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article-28991_0	Inferior Shoulder Dislocations -- Continuing Education Activity	The glenohumeral joint of the shoulder is the most commonly dislocated joint in the body and accounts for approximately 50% of all major dislocations seen in the emergency department. Most shoulder dislocations are anterior, and inferior shoulder dislocations occur are much lower frequencies. Inferior dislocations are generally not difficult to diagnose as the classic presentation is not subtle and can often be made from the doorway of an exam room. This activity describes the pathophysiology, evaluation, and management of inferior shoulder dislocations and highlights the role of the interprofessional team in caring for patients with this condition.	Inferior Shoulder Dislocations -- Continuing Education Activity. The glenohumeral joint of the shoulder is the most commonly dislocated joint in the body and accounts for approximately 50% of all major dislocations seen in the emergency department. Most shoulder dislocations are anterior, and inferior shoulder dislocations occur are much lower frequencies. Inferior dislocations are generally not difficult to diagnose as the classic presentation is not subtle and can often be made from the doorway of an exam room. This activity describes the pathophysiology, evaluation, and management of inferior shoulder dislocations and highlights the role of the interprofessional team in caring for patients with this condition.
article-28991_1	Inferior Shoulder Dislocations -- Continuing Education Activity	Objectives: Identify the etiology of inferior shoulder dislocations. Describe the presentation of a patient with an inferior shoulder dislocation. List the treatment and management options available for inferior shoulder dislocations. Explain the importance of enhancing care coordination amongst interprofessional team members to optimize outcomes for patients with inferior shoulder dislocations. Access free multiple choice questions on this topic.	Inferior Shoulder Dislocations -- Continuing Education Activity. Objectives: Identify the etiology of inferior shoulder dislocations. Describe the presentation of a patient with an inferior shoulder dislocation. List the treatment and management options available for inferior shoulder dislocations. Explain the importance of enhancing care coordination amongst interprofessional team members to optimize outcomes for patients with inferior shoulder dislocations. Access free multiple choice questions on this topic.
article-28991_2	Inferior Shoulder Dislocations -- Introduction	The glenohumeral joint of the shoulder is the most commonly dislocated joint in the body and accounts for approximately 50% of all major dislocations seen in the emergency department. While anterior dislocations are very common and frequently seen in presentation, inferior shoulder dislocations have an incidence of about 1 in 200 (0.5%) of all dislocations. This is not subtle, and diagnosis usually can be made from the doorway of an exam room. [1] [2] [3]	Inferior Shoulder Dislocations -- Introduction. The glenohumeral joint of the shoulder is the most commonly dislocated joint in the body and accounts for approximately 50% of all major dislocations seen in the emergency department. While anterior dislocations are very common and frequently seen in presentation, inferior shoulder dislocations have an incidence of about 1 in 200 (0.5%) of all dislocations. This is not subtle, and diagnosis usually can be made from the doorway of an exam room. [1] [2] [3]
article-28991_3	Inferior Shoulder Dislocations -- Etiology	This type of dislocation is commonly referred to as luxatio erecta which means "erect dislocation" in Latin. This name derives from the typical way in which the arm is usually fully abducted and held above the head on presentation. [4] [5] [6]	Inferior Shoulder Dislocations -- Etiology. This type of dislocation is commonly referred to as luxatio erecta which means "erect dislocation" in Latin. This name derives from the typical way in which the arm is usually fully abducted and held above the head on presentation. [4] [5] [6]
article-28991_4	Inferior Shoulder Dislocations -- Etiology	The majority are traumatic such as when the rider falls and tumbles off a motorbike. The humerus neck is pushed against the acromion and there is usually inferior capsule tears. Soft tissue injury or fractures are common with inferior shoulder dislocation. In addition, neurovascular injury, including axillary nerve damage are not uncommon with these dislocations.	Inferior Shoulder Dislocations -- Etiology. The majority are traumatic such as when the rider falls and tumbles off a motorbike. The humerus neck is pushed against the acromion and there is usually inferior capsule tears. Soft tissue injury or fractures are common with inferior shoulder dislocation. In addition, neurovascular injury, including axillary nerve damage are not uncommon with these dislocations.
article-28991_5	Inferior Shoulder Dislocations -- Epidemiology	Although it accounts for less that one percent of all shoulder dislocations, when luxatio erecta occurs, it is much more frequent in men than in women with a reported ratio of approximately 10:1.	Inferior Shoulder Dislocations -- Epidemiology. Although it accounts for less that one percent of all shoulder dislocations, when luxatio erecta occurs, it is much more frequent in men than in women with a reported ratio of approximately 10:1.
