Download Bio-Terrorism and the Respiratory Therapist

Bio-Terrorism and the
Respiratory Therapist
Prepare, since it is not
a question of “if” but
rather “when.”
Prof. Thomas J. Johnson
Disclaimer
Since medicine is an ever-changing science with new
research and clinical experience broadening our
knowledge, changes in pharmacologic treatment and
other care occur. Although the author has made every
effort to insure that the information contained meets
that standards at the time of publication, the
possibility of human error exists. Therefore the
author nor the University cannot guarantee that the
data contained is complete in every respect and that
they are not responsible for any errors or omissions.
The reader is strongly encouraged to confirm the
information contained herein with other sources.
Prof. Thomas J. Johnson
Biological Warfare in History
 In its three main forms --contamination of food
and water, use of micro-organisms or toxins,
and the use of inoculated fabrics -- bio-warfare
has been around since 400 - 300 B.C1.
 During the French and Indian War, British
forces generously gave blankets deliberately
contaminated with smallpox to attack
immunologically naive indigenous tribes.2
1.
2.
Mayor A. Dirty Tricks in Ancient Warfare. Mil Hist Quart. 1997:10, 1: 32-37
Christopher GW, Cieslak TJ, Pavlin JA, Eitzen EM. Biological Warfare, a historical prospective.
JAMA. 1997; 278:412-417
Prof. Thomas J. Johnson
Bio-Terrorism
 “Medical defense against biological warfare or
terrorism is an area unfamiliar to most military
and civilian health care providers.” USAMRIID
February 4, 2001
 Potential for massive numbers of victims
 Potential for panic among lay and medical
personnel
 Potential for mimic of endemic infectious
diseases.
Prof. Thomas J. Johnson
Indicators of Possible
Bio-Attack
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Unusual or not naturally
occurring disease entity
Large number of cases
or entities
Point-source outbreak
Aerosol route of
infection
High morbidity and/or
mortality
 Limited geographical
areas
 Low attack-rate in
persons in filtered air
 Sentinel dead animals,
esp. multiple species
 No natural vector
 Large number military
and civilian casualties
USAMRIID Medical Management of
Biological Casualties Course (6H-F26)
01 February 2001
Prof. Thomas J. Johnson
Clinical Case Alpha
 You are the respiratory therapist treating an
asthmatic child when you overhear a mother tell
the pediatrician: “I don’t understand it. My Joey
had chickenpox as a preschooler and Susie had
the vaccine. How could they have chickenpox?
There are many kids with chickenpox in the
neighborhood who went to the Columbus Day
parade.” The ER has had several cops with
“chickenpox.” There was a report of an explosion
at the parade. What is your diagnosis? What lab
tests are indicated?
Prof. Thomas J. Johnson
Bioterrorism: Routes of
Infection
 Aerosol weapons primary dispersal
 Percutaneous, e.g. anthrax as “wool sorters
disease”
 Oral, i.e. intake of contaminated food and
water
 Inhalation route has the greatest potential
for mass casualties
Prof. Thomas J. Johnson
Clinical Case Beta
 The Daily Planet reports that large
numbers of rats are found dead. Transit
workers and subway riders are in your ER
complaining of high fevers, chills and
hemoptysis. Auscultation finds bilateral
crackles.
 What lab test will be helpful?
 What bioagent may be responsible?
Prof. Thomas J. Johnson
Bioagents Most Likely to
Succeed
 Smallpox, anthrax, plague, tularemia,
botulinum toxin, mycotoxin and viral
hemorrhagic fevers.
 Salmonella*, Brucellosis, Wheat smut, and
others
*The FBI reported that between August and September of 1984 the Rajneeshee
cult contaminated 10 restaurants with Salmonella in Wasco County, Oregon
Prof. Thomas J. Johnson
Clinical Case Chi
 Terrorist occupying a hotel released a smoke
bomb before committing suicide. Several days
later, several police horses at the scene died.
Additionally numerous police and newspeople
who were there are sick with flu-like symptoms:
fever, malaise, cough, mild chest discomfort.
 Suggest lab tests
 Suggest a possible bioagent
Prof. Thomas J. Johnson
What This Means
 Respiratory Therapists are vital to the care
of victims
 Respiratory Care is unprepared
 Respiratory Therapists have a
responsibility to know how to treat these
victims.
