EMT Ch. 41- Terrorism Response & Disaster Management

international/domestic terrorism

• involves violent/dangerous acts to human life violating federal/state law

• appears to be intended to intimidate/coerce a civilian population; influence policy of government; affect conduct of government by mass destruction, assassination, or kidnapping

common types of terrorist groups

• religious extremist/doomsday cults- may participate in apocalyptic violence

• extremist political groups- violent separatist groups seeking political, religious, economic, social freedom

• cyber terrorists- attack technological infrastructure to draw attention to cause

• single-issue groups- threaten violence for a specific cause

lone wolf terrorism

• deliberate creation/exploitation of fear through (threats of) violence committed by a single actor pursing political change linked to a formulated ideology

• motives may be unclear

• commonly targets schools, festivals, churches

• usually involves firearms, not explosives

acronym for active shooter response

THREAT

• threat suppression

• hemorrhage control

• rapid extrication to safety

• assessment by medical providers

• transport to definitive care

weapon of mass destruction (WMD)/weapon of mass casualty (WMC)

any agent designed to bring about mass death, casualties, massive damage to property/infrastructure

mnemonics for types of WMD

B-NICE

• biologic

• nuclear

• incendiary

• chemical

• explosive

CBRNE

• chemical

• biologic

• radiologic

• nuclear

• explosive

most common WMD used by terrorists

explosive

chemical agents

• manufactured substances that can have devastating effects on living organisms

• can be liquid, powder, vapor form

  • depends on desired route of exposure/dissemination technique

types of chemical agents

• vesicants (blister)

• respiratory (choking)

• nerve

• metabolic (cyanides)

biologic agents

• organisms that cause disease

• generally found in nature but cultivated, synthesized, & mutated in laboratory for terrorist use

weaponization

artificially maximize target population’s exposure to biologic agent

types of biologic agents

• viruses

• bacteria

• toxins

nuclear/radiologic agents

• less common, due to difficulty in securing materials

• can cause widespread panic & civil disturbances

observations for determining potential for terrorist attack

• type of location- monuments, infrastructure, government building, religious congregation, large gatherings, special events occuring

• type of call- report of explosions nearby, people fleeing scene

• number of pts- multiple victims w/ similar signs/symptoms

• victims’ statements- victims giving statements while fleeing scene

• preincident indicators- recent increase in violent political activism, credible threats made against location, gathering, occasion

best location for staging from an incident

upwind & uphill

secondary device

• device intended to primarily injure first responders & secure media coverage

• may be detonated by cell phones or pagers

cross-contamination

an uncontaminated person comes in contact w/ a contaminated person who has not yet been decontaminated

responsibilities of the first provider onscene

• establish command until additional personnel arrive

  • function as medical branch directors, triage supervisors, treatment supervisors, transportation supervisors, logistics officers, command/general staff

persistency/votality

describe how long a chemical agent will stay on a surface before evaporating

vesicants (blister agents)

• primary route of exposure- contact

• can enter respiratory tract if vapors are produced

• common agents include sulfur mustard (H), lewisite (L), phosgene oxime (CX)

• usually causes most damage to moist/damp areas of body (armpits, groin, respiratory tract)

signs/symptoms of vesicant exposure on skin

• skin irritation, burning, reddening

• immediate, intense skin pain (L, CX)

• formation of large blisters

• gray discoloration of skin (permanent damage, common w/ L, CX)

• swollen & closed or irritated eyes

• permanent eye injury (blindness)

signs/symptoms of vesicant exposure if inhaled

• hoarseness & stridor

• severe cough

• hemoptysis

• severe dyspnea

sulfur mustard (H) (mustard gas)

• vesicant with very persistent brownish, yellowish oily, appearance

• distinct smell of garlic or mustard

• quickly absorbed into skin/mucous membranes

  • begins irreversible damage to cells

• mutagen, attacks vulnerable cells within bone marrow, depletes body’s ability to produce white blood cells

• signs/symptoms usually begin to show 4-6 hrs after exposure (dependent on concentration)

  • progressive reddening of affected area, developing into blisters of similar shape/appearance as thermal second-degree burns

• complications include secondary infection, upper/lower airway compromise

lewisite (L) & phosgene oxime (CX)

• highly volatile vesicant w/ rapid onset of symptoms

• produce blister wounds very similar to H

• signs/symptoms include intense pain/discomfort upon contact, gray discoloration at affected site

• do not cause secondary cellular damage

vesicant agent treatment

• decontaminate pt prior to treatment

• provide prompt airway support if agent has been inhaled

• rapidly transport

  • burn centers are best for handling wounds/infections produced by vesivants

pulmonary agents (choking agents)

• primary route of exposure- inhalation

• cause immediate harm upon exposure

• produce respiratory related symptoms (dyspnea, tachypnea)

