Here are some practical pearls for identification, diagnosis, and management of multiple casualty incidents related to toxins:

• Identification of patients suffering from atypical toxidromes involves a high degree of clinical suspicion.
• Neurotoxins can produce varying degrees of impairment, with a few having recognizable patterns of spread. Clostridium botulinum intoxication in adults affects central systems.
• Early establishment of the HICS and an incident action plan, crafted by emergency physicians and others, is critical.
• In an event that involves an unusual disease and a critical clinical evaluation, a small number of clinicians should manage as many patients as possible.
• Medical care plans should be coordinated with the local specialists by having a face-to-face discussion supplemented by disease experts using video and audio links, if needed. In this case, CDC expertise was needed to coordinate the use and release of the antitoxin, and this could be provided efficiently using phone conferences.
• Certain events require an active process of victim identification and notification, and those events must have timely alerting of regional law enforcement, fire, EMS, and public health resources.

Dr. Augustine is director of clinical operations at EMP in Canton, Ohio; clinical associate professor of emergency medicine at Wright State University in Dayton, Ohio; vice president of the Emergency Department Benchmarking Alliance; on the ACEP Board of Directors; and an ACEP Now editorial advisory board member. Dr. Scott is the emergency department assistant director at Fairfield Medical Center in Lancaster, Ohio.