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Chapter 101 WEAPONS OF MASS DESTRUCTION708
to mediastinal lymph nodes where they transform into a vegetative state. Once the bacteria
start replicating, they produce toxins that cause edema (edema factor) and hemorrhage and
necrosis (lethal factor).
31. What are the signs and symptoms of anthrax?
Cutaneous anthrax begins with an area of localized redness and swelling and progresses to a
painless, necrotic black lesion or ulcer. GI anthrax presents with stomach pain, fever, diarrhea,
and loss of appetite. Inhalational anthrax initially is a very nonspecific, flu-like syndrome with
fever, nausea, vomiting, muscle aches, and fatigue. This can quickly progress to difficulty
breathing, respiratory failure, shock, and death. Of 10 patients presenting with inhalational
anthrax in the 2001 attacks, all had fever, chills, malaise, and fatigue. Most of the patients
developed cough, chest discomfort, and dyspnea. Chest radiograph abnormalities were
universal and included widened mediastinum, pleural effusions, air bronchograms, necrotizing
pneumonic lesions, or consolidations.
32. How should I treat anthrax?
Current CDC recommendations for inhalational anthrax include ciprofloxacin and doxycycline,
plus one or two additional antibiotics. For cutaneous anthrax, ciprofloxacin and doxycycline
also are first-line therapy. A potential for reactivation of latent infection may exist. Therefore,
persons with cutaneous anthrax associated with this attack should be treated for 60 days.
A recent addition to the Strategic National Stockpile is raxibacumab (ABthrax
tm
), which is a
monoclonal antibody active against the factor produced by anthrax that allows edema factor
and lethal factor to enter a cell. Animal studies have shown great promise for benefit of this
new medication.
From Public health response to biological and chemical weapons: WHO guidance (2004). www.who.int/
csr/delibepidemics/biochemguide/en/
Infectivity The ability of an agent to enter, multiply, and survive in
a host
ID
50
is the dose that would infect 50% of an exposed
population
Virulence The relative severity of the disease
Different strains of the same agent can cause varying
severities of disease
Incubation period Time between exposure and onset of symptoms
Lethality The ability of an agent to cause death
Contagiousness Measured by the number of secondary cases occurring
after exposure to the primary case
Mechanisms of transmission Manner by which the disease is transmitted (i.e.,
respiratory, blood borne, vector borne, food contamination)
TABLE 101–6. GENERAL CHARACTERISTICS OF BIOLOGIC AGENTS
Chapter 101 WEAPONS OF MASS DESTRUCTION 709
33. What other sources are available to learn more about biological weapons?
The Journal of the American Medical Association (JAMA) has a series of articles titled:
Medical and Public Health Management Following the Use of a Biological Weapon: Consensus
Statements of the Working Group on Civilian Biodefense. They are available through the JAMA
website:
n
Anthrax: jama.ama-assn.org/cgi/reprint/287/17/2236.pdf
n
Botulism: jama.ama-assn.org/cgi/reprint/285/8/1059.pdf
n
Hemorrhagic fevers: jama.ama-assn.org/cgi/reprint/287/18/2391.pdf
n
Plague: jama.ama-assn.org/cgi/reprint/283/17/2281.pdf
n
Smallpox: jama.ama-assn.org/cgi/reprint/281/22/2127.pdf
n
Tularemia: jama.ama-assn.org/cgi/reprint/285/21/2763.pdf
The CDC also maintains extensive information on biological weapons including case
definitions. You can access this information by going to: http://emergency.cdc.gov/
bioterrorism/
34. How should I protect myself when I am caring for patients exposed to
biological weapons?
Universal precautions should be observed at all times when dealing with a biological event.
The following table lists person-to-person transmissibility and isolation requirements by
biological agent, when known. If the agent causing the patient’s symptoms is unknown, as it
likely will be on initial presentation to the ED, strict isolation precautions should be utilized.
See Table 101-7.