• damage lung tissue & causes fluid to leak into lungs, leading to pulmonary edema

• common agents include chlorine (Cl) & phosgene

chlorine (Cl)

• first chemical agent used in warfare

• distinct bleach odor, creates green haze when released as gas

• initially causes upper airway irritation & choking sensation

• signs/symptoms include SOB, chest tightness, hoarseness & stridor, gasping/coughing

• severe exposures may lead to pulmonary edema, complete airway constriction, death

phosgene (pulmonary)

• distinct odor similar to freshly mowed grass

• product of combustion produced by fire involving other chemicals

• very potent agent w/ delayed onset of symptoms

• does not produce severe irritation upon inhalation

• signs/symptoms of mild exposure include nausea, chest tightness, severe cough, dyspnea on exertion

• severe exposures may lead to dyspnea at rest, excessive pulmonary edema leading to hemoptysis, hypovolemia, & hypotension

pulmonary agent treatment

• remove from contaminated atmosphere

• aggressively manage ABCs

  • pay close attention to oxygenation, ventilation, suctioning

• have pt rest in position of comfort w/ head elevated

• rapidly transport

• provide continuous positive airway pressure

• do not allow pt to become active

nerve agents

• extremely toxic & rapidly fatal w/ any route of exposure

• can cause cardiac arrest within seconds of exposure

• discovered while in search of superior pesticide

• common agents include sarin (GB), soman (GD), tabun (GA), V agent (VX)

• cause similar/predictable symptoms despite varying routes of entry/types

sarin (GB)

• primarily a vapor hazard, main route of entry is respiratory

• highly volatile, colorless, odorless liquid

• turns from liquid to gas within seconds to minutes at room temp

• especially dangerous in enclosed environments

• quickly absorbed & evaporated when coming in contact w/ skin

  • immediate onset of symptoms

• has off-gassing effect when coming in contact w/ clothing

off-gassing

continuously releasing vapors over time

soman (GD)

• fruity odor, colorless

• twice as persistent as sarin, five times as lethal

• moderate volatility

• contact & inhalation hazard

• binds to cells & attacks faster than other agents (aging)

  • more difficult to treat exposed pts

  • immediate onset of symptoms

tabun (GA)

• fruity smell, colorless

• contact & inhalation hazard

• half as lethal as sarin, 36 times more persistent

  • immediate onset of symptoms

• low volatility

• will remain present for several days under proper conditions

• manufacturing components are easy to acquire & is easy to mnufacture

V agent (VX)

• odorless, clear, oily agent similar to baby oil

• primarily contact hazard, difficult to decontaminate

• 100 times more lethal than sarin, extremely persistent

  • most lethal chemical agent

• will remain relatively unchanged for weeks to months under proper conditions

• very low volatility

mnemonic for symptoms of exposure to nerve agents

SLUDGEM

• salivation, sweating, seizures

• lacrimation

• urination

• defecation, drooling, diarrhea

• gastric upset/cramps

• emesis

• muscle twitching, miosis

DUMBELS

• diarrhea

• urination

• miosis, muscle weakness

• bradycardia, bronchospasm, bronchorrhea

• emesis

• lacrimation

• seizures, salivation, sweating

most common symptom of nerve agent exposure

miosis

miosis will be seen quickly in a ___ exposure but may occur later after an isolated ___ exposure

vapor; contact

nerve agent treatment

• decontaminate

• aggressively manage ABCs

• administer duodote (atropine & pralidoxime chloride)

metabolic agents (cyanides)

• colorless gas w/ odor similar to bitter almonds

• effects can be rapidly seen at organ/systemic levels

• common in industrial settings (mining, photography, plastics processing)

• common agents include hydrogen cyanide (AC) & cyanogen chloride (CK)

• death is likely unless treated promptly

signs/symptoms of low dose exposures to cyanides

• dizziness

• lightheadedness

• headache

• vomiting

signs/symptoms of high dose exposures to cyanides

• SOB, gasping respirations

• respiratory distress/arrest

• tachypnea

• flushed skin

• tachycardia

• AMS

• seizures

• coma

• apnea

• cardiac arrest

cyanide agent treatment

• remove from contaminated area

• decontaminate by removing all clothing

• manage ABCs

  • always use BVM or ventilator to ventilate pt

• rapidly transport

biologic agents

• can be almost completely undetectable

  • effects similar to other common minor illness

• grouped as viruses, bacteria, neurotoxins

dissemination

means by which a terrorist spreads an agent

disease vector

animal that spreads disease after being infected

incubation

time between person being exposed to agent & appearance of first symptoms

viruses

• germs requiring a living host to multiply & survive

• invades healthy cells & replicates to spread through host

• commonly spread through respiratory droplets or vectors

• potential agents include smallpox, viral hemorrhagic fevers

smallpox

• highly contagious disease

• transmitted through inhalation of coughed droplets, direct skin contact

• signs/symptoms begin w/ high fever, body aches, headaches

  • develops into rash/blisters

    • all lesions are identical in development

    • begin on face/extremities & move towards trunk

• most contagious when blisters begin to form

• other signs/symptoms include bleeding of skin/mucous membranes

• incubation period 10-12 days

• duration of illness 4 weeks

• provide supportive care of ABCs

viral hemorrhagic fevers

• group of diseases caused by viruses including ebola, rift valley, marburg, & yellow fever viruses

