Infectious Diseases in Critical Care Medicine

25

Bioterrorism Infections in Critical Care

Dennis J. Cleri

Department of Medicine, Internal Medicine Residency Program, St. Francis Medical Center, Trenton, and Seton

Hall University School of Graduate Medical Education, South Orange, New Jersey, U.S.A.

Anthony J. Ricketti

Section of Allergy and Immunology, Department of Medicine, and Internal Medicine Residency, St. Francis

Medical Center, Trenton, and Seton Hall University School of Graduate Medical Education, South Orange,

New Jersey, U.S.A.

John R. Vernaleo

Division of Infectious Diseases, Wyckoff Heights Medical Center, Brooklyn, New York, U.S.A.

Half a league, half a league, Half a league onward, All in the valley of Death Rode the six

hundred.

—Alfred, Lord Tennyson (August 6, 1809–October 6, 1892), fromThe Charge of the

Light Brigade

BASICS BEFORE THE INTRODUCTION
The critical care team is entrusted with patients with the severest pathology. Victims of
bioterrorism are often not immediately recognized, and present special and daunting
challenges. However, before these challenges can be addressed, basic precepts must be
followed. The U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID)
Handbook for the Management of Biological Casualties(1) recommends the following:

1. Maintain an index of suspicion.


2. Protect yourself.


3. Assess the patient.


4. Decontaminate as appropriate.


5. Establish a diagnosis.


6. Render prompt treatment.


7. Practice good infection control.


8. Alert the proper authorities.


9. Assist in the epidemiologic investigation and manage the psychological consequences.


10. Maintain proficiency and spread the word(1).

These 10 steps intended for battlefield conditions are applicable to our own battlefield—the
intensive care unit. To this, we add thatthe clinician-in-charge must put himself into the mind of the
enemy. By the application of each of these steps, the intensivist can lead his clinical team to
safely, efficiently, and competently diagnose and deliver the essential care to the victims of a
bioterrorism, and at the same time participate in the overall ongoing defensive response to
these attacks upon ourselves and society.

INTRODUCTION: DEFINITION, HISTORY OF BIOLOGICAL WEAPONS, AND
USAMRIID STEPS FOR THE MANAGEMENT OF BIOLOGICAL CASUALTIES

It is a mistake to try to look too far ahead. The chain of destiny can only be grasped one link at a

time.

—Sir Winston Churchill (November 30, 1874–January 4, 1965)

DA Bray of The National Center for Infectious Diseases, The Centers for Disease Control and
Prevention (CDC) in 2003 defined bioterrorism as “[t]he use or threatened use of biological