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Bioterrorism:. Are Physician Assistants Prepared to Diagnose and Treat?. Mark Bostic Spring 2006 PAS 646. Objectives. 1) Talk about PA preparedness 2) Talk about bioterroristic diseases. What is bioterrorism?.

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Bioterrorism:

Are Physician Assistants Prepared to Diagnose and Treat?

Mark Bostic

Spring 2006

PAS 646


Objectives

  • 1) Talk about PA preparedness

  • 2) Talk about bioterroristic diseases


What is bioterrorism?

  • Form of terrorism in which biological agents are used to inflict harm and/or fear upon a population.

http://www.fbi.gov/anthrax/images.htm#1


Physician Assistant Training

  • Medical school model

  • Consistent with physician training

  • Bioterrorism?


Bioterrorism Training

  • Physician Assistant Programs’ Websites

    • No training specified

  • Accreditation Review Commission on Physician Assistant Programs (ARC-PA)

    • No training mandated

  • Liaison Committee on Medical Education (LCME)

    • No training mandated


Physician Assistant Preparedness

  • Studies lacking for PA’s

  • Physician preparedness

    • HHS Agency for Healthcare Research and Quality (AHRQ) survey indicates physicians unprepared

      • n=614 physicians, 18% trained, 93% expressed interest

    • Johns Hopkins University study indicates physicians unprepared

      • n=2407 physicians, pretest 46.8%, posttest 79%

      • Chickenpox vs. smallpox, botulism vs. Guillain-Barre


CDC top six bioterroristic agents

  • Anthrax

  • Smallpox

  • Plague

  • Viral hemorrhagic fevers

  • Botulism

  • Tularemia


Anthrax

  • Bacillus anthracis

    • Spore-forming bacterium

  • Livestock, meat products, wool sorters

  • Inhalational, cutaneous, gastrointestinal

  • Often misdiagnosed as influenza


Inhalational anthrax

  • Most deadly

  • Incubation period

  • Replication and toxin release

  • Phase I: nonspecific constitutional symptoms

    • Mild fever, malaise, myalgia, nonproductive cough, emesis, chest/abdominal pain

  • Phase II: more severe

    • Higher fever, chest/neck edema, mediastinal widening, dyspnea, cyanosis, meningoencephalitis, shock


Diagnosis: inhalational anthrax

  • Chest x-ray and chest CT

    • Mediastinal widening, pleural effusion, consolidation

  • Blood smear and gram stain/culture

    • Large bacilli

    • Left shift

  • Cerebrospinal Fluid

    • Purulence, decr. glucose, incr. protein, elevated pressure, blood


Inhalational anthrax

www.cdc.gov


Cutaneous anthrax

  • Most prevalent form of infection

  • Skin barrier must be compromised

  • Replication and toxin release

    • May take up to 14 days


Diagnosis: cutaneous anthrax

  • 1) pruritic papule or pustule surrounded by smaller vesicles

  • 2) mild fever and malaise

  • 3) papule enlarges to a circular lesion surrounded by edema

    • Ruptures and necroses

    • Characteristic “Black Eschar”


Cutaneous anthrax

www.cdc.gov


Treatment: anthrax

  • Combination of:

    • Ciprofloxacin (Cipro ®)

    • Doxycycline (Vibramycin ®)

  • Combination varies depending upon:

    • Adult, child, immunocompromised

  • Amoxicillin for pregnant females


Smallpox (Variola)

  • DNA virus

  • Transmitted in droplet form

  • Respiratory tract mucosa

  • 12-14 day incubation period

  • Often misdiagnosed as varicella


Diagnosis: smallpox

  • Rapid onset of nonspecific sx’s

    • Fever, HA, malaise, chills, myalgia, anorexia, N/V, diarrhea, abdominal pain, delirium, convulsions

  • Papules surrounded by rash a few days later

  • Centrifugal distribution

  • Papules  pustules  crusted lesion

  • Simultaneous staging of lesions

  • Not “dewdrops on a rose petal”


