# Medical. : "Theoretical" case of interest



## Pacer (Jan 31, 2010)

Any body want to play?
You and your mates have just returned from a recon mission, and have been sked for 24 rehab before redploy.
You get to eat at the base camp, which, for the purposes of the scenario, has some local refuggees in support roles.
Shower, hot meal, and rack time. Maybe even a brew.

At muster the next am, some 12 hours after arrival, 2 members of your squad are on sick call with nausea, abdominal pain, feeling of constipation, and double vision.

Appropriate historical questions, physical exam queries, reaction plan, and DiffDx, please.


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## Muppet (Jan 31, 2010)

I will attempt to play:

(S): Already stated. 2 members are sick with what appears to be gastroenteritis but with double vision and no diarrhea but constipation. How did the mission go. What did they eat and drink on the mission. ALL shots up to date. What A.O. are they in? Where did they bathe? Who is cooking the food back @ basecamp? What did they eat @ base camp? What kind of beer did they drink, local made / moonshine? Other people feeling like this?

(O): Standard p/e shows: Nausea, abd. pain, consitpation and diplopia. Other exam I assume are normal?

(A): Got me. Any of 100 poss. d/x., I am doing homework now.

(P): A.B.C.'s intact, ECG if I have it, blood tests and hopefully a Batt surg or P.A. to consult. I.V. fluids for rehydration if needed, hemocult to check for trace bleeding inside. Transfer out to difinitive care if I can.

I will do more homework and get back to this.

F.M.


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## Muppet (Jan 31, 2010)

So I was thinking. 2 things come to mind of assessment:
(1): Food poision / Botulism and (2): Chemical poisoning from the ETOH?

F.M.


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## Pacer (Feb 3, 2010)

Good.

Onset 12-72 hours after INGESTION of Botulism toxin will cause GI upset, gut paralysis (ileus) resulting in constipation. hallmark  signs for presumptive diagnosis is diploplia (double vision), ptosis (sagging eyelid), dysparthria, dysphagia (trouble swallowing), and weakness WITHOUT FEVER and with NORMAL SENSORIUM.

These may be the first two, many others, in fact most others, that have the same exposure will beome symtomatic.

So where does Botulinum toxin come from, how is the toxin destroyed, and what is the immediate vs definitive treatment, and HOW WILL YOU obtain that treatment?


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## policemedic (Sep 25, 2010)

So, admittedly I'm coming in late but...

C botulinum is a gram-positive rod that can be found in dirt.  There it lives, happy in its anaerobic environment, enthusiastically producing an exotoxin that is very, very nasty.  There is an immunization that requires three doses, but if memory serves, it doesn't cover every variety.

Essentially, it interferes with ACH.  The anticholinergic symptoms presented above are classic for botulism.

Because it lives in dirt (and doesn't have a geographical preference), it can contaminate food grown in that dirt.  Add poor food handling, and you can have a nice outbreak.  Of course, it can be present in fish and some other snacks.

In addition to the excellent questions FM asked, I'd want to know if these men had been wounded, scratched, etc., and if so, was it in the same geographic area.  I'm looking for wound botulism vs. foodborne botulism; abx vs. HBAT.  I'd also want a good CN/neuro exam.  +/- bowel sounds? A patient with + BS can be purged somewhat if it's foodborne.  

Given the rapid onset, I'm leaning toward foodborne botulism toxin A or B.  Question of the day is, how did it get introduced into the troop's food?  Was it deliberate, or poor food handling?  Who else may have been exposed?  Are they accounted for?

If it were wound botulism, abx are no problem.  I've got an aid bag full of PO and IV abx that will kill C botulinum.  Make an incision, debride the wound, hit them with PCN, Clindamycin, or even Flagyl, monitor them carefully and get them to a higher level of care which hopefully has HBAT.

For foodborne botulism at this stage, I'd consider charcoal/sorbitol, an enema, HBAT if it were available (and it's likely not, so evac to a higher level of care), blood and stool samples, and very close monitoring.  

In an ideal world, I'd want EtCO2 monitoring, SaO2, the works on these folks.  An ABG would be great, but... Not likely out in DurkaDurkastan.

As the paralysis progresses and dysphagia becomes more pronounced, or I see signs of hypoxia, I'd seriously consider RSI and mechanical ventilation, though this is of course problematic with several pts and limited resources.

Botulism isn't hard to cultivate, and would cause a serious problem if unleashed as a bio-weapon.


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