EMS Response to Terrorism
EMS response to terrorism involves specialized knowledge and procedures that build upon foundational topics such as EMT well-being, scene size-up, soft-tissue trauma, hazardous materials, multiple-casualty incidents, and incident management.
Effective scene size-up is critical for identifying potential terrorist threats, ensuring responder safety, and determining the presence of hazardous materials or multiple casualties.
Management of soft-tissue trauma and hazardous materials exposure is often necessary in terrorism-related incidents, requiring integration of trauma care and decontamination protocols.
Incident management principles are essential for coordinating resources, communication, and response efforts during large-scale or complex terrorism events.
Standard
Understanding operational roles and responsibilities is essential for ensuring the safety of patients, the public, and EMS personnel during terrorism incidents.
Effective response to terrorism situations requires coordination among EMS providers, law enforcement, and other emergency services to manage hazards and protect all individuals involved.
Prioritizing scene safety, using appropriate personal protective equipment (PPE), and following established protocols are critical actions to minimize risk during these events.
Core Concepts
Terrorism can be categorized by type and tactics, such as bombings, armed assaults, cyber-attacks, and use of chemical, biological, radiological, or nuclear (CBRN) agents.
Identifying the threat involves assessing the nature of the event, including the methods used, the target, and the potential for escalation or secondary attacks.
Protection strategies include time, distance, and shielding: minimize time exposed to danger, maximize distance from the threat, and use physical barriers or protective equipment to reduce harm.
Effective response to terrorist threats requires situational awareness, communication, and following established emergency protocols to ensure safety and coordinate with authorities.
Applying strategy, tactics, and countermeasures involves using intelligence, surveillance, and security measures to prevent or mitigate attacks, as well as adapting responses based on the evolving situation.
Self-protection and safety awareness are critical, including recognizing suspicious behavior, knowing evacuation routes, and understanding how to use protective equipment or seek shelter.
Learning Objectives
Terrorism can be classified as domestic or international, with each type having distinct features and motivations.
Common agents used in terrorism include chemical, biologic, radiologic/nuclear, and explosive materials, each posing unique harms and requiring specific response strategies.
Terrorists may target arriving public safety personnel, so EMTs must be vigilant for secondary devices or additional attackers and anticipate multiple threats at the scene.
High-risk targets for terrorist attacks include certain events, structures, and dates, which may have symbolic or strategic significance.
On-scene indicators of a terrorist attack can include unusual patterns of illness, unexplained odors, or visible devices, requiring EMTs to remain alert for signs of weaponized agents.
Chemical agents can cause harm through physical, chemical, volatility, and toxicologic properties, with examples including choking agents, vesicants, cyanides, nerve agents, and riot-control agents; each has specific signs, symptoms, and antidote limitations.
Self-protection against chemical, biologic, radiologic/nuclear, and explosive agents involves using appropriate personal protective equipment and following established safety protocols to minimize exposure and harm.
Biologic agents may be living organisms or toxins, with certain agents posing a high risk for mass harm; understanding their features and sources of information is crucial for effective response.
Radiologic/nuclear incidents involve sources of radiation that can cause progressive tissue damage as exposure increases, requiring specific protective measures and awareness of dose-related effects.
Incendiary and explosive devices present risks beyond heat, such as blast injuries, which can affect multiple body regions and require specialized medical response.
Effective response to terrorism events relies on strategies and tactics such as the Incident Command System, prioritizing EMT safety, and thorough scene assessment to identify potential terrorist activity.
Key Terms
Terrorism has a long history, with thousands of bombings and incendiary devices used for terrorist purposes since the early 1900s.
Emergency Medical Services (EMS) have played a significant role in responding to violent acts since their inception in the 1970s, and their responsibilities have expanded, especially after the September 11, 2001 attacks.
EMS, fire rescue, and law enforcement are considered part of the National Critical Infrastructure, which is essential for the continued operation and safety of the nation.
The roles of EMS and fire services are being continually refined and better defined, particularly for agencies with EMS responsibilities, to enhance their effectiveness in responding to terrorism and other emergencies.
EMS serves both public safety and public health functions, ensuring the safety and health of citizens during terrorist events and other emergencies.
Defining Terrorism
Terrorism is defined as the unlawful use of force or violence to intimidate or coerce governments or populations for political or social objectives.
Two main types of terrorism in the U.S. are domestic terrorism and international terrorism.
After the September 11, 2001 attacks, the Department of Homeland Security (DHS) initially used a color-coded threat level system, which was later replaced due to ineffectiveness.
The National Terrorism Advisory System (NTAS) replaced the color-coded system, providing more specific and detailed threat information to the public through various channels, such as email and text messages.
NTAS advisories include three categories:
Bulletin: Communicates current developments or general trends in terrorism threats.
Elevated Alert: Indicates a credible threat against the United States.
Imminent Alert: Indicates a credible, specific, and impending terrorism threat against the United States.
