Chapter 41: Terrorism Response and Disaster Management

What Is Terrorism?

• Terrorist forces have been at work since early civilizations.

• Terrorism involves —- acts or acts —- to human life that violate federal or state law and appears to be intended to: 

  • Intimidate or coerce a —— population

  • Influence the —- of a government by intimidation or coercion

  • Affect the —- of a government by mass destruction, assassination, or kidnapping

• International terrorism occurs primarily —- of the United States. 

• — terrorism occurs primarily within the United States.

• Only a small percentage of groups actually turn to terrorism to achieve their goals.

• Religious extremist groups/doomsday cults

  • May participate in — violence

• Extremist political groups

  • Seek political, religious, economic, and social —-

• Cyber terrorists

  • Attack a population’s — infrastructure

• Single-issue groups

  • Include antiabortion groups, animal rights groups, anarchists, racists, ecoterrorists

violent, dangerous, civilian, policy, conduct

outside, domestic

apocalyptic, freedom , technological

Active Shooter Events

• “Lone wolf” terrorist attack

  • Frequent threat in the United States

  • Motives of the attacker are not always clear.

• Attacks may target

  • Schools

  • Music festivals

  • Shopping centers

• Many lone wolf terrorist attacks involve —- rather than —-.

• This has prompted discussion of:

  • Gun laws

  • Mental health

  • Education of the public and first responders on how to treat casualties 

firearms, explosives

Active Shooter Events

• Hartford Consensus recommends using the acronym THREAT:

  • Threat —

  • H—— control

  • Rapid extrication to safety

  • A—- by medical providers

  • T—- to definitive care

• EMS crews may be equipped with ballistic vests and helmets. 

• May be paired with law enforcement to assist with the —- and —- of injured people form an active scene

• Interagency training is a key component.

suppression, hemorrhage, assessment, transport

treatment evacuation

Weapons of Mass Destruction

• Also called weapons of — —

• Any agent designed to bring about:

  • Mass death

  • Casualties

  • Massive damage to property and infrastructure

• B-NICER and CBRNE are mnemonics for the kinds of WMDs.

• B-NICER

  • —

  • —

  • —

  • —

  • —

  • — 

• CBRNE

  • Chemical

  • Biologic

  • Radiologic

  • Nuclear

  • Explosive

mass causality,

Biologic, nuclear incendiary chemical explosive radiologic 

Weapons of Mass Destruction

• Explosives have been the —- WMD.

• Chemical agents consist of:

  • — (— agents)

  • — agents (— agents)

  • — agents

  • — agents (—)

• Biologic terrorism/warfare

  • Biologic agents are — that cause —.

  • The primary types are:

    • —

    • —

    • —

• Nuclear/radiologic terrorism

  • Only two publicly known incidents: Hiroshima and Nagasaki

  • These materials are far —- for a determined terrorist to acquire and require —- expertise to use.

  • “Dirty bombs” can cause widespread panic.

preferred

vesicants, blister, respiratory, choking, nerve, metabolic, cyanides

organisms disease viruses bacteria toxins

easier, less

EMT Response to Terrorism

• The basic foundations of patient care remain the same.

  • Treatment can and will vary.

  • Always remember — awareness.

• Recognizing a terrorist event

  • Planning of acts of terror is covert.

  • You must know the current threat level issued by the Department of Homeland Security (DHS).

• National Terrorism Advisory System (NTAS)

  • Alerts from the NTAS contain a —- of the threat and the actions that first responders, government agencies, and the public can take to maintain safety. 

• On every call, you must make the following observations:

  • Type of location

  • Type of call

  • Number of patients

  • Victims’ statements

  • Preincident indicators

situational, summary

location

Response Actions

• Scene safety

  • Stage your vehicle a safe —— away.

  • Wait for — —- personnel.

  • If you have any doubt, do not enter.

  • The best location for staging is —- and —- from the incident.

• Secondary device 

  • Additional explosives set to explode after the —- bomb

• Responder safety

  • The best form of protection is —- yourself from coming in contact with the agent.