35. How will I recognize if a biological attack has occurred?
Recognizing a biological attack can be very difficult for the reasons that have already been
stated. In general, disease pattern recognition will be vital to the early identification of a
biologic event. In 2000, Dr. Paul Rega published a list of covert assault clues that can aid
clinicians in this process. These covert assault clues are as follows:
n
Severe manifestations of disease in previously healthy people
n
Greater than normal numbers of patients with fever, respiratory, or GI complaints
n
Multiple patients with similar complaints from a common location
n
An endemic disease that occurs during an unusual time of year
n
An unusual number of rapidly fatal cases
n
A greater number of sick or dead animals
n
Rapidly rising and falling epidemic curve
n
Larger number of patients with severe pneumonia, sepsis, sepsis with coagulopathy, fever
with rash, or diplopia with progressive weakness
Illness Person to Person? Isolation Required?
Anthrax No No
Botulism No No
Hemorrhagic fevers Yes Yes
Plague Yes (pneumonic form) Yes
Smallpox Yes Yes
Tularemia Likely not No
TABLE 101–7. TRANSMISSIBILITY AND ISOLATION REQUIREMENTS FOR BIOLOGICAL WEAPONS
Chapter 101 WEAPONS OF MASS DESTRUCTION710
36. What should I do if I suspect an attack has occurred?
Every emergency provider should familiarize themselves with their hospital’s internal disaster
plan and reporting process. Early involvement of local and state public health is important for
both diagnostic and epidemiologic followup. The CDC provides a mechanism to report an
incident as well as helpful phone numbers that may be needed during the management of an
incident. This information can be accessed at the CDC’s Emergency Preparedness and
Response website located at: http://emergency.cdc.gov/
EXPLOSIVES
37. With all these other highly effective and lethal terrorist weapons, are they
really still using explosives?
Absolutely. The widespread use of NBC weapons is significantly limited as they are expensive
to acquire and difficult to manufacture in an effective dispersal mechanism. Explosive devices
are much easier to acquire and are increasingly being improvised to create maximal body
counts. In the year 2008, worldwide, over 8,000 people were killed in terrorist attacks
by bombing or combined bombing/arson. There has also been a significant increase in
“high-fatality attacks” (those killing more than 10 people), many of which are carried out
using explosive devices. From 2004 to 2006, approximately 205 people were injured or killed
in the United States as a result of criminal bombing incidents.
38. Describe the five blast injury categories after explosions.
n
Primary: The direct effect produced by contact from the blast shockwave with the body.
This creates shear and stress forces on tissues. Typical injuries include tympanic
membrane (TM) rupture, blast lung, ocular injuries, and concussions.
n
Secondary: Injury produced by impact of primary fragments (pieces of the exploding
device) or secondary fragments (fragments from the surrounding environment). Typical
injuries include penetrating trauma, amputations, or lacerations.
n
Tertiary: Injuries created when the blast wave propels victims’ bodies into objects or large
objects strike the body. Typical injuries include crush injuries and blunt trauma.
n
Quaternary: Effects include burns, inhalational injury, exposure to toxic substances, and
injury from environmental contamination that was created as the result of the explosive
device.
n
Quinary: Injuries resulting from additives such as bacteria or radiation (dirty bombs).
39. Is there a quick screening method to triage victims of blast injuries?
Otoscopic examination of the TM is a quick (but not foolproof) way to assess the severity of
blast injury. The TM can be ruptured by an increase in atmospheric pressure as low as 5 psi
above normal. If there is no TM rupture, then the chance of hollow organ injury is significantly
lower. It is not zero, however. It was found that in 17 critically injured patients after the Madrid
train bombing in 2004, 13 had ruptured TMs, but 4 did not. Obviously, if other symptoms
such as shortness of breath are present, one must suspect other injuries.
40. What is blast lung?
Blast lung is the term used to describe the significant pulmonary barotrauma after a high-
order explosive detonation. The blast wave’s impact with the lung causes tearing, hemorrhage,
contusion, and edema with resultant ventilation-perfusion mismatch. Blast lung is a clinical
diagnosis characterized by respiratory difficulty and hypoxia.
