Page 99 - Journal of Special Operations Medicine - Winter 2016

However, it should also be noted that Brucella spp., a end, a broad-spectrum antibiotic is typically included in
highly pathogenic group of organisms, tends to localize the combat pill pack. However, this treatment should
20
in animal testes. Although it is unknown whether the not replace the techniques of proper cleaning, irrigation,
7
bomber intended to cultivate Brucella spp., the use of and debridement, which are essential components of
testes in the mixture is concerning because Brucella has wound care. 17,21 It should be noted that fecal material
long been considered a potential biological weapon. is a potential source for antibiotic-resistant bacteria.
22
8
This is because it can be transmitted via the aerosol Therefore, all suspected exposures and wounds result-
route and because it can cause a debilitating infection ing from a biological dirty bomb detonation should be
in an immunocompetent host with as few as 10 organ- documented on the tactical combat casualty card and
isms. In addition, Brucella produces toxins that sup- communicated to providers at each successive echelon
8
press the immune response, an activity that may serve of care so that bacterial culture and antibiotic sensitivity
to exacerbate the effects of the other bacterial species studies can be performed and the results used to guide
in the mixture, delay wound healing, and increase the treatment. 23,24
probability of a negative outcome. 9

Conclusion
Historical Precedent
Although the insertion of fecal matter and animal tis-
The development of such a “low-tech” device is reminis- sues into a terrorist’s bomb may, at first glance, seem to
cent of the use of “punji sticks” during the Vietnam con- be a simple and insignificant development, there is an
flict. Typically consisting of a sharpened stick smeared underlying complexity to these materials that can pose a
10
with feces, these implements were responsible for many significant threat to military personnel. This complexity
of the penetrating and perforating wounds that were en- arises because the fecal and animal tissue components
countered by military medical personnel. If the use of of these materials harbor numerous pathogenic bacte-
10
such devices becomes more frequent, it will be essential ria capable of magnifying the morbidity and mortality
that Special Operations medical personnel understand of injuries sustained during detonation. To reduce the
the complexity of these devices, that they avoid direct impact of these devices on military personnel, it is essen-
contact with them, and that they decontaminate them- tial that providers understand and recognize the threat,
selves if contact is unavoidable. Further, if a patient is identify incidents of potential exposure, promptly com-
suspected to have been the victim of one of these de- municate all potential exposures to the healthcare team,
vices, it is necessary that this suspicion is communicated and adhere to the previously established principles of
to the hospital staff so that the appropriate antibiotic wound care.
treatment and diagnostic testing procedures can be initi-
ated. During the Vietnam conflict, it was found that fol-
lowing the general principles of war wound treatment References
such as adequate debridement, open wound creation, 1. Norman L. 2016, April 9 Belgian suspect Ameroud said to
irrigation, and the use of prophylactic antibiotics was have carried potentially toxic material. Wall Street Journal.
adequate for the treatment of punji stick injuries. Ex- Retrieved from http://www.wsj.com/articles/belgian-suspect
10
perience will determine whether these methods are ad- -ameuroud-said-to-have-carried-potentially-toxic-material
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equate for the treatment of contaminated blast injuries 2. Rigottier-Gois L, Le Bourhis AG, Geneviève G, et al. Fluores-
caused by biological “dirty bombs.” cent hybridisation combined with flow cytometry and hybridi-
sation of total RNA to analyse the composition of microbial
communities in human faeces using 16S rRNA probes. FEMS
Recommendations Micro Ecol. 2003;43:237–245.
The detonation of an improvised explosive device can 3. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology.
Philadelphia, PA: Elsevier Health Sciences; 2015.
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induced barotrauma to deep penetrating injury. It has ogy and associated approaches to wound management. Clin
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accepted that all combat wounds are susceptible to infec- Micrbiol Rev. 2001;14:244–269.
tion. 12–14 Although some bacteria may die from the blast 5. Ott SJ, Musfeldt M, Ullmann U, et al. Quantification of intes-
and heat of an explosive detonation, it can be expected tinal bacterial populations by real-time PCR with a universal
primer set and minor groove binder probes: a global approach
that wounds resulting from a biological dirty bomb will to the enteric flora. J Clin Microsc. 2004;42:2566–2572.
have an increased likelihood of bacterial contamina- 6. Claros MC, Citron DM, Goldstein EJ. Survival of anaerobic
tion. Nonetheless, the current principles of tactical com- bacteria in various thioglycolate and chopped meat broth for-
bat casualty care should be adhered to in all cases. 15–17 mulations. J Clin Microsc. 1995;33:2505–2507.
Because animal studies have indicated that antimicro- 7. Wanke MM. Canine brucellosis. Anim Reprod Sci. 2004;82:
195–207.
bial therapy reduces progression to sepsis, prophylaxis 8. Pappas G, Panagopoulou P, Christou L, et al. Biological weap-
should be administered as soon as possible. 18,19 To this ons. Cell Mol Life Sci. 2006;63:2229–2236.

Hidden Complexity of Biological “Dirty Bombs” 83