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aerosol form if weaponized. Botulism presents similarly regardless of route of inoculation.
Subjective: Symptoms
Following a latent period of several hours to several days, descending, symmetrical, flaccid paralysis; blurry
vision, difficulty swallowing and speaking, dry or sore throat, and dizziness. As the paralysis proceeds
downward, weakness and difficulty breathing become significant problems.
Objective: Signs
Using Basic Tools: Mydriasis (abnormal pupillary dilation), ptosis (sagging eyelid), difficulty speaking and
swallowing, postural hypotension, absent gag reflex, extraocular muscle palsies, cyanosis, and progressive,
descending, symmetrical, muscle weakness. Fever is generally absent.
Assessment:
Differential Diagnosis - myasthenia gravis, Guillan-Barre syndrome, Eaton-Lambert syndrome,
poliomyelitis, tick paralysis. Nerve agent exposure can also cause paralysis on the battlefield, but the paralysis
would be spastic. Moreover, miosis (abnormal papillary dilation), copious secretions and immediate onset of
symptoms should differentiate nerve agent intoxication botulism.
Plan:
Treatment
Primary: Supportive (oxygen, assisted ventilation if necessary, IV fluids).
Patient Education:
General: Even those with access to antiserum may have a very prolonged course, requiring months of
recovery. Provide adequate ventilatory support throughout this prolonged course.
Prevention: Asymptomatic persons thought to have been exposed to botulism may be salvaged by prompt
administration of antitoxin. A licensed antitoxin is available through the CDC but this product is only effective
against 3 of the 7 types of botulinum toxin (types A, B, E).
Follow-up Actions:
Evacuation/Consultation Criteria: Evacuate all victims. Consult preventive medicine or infectious disease
experts early.
Biological Agents: Pneumonic Plague
Introduction: Plague is caused by infection with Yersinia pestis, a Gram-negative bacillus. Although bubonic
and primary septicemic forms are known, the pneumonic form of the disease would likely occur after
intentional aerosol delivery. A large percentage of symptomatic victims will succumb even in the face of
appropriate therapy. Incubation period is 1-7 days. See also ID: Plague.
Subjective: Symptoms
Fever, malaise, fatigue, cough and shortness of breath.
Objective: Signs
Using Basic Tools: Fever, tachycardia, tachypnea, dyspnea, cyanosis, diaphoresis, rales, and hypotension.
The classic finding in pneumonic plague is the production of bloody sputum in a previously healthy patient,
although this is not present in every case.
Using Advanced Tools: CXR: Increased markings and consolidation of pneumonia; Lab: Gram-stain of
sputum will demonstrate short, bipolar Gram-negative rods, often with a “safety-pin” appearance; blood
cultures.