article-28991_6	Inferior Shoulder Dislocations -- Pathophysiology	The upper extremity articulates with the axial skeleton through the joints of the shoulder girdle which includes the glenohumeral joint. The glenohumeral joint is a ball-and-socket joint that has the largest range of motion of any joint in the body. The glenoid fossa is about 1/3 the size of the humeral head articular surface and is extremely shallow, allowing for extraordinary mobility of the humeral head. A cartilaginous labrum along with muscular and tendinous attachments of the rotator cuff add to the stability of the joint, but given the above factors, dislocation is still a commonly encountered problem. Inferior dislocations frequently occur in patients who fall and grasp for an object overhead, hyperabducting the humeral neck against the acromion which forces the humeral head out of the socket, tearing the inferior capsule. This is typically associated with a serious injury to the shoulder complex. Also, high force trauma to the shoulder, such as that seen in motor vehicle crashes and falls from heights, also can result in dislocation, fracture, and other serious soft tissue and traumatic injuries. [7] [8]	Inferior Shoulder Dislocations -- Pathophysiology. The upper extremity articulates with the axial skeleton through the joints of the shoulder girdle which includes the glenohumeral joint. The glenohumeral joint is a ball-and-socket joint that has the largest range of motion of any joint in the body. The glenoid fossa is about 1/3 the size of the humeral head articular surface and is extremely shallow, allowing for extraordinary mobility of the humeral head. A cartilaginous labrum along with muscular and tendinous attachments of the rotator cuff add to the stability of the joint, but given the above factors, dislocation is still a commonly encountered problem. Inferior dislocations frequently occur in patients who fall and grasp for an object overhead, hyperabducting the humeral neck against the acromion which forces the humeral head out of the socket, tearing the inferior capsule. This is typically associated with a serious injury to the shoulder complex. Also, high force trauma to the shoulder, such as that seen in motor vehicle crashes and falls from heights, also can result in dislocation, fracture, and other serious soft tissue and traumatic injuries. [7] [8]
article-28991_7	Inferior Shoulder Dislocations -- History and Physical	A patient who has suffered an inferior dislocation usually will present with severe pain and the evaluation begins with a good history and physical exam. Details of the mechanism of injury may be important to determine other injuries to the soft tissues surrounding the shoulder. If the injury occurred in a high force trauma, you will want to evaluate for other traumatic injuries. If the injuries occurred through a simple fall while the arm was abducted, there is a potential injury to the inferior capsule of the joint. MRI post-injury commonly has revealed rotator cuff injuries, glenoid labrum injuries, bone bruises, and impaction fractures of the superolateral aspect of the humeral head.	Inferior Shoulder Dislocations -- History and Physical. A patient who has suffered an inferior dislocation usually will present with severe pain and the evaluation begins with a good history and physical exam. Details of the mechanism of injury may be important to determine other injuries to the soft tissues surrounding the shoulder. If the injury occurred in a high force trauma, you will want to evaluate for other traumatic injuries. If the injuries occurred through a simple fall while the arm was abducted, there is a potential injury to the inferior capsule of the joint. MRI post-injury commonly has revealed rotator cuff injuries, glenoid labrum injuries, bone bruises, and impaction fractures of the superolateral aspect of the humeral head.
article-28991_8	Inferior Shoulder Dislocations -- History and Physical	An inspection usually will reveal the classic appearance of the arm being fully abducted above the head with the elbow flexed at a 90-degree angle. You will want to assess for any distal neurovascular injuries, including assessment of the axillary nerve along with the radial and ulnar distributions of the brachial plexus, as these tend to occur in inferior dislocations. The patient will not be able to adduct the arm without significant pain, if at all. The examiner may be able to palpate the humeral head in the axilla or on the lateral chest wall. Keep in mind that a high index of suspicion must be maintained for other serious traumatic injuries to the thorax or abdomen if the dislocation involved high forces.	Inferior Shoulder Dislocations -- History and Physical. An inspection usually will reveal the classic appearance of the arm being fully abducted above the head with the elbow flexed at a 90-degree angle. You will want to assess for any distal neurovascular injuries, including assessment of the axillary nerve along with the radial and ulnar distributions of the brachial plexus, as these tend to occur in inferior dislocations. The patient will not be able to adduct the arm without significant pain, if at all. The examiner may be able to palpate the humeral head in the axilla or on the lateral chest wall. Keep in mind that a high index of suspicion must be maintained for other serious traumatic injuries to the thorax or abdomen if the dislocation involved high forces.
article-28991_9	Inferior Shoulder Dislocations -- Evaluation	The diagnosis is confirmed with standard radiographs of the shoulder. Pre- and post-procedure anterior-posterior (AP) and scapular "Y" view radiographs should be obtained. Axillary views, while helpful in anterior and posterior dislocations, will not show the humeral head to glenoid relationship; an overlapping of those structures would be evident if that view is obtained. Inferior dislocation can be associated with concomitant fractures and physical exam alone is unable to differentiate this. Typically, films will show the superior articular surface of the humeral head inferior to the glenoid fossa. On Scapular "Y" view the head of the humerus will be sitting inferior to the normal expected position in the center of the glenoid, represented by the "Y" of the scapula. If neurovascular injury is suspected, angiography or Doppler studies should be done. EMG may be used to assess nerve injury. MRI is frequently used to evaluate the extent of soft tissue injury.	Inferior Shoulder Dislocations -- Evaluation. The diagnosis is confirmed with standard radiographs of the shoulder. Pre- and post-procedure anterior-posterior (AP) and scapular "Y" view radiographs should be obtained. Axillary views, while helpful in anterior and posterior dislocations, will not show the humeral head to glenoid relationship; an overlapping of those structures would be evident if that view is obtained. Inferior dislocation can be associated with concomitant fractures and physical exam alone is unable to differentiate this. Typically, films will show the superior articular surface of the humeral head inferior to the glenoid fossa. On Scapular "Y" view the head of the humerus will be sitting inferior to the normal expected position in the center of the glenoid, represented by the "Y" of the scapula. If neurovascular injury is suspected, angiography or Doppler studies should be done. EMG may be used to assess nerve injury. MRI is frequently used to evaluate the extent of soft tissue injury.
article-28991_10	Inferior Shoulder Dislocations -- Treatment / Management	Treatment will usually require procedural sedation to get adequate muscle relaxation and facilitate a closed reduction via traction-counter-traction. In some cases, a "buttonhole" deformity exists (humeral head is trapped in a tear of the inferior capsule), in which case open reduction is required. To reduce an inferior shoulder dislocation, extend the arm at the elbow and then apply overhead traction in the longitudinal direction of the humerus, an assistant may also apply cephalad pressure over the humeral head to help guide it into the joint. If needed, counter-traction can be applied toward the patient's feet by wrapping a sheet over the shoulder allowing the force to be applied in the opposite direction.	Inferior Shoulder Dislocations -- Treatment / Management. Treatment will usually require procedural sedation to get adequate muscle relaxation and facilitate a closed reduction via traction-counter-traction. In some cases, a "buttonhole" deformity exists (humeral head is trapped in a tear of the inferior capsule), in which case open reduction is required. To reduce an inferior shoulder dislocation, extend the arm at the elbow and then apply overhead traction in the longitudinal direction of the humerus, an assistant may also apply cephalad pressure over the humeral head to help guide it into the joint. If needed, counter-traction can be applied toward the patient's feet by wrapping a sheet over the shoulder allowing the force to be applied in the opposite direction.
