› Airway and breathing threats
› Fulminant inhalational anthrax
› Rapid progression from flu-like prodrome to respiratory failure within hours
› Biphasic course with brief improvement before collapse
› Oxygenation failure
› SpO2 < 90% on room air
› PaO2 < 60 mmHg from large pleural effusions
› Airway edema from injection or head and neck cutaneous disease
› Massive soft tissue edema
› If expanding airway edema, early definitive airway control
› If respiratory failure, rapid sequence intubation preparation
› Lung protective ventilation
› Pleural drainage before or alongside intubation
› Circulation and toxemia threats
› Anthrax toxin mediated shock
› Lethal toxin and edema toxin driven vascular collapse
› Shock may persist after bacterial sterilization
› Shock physiology
› SBP < 90 mmHg
› MAP < 65 mmHg
› Lactate >= 2 mmol/l
› If septic shock, antibiotics and antitoxin within 1 hour
› Triple antimicrobial therapy
› Adjunctive antitoxin for systemic disease
› Neurologic and hemorrhagic threats
› Hemorrhagic meningitis
› Occurs in up to 50% of systemic cases
› Altered mental status and seizures
› Coagulopathy
› Present in about one third of systemic cases
› Bleeding risk with procedures
› If altered mental status, lumbar puncture and CNS active regimen
› Meropenem for CNS penetration
› Assume meningitis until ruled out
Early recognition and decision points
› Pathognomonic red flags
› Widened mediastinum on chest radiograph in a febrile patient
› Essentially diagnostic of advanced inhalational anthrax
› Hemorrhagic mediastinal lymphadenopathy on CT
› Painless black eschar with disproportionate edema
› Cutaneous form
› Surrounding non-pitting edema
› Clustering of patients with similar respiratory illness
› Suggests intentional aerosol release
› Suspicious powder or mail exposure
› Form based branching
› Cutaneous localized vs systemic
› Localized lesion without systemic signs
› Systemic signs trigger IV therapy and admission
› Inhalational, ingestion, injection
› All systemic forms require ICU level care
› Meningitis complicates any form
Team activation and public health
› Immediate notifications
› Local and state health department
› Anthrax is a nationally notifiable disease
› Report any suspected case
› CDC and Laboratory Response Network
› Confirmatory testing coordination
› Medical countermeasure access
› Consultation triggers
› Infectious disease for all cases
› Regimen selection and antitoxin
› Duration and step-down planning
› Critical care for systemic disease
› Vasopressor and ventilator management
› Pleural drainage coordination
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