare resources. requires that they be protectedfrom overstimulation' during the immediate postdisaster period. Jealously protect the individual's "quiet time." Hospitalized REFERENCES heroes' real achievements should be acknowledged

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