Medical Management of Potential Biological Casualties: A Stepwise Approach Chapter 5 MEDICAL MANAGEMENT OF POTENTIAL BIOLOGICAL CASUALTIES: A STEPWISE APPROACH THEODORE J. CIESLAK, MD* INTRODUCTION 10-STEP APPROACH TO CASUALTY MANAGEMENT Step 1: Maintain a Healthy Index of Suspicion Step 2: Protect Yourself Step 3: Save the Patient’s Life (Primary Assessment) Step 4. Disinfect or Decontaminate as Appropriate Step 5: Establish a Diagnosis (Secondary Assessment) Step 6: Provide Prompt Therapy Step 7: Institute Proper Infection Control Measures Step 8: Alert the Proper Authorities Step 9: Conduct an Epidemiological Investigation and Manage the Psychological Aftermath of a Biological Attack Step 10: Maintain a Level of Proficiency SUMMARY *Colonel, Medical Corps, US Army; Pediatric Infectious Diseases Physician, San Antonio Military Medical Center, Department of Pediatrics, 3551 Roger Brooke Drive, Fort Sam Houston, Texas, 78234 109 244-949 DLA DS.indb 109 6/4/18 11:57 AM Medical Aspects of Biological Warfare INTRODUCTION Response to a biological attack is relatively straight- little immediate support. Civilian clinicians, first re- forward when the etiologic agent employed is known. sponders, and public health personnel practicing in A larger problem arises, however, in the context of rural or remote areas during a terrorist attack would diagnostic uncertainty. In some cases, an attack may face similar decision-making challenges. In the setting be threatened or suspected, but whether such an attack of a biological (or chemical or radiological) attack, has, in fact, occurred can remain unclear. Moreover, similar to the setting of a MASCAL trauma event, it may be uncertain whether casualties in certain such decisions may have life-and-death implications. situations arise from exposure to a biological agent, a In such situations, a stepwise or algorithmic approach chemical or radiological agent, a naturally occurring becomes invaluable. infectious disease process, or toxic industrial exposure, USAMRIID has developed a 10-step approach to or may simply reflect a heightened awareness of back- managing casualties that might result from biological ground disease within a community or population. Ex- warfare or terrorism. Many facets of this approach perience with West Nile virus,1 severe acute respiratory may be helpful in dealing with potential chemical syndrome,2 pneumonic tularemia,3,4 and monkeypox5 or radiological casualties as well. In today’s complex highlight this dilemma. In each of these cases, the pos- world, it is no longer adequate for most clinicians sibility of bioterrorism was properly raised, although and medical personnel to simply understand disease each outbreak ultimately proved to have a natural processes. Rather, these personnel, whether military or origin. In some instances, proof of such an origin may civilian, must have tactical, operational, and strategic be difficult or impossible to attain, providing “plausible knowledge of threat response—and, in fact, of disaster deniability,” precisely the reason some belligerents may response in general—as it applies to weapons of mass opt to employ biological agents. This chapter provides destruction. Tactical response concerns those elements a structured framework for dealing with outbreaks of diagnosis and treatment of specific diseases that of unknown origin and etiology on the battlefield, as traditionally have been the realm of the individual well as in a potential bioterrorism scenario involving practitioner. Operational response can be thought of military support installations or the civilian populace. as involving the mechanisms by which the provider In responding to the unknown, it is helpful in many interacts with his or her institution (hospital, clinic, situations to employ a standardized, stepwise ap- medical unit) to provide mass care during a disaster. proach. This is especially true in the setting of a medical Strategic response involves system-wide disaster mass casualty event (MASCAL), where the use of such preparedness and response. In a civilian setting, this an approach (as advocated by the Advanced Trauma includes mechanisms by which state and federal Life Support [ATLS] model sponsored by the American disaster response elements might become involved. College of Surgeons6) is already well accepted and Medical personnel today need to have at least a basic practiced. It is also especially true under austere or understanding of operational and strategic response battlefield conditions. Although major theater-level in addition to a firm grounding in tactical medical and and continental United States-based military medi- public health intervention. The first 7 steps of this 10- cal centers (and research institutions, such as the US step