  • Contamination occurs when you have —- —- with the WMD.

  • Cross-contamination occurs when you come in contact with a —- —-.

• Notification procedures

  • Notify the dispatcher of:

    • The —- of the event

    • Any additional —- that may be required

    • The estimated —- of patients

    • The upwind or optimal —- of approach

  • Establish a — area.

  • Trained responders in —- are the only persons equipped to handle the WMD incident.

distance, law enforcement, upwind uphill

initial

preventing, direct contact, contaminated person

nature, resources, number, route, staging, PPE

Response Actions

• Establishing command

  • You may need to establish —- until additional personnel arrive.

  • You and other EMTs may function as:

    • Medical branch directors

    • Triage, treatment, or transportation supervisors

    • Logistics officers

    • Command and general staff

• Reassessing scene safety

  • Constantly —- and —- the scene for safety.

  • This is an important component of — awareness

command, assess reassess , situational 

Chemical Agents

• — or —- that are dispersed to kill or injure

  • Persistent (—-) agents can remain on a surface for —- periods.

  • Nonpersistent (—) agents evaporate —.

• Route of exposure is how the agent most effectively —— the body.

  • Agents with a vapor hazard enter through the —— tract in the form of vapors.

  • Agents with a contact hazard (or skin hazard) give off very little vapor or no vapors and enter the body through the ——.

liquids gases, nonvolatile, long, volatile, rapidly, enters

respiratory, skin

Vesicants

• Primary route is the —- (—-).

  • If vesicants are left on the skin long enough, they produce —— that can enter the respiratory tract.

• Cause burnlike —- to form on the victim’s —- and in the —- tract

• Usually cause the most damage to —- or —- areas of the body

• Signs of vesicant exposure on the skin:

  • Skin irritation, burning, and reddening

  • Immediate, intense skin —

  • Formation of large —-

  • — discoloration of skin

  • Swollen and closed or irritated —

  • Permanent eye injury (including —)

• Vesicant agent treatment

  • No antidotes for — or —- exposure

  • Ensure that the patient has been — before treatment is initiated.

  • If agent has been inhaled, the patient may require prompt —- support. 

  • Initiate transport as soon as possible.

  • Generally, —- centers are best equipped to handle the wounds and infections.

skin, contact, vapors

blisters, skin, respiratory, damp moist

pain, blisters gray, eyes blindness

mustard CX, decontaminated, airway, burn 

Vesicants

• Sulfur mustard (H)

  • Brown-yellow oily substance

  • Generally considered very —- (nonvolatile)

  • Begins an —- process of damage to the —-

  • Attacks vulnerable cells within the —- —- and depletes the body’s ability to reproduce —- blood cells

  • Sulfur mustard vapors can be inhaled, creating — and — airway compromise. 

• Lewisite (L) and phosgene oxime (CX)

  • Produce —- wounds very similar to those caused by mustard

  • Produce immediate intense —- and discomfort when — is made

  • The patient may have a —- discoloration at the contaminated site.

persistant irreversible, cells, bone marrow, white, upper lower

blister, pain, contact, gray

Pulmonary Agents

• — that cause — harm to persons exposed to them

• Primary route is through the — tract.

  • Once inside the lungs, they damage the lung —- and —- leaks into the —-.

  • Pulmonary —- develops, resulting in —- breathing because of severely impaired —- —-. 

• Pulmonary agent treatment

  • — the patient from the contaminated atmosphere.

  • Manage the —- aggressively.

  • Pay particular attention to —, —-, and suctioning.

  • Do not allow the patient to be —-.

  • There are —- antidotes.