• transmitted through direct contact w/ infected bodily fluids, droplets

• causes blood in body to seep out from tissues/blood vessels

• signs/symptoms begin w/ flu-like symptoms (fever, weakness, muscle pain, headache, sore throat)

  • develops to internal/external hemorrhaging & vomiting

• provide supportive care of ABCs, treat for shock/hypotension if present

bacteria

• single-celled microorganisms

• do not require host to live/multiply (self-sufficient)

• most infections can be treated w/ antibiotics

• signs/symptoms begin w/ flu-like symptoms

  • difficult to differentiate between biologic attack & natural infection

• common agents include pulmonary/cutaneous anthrax, bubonic/pneumonic plague

pulmonary/cutaneous anthrax

• caused by deadly bacteria that lie dormant in a spore

  • germ is released when exposed to optimal temp/moisture

• routes of transmission are inhalation, cutaneous, gastrointestinal

  • deadliest form is pulmonary (90% death rate if untreated)

    • presents as severe cold

• general signs/symptoms include flu-like symptoms, fever, respiratory distress w/ tachycardia, shock, pulmonary edema, respiratory failure

• provide supportive care for ABCs

  • (pulmonary) ventilatory support if pt has pulmonary edema or respiratory failure

  • (cutaneous) apply dry sterile dressing to prevent accidental contact

bubonic plague

• carried by rodents, fleas

• infects lymphatic system

  • lymph nodes become infected & become enlarged, forming buboes

• if left untreated, may spread through entire body & lead to sepsis & death

• provide supportive care for ABCs, oxygen if indicated, rapidly transport

pneumonic plague

• lung infection resulting from inhalation of plague bacteria

• higher death rate than bubonic form

• provide supportive care for ABCs, oxygen if indicated, rapidly transport

neurotoxins

• deadliest substances known to humans

• produced from plants, marine animals, molds, bacteria

• route of transmission is ingestion, inhalation, injection

• not contagious, more rapid onset of symptoms

• common agents include botulinum toxin, ricin

botulinum toxin (botox)

• most potent neurotoxin

• route of entry is ingestion, inhalation

• affects nervous system function

  • voluntary muscle control diminishes as toxin spreads

  • may lead to muscle paralysis beginning at head & spreading downward

    • paralyzes diaphragm & leads to respiratory arrest

• signs/symptoms include dry mouth, intestinal obstruction, urinary retention, constipation, nausea/vomiting, abnormal pupil dilation, blurred vision, double vision, drooping eyelids, difficulty swallowing, difficulty speaking, respiratory failure

• provide supportive care of ABCs, ventilatory support in case of paralysis of respiratory muscles, rapidly transport

ricin

• derived from mash left from castor bean

• routes of entry are inhalation, ingestion, injection

  • most toxic by inhalation

  • least toxic by ingestion

• causes pulmonary edema, respiratory/circulatory failure, death

• signs/symptoms appear 4-8 hrs after exposure

• inhalation leads to nonspecific weakness, cough, fever, hypothermia, hypotension

• ingestion leads to rapid onset of nausea, vomiting, abdominal cramps, severe diarrhea, followed by vascular collapse

• injected signs/symptoms include swelling at injection site, death

• provide supportive care of ABCs

signs/symptoms of ricin ingestion

• fever

• chills

• headache

• muscle aches

• nausea

• vomiting

• diarrhea

• severe abdominal cramping

• dehydration

• gastrointestinal bleeding

• necrosis of liver, spleen, kidneys, gastrointestinal tract

signs/symptoms of ricin inhalation

• fever

• chills

• nausea

• local irritation of eyes, nose, throat

• profuse sweating

• headache

• muscle aches

• nonproductive cough

• chest pain

• dyspnea

• pulmonary edema

• severe lung inflammation

• cyanosis

• seizures

• respiratory failure

syndromic surveillance

monitoring (usually by local/state health departments) of pts presenting to emergency departments & alternative care facilities

points of distribution (PODs)

existing facilities used as mass distribution sites for antibiotics, antidotes, vaccinations, & other medications/supplies during emergencies

ionizing radiation

• energy emitted in the form of rays or particles

• commonly found in radioactive material

alpha radiation

• least harmful penetrating type of radiation

• cannot penetrate through most objects

  • can be stopped by a piece of paper

beta radiation

• slightly more penetrating form of radiation

• requires a layer of clothing to stop

gamma rays

• more powerful/faster traveling form of radiation

• can penetrate through human body

  • require lead or several inches of concrete to stop penetration

neutron radiation

• among most powerful forms of radiation

• can easily penetrate through lead & require several feet of concrete to stop

common locations where radioactive waste is found

• hospitals/other healthcare facilities w/ radiology departments

• colleges/universities

• nuclear power plants

• chemical/industrial sites

radiologic dispersal device (dirty bomb)

