Current concepts in the management of biologic and chemical warfare causalities Bellal Joseph, MD, Carlos V. Brown, MD, Conrad Diven, MD, Eric Bui, MD, Hassan Aziz, MD, and Peter Rhee, MD, Tucson, Arizona B iologic warfare, also known as germ warfare, is the use of biologic toxins, infectious agents, or insects as an act of war. 1 Biologic weapons or ‘‘bioagents’’ are living organisms that can replicate within their host victims. Such weapons are characterized by low visibility, high potency, and relatively easy delivery. 2 Chemical warfare is the use of chemicals formulated to inflict death or harm to human beings. 3 They are separate from biologic weapons (which cause diseases), nuclear weapons (which use subnuclear fission), and radiologic weapons (which use radioactive decay of elements). 4 Chemical weapons can be widely dispersed in gas, liquid, and solid formsVand can easily afflict others beyond the intended targets. Civilian physicians have rarely seen the effects of either biologic or chemical warfare, but the threat in the modern era is ever present and most likely increasing. 2Y4 In this article, we briefly review the major forms of bi- ologic and chemical warfare, their clinical effects, and current treatment options. BIOLOGIC WEAPONS Bioterrorism is the deliberate release of viruses, bacteria, or other biologic agents to cause illness or death. 2 The use of biologic agents is not a new concept. As far back as 400 BC, nomadic archers in Scythia infected their arrows by dipping them in decomposing bodies or in blood mixed with manure. 5 The ancient Romans were known to throw feces in the faces of their enemies as a form of biologic terrorism. 3 In the middle ages, animals infected with diseases such as smallpox were thrown over the walls of fortresses. These agents are explained later. Communicable Agents Communicable biologic warfare agents that remain highly relevant today include Yersinia pestis, the causative agent of the plague that killed an estimated 70 million people in the 14th century; smallpox; and viral hemorrhagic fevers (VHFs). 1,6Y8 Yersinia A gram-negative bacterium, Y. pestis killed up to 60% of the European population in the 14th century. 1 In the 19th century, outbreaks of Yersinia were prevalent throughout the Indian subcontinent and Hong Kong and, because of fleas, transported on infected rats that had stowed away on Chinese steamships. 6 More recently, Yersinia was used during World War II as a biologic weapon. 7 Every year, the World Health Organization (WHO) reports 1,000 to 3,000 new cases of plague, although only 5 to 15 cases occur in the United States. 8 Transmitted to fleas by rodents and then to humans with subsequent bites, Yersinia proliferates in lymph nodes, where it is able to avoid the immune system. There exist two forms of plague: (1) bubonic form and (2) pneumonic form. 9 The bu- bonic form of plague is not communicable. Symptoms usually manifest 2 days to 5 days after exposure to Yersinia. The main symptom is swollen lymph nodes (buboes), which are com- monly found in the armpits, groin, or neck. In contrast, the pneumonic form of plague is communicable. 10 It can occur when a person breathes in Yersinia particles, although such naturally occurring pneumonic plague is uncommon; usually, it is the sequel of untreated bubonic plague. Symptoms include shortness of breath, chest pain, and hemoptysis. To isolate Yersinia, advanced knowledge and technology are needed. For individual patients, identification of the bac- terium is from culture analysis. In addition, a rapid dipstick test can identify the Yersinia antigen. 11 Currently, no vaccine is available, although a recombi- nant protein vaccine is now undergoing trials in a murine model. 12 The standard antibiotic therapy for bubonic or pneumonic plague is Streptomycin. 13 Therapeutic effect may be expected with 30 mg/kg per day (up to a total of 2 g/d) in divided doses given intramuscularly, to be continued for a total of 10 days or until 3 days after the temperature has returned to normal. 13 Successful treatment reduces the mortality rate to 1% to 15%. 9 Smallpox There is long history of smallpox and its devastation to mankind. 14 More recently, in the 18th century, it was used by the United States against the French and their Native American Indian allies at the Siege of Fort Pitt in southwestern Pennsylvania. 15 Smallpox is a highly contagious virus that can cause variola major (severe form of the disease) and variola REVIEW ARTICLE J Trauma Acute Care Surg Volume 75, Number 4 582 Submitted: May 21, 2013, Revised: June 16, 2013, Accepted: June 18, 2013. From the Division of Trauma, Critical Care, and Emergency Surgery (B.J., C.D., H.A., P.R.), Department of Surgery, University of Arizona, Tucson, Arizona; Division of Trauma, Critical Care, and Emergency Surgery (C.V.B., E.B.), Department of Surgery, Brackenridge Hospital, University of Texas Medical Branch-Austin, Austin, Texas. Division of Acute Care Surgery, Department of Surgery,University Medical Center Brackenridge,University of Texas South- western - Austin, Austin, TX Address for reprints: Bellal Joseph, MD, University of Arizona, Department of Surgery, Division of Trauma, Critical Care, and Emergency Surgery, 1501 N. Campbell Ave, Room 5411, PO Box 245063, Tucson, AZ 85727; email: bjoseph@surgery.arizona.edu. DOI: 10.1097/TA.0b013e3182a11175 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.