approach deal predominately with tactical issues Army Medical Research Institute of Infectious Diseases (ie, at the level of the individual provider). Steps 8 and [USAMRIID] and US Army Medical Research Insti- 9 transition into operational and strategic response tute of Chemical Defense) may possess sophisticated (ie, at the level of the institution and of the system, diagnostic and response capabilities, providers on the as a whole). The derivation of the 10-step approach is battlefield and at lower-role medical treatment facili- reported elsewhere,7–10 and a condensed version ap- ties are typically required to make rapid therapeutic pears in recent editions of USAMRIID’s Blue Book.11 It decisions based on incomplete information and with is expanded upon here. 10-STEP APPROACH TO CASUALTY MANAGEMENT Step 1: Maintain a Healthy Index of Suspicion (both temporally and geographically) to a dispersal device. Complicating the discovery of the intentional In the case of chemical warfare or terrorism, the nature of a biological attack, however, is the fact that intentional nature of an attack is often evident. In this biological agents possess inherent incubation periods, case, victims would likely be tightly clustered in time while conventional, chemical, and nuclear weapons do and space; they would succumb in close proximity not. These incubation periods, typically of several days 110 244-949 DLA DS.indb 110 6/4/18 11:57 AM Medical Management of Potential Biological Casualties: A Stepwise Approach (but up to several weeks in the case of agents such as Coxiella burnetii and the Brucellae), allow for the wide EXHIBIT 5-1 dispersion of victims in time and space. Additionally, EPIDEMIOLOGICAL CLUES TO A they make it likely that the first responder to a biologi- BIOTERRORIST ATTACK cal attack would not be the firefighter, police officer, paramedic, or other traditional first responder, but • Presence of an unusually large epidemic rather primary care providers, hospital emergency • High infection rate departments, and public health officials. In such cir- • Disease limited to a discrete population cumstances, maintaining a healthy index of suspicion • Unexpected severity of disease is imperative. • Evidence of an unusual route of expo- In some instances, maintaining an index of sus- sure picion might be simplified by the fact that diseases • Disease in an atypical geographic locale caused by biological agents may present with specific • Disease occurring outside normal trans- characteristic clinical findings, which allow for a very mission seasons limited differential diagnosis. The hallmark of inha- • Disease occurring in the absence of usual lational anthrax is a widened mediastinum, a clinical vector finding seen in few naturally occurring conditions. • Simultaneous outbreaks of multiple With botulism, the hallmark presentation is that of a diseases descending, symmetric, flaccid paralysis. Whereas an • Simultaneous occurrence of human and individual patient with flaccid paralysis might prompt zoonotic disease consideration of disorders such as Guillain-Barré syn- • Unusual organism strains drome, Eaton-Lambert syndrome, poliomyelitis, and • Unusual antimicrobial sensitivity pat- myasthenia gravis, the near-simultaneous presenta- terns tion of multiple patients with flaccid paralysis should • Disparity in attack rates among persons quickly lead one to a diagnosis of botulism. Similarly, indoors and outdoors patients with plague and melioidosis may exhibit he- • Terrorist claims moptysis in the later stages of illness. Such a finding • Intelligence reports is uncommon among previously healthy individuals, • Discovery of unusual munitions but can be caused by tuberculosis, staphylococcal and Klebsiella pneumonia, carcinoma, and trauma. Multiple Data source: Pavlin JA. Epidemiology of bioterrorism. patients with hemoptysis, however, should prompt Emerg Infect Dis. 1999;5:528–30. consideration of a plague or melioidosis diagnosis. Smallpox is characterized by a very unique exanthem, perhaps evocative of Varicella or syphilis in its earliest stages, but readily distinguishable from these entities should raise suspicion. Similarly, unexpected deaths as it progresses. and cases of unexpectedly severe illness merit concern. Yet, by the time each of these characteristic findings An outbreak of a disease not typically seen in a specific develops, treatment is less likely to be effective. Thera- geographic location, in a given age group, or during a py is thus best instituted during the incubation or pro- certain season, likewise warrants further investigation. dromal phases of these diseases if it is to be beneficial. Simultaneous outbreaks of a disease in noncontiguous Unfortunately, during their prodromes, these diseases areas