  • Consider requesting ALS.

gases, immediate, respiratory, tissue, fluids lungs , edema, difficulty, gas exchange

remove, ABCs, oxygenation ventilation, active, no

Pulmonary Agents

• Chlorine (Cl)

  • — chemical agent ever used in warfare

  • Initially, produces upper airway —- and a — sensation

  • Patient may later experience:

    • — of breath

    • Chest —

    • Hoarseness and —-

    • Gasping and coughing

    • Pulmonary —

• Phosgene

  • Product of —

  • Very potent agent with a — onset of symptoms

  • Initially, a mild exposure may include:

    • Nausea

    • Chest —

    • Severe cough

    • — on exertion

    • Pulmonary —

first, irritation choking, shortness, tightness, stridor, edema

combustion, delayed, tightness dyspnea edema

Nerve Agents

• Among the most — chemicals developed

  • Can cause — — within seconds to minutes of exposure

• Organophosphates

  • Found in household bug sprays and agricultural sprays

  • Block an essential — in the nervous system

  • — agent

• Nerve agents all produce similar symptoms but have varying routes of entry.

  • Use DUMB3ELS3 = ——————

• Nerve agent treatment

  • — Auto-Injector (Antidote Treatment Nerve Agent Auto-Injector [ATNAA]) 

deadly, cardiac arrest, enzyme, cholinergic

diarrhea, urination, miosis, bradycardia bronchospasm, bronchorrhea, emesis lacrimation seizures salivation sweating

duodote

Metabolic Agents

• Hydrogen cyanide (AC) and cyanogen chloride (CK) affect the body’s ability to use —-.

• Commonly found in many — settings

• Associated with dizziness, light-headedness, headache, and vomiting

• High doses will produce

  • — of breath/— respirations

  • Respiratory — or — 

  • —

  • Flushed skin

  • —

  • — mental status

  • Seizures

  • Coma

  • Apnea

  • Cardiac arrest

• Cyanide agent treatment

  • All of the patient’s clothes must be —- to prevent off-gassing in the ambulance.

  • Support the patient’s ABCs.

  • Initiate transport immediately if antidote by ALS is not available.

oxygen, industrial, shortness, gasping, distress arrest, tachypnea, tachycardia altered 

removed, 

Biologic Agents

• Can be almost completely ——

• Diseases caused will be similar to other minor illnesses.

• May be spread in various ways

  • Dissemination is the means by which a terrorist will —— the agent.

  • A disease vector is an —- that spreads disease to another —-.

• How —— the disease is able to spread from one human to another human is called communicability.

• Incubation is the period of —- between the person becoming —- to the agent and the appearance of the first ——.

undetectable, spread animal animal, easily, time, exposed symptoms

Viruses

• Germs that require a —- host to multiply and survive

• Invades healthy —— and —— itself to spread through the host

• Moves from host to host by —- methods or through —-

• Smallpox is highly —.

  • You must wear examination —-, a HEPA-filtered —, and — protection.

  • Observe the size, shape, and location of the —.

• Viral hemorrhagic fever (VHF)

  • Causes the blood in the body to seep out from the —- and — —-

  • The patient will have —- symptoms, progressing to more serious symptoms such as internal and external —-.

  • All standard precautions must be taken.

living, cells, replicates direct, vectors

contagious, gloves, respirator, eye, lesions

tissues blood vessels, flulike, hemorrhaging,

Bacteria

• Do —- require a host to multiply and live

• More —- than viruses and can grow up to 100 times larger

• Most can be fought with —-.

• Most will generally begin with —— symptoms.

• Inhalation and cutaneous anthrax

  • Anthrax is caused by a deadly bacterium that lays dormant in a —-.

  • Routes of entry are —-, —, and —.

  • — anthrax is the deadliest.

  • Antibiotics can be used to treat anthrax successfully.

  • A vaccine is available.

• Plague

  • Natural vectors are — and —.

  • Bubonic plague infects the — system and creates —-.

  • Pneumonic plague is a —- infection that results from —- of plague bacteria.

not, complex, antibiotics, flulike, spore, inhalation cutaneous gastrointestinal, pulmonary

rodents fleas, lymphatic, buboes, lung, inhalation

Neurotoxins

• Most —- substances known to humans

• Produced from plants, marine animals, molds, and bacteria

• Route of entry is —-, —-, or —-.

• — contagious and have a — onset of symptoms

• Botulinum toxin

  • Most — neurotoxin

  • Produced by —

  • Affects the nervous system’s ability to —

  • — muscle control diminishes.

  • Eventually the toxin causes muscle —, leading to — —.

• Ricin

  • Derived from mash from the castor bean

  • Causes — —, and — and — —, leading to death

  • Quite —- and extremely —

  • Treatment is supportive and includes both respiratory support and cardiovascular support as needed.

deadly, ingestion inhalation injection 

not faster

potent bacteria function voluntary paralysis respiratory arrest 

castor bean, pulmonary edema, respiratory cardiac failure, stable toxic, 

Other EMT Roles

• Syndromic surveillance

  • Monitoring of patients presenting to EDs and alternative care facilities

  • Patients with signs and symptoms that resemble —- are important.

  • Quality assurance and dispatch need to be aware of an unusual —- of calls from patients with —- symptom clusters.

• Points of distribution (POD)

  • Established in the time of need for the —- distribution of antibiotics, antidotes, vaccinations, and other medications and supplies

  • Push packs distributed by the Centers for Disease Control and Prevention Strategic National Stockpile 

    • Push packs have a delivery time of — —-anywhere in the country.

influenza, number, unexplainable mass, 12 hours

Radiologic/Nuclear Devices

• — radiation is emitted in the form of —, or —.

• Alpha, beta, gamma (x-ray), and neutron radiation

  • Alpha is the least harmful type.

  • Beta is slightly more penetrating.

  • Gamma rays are faster and stronger and —- penetrating

  • — particles are the most powerful.

• Once radiologic material has been used, the remaining material is called radiologic —-.

• These materials can be found at:

  • Hospitals and health care facilities with radiology departments 

  • Colleges and universities

  • Nuclear power plants 

  • Chemical and industrial sites

• Radiologic dispersal devices (RDDs)

  • Any container designed to —- radioactive material

  • A “— —” can injure victims with the radioactive or explosive material.

  • The dirty bomb is an — WMD

    • More used to create fear than mass destruction

    • Uses conventional explosives to disperse radioactive material across a wide area

ionizing ray particles

least, slightly, very, neutron 

waste

disperse, dirty bomb, ineffective 

Radiologic/Nuclear Devices

• Nuclear energy is artificially made by —- (splitting) radioactive atoms.

  • The result is an immense amount of —- that usually takes the form of —-.

  • Nuclear material is used in:

    • Medicine

    • Weapons

    • Naval vessels

    • Power plants

• Nuclear weapons

  • Kept only in secure facilities

  • The likelihood of a nuclear attack is extremely remote.

  • The whereabouts of many small nuclear devices are unknown.

    • Special Atomic Demolition Munition (SADM)

• Patients exposed to excessive radiation are considered victims of —— radiation toxicity. 

• Effects of radiation exposure will vary depending on the —- of radiation and the —- of entry.

  • Radiation can be introduced into the body by —- routes of entry.

altering, energy heat, acute, amount route, all

Radiologic/Nuclear Devices

• Being exposed to a radiation source does not make a patient —— or radioactive.

  • However, when patients have a radioactive source on their body, they must be initially cared for by a —- responder.

  • After decontamination, you may begin treatment with the —-.

  • Wear appropriate PPE, and place all body fluids in containers for proper disposal. 

• There is no protective gear designed to completely —- you from radiation.

  • The less —- that you are exposed to the source, the less the —- will be.

  • Make certain that responders are stationed —— enough from the incident.

  • Always assume it is the —— form of radiation and use —- shielding.

contaminated, radioactive, hazmat, ABCs shield, time effects, far strongest, concrete

Incendiary and Explosive Devices

• Incendiary (used to —- fires) and explosive devices come in various shapes and sizes.

  • It is important to identify an object you believe is a potential device.

  • Notify the —-, and safely —- the area.

• Always remember that there is the possibility of a —- device when you respond to the scene.

• Primary blast injury

  • — effects of the — — on the body

  • Seen almost exclusively in the — organs

  • An injury to the —- causes the greatest morbidity and mortality.