Domestic Terrorism
Domestic terrorism refers to acts of terrorism committed by individuals or groups against their own government or population.
There is a current trend toward fragmented, leaderless domestic terrorism, with individuals or small groups acting independently, though this could shift back to more organized structures in the future.
Motivations for domestic terrorism in the United States (2010–2021) include:
Racially or ethnically motivated violent extremism (35% of incidents)
Anti-government or anti-authority violent extremism (32%)
All other domestic terrorist threats (23%)
Animal rights or environmental extremism (6%)
Abortion-related violent extremism (4%)
Recent awareness has increased regarding American citizens becoming radicalized, either through foreign influence or domestic extremist groups, leading to acts of terrorism.
Examples of domestic terrorism include mass killings motivated by race or religion, such as the Buffalo supermarket and Pittsburgh synagogue shootings.
Some American terrorists have been trained overseas (e.g., the 2001 “shoe bomber” and the 2010 Times Square car bomb attempt), while others, like the Boston Marathon bombers, were radicalized online or through family connections abroad.
Radicalization is also occurring within U.S. prison populations, contributing to the domestic terrorism threat.
Domestic terrorist groups are diverse, including environmental extremists, antigovernment militias, racial-hate groups, and those with extreme political or religious beliefs, and may be influenced by both domestic and foreign sources.
International Terrorism
International terrorism refers to terrorist acts that are foreign-based, directed by external groups or countries, or that cross national borders.
There has been a shift from state-sponsored, localized terrorist groups to loosely organized international networks, which can vary in organizational complexity.
Funding for international terrorism comes from diverse sources such as private sponsorship, drug trafficking, crime, illegal trade, and money-laundering schemes, with significant contributions originating from within the United States.
Types of Terrorism Incidents
CBRNE agents—Chemical, Biological, Radiological, Nuclear, and Explosive—are key hazardous agents associated with terrorism and are often referred to as weapons of mass destruction (WMD) due to their potential for widespread harm and fear.
CBRNE agents are a subset of technologic hazardous agents, which also include hazardous materials (HAZMATs).
Terrorism incidents can overlap with criminal activities such as arson, environmental crime, and industrial sabotage, blurring the lines between criminal and technologic incidents.
Terrorist acts may use both conventional and unexpected methods, including unconventional tactics like using airplanes as weapons.
Any terrorist event in the United States is treated as a crime scene, involving multiple law enforcement agencies at local, state, and federal levels.
EMS and fire service personnel play a crucial role in terrorism countermeasures by reporting suspicious situations that may indicate criminal or terrorist activity.
The responsibilities of EMS in violent incidents extend beyond the narrow legal definition of terrorism, especially in cases involving CBRNE agents.
Responding to terrorist incidents typically involves dealing with events of unprecedented scope and duration.
Terrorism and EMS
Emergency medical responders are frequently targeted in terrorist attacks, making their safety a primary concern at such incidents.
Never assume a scene is safe; always wait for confirmation from appropriate authorities before proceeding.
Weigh the risks and benefits of your actions carefully, especially in potentially dangerous situations like terrorist attacks.
Responder safety is the top priority—if you are injured, you cannot assist others.
Point of View: EMT
Multiple-casualty incidents (MCIs) can vary greatly in scale, from smaller events like car crashes with several patients to large-scale disasters such as terrorist incidents.
Training and prior experience may not fully prepare you for the emotional and logistical magnitude of major MCIs, where the scale and chaos can be overwhelming.
During large incidents, you may feel both insignificant and crucial at the same time, highlighting the importance of every responder’s role despite the enormity of the situation.
The sheer scale and confusion of major MCIs can overshadow the specific injuries or medical tasks, emphasizing the need for adaptability and resilience.
Major MCIs are unpredictable and can happen anywhere, reinforcing the importance of readiness and the value of being present to help when needed.
Identify the Threat Posed by the Event
EMS response to terrorist events is complex due to potential hazardous materials, mass-casualty situations, deliberate targeting of responders, and crime scene considerations.
Terrorists may use multiple devices or booby traps to harm emergency responders, as seen in incidents like the 1997 Atlanta bombing and the Boston Marathon attack; the term "multiple devices" is preferred to emphasize the risk of additional destructive events after the initial attack.
Terrorist incidents are also crime scenes, requiring responders to preserve evidence and guard against further criminal activity, which complicates operations compared to nonterrorist mass-casualty incidents.
Responders must follow established operating guidelines, use the Incident Command System, and maintain staff-personnel accountability compatible with all agencies involved.
Recognizing suspicious incidents relies on being alert to clues, summarized by the OTTO signs: Occupancy or location, Type of event, Timing of the event, and On-scene warning signs.
High-risk occupancies or locations include symbolic/historical targets (e.g., government buildings, monuments), public buildings or assembly areas (e.g., malls, arenas), controversial businesses (e.g., family-planning clinics, nuclear facilities), and infrastructure systems (e.g., bridges, power plants, hospitals).