In general, blast lung is treated similarly to any other pulmonary contusion. Patients
exposed to a significant explosion who have normal chest radiographs, normal arterial blood
gases, and no complaints that would suggest blast lung injury can be considered for
discharge after 4 to 6 hours of observation.
Chapter 101 WEAPONS OF MASS DESTRUCTION 711
DECONTAMINATION
41. What should I know about decontamination?
Decontamination is a critical aspect of the medical management of NBC attacks. The benefits
of decontamination are threefold. It protects the patient from continued injury due to residual
agent on the patient’s clothes or skin, the health care providers from exposure and injury, and
the health care facility itself, allowing it to remain open and to care for more patients.
42. How do I decontaminate victims of chemical exposure?
Decontamination of patients exposed to chemical agents should ideally be performed in the
prehospital setting. However, hospitals should be prepared to provide decontamination outside
of the ED for the patients that will inevitably self-present for evaluation and care. Hospital staff
members involved in the decontamination process should utilize Level C protection. Wet
decontamination is the method of choice for liquid chemical exposure. Patients should first
have their clothes removed, maintaining as much modesty as possibly. Soap and copious
amounts of water should then be applied and are considered adequate for decontamination.
While a variety of neutralizing solutions, such as dilute bleach solution, have been suggested
as decontamination solutions, most are not used in the hospital setting as they require
prolonged contact time (15-20 minutes) and have the potential for causing additional skin
injury.
43. How do I decontaminate a patient that has been exposed to radioactive
material?
Once the patient is removed from the radiological hazardous environment, standard PPE is
adequate for decontamination personnel (scrubs, masks, gloves, eye protection, and shoe
coverings). Decontamination personnel should be equipped with dosimeters to monitor
radiation exposure. Decontamination can then be broken down into two components:
n
Gross Decontamination: This involves removing all of the patient’s clothes and bagging the
clothes appropriately. The patient should then be washed with copious amounts of soap
and water or the commercially available 0.5% hypochlorite solution. Care must be taken to
avoid washing contaminated water towards mucous membranes. Care must also be taken
to not abrade the skin as radionuclides can be absorbed through skin abrasions. This
process will successfully remove approximately 95% of the contamination.
n
Secondary Decontamination: This is a meticulous process to ensure the patient is fully
decontaminated. Eyes, ears, mucous membranes, and wounds should be swabbed, and
the swabs should be analyzed for radioactivity. Additionally, these same areas should be
copiously irrigated. The patient’s eyes should be anesthetized and copiously irrigated.
The ears should be checked for perforated TMs and irrigated copiously if intact. Dentures
should be removed and the mouth rinsed copiously without swallowing the rinse water.
Wounds should also be irrigated and covered with waterproof dressings to avoid run-off
contamination from irrigating other areas. The hospital’s radiation safety officer should be
involved with this process.
44. How are victims of biologic agent exposure decontaminated?
In most cases, victims of a biologic attack will present when they become clinically ill. This
finding indicates that the exposure occurred days earlier, in which case decontamination is not
necessary. Only in those instances of recognized powder exposure is decontamination
required. As with chemical exposure, decontamination personnel must use appropriate PPE
during the decontamination process. Clothing should be removed and then showering with
soap and water accomplished.
Chapter 101 WEAPONS OF MASS DESTRUCTION712
1. The ideal terrorist weapon is cheap, easy to manufacture, easy to disseminate, and will
produce large numbers of casualties.
2. The most likely WMD to be used by a terrorist is a conventional explosive.
3. A chemical agent attack will generally be recognized by having a large number of casualties
present with similar symptoms over a short period of time in a relatively small geographic
area.
4. In the event of a biological agent attack, all patients should be considered to be infectious
until a definitive diagnosis of a nontransmissible agent is confirmed.
