Agents of biological warfare are unconventional weapons considered to be a modern threat in military and civilian settings. Although these agents are relatively inefficient as weapons on the modern battlefield, the relative ease in which they can be obtained, produced, and delivered makes them attractive to terrorist organizations, antagonistic foreign governments, and related entities. Several unique factors make biological warfare situations problematic for the trauma team. The presence of these toxic agents may remain unnoticed for days or weeks due to delayed onset of illness after exposure or when initially being overlooked as the effects of a natural endemic [13–15]. Multi-casualty or mass-casualty events of both victims of these toxic agents and the “worried well” may overwhelm healthcare facilities [13–15]. Patients may require critical decontamination to mitigate further effects of such poisoning to include preventing the spread of these agents to healthcare providers as secondary casualties [13–15]. Care of the trauma patient in the setting of biological warfare can be optimized by an understanding of some aspects of these rarely encountered agents as well as unique considerations of their impact to the trauma team dynamics.

Biological warfare agents are generally infectious and often living particles [13, 14]. Most of these entities can be categorized as bacterial, viral, or toxin in nature and are generally most efficiently weaponized as an aerosol (Table 31.2). There are a great number of bacterial organisms which include anthrax, cholera, and plague, while viral agents include smallpox and viral hemorrhagic fevers, and weaponized toxins include ricin and Clostridium botulinum spores. A myriad of physiological derangements may manifest after exposure to these agents and may complicate the spectrum of care of the trauma patient (Table 31.3).