Types of events that may indicate terrorism include explosions/incendiaries, incidents involving firearms (especially with other suspicious factors), and nontrauma mass-casualty incidents where victims show illness without obvious injury.
Timing of events can be a clue, with attacks often occurring on significant anniversaries, holidays, or at times designed to maximize casualties and public alarm (e.g., rush hour).
On-scene warning signs include unexplained illness or death patterns, symptoms of chemical exposure (skin, eye, airway irritation), unusual odors or tastes, visible vapor clouds or plumes, chemical containers or lab equipment in odd places, and abnormal fires or items that seem out of place.
Early recognition and reporting of suspicious signs by first responders are critical for effective mitigation of terrorist events.
Recognize the Harms Posed by the Threat
TRACEM-P categorizes seven types of harm: Thermal, Radiologic, Asphyxiation, Chemical, Etiologic, Mechanical, and Psychological.
Thermal harm involves injury from extreme heat (e.g., burning liquids/metals) or cold (e.g., cryogenic materials like liquid oxygen); radiant heat can damage protective gear.
Radiologic harm is caused by exposure to alpha, beta, or gamma radiation, with alpha particles stopped by paper, beta by skin, and gamma requiring lead for protection; these are associated with nuclear materials and classified as Hazard Class 7.
Asphyxiation results from insufficient oxygen, often due to heavier-than-air gases (argon, carbon dioxide) or chemical vapors in confined spaces; normal breathing requires at least 19.5% oxygen.
Chemical harm comes from toxic or corrosive substances, including acids (sulfuric acid), caustics (lye), and toxins (cyanides, nerve agents).
Etiologic harm refers to diseases or toxins from living organisms, such as bacteria, viruses, or biological toxins.
Mechanical harm includes physical trauma like gunshot wounds, falls, or injuries from bomb fragments.
Psychological harm arises from traumatic events, especially terrorism, and can lead to fear, panic, posttraumatic stress, and survivor guilt; effects may be immediate or delayed, and professional counseling resources should be identified in advance.
Protect Yourself with Time/Distance/Shielding
Protection for emergency responders relies on three main principles: time, distance, and shielding.
Minimizing time spent in hazardous areas reduces risk of injury and contamination; rapid entry and exit for reconnaissance or rescue is essential.
Maximizing distance from hazards is critical; safe distances vary by threat, such as vehicle bombs, with recommended minimum evacuation distances ranging from 1,500 feet (457 meters) for a compact sedan up to 7,000 feet (2,134 meters) for a semi-trailer, and lethal air blast ranges from 100 feet (30 meters) to 600 feet (183 meters) depending on vehicle size and explosive capacity.
Shielding involves using physical barriers and protective equipment, such as buildings, specialized clothing, HAZMAT suits, and PPE; however, vehicles do not provide adequate protection from explosives.
All three protective measures—time, distance, and shielding—should be used together for maximum safety, and feeling shielded does not justify spending more time near hazards.
Responses to Terrorist Incidents
TRACEM-P harms are specific types of threats associated with CBRNE (Chemical, Biological, Radiological/Nuclear, Explosive) terrorism, and only relevant harms are considered for each category.
Each harm within a CBRNE category is classified as either primary (directly caused by the agent) or secondary (resulting from the agent's effects or response actions).
Time, distance, and shielding are essential protective strategies to reduce exposure and harm during a terrorist event involving CBRNE agents.
Responses to a Chemical Incident
Chemical incidents involve hazardous materials that can enter the body through inhalation, ingestion, absorption, or injection, and may include industrial chemicals or warfare agents.
Approaching a chemical incident should always be done from upwind to avoid airborne chemicals, and obtaining a weather report is crucial for safety.
Types of harm from chemical incidents include:
Thermal harm: Caused by heat from chemical reactions or flammable chemicals.
Asphyxiation: Occurs when chemicals deplete or displace oxygen.
Chemical harm: The primary risk, involving corrosivity, reactivity, and systemic effects on major body systems (nervous, cardiovascular, respiratory, etc.).
Mechanical harm: Results from corrosive chemicals weakening structures.
Psychological harm: Emotional responses to exposure, which can affect both victims and responders.
Self-protection at chemical incidents relies on minimizing exposure through time, distance, and shielding, as well as using respiratory protection and protective clothing.
Specialized response teams are often available for chemical incidents, but all responders must prioritize their own safety to prevent contamination and secondary exposure, as illustrated by the 1995 Tokyo subway sarin attack.
Responses to a Biologic Incident
Biologic incidents can be classified as focused emergencies (localized cases with identifiable sources) or public health emergencies (widespread, unexplained outbreaks). Causative agents include bacteria, viruses, and toxins, which may harm by inhalation or ingestion.
Bacteria can cause disease by growing inside the body or producing toxins externally. