01Approach to the Critical Patient/attcp67

Immediate priorities

›Airway and breathing threats

›Malignant edema of head, neck, or thorax

›Stridor or voice change

›Progressive facial or cervical swelling

›Airway obstruction risk

›Dysphagia or drooling

›Tongue or pharyngeal swelling

›If impending airway compromise, early definitive airway control

›Anesthesia and ENT at bedside

›Prepare for difficult airway and surgical airway

›Circulation and systemic toxicity threats

›Shock physiology

›SBP < 90 mmHg

›MAP < 65 mmHg

›Systemic dissemination markers

›High fever and rigors

›Tachycardia and hypotension

›If septic, broad spectrum antibiotics within 1 hour

›Blood cultures before antibiotics when feasible

›Balanced crystalloid resuscitation

›Key early branching

›Uncomplicated localized cutaneous anthrax

›Painless eschar with minimal edema

›No systemic symptoms

›Complicated cutaneous anthrax

›Extensive malignant edema

›Head or neck involvement with systemic features

02History/hx61

Presentation pattern

›Core syndrome

›Initial pruritus at inoculation site

›Painless papule onset

›Skin break at exposure site

›Vesicle formation

›Clear or serosanguinous fluid

›Satellite vesicles around primary lesion

›Evolution to black eschar

›Painless ulcer then eschar over 24 to 48 hours

›Surrounding non-pitting edema

›Symptom timeline

›Incubation period

›1 to 12 days

›Mean approximately 5 days

›Characteristically painless lesion

›Pain suggests secondary bacterial superinfection

›Non-purulent unless superinfected

Exposure and risk factors

›Animal and occupational exposure

›Livestock contact

›Cattle, goats, and sheep

›Sick or dead animals

›Animal product handling

›Hides, wool, and bone meal

›Drum makers using animal skins

›High risk occupations

›Farmers and veterinarians

03Physical Exam/exam62

Vitals and general

›Stability snapshot

›Temperature

›Mild to moderate fever in uncomplicated disease

›High fever as systemic marker

›Blood pressure

›SBP < 90 mmHg as alarm sign

›MAP < 65 mmHg

›Heart rate

›Tachycardia as toxicity marker

›Trend with resuscitation

›General appearance

›Well appearing in localized disease

›Stable vitals common

›Painless lesion despite striking appearance

›Toxic appearance in systemic disease

›Rigors and diaphoresis

›Altered mental status

Skin and lesion exam

›Classic lesion progression

›Early stage

›Pruritic papule

›Vesicle with clear or serosanguinous fluid

›Late stage

›Painless depressed black eschar

›Satellite vesicles at margin

›Surrounding edema

›Non-pitting and disproportionate to lesion size

04Differential Diagnosis/ddx44

Infectious mimics

›Bacterial skin infections

›Staphylococcal furuncle or carbuncle

›Typically painful and purulent

›No gelatinous edema

›Ecthyma and ecthyma gangrenosum

›Ecthyma gangrenosum in neutropenic hosts

›Pseudomonas bacteremia association

›Rat bite fever

›Eschar at bite site

›Systemic symptoms

›Zoonotic and travel related

›Tularemia ulceroglandular form

›Painful ulcer with lymphadenopathy

›Rabbit or tick exposure

›Cutaneous leishmaniasis

›Painless slowly evolving ulcer

›No black eschar

›Orf or ecthyma contagiosum

›Sheep or goat contact

›No large eschar or gelatinous edema

›Buruli ulcer

›Painless expanding ulcer

›Tropical freshwater exposure

›Rickettsial and other

›Scrub typhus and spotted fevers

›Eschar with fever

›Tick or mite exposure

05Laboratory Tests/lt45

Microbiologic studies

›Lesion sampling

›Vesicular fluid swabs

›Unroof vesicle and soak 2 dry swabs

›Positive in over 80% of untreated lesions

›Eschar edge swabs

›Rotate 2 moist swabs under eschar edge

›Avoid squeezing the lesion

›Gram stain of vesicular fluid

›Large gram-positive bacilli in chains

›Boxcar appearance

›Blood cultures

›Usually negative in uncomplicated disease

›Negative supports localized infection

›Obtain before antibiotics when feasible

›Positive result implications

›Indicates systemic dissemination

›Associated with mortality

Hematology and chemistry

›Complete blood count

›Often normal white count

›Mild leukocytosis possible

›Marked leukocytosis in systemic disease

›Hemoglobin and platelets

›Baseline for trend

›Thrombocytopenia with DIC

›Coagulation studies

›DIC screening when systemic disease suspected

06Diagnostic Tests/dt72

Scoring Systems

›Anthrax triage and severity tools

›CDC anthrax triage checklist

›Developed for mass exposure events

›Sensitivity approximately 95% for adult cases

›Clinical severity stratification

›Uncomplicated localized disease

›Complicated and systemic disease

›qSOFA for systemic illness

›RR >= 22 per minute

›SBP <= 100 mmHg

›Altered mental status

›Limitations

›No validated cutaneous-specific severity score

›Clinical trajectory supersedes single tools

›Exposure history central to diagnosis

›Triage tools for screening only

›Not a substitute for microbiologic confirmation

›ACEP Level C recommendation for adjunct use

MRI

›Soft tissue MRI role

›Limited acute utility

›Availability constraints