• any container designed to disperse radioactive material, generally w/ a bomb

• destructive capability is limited to the explosives & objects attached to it

signs/symptoms of acute radiation toxicity

• low exposure- nausea, vomiting, diarrhea, dizziness, headache

• moderate exposure- first-degree burns, hair loss, compromised immune system (WBC death), cancer

• severe exposure- second/third-degree burns, cancer, death

protective measures for radioactive situations

• time- limit duration of exposure

• distance- type of radiation (alpha, beta) & distance it can travel

• shielding- use concrete shielding between self & incident

incendiary devices

weapons used to start fires (molotov cocktails, flamethrowers, chemicals)

most common cause of death from blast injury

blast lung

The 1996 Summer Olympics bombing is an example of:

domestic terrorism

The chemical attacks that occurred in Tokyo between 1994 & 1995 were carried out by a(n):

violent religious group

Terrorist attacks:

pose a threat to nations & cultures everywhere

Most terrorist attacks are:

covert

As you & your partner report for duty, you check your ambulance & begin talking about the possibility of a terrorist attack. The most effective & appropriate way to determine the likelihood of this happening is to:

know the current threat level issued by the Department of Homeland Security

In determining the potential for a terrorist attack, you should routinely observe all of the following on every call, except:

weather conditions

You are dispatched to the scene of a building explosion. Upon arrival, you see people frantically fleeing the building, screaming, "Everyone is passing out!" You should:

carefully assess the situation & ensure your own safety

The EMT should expect that a patient who was exposed to cyanide will have:

a normal pulse oximetry reading

You & your partner arrive at the scene of a fire at a large office complex. Witnesses tell you that they heard a loud explosion shortly before the building caught fire. You should:

ensure that your ambulance is parked upwind & uphill from the building

As the first arriving emergency responder at the scene of a suspected terrorist or weapon of mass destruction incident, you should request additional resources as needed & then:

function as the incident commander until additional personnel arrive

Continual reassessment of the scene at a suspected terrorist or weapon of mass destruction incident is most important because:

a secondary explosive device might detonate

A persistent or nonvolatile chemical agent can:

remain on a surface for more than 24 hours

Which of the following statements regarding the persistency & volatility of a chemical agent is correct?

VX, a highly persistent nerve agent, can remain in the environment for weeks to months

The primary route of exposure of vesicant agents is the:

skin

Exposure to _________ would most likely result in immediate respiratory distress.

chlorine

When multiple patients present with an acute onset of difficulty breathing, chest tightness, & hoarseness or stridor, you should be most suspicious of exposure to:

phosgene or chlorine

Signs & symptoms of exposure to a nerve agent include:

salivation, pinpoint pupils, & diarrhea

Multiple people in a small town began experiencing abdominal cramps, excessive salivation & urination, & muscle twitching shortly after a small crop duster plane made several passes over the community. As you are assessing the patients, you further determine that most of them are bradycardic & have miosis. In addition to high-flow oxygen, the most appropriate treatment for these patients includes:

atropine & pralidoxime chloride

You are treating a patient who experienced a significant exposure to cyanide. He is semiconscious & is breathing inadequately. The most appropriate method of providing assisted ventilations to this patient is to:

use a bag-valve mask

The primary clinical feature associated with exposure to phosgene oxime is:

skin blistering

Unlike bacterial agents, viral agents:

are usually not treatable

A 52-year-old male presents with a fever of 102.5°F & a severe headache. As you assess him, you note the presence of multiple blisters on his face & chest, which are all identical in shape & size. This patient's clinical presentation is most consistent with:

smallpox

Initial signs & symptoms associated with viral hemorrhagic fevers include:

headache & sore throat

Which of the following statements regarding anthrax is correct?

Pulmonary anthrax is the deadliest form

Most cases of anthrax begin with:

flulike symptoms

After eating at a local restaurant, a 20-year-old male complains of blurred vision, difficulty speaking, & difficulty breathing. He is conscious; however, his respirations are profoundly labored & producing minimal tidal volume. You should:

assist his ventilations with high-flow oxygen

When introduced into the body, ricin causes:

pulmonary edema & circulatory failure

Which of the following statements regarding a "dirty bomb" is correct?

Dirty bombs could injure victims with both radioactive material & the explosive material used to deliver it