5. The most likely radiologic incident will be a dirty bomb, i.e., radiologic dispersal device that
involves using a conventional explosive to disperse some radioactive material.
KEY POINTS: WMD
WEBSITES
Anthrax: http://www3.niaid.nih.gov/topics/anthrax/overview.htm
Biological weapons: http://emergency.cdc.gov/bioterrorism/
Bioterrorism agents: http://emergency.cdc.gov/agent/agentlist-category.asp#catdef
CDC’s Emergency Preparedness and Response website located at: http://emergency.cdc.gov/
Journal of the American Medical Association: http://jama.ama-assn.org
KI tablets: http://www.bt.cdc.gov/radiation/ki.asp
U.S. Department of Health & Human Services: http://www.hhs.gov/disasters/emergency/
manmadedisasters/bioterorism/index.html
BIBLIOGRAPHY
1. Bushberg JT, Kroger LA, Hartman MB, et al: Nuclear/radiological terrorism: emergency department management
of radiation casualties. J Emerg Med 32(1);71–85, 2007.
2. CDC, Emergency preparedness and response. Blast injuries: fact sheet for professionals. Lung Injury:
www.bt.cdc.gov/masscasualties/blastlunginjury.asp
3. CDC, Emergency preparedness and response: chemical emergencies, Centers for Disease Control: www.
bt.cdc.gov/chemical
4. CDC, Emergency preparedness and response: radiation emergencies. Centers for Disease Control: www.
bt.cdc.gov/radiation
5. Centers for Disease Control (CDC): Emergency preparedness and response. Acute radiation syndrome: a fact
sheet for physicians: http://emergency.cdc.gov/radiation/arsphysicianfactsheet.asp
6. Champion HR, Holcomb JB, Young LA: Injuries from explosions: physics, biophysics, pathology and required
research focus. J Trauma 66:1468–1477, 2009.
7. Currance PL: Medical response to weapons of mass destruction, St. Louis, 2005, Mosby.
8. Depalma RG, Burris DG, Champion HR, et al: Blast injuries. N Engl J Med 352:13, 2005.
9. Flynn DF, Goans RE: Nuclear terrorism: triage and medical management of radiation and combined-injury
casualties. Surg Clin North Am 86:601–636, 2006.
10. Guidance for Radiation Accident Management, Radiation Emergency Assistance Center/Training Site (REAC/TS):
http://orise.orau.gov/reacts/guide/injury.htm
11. Inglesby TV, O’Toole T, Henderson DA, et al: Anthrax as a biological weapon: updated recommendations for
management. JAMA 287:2236–2252, 2002.
Chapter 101 WEAPONS OF MASS DESTRUCTION 713
12. Karwa M, Currie B, Kvetan V: Bioterrorism: preparing for the impossible or the improbable. Crit Care Med
33:1, 2005.
13. Koenig KL, Boatright CJ, Mancock JA, et al: Health care facilities’ “war on terrorism”: a deliberate process for
recommending personal protective equipment. Am J Emerg Med 25:185–195, 2007.
14. Koenig KL, Goans RE, Hatchett RJ, et al: Medical treatment of radiological casualties: current concepts. Ann
Emerg Med 45:643–652, 2005.
15. Maniscalco PM, Christen HT: Understanding terrorism and managing the consequences, Upper Saddle River,
NJ, 2002, Prentice Hall.
16. Medical management of radiologic casualties handbook, ed 2, Bethesda, MD, 2003, Military Medical
Operations, Armed Forces Radiobiology Research Institute,www.afrri.usuhs.mil/outreach/
pdf/2edmmrchandbook.pdf.
17. Mettler FA, Voelz GL: Major radiation exposure-What to expect and how to respond. N Engl J Med 346:
1554–1561, 2002.