›Reserved for problem solving

›Problem solving indications

›Deep tissue edema extent

›Neck involvement near airway

›Contraindications

07Disposition/dispo43

Level of care selection

›Admission indications

›Extensive or malignant edema

›Head or neck involvement

›Airway compromise risk

›Systemic involvement

›High fever, hypotension, or tachycardia

›Bacteremia

›Neurologic symptoms suggesting meningitis

›Meningismus

›Altered mental status

›Inability to tolerate oral medications

›Persistent vomiting

›Need for parenteral therapy

›ICU indications

›Airway compromise

›Intubation or surgical airway need

›Malignant edema progression

›Septic shock

›Vasopressor requirement

›Rising lactate despite resuscitation

›Anthrax meningitis

›Seizure management

›Intracranial complication monitoring

Discharge criteria and follow up

›Outpatient criteria

›Uncomplicated localized lesion

›No systemic symptoms

08Treatment/t68

Initial stabilization and wound care

›Immediate measures

›ABC assessment

›Airway evaluation with head or neck edema

›IV access for systemic symptoms

›Resuscitation for systemic disease

›Balanced crystalloid for hypotension

›Vasopressors for refractory shock

›Wound management

›Conservative local care

›Keep lesion clean and covered

›Do not incise or debride eschar

›Avoid harmful manipulation

›No excision of eschar

›No squeezing of lesion

First-line antibiotics

›Naturally acquired uncomplicated disease

›Ciprofloxacin

›500 mg PO every 12 hours

›7 to 10 day course

›Doxycycline

›100 mg PO every 12 hours

›7 to 10 day course

›Duration principle

›Antibiotics prevent systemic spread

›Do not accelerate eschar healing

›Penicillin-susceptible isolates

›Penicillin V

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Antibiotic selection

›Ciprofloxacin preferred for life-threatening anthrax

›Avoid prolonged doxycycline due to fetal effects

›Severe disease management

›Do not withhold effective therapy for systemic anthrax

›Antitoxin when systemic disease present

›Maternal and fetal monitoring

›Maintain maternal SpO2 >= 95%

›Fetal monitoring when viable gestation

›Imaging approach

›Chest radiograph with shielding when indicated

›CT only when benefits outweigh risks

Geriatric

›Older adult features

›Atypical presentation

›Blunted fever response

›Delirium as early systemic clue

›Medication considerations

›Renal dosing adjustment for ciprofloxacin

›QT prolongation risk with fluoroquinolones

›Comorbidity impact

›Reduced physiologic reserve

›Lower threshold for admission

›Edema and airway risk

›Higher complication risk with head or neck disease

›Early airway planning

10Background/b44

Epidemiology

›Frequency and burden

›Most common form of anthrax

›Over 95% of all anthrax infections

›Spore inoculation through skin breaks

›Demographic pattern

›Male predominance approximately 79% in case series

›Occupational and agricultural exposure

›Mortality outcomes

›Untreated mortality 10% to 20%

›Near zero with appropriate antibiotics

Pathophysiology

›Organism and toxins

›Bacillus anthracis

›Spore-forming gram-positive rod

›Spores germinate after skin inoculation

›Virulence factors

›Edema toxin causing tissue edema

›Lethal toxin driving systemic toxicity

›Antiphagocytic capsule

›Poly-D-glutamic acid capsule

›Evades immune clearance

›Disease evolution

›Local lesion development

›Papule to vesicle to eschar

›Surrounding gelatinous edema from edema toxin

›Systemic dissemination pathway

›Lymphatic and hematogenous spread

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Cutaneous anthrax home care

›Take all antibiotics exactly as prescribed until finished

›Complete the full course even if the sore looks better

›Keep the sore clean and covered

›Do not pick, squeeze, or cut the black scab

›What to expect

›The black scab dries and falls off over about 2 weeks

›Most sores heal without scarring

›Anthrax is not spread person to person

›Return to ER immediately for

›Increasing swelling spreading to face, neck, or chest

›New fever, chills, or worsening tiredness

›Trouble breathing or swallowing

›Headache with neck stiffness or confusion

›New skin sores at other sites

›Follow up

›Clinician reassessment within 24 to 48 hours

›Repeat visits every 2 to 3 days until the scab loosens

›Tell close contacts to seek evaluation if exposed

12References/r12

Guidelines and key sources

›Guideline sources

›CDC Guidelines for the Prevention and Treatment of Anthrax 2023

›IDSA Skin and Soft Tissue Infection Guidelines 2014

›JAMA Anthrax as a Biological Weapon updated recommendations

›Evidence summaries

›NEJM Anthrax review and update articles

›Systematic review of hospital treatment outcomes for anthrax 1880 to 2018

›Retrospective study on corticosteroids and antibiotics in cutaneous anthrax

›Decision tools and coding

›CDC anthrax mass exposure triage checklist

›ICD-10 A22.0 cutaneous anthrax

›SNOMED CT cutaneous anthrax disorder concept

Evidence & Review

Evidence & Review