Terrorism Resources

Recommended Protocol For The Emergency Department Management of Persons Allegedly Exposed to Anthrax

Updated November 12, 2001

Overview

• Identify patient who states he or she was possibly exposed to anthrax (Bacillus anthracis)

• Notify the charge nurse

• Prepare for decontamination by moving patient to the Decontamination Room

• Determine the need for decontamination in consultation with the ED Attending

• Decontaminate the patient if appropriate

• Physician evaluation of patient

• Notify law enforcement and public health (if not yet notified)

• Determine the need for laboratory testing

• Determine the need for chemoprophylaxis

• Administer chemoprophylaxis

• Refer the patient for follow-up

1. Identify patient who states he or she was possibly exposed to B. anthracis
The case definition for this protocol is any patient who states that she or she was possibly exposed to B. anthracis.

All emergency department personnel should be aware that a patient may present to any part of the emergency department or medical center stating that he or she may have been exposed to B. anthracis.

Possible exposures include

• Any exposure to suspicious mail, package, or powder

• Visitor to site with known or suspected B. anthracis contamination

• Close contact of a person with suspected anthrax (e.g., co-worker, immediate family member)

2. Notify the ED Charge Nurse
Upon identifying a patient who may have been exposed to B. anthracis, ED personnel should notify the ED Charge Nurse, who will then assign a Nurse to the patient.

3. Determine the need for decontamination

Wearing appropriate personal protection equipment (see Appendix A), the Nurse will then immediately take the patient to the Decontamination Area. The Nurse will then determine the need for decontamination (in consultation with the attending emergency physician on duty).

The need for decontamination depends on the type of exposure, elapsed time since exposure and whether patient has been decontaminated prior to arrival at the Emergency Department

4. Decontaminate the patient
The patient should be provided a pre-labeled plastic bag and a paper gown to wear after their shower. The Nurse will provide any assistance that the patient may require during the decontamination process. Any ED personnel entering the Decontamination Area will also require appropriate PPE (Appendix A)

In the Decontamination Area, the patient will remove all of his or her clothing and jewelry (simply removing the patient's clothes accomplishes 80% of decontamination). The patient's personal items will be placed into a pre-labeled plastic bag and its opening will be tied securely. This plastic bag with the patient's personal items constitutes criminal evidence and will be saved in the Decontamination Area for forensic analysis by law enforcement authorities. The patient's belongings may also be examined as part of an environmental investigation by the Department of Public Health.

The patient should then shower for at least 10 minutes, taking care to rinse first and then clean their entire skin with soap and water, followed by another rinse. This step is aimed at physically removing any residual B. anthracis spores. In the event of possible exposure to biological warfare agents other than B. anthracis, then decontamination will also include a rinse with 0.5% hypochlorite solution (made by diluting commercial bleach 10:1 with water) after the soap and water step. Personal items like car keys can also be decontaminated with 0.5% hypochlorite. Hypochlorite rinse is unnecessary in alleged B. anthracis exposures, because the spores are only killed by extreme heat, radiation, and specific chemicals, such as Sandia foam.

After showering, the patient will put on a new paper gown, exit the Decontamination Area and await direction into the emergency department treatment area. The Nurse or other ED personnel will also remove his or her PPE before exiting the Decontamination Area. The patient should be evaluated as quickly as possible.

5. Physician evaluation

The ED physician (or physician assistant) will then evaluate the patient. The goals of evaluation are to determine the likelihood of exposure to B. anthracis and the need for chemoprophylaxis in the individual patient as well as to collect information that may impact public health. The examining physician should document certain key points listed in the table below during his or her evaluation. If the patient has symptoms or signs consistent with cutaneous or inhalation anthrax, then the physician should refer to the "Recommended Protocol for the Emergency Department Management of Persons With Suspected Inhalational Anthrax" or "Recommended Protocol for the Emergency Department Management of Cutaneous Anthrax".

Key aspects of patient evaluation in alleged B. anthracis exposure

• Source of alleged exposure (e.g., letter with unidentified powder)

• Possible route of exposure to B. anthracis (e.g., dermal, inhalational)

• Possible exposure of other individuals

• Timing of incident

• Location of incident

• Whether the patient was decontaminated prior to ED arrival

• Whether the patient received any chemoprophylaxis

• Presence of symptoms and signs of active anthrax infection

• Cutaneous anthrax: small ulcer with black eschar surrounded by zone of nonpitting edema on exposed skin (progression = red macule to papule to vesicle to pustule to vesicle to ulcer)

• Inhalational anthrax: severe viral-like upper-respiratory tract infection

• Allergies to quinolones or tetracyclines

6. Notify local law enforcement and public health department
Notify local law enforcement and public health department in order to initiate any law enforcement response or environmental investigation that may be required.

7. Determine the need for laboratory testing of the patient
The examining emergency physician should determine the need for laboratory testing of the patient. No current test reliably confirms or excludes exposure to B. anthracis.

8. Determine the need for chemoprophylaxis
The examining emergency physician should determine the need for chemoprophylaxis. An alleged exposure that is believed to be a hoax does not require chemoprophylaxis. An alleged exposure that is uncertain or is suspected of being an actual exposure to B. anthracis does require chemoprophylaxis until actual exposure can be ruled out.

9. Administer chemoprophylaxis
The CDC recommends that adults exposed to B. anthracis receive chemoprophylaxis with doxycycline 100 mg bid or ciprofloxacin 500 mg po bid for 60 days. Levaquin may also be used.

The CDC recommends that children exposed to B. anthracis receive ciprofloxacin or doxycycline according to the following table:

Both ciprofloxacin and doxycycline can cause adverse health effects in children. The risk of developing a life-threatening disease due to B. anthracis must be weighed against these risks. As soon as the penicillin susceptibility of the organism has been confirmed, then prophylactic therapy for children should be changed to amoxicillin 80 mg/kg po tid.

All patients prescribed prophylactic antibiotics in the Emergency Department should be given a prescription for 3-10 days with a refill for the remainder of the 60-day course. The duration of the initial prescription should be based on the expected time it will take for: 1) the patient to secure a follow-up appointment with their private physician or a physician to whom they are being referred; and 2) an environmental investigation to be performed by the Massachusetts Department of Public Health. Recent environmental investigations have been completed within 10 days.

10. Refer the patient for follow-up
Patients should be advised to follow-up with their follow-up physician (either their private physician or the physician to whom they are being referred from here) regarding the need for continuing all 60 days of chemoprophylaxis. The need to continue chemoprophylaxis will be determined by their follow-up physician in conjunction with the results of the environmental investigation related to their alleged exposure (performed by the Massachusetts Department of Public Health via laboratory testing in Jamaica Plains, MA).

11. Send the patient's chart to the Emergency Department Follow-up Nurse
The ED Follow-up Nurse will track and review all charts of patients evaluated in the ED for alleged exposure to B. anthracis (or other bioterrorist agents). Please complete the patient's chart before going off-duty and place it in the ED Follow-up Nurse box in the ED treatment area.

Appendix A
Personal protection equipment required in the ED decontamination of patients allegedly exposed to B. anthracis

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