article-28991_11	Inferior Shoulder Dislocations -- Treatment / Management	After reduction, bring the abducted arm into adduction against the body while supinating the forearm. Alternatively, a two-step closed reduction technique can be utilized. Here, the inferior dislocation is first converted into an anterior dislocation before being reduced. One hand is on the shaft of the dislocated humerus and the other hand on the medial condyle. An anteriorly directed force on the shaft rotates the humeral head from an inferior to an anterior position. The humerus is then adducted and any of the common anterior reduction techniques can be used (e.g. traction-counter-traction, Stimson, Cunningham, etc.) to reduce the head of the humerus into the glenoid fossa. The advantages of the two-step maneuver are that it requires a single operator, fewer attempts, minimal force, and only local analgesia or minimal procedural sedation. Often a "clunk" is felt or heard as the humeral head returns to its normal anatomic position and the range-of-motion will once again be free allowing the arm to be adducted and the forearm supinated.	Inferior Shoulder Dislocations -- Treatment / Management. After reduction, bring the abducted arm into adduction against the body while supinating the forearm. Alternatively, a two-step closed reduction technique can be utilized. Here, the inferior dislocation is first converted into an anterior dislocation before being reduced. One hand is on the shaft of the dislocated humerus and the other hand on the medial condyle. An anteriorly directed force on the shaft rotates the humeral head from an inferior to an anterior position. The humerus is then adducted and any of the common anterior reduction techniques can be used (e.g. traction-counter-traction, Stimson, Cunningham, etc.) to reduce the head of the humerus into the glenoid fossa. The advantages of the two-step maneuver are that it requires a single operator, fewer attempts, minimal force, and only local analgesia or minimal procedural sedation. Often a "clunk" is felt or heard as the humeral head returns to its normal anatomic position and the range-of-motion will once again be free allowing the arm to be adducted and the forearm supinated.
article-28991_12	Inferior Shoulder Dislocations -- Treatment / Management	Once back into anatomical position the arm should be placed in a shoulder immobilizer to avoid recurring dislocation as the soft tissue and muscle stabilizers are injured and will be lax. After reduction is achieved another thorough neurovascular exam should be performed, most neuropraxia will resolve after reduction. Post-reduction x-rays are also usually done to confirm reduction and check for any procedural injuries. In rare cases, closed reduction is not possible (i.e. the "buttonhole deformity" discussed earlier) and an operative reduction must be performed. Indications for surgery include irreducible dislocation by closed techniques, open dislocation, and vascular injury.	Inferior Shoulder Dislocations -- Treatment / Management. Once back into anatomical position the arm should be placed in a shoulder immobilizer to avoid recurring dislocation as the soft tissue and muscle stabilizers are injured and will be lax. After reduction is achieved another thorough neurovascular exam should be performed, most neuropraxia will resolve after reduction. Post-reduction x-rays are also usually done to confirm reduction and check for any procedural injuries. In rare cases, closed reduction is not possible (i.e. the "buttonhole deformity" discussed earlier) and an operative reduction must be performed. Indications for surgery include irreducible dislocation by closed techniques, open dislocation, and vascular injury.
article-28991_13	Inferior Shoulder Dislocations -- Differential Diagnosis	Clavicular fracture Frozen shoulder Fracture of the humerus Rotator cuff tear	Inferior Shoulder Dislocations -- Differential Diagnosis. Clavicular fracture Frozen shoulder Fracture of the humerus Rotator cuff tear
article-28991_14	Inferior Shoulder Dislocations -- Prognosis	The majority of individuals who suffer inferior shoulder dislocation are young. A significant number of them will suffer a recurrent dislocation in the future. Rotator cuff tear is often the key pathology. Minor trauma accounts for the majority of recurrent dislocations. Some patients with pain may not be able to return to sporting activities and others may have restricted arm and shoulder use for 2-6 weeks. Recurrence rates among athletes vary from 30-90%.	Inferior Shoulder Dislocations -- Prognosis. The majority of individuals who suffer inferior shoulder dislocation are young. A significant number of them will suffer a recurrent dislocation in the future. Rotator cuff tear is often the key pathology. Minor trauma accounts for the majority of recurrent dislocations. Some patients with pain may not be able to return to sporting activities and others may have restricted arm and shoulder use for 2-6 weeks. Recurrence rates among athletes vary from 30-90%.
article-28991_15	Inferior Shoulder Dislocations -- Complications	Fracture Neurovascular injury Frozen shoulder Soft tissue injury	Inferior Shoulder Dislocations -- Complications. Fracture Neurovascular injury Frozen shoulder Soft tissue injury
article-28991_16	Inferior Shoulder Dislocations -- Pearls and Other Issues	Inferior shoulder dislocation injuries when due to a traumatic mechanism are almost always accompanied by moderate to severe soft tissue injury, proximal humerus fractures, avulsion fractures of the greater tuberosity, fractures of the acromion, clavicle, coracoid process, or glenoid rim, and rotator cuff tears. Rotator cuff and greater tuberosity fractures can occur in approximately 80% of patients. Neurovascular compromise may affect the axillary nerve and brachial plexus. About 60% of patients have neurologic dysfunction, with the axillary nerve most commonly injured. Arterial injury occurs in three percent of patients that presents with absent radial pulses. Neurologic dysfunction typically resolves with shoulder reduction as the brachial plexopathy is also reduced. Adhesive capsulitis and recurrent dislocations are known long term complications of all shoulder dislocations. Despite the associated injuries, in a case series of 11 patients all were treated with closed reduction techniques and no one had persistent instability at follow up.	Inferior Shoulder Dislocations -- Pearls and Other Issues. Inferior shoulder dislocation injuries when due to a traumatic mechanism are almost always accompanied by moderate to severe soft tissue injury, proximal humerus fractures, avulsion fractures of the greater tuberosity, fractures of the acromion, clavicle, coracoid process, or glenoid rim, and rotator cuff tears. Rotator cuff and greater tuberosity fractures can occur in approximately 80% of patients. Neurovascular compromise may affect the axillary nerve and brachial plexus. About 60% of patients have neurologic dysfunction, with the axillary nerve most commonly injured. Arterial injury occurs in three percent of patients that presents with absent radial pulses. Neurologic dysfunction typically resolves with shoulder reduction as the brachial plexopathy is also reduced. Adhesive capsulitis and recurrent dislocations are known long term complications of all shoulder dislocations. Despite the associated injuries, in a case series of 11 patients all were treated with closed reduction techniques and no one had persistent instability at follow up.
