Identifying the affected population, possible routes of exposure, signs and symptoms of disease, along with rapid laboratory identification of the causative agents, will greatly increase the ability to institute an appropriate medical and public health response. Good epidemiologic information can guide the appropriate follow-up of those potentially exposed, as well as assist in risk communication and responses to the media.

Assessing the Patientblue arrow
  • Assess airway adequacy and address breathing and circulation problems.
  • Evaulate the need for decontamination.
  • Determine if the administration of antidotes for rapid-acting chemical agents (nerve agents and cyanide) is needed.
  • Concentrate on the pulmonary and neuromuscular systems.
  • Attend to any unusual rashes or bleeding.
  • Review patient history: exposure to illnesses among other unit members, the presence of unusual munitions, food and water procurement sources, vector exposure, vaccination history, travel history, occupational duties, and MOPP status.

Signs and Symptomsblue arrow

Chemical and biological warfare diseases can be generally divided into categories based on time to presenting symptoms.

  • Chemical agents typically present "immediately" with little or no incubation or have latent periods.
  • Biological agents typically present with a considerable delay.
  • Viral agents are more expensive to manufacture so are less likely than bacterial agents.
  • Many diseases caused by weaponized biological agents present with nonspecific clinical features that may be difficult to diagnose.
  • Be prepared for the unexpected, such as the use of multiple different agents, including mixed chemical and biological agents or multiple biological agents depending upon the intentions of the perpetrator.

  Rapid-onset agents Delayed-onset agents
Respiratory system Nerve Agents*
Cyanide*
Mustard
Lewisite
Phosgene
SEB Inhalation		 Inhalational Anthrax*
Pneumonic Plague*
Pneumonic Tularemia*
Q Fever
SEB Inhalation
Ricin Inhalation
Mustard
Lewisite
Phosgene
Neurological system Nerve Agents*
Cyanide		 Botulism*
VEE-CNS Symptoms
*Empiric therapy is available.

A sound epidemiologic investigation will assist medical personnel in identifying the pathogen and lead to the institution of appropriate medical interventions.

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Diagnosisblue arrow

Diagnosis should involve a combination of clinical, epidemiological, and laboratory examinations. The amount of expertise and support available to the clinician will vary at each echelon of care.

Sample collection

The use of biological weapons is a criminal act. Therefore, if an intentional attack is suspected, establish a clear chain of custody for the sample collection; this evidence may be used in court proceedings.

This may not be an isolated case. Establish communication and information sharing between public health and law-enforcement authorities.

Nasal swabs (important for culture and polymerase chain reaction (PCR), even if the clinician is unsure which organisms are present), blood cultures, serum, sputum cultures, blood and urine for toxin analysis, throat swabs, should be obtained. Environmental samples should also be collected according to established protocols, and analyzed accordingly. In no case, however, should the performance of (or unavailability of) laboratory studies delay empiric diagnosis and therapy.

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Treatmentblue arrow

Treatment is most effective in the prodromal phase of many diseases. Evaluate the situational circumstances and determine if empiric therapy of pneumonia or undifferentiated febrile illness is warranted.

  • Rapid-onset respiratory casualties use a cyanide antidote kit.
  • Rapid-onset neurological casualties use a nerve agent antidote kit.
  • Delayed-onset respiratory casualties are patients with undifferentiated febrile illnesses who might have prodromal anthrax, plague, or tularemia and would all be managed similarly. Doxycycline, for example, is effective against most strains of Bacillus anthracis, Yersinia pestis, and Francisella tularensis, as well as against Coxiella burnetii, and the Brucellae. Other tetracyclines and fluoroquinolones might also be considered.

Careful and thorough diagnostic evaluation remain essential, when conditions permit.

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