108 exam

indicators for chemical attack

• groups of people displaying unusual behaviour, signs and symptoms or unexplained illness

• fog or could have unusual odour

• abandoned devices and packages

• unexplained pools of fluid

• dead animals

• an explosion

biological attack indicators

• groups of people with flu or food poisoning like symptoms

• unscheduled spraying in an area

• abandoned spraying devices

radiological attack indicators

• localized burns with no apparent cause

• groups with nausea, vomiting, abnormal blood counts, no noted disease cause

atropine

blocks nerve agents overstimulation of the body

mechanical dissemination

• no external source for dissemination

• contain a solid, liquid or gas product

• left alone to disseminate or thrown into a path of victim

• most effective in warm temperatures with air exchange

pneumatic dissemination

• uses high pressure to disseminate

• consists of an agent and pressurized gas

explosive dissemination

• uses explosives

• explosion releases agent without destroying it

cross contamination

• can occur through direct contact with contaminated clothes, skin, hair, or personal belongings

• can come from direct contact, airborne droplets, microscopic dust particles, or contact with bodily fluids

universal/routine precautions

• designed to protect workers from exposure to disease spread by blood and bodily fluids

• all patients should be assumed to be infectious for blood-borne diseases

CRBNE contamination avoidance techniques

• approach uphill and upwind

• reserve resources

• limit casualties

• do not enter without proper PPE

• avoid cross contamination

• after decontamination ensure use of routine PPE

scene size up CRBNE

• stop and proceed carefully

• minimal resources used and exposure to contaminant

• determine number of victims and severity of symptoms

• wear PPE, time, distance, shielding

• take note of weather and terrain

• consider type and quality of agent

• dissemination methods

minimum inner perimeter for enclosed source

100 metres

minimum inner perimeter for outside source

900 metres

outer security perimeter

• restrict public access

• working area for responders

• should be established at a greater distance

hot zone

• contaminant is deemed to be sufficient enough to cause death or injury

• should have designated exit with pre-decontamination area

warm zone

• decontamination zone

• control points

• staging area for equipment

cold zone

• designated clean area

• command centre

• other key support

control of contaminated casualties

• never go within 5 metres without PPE

• tell casualties not to come closer

• remain upwind when facing casualties

• separate casualties by closest to site and farther away

• speak loudly and firmly

• direct casualties to proper gathering point for decontamination

emergency washdown procedure

• deal with casualties using resources on hand until support shows up

• prioritize casualties with sever signs or symptoms of contamination

• remove all clothing

• place belongings in double plastic bags if possible

• wash from top down

• remain in temporary shelters that should be provided for casualties

• do not wipe face with hands

mass casualty triage

treat the greatest number for the greatest good

pre entry assessment of responders

• vitals

• body weight

• general health

• hydration

• personal fitness

• environment

• PPE

• duration of entry

green tag

• minor injuries

• walking wounded

• assemble near you unit

• may assist other patients if able

red tag

• immediate life threatening

• respiratory rate greater than 30pm

• absent radial pulse or capillary refill over 2 seconds

• unable to follow simple commands

yellow tag

• delayed

• serious but non-life threatening injuries

• also can be orange

black tag

• deceased

• death expected

• no pulse, no breathing

directed first aid

• wash with soap and water

• flush eyes with water

• basic first aid

bull horn first aid

when transporting CBRN patients

• ideally only transport decontaminated patients

• if emergency decontaminated, risk vs reward situation

MCI has how much more psychological victims than physical victims

4-20 times as many

CSIS

canadian security intelligence service

CBRNE

chemical, biological, radiologic, nuclear, and explosive event

biologic terrorism

• organisms made in labs to kill

• viruses, bacteria, neurotoxins

nuclear/radiologic terrorism

• use of a nuclear device for terrorism

chemical agents classifications

• vesicants or blister agents

• pulmonary or choking agents

• nerve agents

• metabolic or blood agents

• irritating agents

terrorist event indicators

• most terrorist attacks are covert

• pre incident indicators (threats)

• type of location

• type of call (suspicious people, explosion)