18. National Counterterrorism Center, 2008 Report on Terrorism: http://www.nctc.gov
19. Newmark J: Nerve agents. Neurol Clin 23:623–641, 2005.
20. Public health response to biological and chemical weapons: WHO guidance. 2004: http://www.who.int/csr/
delibepidemics/biochemguide/en/
21. Rega P: Bio-terry: a stat manual to identify and treat diseases of biologicalterrorism. Maumee, OH, 2000,
Mascap, Inc,, pp 1–4.
22. Talmor, D: Nonconventional terror—the anesthesiologist’s role in a nerve agent event. Anesthesiol Clin
25;189–199, 2007.
23. Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and
antimicrobial therapy, October 2001. MMWR Morbidity and Mortality Weekly Report 50(42):909–919, 2001.
24. U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry: Medical
Management Guidelines for Nerve Agents: Tabun (GA; Sarin (GB); Soman (GD); GF; and VX: http://www.atsdr.
cdc.gov/MHMI/mmg166.html
A
ABCs
of burn management, 638
of comatose patient management, 73
of facial trauma management, 568
of pediatric patient management, 468, 617
of pelvic fracture management, 607
of resuscitation, 11
exceptions to, 12
of seizure management, 114-116
of stroke management, 156
ABCDEs
of abdominal trauma management, 602
of spinal trauma management, 575
Abdomen
pain in. See Pain, abdominal
palpable mass in, 64-65
traumatic injuries to, 602-606
child abuse-related, 455-456
in pediatric patients,455-456, 620, 630
ultrasound evaluation of, 34-35, 35f, 36
Abortion, spontaneous, 547-548
septic, as tetanus cause, 352, 548
Abscess
abdominal, 65-66
amebic, 357
anorectal, 246
culture of, 332
deep space, 334
dental, 149-150
differential diagnosis of, 332
differentiated from cellulitis, 331, 331b
lateral pharyngeal, 150
methicillin-resistant Staphylococcus
aureus-related, 380-381
pelvic, 64-65
perianal, 334
perirectal, 334
peritonsillar, 143-144
retropharyngeal, 144, 432, 433t, 434
as tetanus booster indication, 336
treatment of, 333-334
Absolute lymphocyte count, in radiation-exposed
patients, 703t
Acetaminophen
as antipyretic agent, 76, 78
pediatric use of, 418
in combination with dextromethorphan, 515
INDEX
as headache treatment, 103t, 104-105
as mortality cause, 473
overdose of, 476, 478-479, 491-494
Acetaminophen-alcohol syndrome, 494
N-Acetylcysteine, as acetaminophen overdose
treatment, 479, 493-494
Acid-base disorders, 307-311
in poisoning patients, 476
salicylate toxicity-related, 489
Acidosis
as hyperkalemia cause, 303
lactic, 307
causes of, 308
grand mal seizure-related, 308
as metabolic acidosis cause, 310
metabolic, 307
alcohol-related, 308-309, 482
anion-gap, 310, 486
fatal, 308
heatstroke-related, 309
hyperchloremic, 301, 306
ibuprofen overdose-related, 495
with narrow anion gap, 302
in near-drowning victims, 397
with normal anion gap, 301, 308
in pediatric patients, 308
salicylate overdose-related, 489
sulfuric, 307
ventilator settings in, 172t
Wernicke’s encephalopathy-related,
308
with wide anion gap, 301, 302t, 305-306
pseudometabolic, 309
respiratory, 307
in near-drowning victims, 397
in pregnancy, 613-614
salicylate overdose-related, 489
Acids, ingestion of, 474
Acquired immunodeficiency syndrome (AIDS).