article-28991_17	Inferior Shoulder Dislocations -- Enhancing Healthcare Team Outcomes	An inferior shoulder dislocation is best managed by an interprofessional team that includes the orthopedic nurses and therapists. While the diagnosis of an inferior shoulder dislocation is relatively simple, clinicians should assess for any distal neurovascular injuries, including assessment of the axillary nerve along with the radial and ulnar distributions of the brachial plexus, as these tend to occur in inferior dislocations. The patient will not be able to adduct the arm without significant pain, if at all. The examiner may be able to palpate the humeral head in the axilla or on the lateral chest wall. Keep in mind that a high index of suspicion must be maintained for other serious traumatic injuries to the thorax or abdomen if the dislocation involved high forces. To ensure proper long term healing and to mitigate any associated disability, orthopedic referral should be recommended for all patients that have been dislocated and reduced. The outcomes in most patients are fair but recurrence is a common problem.	Inferior Shoulder Dislocations -- Enhancing Healthcare Team Outcomes. An inferior shoulder dislocation is best managed by an interprofessional team that includes the orthopedic nurses and therapists. While the diagnosis of an inferior shoulder dislocation is relatively simple, clinicians should assess for any distal neurovascular injuries, including assessment of the axillary nerve along with the radial and ulnar distributions of the brachial plexus, as these tend to occur in inferior dislocations. The patient will not be able to adduct the arm without significant pain, if at all. The examiner may be able to palpate the humeral head in the axilla or on the lateral chest wall. Keep in mind that a high index of suspicion must be maintained for other serious traumatic injuries to the thorax or abdomen if the dislocation involved high forces. To ensure proper long term healing and to mitigate any associated disability, orthopedic referral should be recommended for all patients that have been dislocated and reduced. The outcomes in most patients are fair but recurrence is a common problem.
article-28991_18	Inferior Shoulder Dislocations -- Review Questions	Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.	Inferior Shoulder Dislocations -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.
article-131243_0	Comprehensive Review of Bioterrorism -- Continuing Education Activity	Bioterrorism involves the deliberate release of bioweapons to cause death or disease in humans, animals, or plants. Biological weapons may be developed or used as part of a government policy in biological warfare or by terrorist groups or criminals. Biological weapons can initiate large-scale epidemics with an unparalleled lethality, and nation-states and terrorist groups have used dangerous and destructive Biological weapons in the past. This activity reviews the types, evaluation, and treatment of different biological weapons that have been used and has the potential to be used in bioterrorism attacks and discusses the role of the inter-professional team in evaluating and treating catastrophic events associated with bioterrorism.	Comprehensive Review of Bioterrorism -- Continuing Education Activity. Bioterrorism involves the deliberate release of bioweapons to cause death or disease in humans, animals, or plants. Biological weapons may be developed or used as part of a government policy in biological warfare or by terrorist groups or criminals. Biological weapons can initiate large-scale epidemics with an unparalleled lethality, and nation-states and terrorist groups have used dangerous and destructive Biological weapons in the past. This activity reviews the types, evaluation, and treatment of different biological weapons that have been used and has the potential to be used in bioterrorism attacks and discusses the role of the inter-professional team in evaluating and treating catastrophic events associated with bioterrorism.
article-131243_1	Comprehensive Review of Bioterrorism -- Continuing Education Activity	Objectives: Explain the definition of bioterrorism. Review the types of commonly used as well as potential bioweapons. Explain why health professionals need to be up to date in the workup and treatment of biological weapon-based attacks. Describe the types of bioterrorism events and discuss the role of the inter-professional team in evaluating and treating the victims of a potential bioterrorism attack. Access free multiple choice questions on this topic.	Comprehensive Review of Bioterrorism -- Continuing Education Activity. Objectives: Explain the definition of bioterrorism. Review the types of commonly used as well as potential bioweapons. Explain why health professionals need to be up to date in the workup and treatment of biological weapon-based attacks. Describe the types of bioterrorism events and discuss the role of the inter-professional team in evaluating and treating the victims of a potential bioterrorism attack. Access free multiple choice questions on this topic.
article-131243_2	Comprehensive Review of Bioterrorism -- Introduction	Biological weapons are devices or agents used or intended to be used in a deliberate attempt to disseminate disease-producing organisms or toxins using aerosol, food, water, or insect vectors. Their mechanism of action tends to be broadly through infection or intoxication. [1] Bioterrorism involves the deliberate release of bioweapons to cause death or disease in humans, animals, or plants. These biological agents can include bacteria, viruses, toxins, or fungi. [2]	Comprehensive Review of Bioterrorism -- Introduction. Biological weapons are devices or agents used or intended to be used in a deliberate attempt to disseminate disease-producing organisms or toxins using aerosol, food, water, or insect vectors. Their mechanism of action tends to be broadly through infection or intoxication. [1] Bioterrorism involves the deliberate release of bioweapons to cause death or disease in humans, animals, or plants. These biological agents can include bacteria, viruses, toxins, or fungi. [2]
article-131243_3	Comprehensive Review of Bioterrorism -- Introduction	Biological weapons may be developed or used as part of a government policy in biological warfare or by terrorist groups or criminals. Biological weapons can initiate large-scale epidemics with an unparalleled lethality, and nation-states and terrorist groups have used dangerous and destructive biological weapons in the past. [1] The degree of the potential damage, coupled with the unpredictable nature of these agents, has led to an increased interest by numerous countries, including the United States, in drawing up policies and guidelines in the event of such an attack to be prepared.	Comprehensive Review of Bioterrorism -- Introduction. Biological weapons may be developed or used as part of a government policy in biological warfare or by terrorist groups or criminals. Biological weapons can initiate large-scale epidemics with an unparalleled lethality, and nation-states and terrorist groups have used dangerous and destructive biological weapons in the past. [1] The degree of the potential damage, coupled with the unpredictable nature of these agents, has led to an increased interest by numerous countries, including the United States, in drawing up policies and guidelines in the event of such an attack to be prepared.