• number of patients

• victims statements

response actions for CRBNE

• ensure scene safety and personal safety

• notify dispatch and supervisor

• request additional resources

• establish or coordinate with command

• initiate mass casualty procedures

how should ambulance be parked generally

uphill and upwind from the incident

best form of protection from CBRNE

preventing yourself from coming into contact with the agent

• contamination

• cross contamination

procedure for notification CBRNE

• inform on nature of event

• any additional resources needed

• estimated number of patients

• optimal route for approach

secondary device/event

• used to injure responders

• secures media coverage

chemical agents

• liquid or gases that are dispersed to kill or injure

• vapour or contact hazard

persistency/volatility

• how long a substance takes to evaporate off a surface

• nonvolatile/persistent last for a long time

route of exposure

how the agent most effectively enters the body

level A PPE

• highest protection against vapours, gases, and particles

• chemical suit

• full face SCBA

• chemical boots and gloves

Level B PPE

• protects against liquid splashes

• full face SBCA

• chemical boots and gloves

• doesn’t provide optimal vapour protection

level C PPE

• provides splash protection

• air purifying respirator

• chemical resistant boots and gloves

level D PPE

• coveralls

• tyvek suit

• chemical resistant footwear and gloves

• routine PPE

warm zone

decontamination area

cold zone

• ambulance staging

• command

• helicopter landing

vesicants (blister agents)

• primary route of exposure is skin

• can produce harmful vapour as well

• skin irritation

• skin pain

• large blisters

• grey skin

• swollen/irritated eyes

• severe cough

• stridor

• hemoptysis

• severe dyspnea

mutagen

mutates, damages, and changes the structures of cells

vesicant treatment

• decontamination asap

• assess ABCDE

• gain IV access asap

• ay need airway support

pulmonary agents

• gases that cause immediate harm

• inhalation or vapour hazard (inhalation)

• SOB, burning and tightness in chest, hoarseness and stridor, gasping and coughing, watery eyes and drooling

pulmonary agent treatment

• remove patient from contaminated atmosphere

• aggressive management of ABC

• use proper PPE

• patient should not be active

• gain IV access

• elevated head

• positive pressure ventilation with supplementary oxygen

nerve agents

• made to kill as many people as possible with as little agent as possible

• can cause cardiac arrest within minutes

• block cholinesterase causing overstimulated organs

• cause pinpoint pupils (miosis)

• SLUDGEM/DUMBELS

G agents

nerve agents developed by German scientists during WWI and WWII

• sarin GB

  • colourless odourless

  • vapour hazard

• soman GD

  • twice as persistent as GB and 5x as lethal

  • fruity odour, colourless

  • contact and inhalation hazard

• Tabun GA

  • half as lethal as GB

  • 36x more persistant

  • fruity smell, colourless

  • inhalation and contact

VX nerve agent

• most toxic chemical ever produced

• lethal dose is the size of a 1×1 lego

• no odour, clear, oily

• 100x more lethal than GB

• very persistent

• primarily contact hazard

• DUMBELS/SLUDGEM

nerve agent treatment

• wear PPE

• decontamination prior to treatment

• manage ABCs

• may need nerve agent antidote kit

• gain IV access

DUMBELS

Defecation

Urination

Miosis

Bradycardia, bronchorrhea, bronchoconstriction

Emesis

Lacrimation

Salivation

SLUDGEM

Salivation

Lacrimation

Urination

Defecation

Gastrointestinal distress

Emesis

Miosis

Metabolic agents (cyanides)

• affect the body’s ability to use oxygen

• can kill within seconds

• commonly found in industrial settings

Cyanide

• metabolic agent

• colourless, almond smell

• produced for industrial and medical processes

• SOB, tachypnea, flushed, tachycardia, mental status, seizures, coma, apnea, cardiac arrest

cyanide (metabolic) agent treatment

• wear PPE

• remove from source of exposure

• all clothing must be removed

• ABCs and IV access

• administer supplementary oxygen

• aggressive oxygenation and ventilation may be needed

• Cyanokit

• if no antidote is available immediately transport

biologic agents

• can be nearly undetectable

• viruses, bacteria, neurotoxins

• disease caused by agent may be similar to common illness

dissemination

when agent is spread intentionally

• poisoning water supply, etc.

disease vector

animal that spreads disease to another animal

smallpox

• highly contagious

• routine precautions and PPE required

• high fever, body and head aches

• all lesions are identical and begin on face and extremities before spreading to chest and abdomen