See also Human immunodeficiency virus
(HIV) infection
anion gap in, 310
dementia associated with, 344
diagnosis of, 342, 342t
headaches associated with, 104
myocarditis associated with, 233
neurologic complications of, 343-344
Acetaminophen (Continued)
715
INDEX716
Acrolein, as smoke component, 507
Acute abdomen. See Pain, abdominal
Acute chest syndrome, 293
Acute coronary syndrome, 81, 81f, 83-84, 202-203,
686
Acute necrotizing ulcerative gingivitis (ANUG), 150
Acute radiation syndromes (ARS), 702-703, 703t
Acute respiratory distress syndrome
in near-drowning victims, 397
sepsis-related, 327
smoke inhalation-related, 506
Acute urethral syndrome, 270
Acyclovir, neonatal use of, 421
Adenosine, as wide-complex tachycardia treatment,
211t
Adhesions, intestinal, 244
Adie’s pupils, 132
Adrenal crisis, 324, 324-325, 325b
as oncologic emergency, 297t
Adrenal insufficiency
acute, 322, 324-325
chronic, 325
as hyperkalemia cause, 303
primary, 322-323, 323t
secondary, 322-323, 323t, 324
Adrenergic agonists, as cardiac arrest treatment, 12-13
Adrenocorticotropic hormone, secretion of, 322
Adrenocorticotropic hormone-secreting tumors, 322
Adrenocorticotropic stimulation test, rapid, 324-325
Advanced Cardiac Life Support (ACLS), guidelines for,
15-16
Afferent pupillary defect, 131, 132b
Aging. See also Elderly patients
physiologic changes associated with, 41
Agitation, hypoglycemia-related, 316
Air embolism, in hemodialysis patients, 280
Airplanes, lightning strikes on, 385
Airway
assessment of, 564
pediatric, 467-468
thermal burns to, 639
Airway management, 18-27
in alcohol intoxication, 480
in anaphylaxis, 122
in burn patients, 638
in cardiopulmonary resuscitation, 11
in neck trauma, 12, 591, 593
in pediatric patients, 468, 617-618
in seizures, 114-116
in vomiting, 94
Airway obstruction
infectious mononucleosis-related, 449
most common cause of, 18
as oncologic emergency, 297t
in pediatric patients, 431, 433t, 439
prevention of, 18
Airway rewarming, following hypothermia, 403
Albuterol
as asthma treatment, 176t, 436-437
as bronchiolitis treatment, 436
Alcohol
co-ingestion with cocaine, 521
odor of, 72
Alcohol abuse, disorders associated with
gout, 373
ketoacidosis, 308-309, 310
intimate partner violence, 678
mood disorders, 664
psychosis, 659
suicide, 666
Alcohol dehydrogenase, 483-484, 485
Alcohol intoxication
as altered mental status cause, 72, 480
management of, 480
Alcohol withdrawal, 480
seizures associated with, 480-481, 483
Alcoholics
combative, restraint of, 482
head trauma in, 581
Aldehydes, as smoke component, 507
Alkalosis
metabolic, 307
salicylate overdose-related, 489
respiratory, 307
salicylate overdose-related, 489
Wernicke’s encephalopathy-related, 308
Allen test, 632-633
Alopecia, AIDS-related, 345
Alteplase. See Tissue plasminogen activator (tPA)
Altered mental status, 69-74
alcohol intoxication-related, 72, 480
cholangitis-related, 248
diagnostic approach to, 72-73, 73b
end-stage renal disease-related, 281
malaria-related, 360-361
in near-drowning victims, 397
sepsis-related, 327
toxidrome-related, 517t
Amanita phalloides poisoning, 355, 357, 519,
519t
Amatoxins, 519, 519t
American Heart Association, cardiopulmonary
resuscitation guidelines of, 11, 15-16
Amidarone, 211, 211t
Aminophylline, as asthma treatment, 438
Amiodarone
as cardiac arrest treatment, 12-13, 16
as ventricular fibrillation treatment,
14
Amnesia, lightning strike-related, 386
Amnestic shellfish poisoning, 356
Amphetamines, 520
designer drug analogs of, 521-522