Smallpox

www.cdc.gov


Treatment: smallpox

  • No cure

  • Tx is supportive

  • Vaccination available = Vaccinia


Plague

  • Yersinia pestis

    • Gram negative, pleomorphic coccobacillus

    • Infects by fleas carried by rodents

  • Bubonic, septicemic, pneumonic


Diagnosis: bubonic and pneumonic plague

  • Onset of nonspecific sx’s in 2 to 6 days

    • Fever, chills, weakness, malaise, myalgia, lethargy

    •  chest pain, dyspnea, watery/bloody expectorated sputum

    • Tender buboes (swollen lymph nodes)

    • 2 to 4 days later, lung exhibits necrosis, infiltration, hemorrhaging, effusion, abscesses

  • Chest x-ray

  • Hypotension, respiratory distress, pulmonary edema = death in 24 hours


Plague

www.cdc.gov


Diagnosis: septicemic plague

  • Fever, chills, prostration, N/V, abdominal pain

  • Purpura and DIC  hypotension, shock, and death

  • Blood cultures (all types of plague)

    • Prior to tx with antibiotics

  • Gram stain & culture (all types of plague)

    • Prior to tx with antibiotics

  • Sputum sample


Treatment: plague

  • Streptomycin (1st line)

  • Gentamicin (2nd line)

  • Tetracylines such as chloramphenicol


Viral hemorrhagic fevers

  • RNA viruses:

    • Arenavirus, bunyavirus, filovirus, flavivirus

  • Infection via vectors:

    • Mosquitoes, ticks, cats, rabbits, people

  • History should include travel to tropical regions


Diagnosis: VHF

  • Onset of nonspecific symptoms:

    • Fever, HA, myalgia/arthralgia, N/V, diarrhea

    • Possible bradycardia, tachycardia, liver necrosis, delirium, confusion, coma

  • Hallmark: generalized systemic coagulopathy with profuse bleeding

    • Petechiae, ecchymoses, epistaxis, hematemesis

    • Bleeding from gingiva, vagina, any puncture sites

  • Definitive: immunoglobulin Antibody to specific virus


Viral hemorrhagic fevers

http://www.gata.edu.tr/dahilibilimler/infeksiyon/resimler/VIRAL_HEMORRHAGIC_FEVER/__VIRAL_HEMORRHAGIC_FEVERS_2.JPG


Treatment: VHF

  • No FDA approved drugs

  • Ribavirin may be effective

  • Supportive treatment of shock:

    • Hydration, blood transfusions, etc.


Botulism

  • Spore-forming anaerobic bacterium Clostridium botulinum

  • Toxin is most lethal of all toxins

    • 100,000x sarin gas

    • 15,000x nerve gas

  • Iraq: enough to kill every human 3 times

  • Bacterium or toxin may be aerosolized, placed in food supplies

  • Blocks ACh release


Diagnosis: botulism

  • Descending paralysis

  • Ptosis, diplopia, blurred vision, and dilated, sluggish pupils

  • Difficulty speaking, chewing, swallowing

  • Paralytic asphyxiation or flaccid airway collapse

  • Culture serum, stool, gastric contents, suspected food


Treatment: botulism (cont.)

  • Equine botulinum antiserum

  • Antibiotic therapy experimental

    • Metronidazole

    • PCN

  • Supportive: ventilation and tube feeding


Tularemia

  • Nonmotile, aerobic gram negative coccobacillus Francisella tularensis

    • 2 subspecies: biovar tularensis & biovar palaeartica

  • Bite of tick, mosquito, handling infected carcass

  • Aerosolization possible

  • Incubates, then moves to LN and multiplies

  • Pathology at all sites where bacillus spreads


Diagnosis: tularemia

  • Site of inoculation: papule-pustule-ulcer pattern

  • Eye: ulceration of conjunctiva with LAD

  • Oral: tonsillitis or pharyngitis with cervical LAD

  • Lungs: bronchiolitis, pneumonitis, pleuropneumonitis with LAD

  • Fever, abdominal pain, diarrhea, emesis

  • IF, GS&C


Tularemia

http://www.logicalimages.com/resourcesBTAgentsTularemia.htm

http://phil.cdc.gov/Phil/details.asp


Treatment: tularemia

  • Ciprofloxacin or doxycycline (early)