 Preparation, Anticipation, Recognition,
Action-Plan Issues
Prof. Thomas J. Johnson
Clinical Case Delta
 A TV station reports that a terrorist group claims
to have attacked Coney Island with a bioagent.
As a therapist at a Brooklyn hospital you have
seen numerous patients with fever, headache,
malaise, chest discomfort, non-productive cough,
anorexia, and conjuntival and periorbital edema.
 What diagnostic test should be performed?
 What lab tests?
 What bioagent do you suspect?
Prof. Thomas J. Johnson
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Inhalational Anthrax
Incubation period 1-6 days up to 45 days
Annual Occurrence: None
Human-to-Human Transmission: None known
Presentation: Fever, malaise, cough, mild chest
discomfort; later dyspnea, diaphoresis, stridor,
cyanosis, hypotension, hemorrhagic meningitis
 DX: Mediastinal widening w/o infiltrates on
CXR, Serology, Gram stain, PCR
 TX: Standard precautions for HCW; doxycycline
200 mg IV initial then 100 mg IV Q12 hr.
Prof. Thomas J. Johnson
Pulmonic Plague

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Incubation Period: 2 - 3 days
Natural Occurrence: 2 or 3 cases annual
Droplet Precautions
Presentation: High fever, chills, hemoptysis,
toxemia, shock, stridor, B/S crackles, ARF
 DX: Gram stain, C&S, Immunoassay for
capsulated antigen, PCR, Immunohistochemical
stains (IHC)
 TX: Streptomycin 30 mg/kg/day IM
Prof. Thomas J. Johnson
Tularemia
 Incubation Period: 1 - 10 days (avg. 3-5)
 Natural Occurrence: 150 cases annual from
animal sources
 Human-to-Human Transmission: None known
 Presentation: fever, headache, malaise, chest
discomfort, productive/non-productive cough,
anorexia and conjuntival and periorbital edema.
 DX: CXR- mediastinal lymphoadenopathy,
Serology(ELISA), C&S, PCR & IHC
 TX: Standard precautions, Streptomycin or
gentamycin
Prof. Thomas J. Johnson
Smallpox
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Incubation Period: 7 - 17 days
Natural Occurrence: None
Droplet & Airborne Precautions – 17 days
Presentation: Fever, backpain, vomiting,
malaise, headache, rigors; papules (2-3 days)
to pustular vessicles face and extremities.
 DX: Giemsa or modified silver stain, PCR
and viral isolation IHC
 TX: Immediate vaccination and supportive
care
Prof. Thomas J. Johnson
Botulism
 Incubation Period:1 - 5 days
 Natural Occurrence: 30 cases annually
 Human-to-Human Transmission: None known
 Presentation: Ptosis, blurred vision, diplopia,
malaise, dizziness, dysarthia, and disphonia
 DX: Serology, toxin assays/ anaerobic
cultures of blood or stool, EMG studies
 TX: Antitoxin 1 vial (10 ml) IV
Prof. Thomas J. Johnson
SEB: Staphyloccocal Enterotoxin B
 SEB causes symptoms when inhaled in very low
doses.
 Standard Precautions
 Latent period: Inhalation 3-12 hrs.
 Presentation: non-specific flu, non-productive
cough, retrosternal pain, dyspnea.
 DX: Suspicion, ELISA, PCR; no CXR
abnormalities
 TX: Oxygen, hydration; CMV w PEEP,
vasopressors and diuretics
Prof. Thomas J. Johnson
Epidemiologic Clues
 Large # of people w/
similar
disease/syndrome
 Large # of
unexplained illnesses
or deaths
 Unusual illness in
population
 Higher morbidity /
mortality
 Single case of
uncommon agent
 Unusual/unexplained
co-existing diseases in
one pt.
Prof. Thomas J. Johnson
Medical Response to
Bioterrorism Ten
Commandments
1. Maintain an index of
suspicion
2. Protect thyself
3. Assess thy patient
4. Decontaminate PRN
5. Establish a
Diagnosis
6.
Render thy patient
prompt treatment
7. Practice good infection
control
8. Inform thy authorities
9. Assist in Epidemiologic
Investigation
10. Maintain, Update thy
proficiency & Spread
the gospel.
Prof. Thomas J. Johnson
Take Home Message
 Educate your people!
 Contact your local office of Emergency
Preparedness
 Work with your Emergency Medical and
Nursing staff to develop an action-plan.
 Conduct disaster drills on all shifts.
Prof. Thomas J. Johnson