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SUMMARY OF SECTION II

Avoidance by way of physical protection is the most
effective approach to biological warfare-agent exposure.
 Clinical recognition of symptoms and signs in mass
casualties may be the first indication of an attack. Patient
specimens (blood, urine) should not be a unique risk to medical
personnel, although vegetative anthrax, plague, or tularemia
organisms may be in blood. ,

PARALYSIS IN THE BW/CW SETTING

The differential diagnosis must include both botulinum and
nerve agent intoxications:

Nerve agent is rapid in onset (minutes to 1-2 hours). A
rigid paralysis develops with parasympathetic excess
(salivation, miosis, sweating, involuntary defecation, and
urination); central nervous system dysfunction and death
soon follow. If exposure is by aerosol or vapor,
constricted pupils, rhinorrhea, and broncho constriction
also occur.

Botulinum toxin is slower in onset (3 hours to several
days). Descending paralysis (bulbar to extremities to
respiratory) and parasympathetic blockade (dry mouth,
pupillary dilation, constipation, urinary retention, absence
of sweating) are characteristic. Paralysis, nausea,
vomiting, and diarrhea may, however, occur after exposure to
either nerve agent or botulinum toxin. Central signs
(confusion, seizure, coma) are rare after botulinum, but
common after nerve agent intoxication.

Anticholinergics, such as atropine can, of course, cause
central nervous system changes such as agitation, confusion,
and hallucinations as well as dry mouth, dry skin, and
constipation. These changes could easily obscure the
correct diagnosis in a soldier who used his injector even
without exposure to an agent.

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