article-131243_4	Comprehensive Review of Bioterrorism -- Introduction	Keeping in mind the horrific nature of these agents, the Geneva protocol, first signed in 1925, and currently signed by 65 out of 121 country states, prohibited the development, production, and use of biological weapons in war. [3] However, not being country states, biological weapons to wage bioterrorism tend to be a relatively common choice for terrorist organizations. The relative ease with which the agents may be deployed, the devastating effects on the victims, and their inexpensive nature make them all more lucrative to these organizations. However, the unpredictable nature of these biological weapons means that they may affect both the intended victims and inadvertently affect friendly forces. Despite this drawback, terrorist organizations favor the use of biological weapons. [2]	Comprehensive Review of Bioterrorism -- Introduction. Keeping in mind the horrific nature of these agents, the Geneva protocol, first signed in 1925, and currently signed by 65 out of 121 country states, prohibited the development, production, and use of biological weapons in war. [3] However, not being country states, biological weapons to wage bioterrorism tend to be a relatively common choice for terrorist organizations. The relative ease with which the agents may be deployed, the devastating effects on the victims, and their inexpensive nature make them all more lucrative to these organizations. However, the unpredictable nature of these biological weapons means that they may affect both the intended victims and inadvertently affect friendly forces. Despite this drawback, terrorist organizations favor the use of biological weapons. [2]
article-131243_5	Comprehensive Review of Bioterrorism -- Introduction	Healthcare professionals need to be aware of the essentials of bioterrorism and biological weapons, as these may be used as part of a terrorist attack in any part of the world. Thus, healthcare professionals need to be trained and prepared in case of a potentially catastrophic event, where quick action and decision-making may potentially save lives. This article reviews the previous incidents of biological terrorism, types of biological weapons, evaluation of patients exposed to potential biological weapons, and treatment of patients who have been potentially exposed to the various commonly employed biological weapons. This article also aims to discuss an inter-professional team's role in evaluating and managing a bioterrorism attack. For this activity, bioterrorism's biological weapons have been broadly classified under four major headings, including bacterial agents, viral agents, fungal agents, protozoal agents, and toxins.	Comprehensive Review of Bioterrorism -- Introduction. Healthcare professionals need to be aware of the essentials of bioterrorism and biological weapons, as these may be used as part of a terrorist attack in any part of the world. Thus, healthcare professionals need to be trained and prepared in case of a potentially catastrophic event, where quick action and decision-making may potentially save lives. This article reviews the previous incidents of biological terrorism, types of biological weapons, evaluation of patients exposed to potential biological weapons, and treatment of patients who have been potentially exposed to the various commonly employed biological weapons. This article also aims to discuss an inter-professional team's role in evaluating and managing a bioterrorism attack. For this activity, bioterrorism's biological weapons have been broadly classified under four major headings, including bacterial agents, viral agents, fungal agents, protozoal agents, and toxins.
article-131243_6	Comprehensive Review of Bioterrorism -- Function	The Centers for Disease Control and Prevention (CDC) have classified biological weapons into three categories based on various factors, including the morbidity and mortality caused by the disease in humans: [2] Category A: Highest priority. Pose a risk to national security. They are easily transmitted from person to person and have high morbidity and mortality. They would have a major public health impact, cause panic, and result in special public health preparedness requirements. Category B: Second highest priority. These include diseases with lower morbidity and mortality as compared to category A. They are also more difficult to disseminate. Category C: Third highest priority. They have the potential to cause significant morbidity and mortality but consist mostly of emerging pathogens that could potentially be engineered for mass dispersion in the future.	Comprehensive Review of Bioterrorism -- Function. The Centers for Disease Control and Prevention (CDC) have classified biological weapons into three categories based on various factors, including the morbidity and mortality caused by the disease in humans: [2] Category A: Highest priority. Pose a risk to national security. They are easily transmitted from person to person and have high morbidity and mortality. They would have a major public health impact, cause panic, and result in special public health preparedness requirements. Category B: Second highest priority. These include diseases with lower morbidity and mortality as compared to category A. They are also more difficult to disseminate. Category C: Third highest priority. They have the potential to cause significant morbidity and mortality but consist mostly of emerging pathogens that could potentially be engineered for mass dispersion in the future.