  • Streptomycin or gentamicin (late)

  • No vaccine


Reporting

  • Written plan in every health care facility

  • Notify local health care officer for suspected or confirmed cases


Conclusion

  • Data suggest that physicians are unprepared to diagnose and manage diseases of a bioterroristic cause.

  • Studies need to be performed to determine whether or not PA’s are prepared.


  • Thank you for your attention!


References

  • ARC-PA (2005). “Accreditation standards for physician assistant education.” Section B(1-7): 11-13.

  • CDC (2005). “Agents, diseases, and other threats.” Cited on World Wide Web 1 December 2005 at http://www.bt.cdc.gov/agent/.

  • Cosgrove, S. E., T. M. Perl, X. Song, S. D. Sisson (2005). “Ability of physicians to diagnose and manage illness due to category A bioterrorism agents.” Archives of Internal Medicine 165(17): 2002-2006.

  • Endy, T. P., S. J. Thomas, J. V. Lawler (2005). “History of U.S. Military Contributions To The Study of Viral Hemorragic Fevers.” Military Medicine 170(4): 77-91.

  • Goad, J. A., J. Nguyen (2003). “Hemorrhagic Fever Viruses.” Top Emerg Med 25(1): 66-72.

  • Hickner, J., F. M. Chen (2002). “Survey on Eve of Anthrax Attacks Showed Need for Bioterrorism Training.” Press release 5 September 2002. Agency for Healthcare Research and Quality, Rockville, MD. Cited on World Wide Web on 22 December 2005 at http://www.ahrq.gov/news/press/pr2002/anthraxpr.htm

  • Karwa, M. (2005). “Bioterrorism: Preparing for the impossible or the improbable.” Critical Care Medicine 33(1 Suppl): S75-95.


References

  • LCME (2004). “Functions and structure of a medical school.” Section II(A): 2.

  • Leger, M. M., R. McNellis, R. Davis, L. Larson, R. Muma, T. Quigley, S. Toth (2001). “Biological and chemical terrorism: Are we clinicians ready?” American academy of physician assistants. Cited on world wide web 3 January 2005 at http://www.aapa.org/

  • clinissues/BTtext.htm.

  • Lohenry, K. (2004). “Anthrax exposure – stay alert, act swiftly” Journal of the American Academy of Physician Assistants 17(8): 29-33.

  • NPR online, (2005). “History of Biological Warfare.” Cited on World Wide Web 21 November 2005 at http://www.npr.org/news/specials/response/anthrax/features/2001/

  • oct/011018.bioterrorism.history.html.

  • O’Brien, K., M. Higdon, J. Halverson (2003). “Recognition and Management of Bioterrorism Infections.” American Family Physician 67(9): 1927-34.

  • Straight, T. M., A. A. Lazarus, C. F. Decker (2002). “Defending Against Viruses in Biowarfare.” Postgraduate Medicine 112(2): 75-80.


References

  • Varkey, P., G. Poland, F. Cockerill, T. Smith, P. Hagen (2002). “Confronting Bioterrorism: Physicians on the Front Line.” Mayo Clinic Proceedings 77(7): 661-72.

  • United States Department of Health and Human Services (2002). “HHS announces $1.1 billion in funding to states for bioterrorism preparedness.” HHS press release 31 January 2002. Cited on World Wide Web 30 December 2005 at http://www.hhs.gov/news/press/

  • 2002pres/20020131b.html.


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