• contact with blisters or inhalation of droplets can transmit

• aerosolized for terrorist attacks

• incubation 10-12 days

viral hemorrhagic fevers

• group of diseases that include ebola, rift valley, yellow fever

• causes blood to seep out from tissue and blood vessels

• initially starts with flulike symptoms

• transmitted through direct contact with bodily fluid

bacteria

• do not require a host to multiply

• can grow up to 100x larger than virus

• can be fought with antibiotics

• usually begin with flulike symptoms

inhalation and cutaneous anthrax

• anthrax is deadly bacterium that lays dormant in a spore

• pathogen is released from spore at right humidity and temperature

• inhalation, cutaneous, consuming food with spores

• 90 percent death rate if untreated

• cutaneous shows as a raised itchy bump that swells and develops a black centre

• antibiotics are effective

• inhalation form shows as a severe cold

plague- bubonic/pneumonic

bubonic transited through contact with bubo fluid

• bubonic affects lymphatic system

  • lymph nodes become infected and grow (buboes)

  • not contagious

• pneumonic is a lung infection

  • inhalation of plague bacteria

  • much higher death rate than bubonic

  • is contagious

neurotoxins

• deadliest substances known to human

• produced from plants, marine animals, moulds, bacteria

• ingestion, inhalation, injection

• not contagious

• quick onset of symptoms

• respiratory and cardiovascular support

botulinum toxin

• produced by bacteria

• affects nervous system function

• voluntary muscle control diminishes

• paralysis from head to toe

• paralysis causes respiratory arrest

• provide supplemental oxygen and transport

ricin

• communicable through aerosol or ingestion and injection

• causes local hemorrhage and necrosis of liver, spleen, kidney, and gastrointestinal tract

• fever, chills, headache, muscle aches, nausea, vomiting, diarrhea, abdominal cramping, dehydration, gastrointestinal bleeding

• if inhaled fever, chills, nausea, irritation of eyes nose and throat, sweating, headache, muscle aches, cough, chest pain, dyspnea, pulmonary edema, lung inflammation, cyanosis, convulsion, respiratory failure

• respiratory support and cardiovascular support, intubation, ventilation, positive end expiratory pressure combined with edema treatment, gain IV access for dehydration

syndromic surveillance

• monitoring of patients presenting to EDs

• recording EMS call volume

• amount of over the counter medication

• used to discover an outbreak early

ionizing radiation

energy that is emitted in the form of rays or particles from radioactive material

decay

unstable radioactive material attempting to stabilize giving off radiation

alpha rays

• least harmful

• cannot travel through most objects

beta rays

• can be stopped by clothing

• stronger than alpha

gamma rays

• fast

• require several centimetres of lead or concrete to stop

neutron energy

• fastest moving and most powerful radiation

• several meters of concrete to stop

radiologic dispersal devices RDD

• container that is designed to disperse radioactive material

• same effectiveness as a bomb

• fear factor is higher than bomb

special atomic demolition munitions SADM

• small suitcase sized nuclear bomb

• designed to destroy individual targets

• 80 are missing

radioactive exposure

• exposure occurred

• might not be contaminated

external contamination

• skin contaminated

• inside of body is not contaminated

internal contamination

• inside of body is contaminated

signs of radiation sickness

• dizziness

• nausea

• vomiting

• internal and external bleeding

• petechiae

• diarrhea

• altered mental status

treating radiation related illness

• decontamination

• treat ABCs

• burns

protective measures for radiation

• time

• distance

• shielding

civil law

patient can sue you for a perceived injury

• malpractice suits

criminal law

the province or federal government prosecute for breaking legal statute

• medication misuse

tort

wrongful act that causes a civil lawsuit

• unintentional tort: negligence

• intentional tort: malicious, intentional

two most common civil lawsuit calls

1. calls where there was no transport or when transport was delayed

• after not being transported conditions deteriorate

• issue arises due to late transport

• 2. quality of care provided was insufficient

• clinical errors

• harmful intervention

most likely prosecutions for paramedics

assault: instills fear of immediate bodily harm whether or not it is carried out

battery: harmful or offensive touching without consent

false imprisonment: person is detained against their will

traffic related: at fault collisions

libel

false statement in written form that harms a persons reputation

slander

verbally making a false statement that injures someones good name

tunnel vision

concentrating on only the patients condition and ignoring potential danger to yourself or the patient

how to position ambulance on highway

• minimum 6 feet behind other car

• 10 degree angle with driver side facing centre of road

• front wheels turned all the way left

what to do when not the first on scene

• ask incident commander where to park

• park downstream

if there is a potential violent situation with a vehicle

• report license plate number before leaving ambulance

• notify dispatch of situation