article-131243_7	Comprehensive Review of Bioterrorism -- Function	For the purpose of this review, the biological weapons and agents which can be used in bioterrorism have been broadly classified as bacterial, viral, fungal, protozoal, and toxins. A brief overview of specific agents which have been used in prior attacks as well as have the potential to weaponized are discussed in this review. The agents being discussed are summarized below: [1] [4] [5]	Comprehensive Review of Bioterrorism -- Function. For the purpose of this review, the biological weapons and agents which can be used in bioterrorism have been broadly classified as bacterial, viral, fungal, protozoal, and toxins. A brief overview of specific agents which have been used in prior attacks as well as have the potential to weaponized are discussed in this review. The agents being discussed are summarized below: [1] [4] [5]
article-131243_8	Comprehensive Review of Bioterrorism -- Function	Bacterial: Bacillus anthracis (anthrax), Brucella species (brucellosis), Burkholderia mallei (glanders), Burkholderia pseudomallei (melioidosis), Franciscella tularensis (tularemia), Salmonella typhi (typhoid fever), and other Salmonella species (Salmonellosis), Shigella species (shigellosis), Vibrio cholerae (cholera), Yersinia pestis (plague), Rickettsial agents including Coxiella burnetii (Q fever), Rickettsia prowazekii (typhus fever), Rickettsia rickettsii (Rocky Mountain spotted fever), and Chlamydia psittaci (Psittacosis) . Viral: Variola major (Smallpox), viral hemorrhagic fevers, viral encephalitis. Fungal : Coccidiodes immitis (coccidioidomycosis), Histoplasma capsulatum (histoplasmosis). Protozoal: Cryptosporidium parvum (Cryptosporidiosis). Toxins: ricin, abrin, Clostridium perfringens toxins , Clostridium botulinum toxins, tetrodotoxin, nerve agents	Comprehensive Review of Bioterrorism -- Function. Bacterial: Bacillus anthracis (anthrax), Brucella species (brucellosis), Burkholderia mallei (glanders), Burkholderia pseudomallei (melioidosis), Franciscella tularensis (tularemia), Salmonella typhi (typhoid fever), and other Salmonella species (Salmonellosis), Shigella species (shigellosis), Vibrio cholerae (cholera), Yersinia pestis (plague), Rickettsial agents including Coxiella burnetii (Q fever), Rickettsia prowazekii (typhus fever), Rickettsia rickettsii (Rocky Mountain spotted fever), and Chlamydia psittaci (Psittacosis) . Viral: Variola major (Smallpox), viral hemorrhagic fevers, viral encephalitis. Fungal : Coccidiodes immitis (coccidioidomycosis), Histoplasma capsulatum (histoplasmosis). Protozoal: Cryptosporidium parvum (Cryptosporidiosis). Toxins: ricin, abrin, Clostridium perfringens toxins , Clostridium botulinum toxins, tetrodotoxin, nerve agents
article-131243_9	Comprehensive Review of Bioterrorism -- Issues of Concern	There have been numerous incidents in the past where bioweapons were used in biowarfare. The intentional use of biological weapons, including infectious agents during the war, led to a new and yet unknown threat. The initial and early attempts at using biological weapons in warfare date to the middle ages and included crude methods such as using cadavers and carcasses of humans and animals to contaminate water sources of enemy armies and enemy civilians during warfare. [1]	Comprehensive Review of Bioterrorism -- Issues of Concern. There have been numerous incidents in the past where bioweapons were used in biowarfare. The intentional use of biological weapons, including infectious agents during the war, led to a new and yet unknown threat. The initial and early attempts at using biological weapons in warfare date to the middle ages and included crude methods such as using cadavers and carcasses of humans and animals to contaminate water sources of enemy armies and enemy civilians during warfare. [1]
article-131243_10	Comprehensive Review of Bioterrorism -- Issues of Concern	One of the first reported instances of biological weapon use was as early as 600 BC. Solon used a purgative herb called hellebore during the siege of Krissa. [4] The ingestion of white hellebore (Veratrum Album L.) has been reported to cause nausea, vomiting, abdominal pain, bradycardia, and hypotension, with complete atrioventricular block reports in one patient who had accidental ingestion. [6]	Comprehensive Review of Bioterrorism -- Issues of Concern. One of the first reported instances of biological weapon use was as early as 600 BC. Solon used a purgative herb called hellebore during the siege of Krissa. [4] The ingestion of white hellebore (Veratrum Album L.) has been reported to cause nausea, vomiting, abdominal pain, bradycardia, and hypotension, with complete atrioventricular block reports in one patient who had accidental ingestion. [6]
article-131243_11	Comprehensive Review of Bioterrorism -- Issues of Concern	In 1155 AD, in Tortona, Italy, Emperor Barbarossa poisoned wells with human bodies. In 1346, the Tatar forces who were laying siege to the city of Kaffa (presently Feodosia, Ukraine) engaged in biological warfare by employing the use of catapulting people suffering from the bubonic plague over the walls of the city to initiate a bubonic plague epidemic in its inhabitants and weaken them. [1] [4] [7] This led to a bubonic plague outbreak followed by a retreat of the defending army and the subsequent conquest of Kaffa by the Tatars. Following this, ships carrying possibly bubonic plague-infected people and vectors (rats) sailed to Genoa, Constantinople, Venice, and other Mediterranean ports. This is thought to have directly contributed to the second plague pandemic, outlining the sheer destructive and unpredictable nature of biological weapons leading to unintended widespread disease. [8] In 1495, in Naples, Italy, the Spaniards mixed wine with blood from leprosy patients to sell to their French foes. [4] In 1710, similar to the events of 1346, Russian troops catapulted the bodies of bubonic plague victims into Swedish cities. [4]	Comprehensive Review of Bioterrorism -- Issues of Concern. In 1155 AD, in Tortona, Italy, Emperor Barbarossa poisoned wells with human bodies. In 1346, the Tatar forces who were laying siege to the city of Kaffa (presently Feodosia, Ukraine) engaged in biological warfare by employing the use of catapulting people suffering from the bubonic plague over the walls of the city to initiate a bubonic plague epidemic in its inhabitants and weaken them. [1] [4] [7] This led to a bubonic plague outbreak followed by a retreat of the defending army and the subsequent conquest of Kaffa by the Tatars. Following this, ships carrying possibly bubonic plague-infected people and vectors (rats) sailed to Genoa, Constantinople, Venice, and other Mediterranean ports. This is thought to have directly contributed to the second plague pandemic, outlining the sheer destructive and unpredictable nature of biological weapons leading to unintended widespread disease. [8] In 1495, in Naples, Italy, the Spaniards mixed wine with blood from leprosy patients to sell to their French foes. [4] In 1710, similar to the events of 1346, Russian troops catapulted the bodies of bubonic plague victims into Swedish cities. [4]