• Secondary blast injury

  • Penetrating or nonpenetrating injury that results from — —-

• Tertiary blast injury

  • Whole body —- and subsequent — with environmental objects

  • Also includes —- injury

• Quaternary blast injury

  • Any —- injury caused by a blast 

start, authorities evacuate, secondary

direct, pressure wave, hollow, lungs

flying debris 

displacement, impact crush 

other 

Incendiary and Explosive Devices

• The physics of an explosion

  • When a substance is detonated, a solid or liquid is chemically converted into —- under high —-.

  • This generates a spherical —- —-.

  • — — and — — commonly cause conventional blunt and penetrating trauma.

• Hollow organs such as the — —, —, and — tract are most susceptible to — changes.

  • The —- is the organ system most sensitive to blast injuries.

  • Primary pulmonary blast injuries occur as —- and —.

• — — is the most common cause of death from blast injury. 

  • — injuries and — trauma are also common causes of death from blast injuries.

  • — injuries, including traumatic —, are common.

gas pressure blast wave, flying debris high winds

middle ear, lungs GI , pressure, ear , contusions hemorrhage

blast lung

neurologic head

extremity, amputations

What type of terrorist group would MOST likely bomb an abortion clinic?

1. Single-issue group

1. Technology terrorists

2. Extremist political group

3. Violent religious group

Single-issue group

The term “weaponization” is defined as:

1. the period of time that a chemical agent will remain on a given surface before it evaporates. 

2. the method or mechanism by which a terrorist or terrorist group delivers a chemical or biologic agent. 

1. the cultivation, synthetization, and/or mutation of an agent in order to maximize the target population’s exposure. 

1. the detonation of an explosive device utilizing an item that is inconspicuous, such as a briefcase or suitcase.

the cultivation, synthetization, and/or mutation of an agent in order to maximize the target population’s exposure. 

The Department of Homeland Security posts a daily advisory system to keep the public aware of the current terrorist threat level. What does an orange level indicate?

1. Low: Low risk of terrorist attacks

1. High: High risk of terrorist attacks

1. Severe: Severe risk of terrorist attacks

2. Elevated: Significant risk of terrorist attacks

High: High risk of terrorist attacks

You are dispatched to a bombing along with 15 other ambulances. Upon arriving at the scene, you should stage your ambulance: 

1. as close to the bombing site as possible.

1. upwind and uphill from the bombing site.

1. downwind and uphill from the bombing site.

2. upwind and downhill from the bombing site.

upwind and uphill from the bombing site.

A terrorist would MOST likely use a secondary explosive device:

1. to ensure that a structure is completely destroyed.

2. in case the primary explosive device fails to detonate.

3. as a means of dispersing a biologic or chemical agent. 

1. to injure rescuers and gain maximum public attention.

to injure rescuers and gain maximum public attention.

When assessing a patient who was exposed to a vesicant agent, you should expect to encounter:

1. skin blistering. 

1. loss of hearing. 

2. vomiting blood. 

3. profound bradycardia.

skin blistering. 

What does sulfur mustard do to the cells within the body?

1. It makes the cells retain water until they explode.

2. It causes the cells to release all their energy, which then causes cellular death.

1. It makes the cells mutate, which damages and changes the cells and causes cellular death.

1. It makes the cells release all their fluids and causes severe dehydration until cellular death occurs.

It makes the cells mutate, which damages and changes the cells and causes cellular death.

Pinpoint pupils, vomiting, bradycardia, and excessive salivation are signs of exposure to:

1. lewisite. 

1. soman. 

1. cyanide. 

2. phosgene.

soman

You respond to a plastic factory, where numerous people present with shortness of breath, flushed skin, and altered mental status. One of the patients tells you he smelled almonds before he started feeling sick. These people were MOST likely exposed to:

1. sarin.

2. bleach.

3. cyanide.

4. chlorine.

cyanide

Factors that have the GREATEST impact on the severity of radiation exposure include: 

1. age and overall health. 

2. gender and wind speed. 

3. the method of dispersal. 

1. time, distance, and shielding.

time, distance, and shielding.