differentiated from cocaine, 520-521
A MUD PILES (mnemonic), for wide-gap acidosis
diagnosis, 301, 482-483, 485
A MUST (mnemonic), for spinal trauma management,
575
Amylase, as pancreatic injury indicator, 603
Anal fissures, 246-247
INDEX 717
Analgesia
levels of, 461
in pediatric patients, 460-466
reversal agents for, 463t, 466
Analgesics
narcotic, use in abdominal pain management,
88-89
as renal colic treatment, 258-259, 258t
Anaphylactoid reactions, 120
Anaphylaxis, 120-123
biphasic, 122
as cardiopulmonary arrest cause, 13
Hymenoptera sting-related, 499
idiopathic, 120
as shock cause, 32
as wheezing cause, 174
Anaplasmosis, 363t, 365-366
Anatomic snuffbox, in wrist trauma, 625
Anchoring, 53-54
Anemia
hemolytic microangiopathic, 287
hypothermia-related masking of, 402-403
malaria-related, 360-361
as oncologic emergency, 297t
of pregnancy, 613-614
Aneurysm
abdominal, 224-226, 226b
ruptured, 219, 224-225
ultrasonographic evaluation of, 37, 38f
abdominal aortic
as low back pain cause, 127
ultrasonographic evaluation of, 37, 38f
aortic, 224, 686
differentiated from aortic aneurysm, 224
dissecting, 203
misdiagnosed as renal colic, 255, 257
true, 224
iliac, misdiagnosed as renal colic, 255
Angina, 80, 82t, 84
Ludwig, 150
Prinzmetal, 201
stable, 80, 201
typical features of, 202b
unstable, 80, 201, 206
Angioedema, hereditary, 121
Angiography
pulmonary, 191
of vascular neck injuries, 594
Angiotensin-converting enzyme inhibitors (ACEI), as
congestive heart failure treatment, 199
Anion gap
clinical usefulness of, 307
definition of, 301, 485
elevated, 301, 307, 310, 485
in human immunodeficiency virus infection, 310
normal, 301, 308
Aniscoria, 132, 132b
Ankle, sprains of, 627
Ankle-brachial index (ABI), 628
Anorexia, peritoneal inflammation-related, 88
Anoscopy, 246
Antacids, use in chest pain evaluation, 84
Anterior cord syndrome, 578-579
Anterior cruciate ligament, rupture of, 627
Anterior interosseous nerve, supracondylar humerus
fracture-related injury to, 630
Anterior talofibular ligament, ankle sprain-related injury
to, 627
Anthrax, as biological weapon, 706-708, 709, 709t
Ant stings, 498
Antibiotic prophylaxis
for dog or cat bite victims, 500
following tooth reimplantation, 148
for Lyme disease, 364
for meningitis-exposed persons, 167
in near-drowning victims, 397
for pneumonia, 185t
for traveler’s diarrhea, 357, 358f
in wound care, 653
Antibiotic therapy
for abscesses, 334
for bacteremia, in children, 421
for botulism, 355
for cat-bite wounds, 624
for cellulitis, 334
for chronic obstructive pulmonary disease, 178
for cystitis, 274
for dental infections, 149
as fever cause, 77t
for mandibular fractures, 151
for meningitis, 166, 167t
for patients with fever, 77
for pneumonia, 182
for prostatitis, 274
for pyelonephritis, 274
for septic arthritis, 370
for soft-tissue infections, 337t
for toxic shock syndrome, 350
Anticholinergic syndrome, 477t, 665
Anticholinergics
as chronic obstructive pulmonary disease
treatment, 177-178
inhaled, as asthma treatment, 176t
Anticoagulant therapy
as epistaxis (nosebleed) cause, 135
for ischemic stroke, 160
prior to cardioversion, 212
for pulmonary embolism, 192
as reperfusion therapy adjuvant, 205
Anticonvulsant therapy, 116, 116t, 119, 425, 428-429
as fever cause, 77t
side effects of, 428
Antidepressants, 664-665
as dextromethorphan and meperidine
contraindication, 514
as mortality cause, 473
tricyclic, 664
as cardiopulmonary arrest cause, 14
overdose of, 476
Antidotes, for common poisonings, 478-479