article-131243_12	Comprehensive Review of Bioterrorism -- Issues of Concern	In the 18th century, smallpox was a popular choice for biological weapons. [7] During the French and Indian War between 1754 to 1767, the commander of British forces in North America, Sir Jeffrey Amherst, employed the deliberate use of smallpox to "reduce" the populations of the Native American tribes who were hostile to the British. [7] A naturally occurring smallpox outbreak at Fort Pitt helped the British troops execute Amherst's plan by virtue of the generation of smallpox-laden fomites. In 1763, one of Amherst's subordinates, Captain Ecuyer, gave the Native Americans a handkerchief and a few blankets taken from the smallpox hospital. This resulted in an epidemic among the Native American tribes. [7] In 1797, Napoleon flooded the plains around Mantua in Italy to increase the spread of malaria. In the United States, in 1863, the Confederates sold clothing obtained from patients suffering from yellow fever and smallpox to Union troops during the Civil War. [4]	Comprehensive Review of Bioterrorism -- Issues of Concern. In the 18th century, smallpox was a popular choice for biological weapons. [7] During the French and Indian War between 1754 to 1767, the commander of British forces in North America, Sir Jeffrey Amherst, employed the deliberate use of smallpox to "reduce" the populations of the Native American tribes who were hostile to the British. [7] A naturally occurring smallpox outbreak at Fort Pitt helped the British troops execute Amherst's plan by virtue of the generation of smallpox-laden fomites. In 1763, one of Amherst's subordinates, Captain Ecuyer, gave the Native Americans a handkerchief and a few blankets taken from the smallpox hospital. This resulted in an epidemic among the Native American tribes. [7] In 1797, Napoleon flooded the plains around Mantua in Italy to increase the spread of malaria. In the United States, in 1863, the Confederates sold clothing obtained from patients suffering from yellow fever and smallpox to Union troops during the Civil War. [4]
article-131243_13	Comprehensive Review of Bioterrorism -- Issues of Concern	More recently, in the 20th century, biological weapons were reportedly used to a limited extent. Some evidence suggests that during World War I, Germany had developed a biological warfare program that planned on covert operations to infect the livestock and contaminate the animal feed, which was to be exported to the Allied forces from neutral countries. Reports circulated of attempts to ship cattle and horses inoculated with Bacillus anthracis (causing anthrax) and Burkholderia mallei (causing glanders) to the United States and other countries. [1] [4] These same organisms were also used to infect Romanian sheep, which were planned to be exported to Russia. There were also other allegations of attempts to spread the plague in Russia and cholera in Italy. Germany denied all such allegations of indulging in biological warfare. However, following these allegations, keeping in mind the horrific and unpredictable nature of these agents, the Geneva Protocol was signed in 1925, which prohibited the development, production, and use of Biological weapons in war. [3]	Comprehensive Review of Bioterrorism -- Issues of Concern. More recently, in the 20th century, biological weapons were reportedly used to a limited extent. Some evidence suggests that during World War I, Germany had developed a biological warfare program that planned on covert operations to infect the livestock and contaminate the animal feed, which was to be exported to the Allied forces from neutral countries. Reports circulated of attempts to ship cattle and horses inoculated with Bacillus anthracis (causing anthrax) and Burkholderia mallei (causing glanders) to the United States and other countries. [1] [4] These same organisms were also used to infect Romanian sheep, which were planned to be exported to Russia. There were also other allegations of attempts to spread the plague in Russia and cholera in Italy. Germany denied all such allegations of indulging in biological warfare. However, following these allegations, keeping in mind the horrific and unpredictable nature of these agents, the Geneva Protocol was signed in 1925, which prohibited the development, production, and use of Biological weapons in war. [3]
article-131243_14	Comprehensive Review of Bioterrorism -- Issues of Concern	During World War II, there were once again attempts made by various nation-states to indulge in the use of biological weapons. [1] Japan engaged in research related to biological weapons from 1932 until the end of World War II. The agents of interest to the Japanese biological weapons program included Bacillus anthracis, Vibrio cholerae, Shigella spp, Neisseria meningitidis, and Yersinia pestis . Between 1932 and 1945, more than 10,000 prisoners died due to experimental infection as part of this biological weapons research. A majority of these prisoners’ deaths were a direct consequence of experimental inoculation of biological weapons and pathogens, which caused anthrax, cholera, meningococcal infection, dysentery, plague, and so on. Research on tetrodotoxin (an extremely potent toxin derived from the ‘fugu’ fish) was conducted. [4] [5]	Comprehensive Review of Bioterrorism -- Issues of Concern. During World War II, there were once again attempts made by various nation-states to indulge in the use of biological weapons. [1] Japan engaged in research related to biological weapons from 1932 until the end of World War II. The agents of interest to the Japanese biological weapons program included Bacillus anthracis, Vibrio cholerae, Shigella spp, Neisseria meningitidis, and Yersinia pestis . Between 1932 and 1945, more than 10,000 prisoners died due to experimental infection as part of this biological weapons research. A majority of these prisoners’ deaths were a direct consequence of experimental inoculation of biological weapons and pathogens, which caused anthrax, cholera, meningococcal infection, dysentery, plague, and so on. Research on tetrodotoxin (an extremely potent toxin derived from the ‘fugu’ fish) was conducted. [4] [5]
article-131243_15	Comprehensive Review of Bioterrorism -- Issues of Concern	Prisoners in Nazi concentration camps in Germany were deliberately infected with Rickettsia prowazekii , Plasmodium species, and hepatitis A virus to be treated with experimental drugs and vaccines. [7] In England, experiments involving weaponized spores of Bacillus anthracis were conducted off Scotland's coast, which resulted in heavy contamination. Still, viable anthrax spores remained on the island until it was decontaminated with formaldehyde and seawater in 1986.	Comprehensive Review of Bioterrorism -- Issues of Concern. Prisoners in Nazi concentration camps in Germany were deliberately infected with Rickettsia prowazekii , Plasmodium species, and hepatitis A virus to be treated with experimental drugs and vaccines. [7] In England, experiments involving weaponized spores of Bacillus anthracis were conducted off Scotland's coast, which resulted in heavy contamination. Still, viable anthrax spores remained on the island until it was decontaminated with formaldehyde and seawater in 1986.
article-131243_16	Comprehensive Review of Bioterrorism -- Issues of Concern	In 1942, the United States initiated a biological warfare program. The program included research on B. anthracis and Brucella suis in various research facilities, including a development facility at Camp Detrick in Maryland, known today as the US Army Medical Research Institute of Infectious Diseases (USAMRIID). About 5000 bombs containing B. anthracis spores were developed at Camp Detrick, but since the facility lacked adequate safety measures, further production during World War II was stopped. [4] [7]	Comprehensive Review of Bioterrorism -- Issues of Concern. In 1942, the United States initiated a biological warfare program. The program included research on B. anthracis and Brucella suis in various research facilities, including a development facility at Camp Detrick in Maryland, known today as the US Army Medical Research Institute of Infectious Diseases (USAMRIID). About 5000 bombs containing B. anthracis spores were developed at Camp Detrick, but since the facility lacked adequate safety measures, further production during World War II was stopped. [4] [7]
article-131243_17	Comprehensive Review of Bioterrorism -- Issues of Concern	Post World War II, various other nation-states and organizations dabbled in developing biological weapons. By the 1960s, the United States military developed a large biological weapons arsenal that consisted of various biological pathogens, toxins, and fungal plant pathogens that could induce crop failure and result in subsequent famines. In 1972, a United States-based extremist group called themselves ‘Order of the Rising Sun’ was found to possess typhoid bacteria cultures intended to disseminate the water supplies of numerous major mid-western cities.	Comprehensive Review of Bioterrorism -- Issues of Concern. Post World War II, various other nation-states and organizations dabbled in developing biological weapons. By the 1960s, the United States military developed a large biological weapons arsenal that consisted of various biological pathogens, toxins, and fungal plant pathogens that could induce crop failure and result in subsequent famines. In 1972, a United States-based extremist group called themselves ‘Order of the Rising Sun’ was found to possess typhoid bacteria cultures intended to disseminate the water supplies of numerous major mid-western cities.
article-131243_18	Comprehensive Review of Bioterrorism -- Issues of Concern	In 1978, a Bulgarian exile, Georgi Markov, was assassinated in London in what later came to be known as the “umbrella killing” due to the murder weapon being a device hidden inside an umbrella. A tiny pellet was discharged into Markov’s leg at a bus stop in London. The next day, he became severely ill and died 3 days after the incident. 10 days before Markov’s assassination, an attempted assassination had occurred in Paris, France. Another Bulgarian exile, Vladimir Kostov, felt a sharp pain in his back in a metro stop in Paris. He reported seeing a man carrying an umbrella fleeing the scene. Two weeks later, after learning of Markov's assassination, Kostov was examined by a French medical team, and they extracted a similar pellet. It was made out of an alloy of platinum and iridium and contained the plant toxin ricin (made from castor beans).	Comprehensive Review of Bioterrorism -- Issues of Concern. In 1978, a Bulgarian exile, Georgi Markov, was assassinated in London in what later came to be known as the “umbrella killing” due to the murder weapon being a device hidden inside an umbrella. A tiny pellet was discharged into Markov’s leg at a bus stop in London. The next day, he became severely ill and died 3 days after the incident. 10 days before Markov’s assassination, an attempted assassination had occurred in Paris, France. Another Bulgarian exile, Vladimir Kostov, felt a sharp pain in his back in a metro stop in Paris. He reported seeing a man carrying an umbrella fleeing the scene. Two weeks later, after learning of Markov's assassination, Kostov was examined by a French medical team, and they extracted a similar pellet. It was made out of an alloy of platinum and iridium and contained the plant toxin ricin (made from castor beans).
article-131243_19	Comprehensive Review of Bioterrorism -- Issues of Concern	In 1979, there was an outbreak of anthrax in the Russian city of Sverdlovsk (now Yekaterinburg). The outbreak occurred in people close to a Soviet military microbiology facility (called Compound 19). As well as humans, livestock in the area also died of anthrax. The unintentional release of anthrax spores was thought to have resulted in a total of 66. [9] In 1980, the Baader-Meinhof group (also called the Red army faction) in Germany was found to have access to Clostridium botulinum cultures as well as to a biological laboratory. [1] In 1986, the Rajneesh cult in Dalles, United States, contaminated salad bars in local restaurants with a resulting 751 cases. The cult was attempting to prevent citizens from voting in an upcoming election. [1] [10]	Comprehensive Review of Bioterrorism -- Issues of Concern. In 1979, there was an outbreak of anthrax in the Russian city of Sverdlovsk (now Yekaterinburg). The outbreak occurred in people close to a Soviet military microbiology facility (called Compound 19). As well as humans, livestock in the area also died of anthrax. The unintentional release of anthrax spores was thought to have resulted in a total of 66. [9] In 1980, the Baader-Meinhof group (also called the Red army faction) in Germany was found to have access to Clostridium botulinum cultures as well as to a biological laboratory. [1] In 1986, the Rajneesh cult in Dalles, United States, contaminated salad bars in local restaurants with a resulting 751 cases. The cult was attempting to prevent citizens from voting in an upcoming election. [1] [10]
article-131243_20	Comprehensive Review of Bioterrorism -- Issues of Concern	From 1990 to 1994, a Japanese religious cult calling themselves Aum Shinrikyo (presently called Aleph) made nine failed attempts to release anthrax spores as well as an aerosol containing botulinum toxin in Tokyo with the intent to murder innocent civilians. [1] However, in 1995, they succeeded in releasing a nerve gas called sarin in Tokyo’s subway system, which resulted in the death of 12 people and injury to approximately 3,800 people. [9]	Comprehensive Review of Bioterrorism -- Issues of Concern. From 1990 to 1994, a Japanese religious cult calling themselves Aum Shinrikyo (presently called Aleph) made nine failed attempts to release anthrax spores as well as an aerosol containing botulinum toxin in Tokyo with the intent to murder innocent civilians. [1] However, in 1995, they succeeded in releasing a nerve gas called sarin in Tokyo’s subway system, which resulted in the death of 12 people and injury to approximately 3,800 people. [9]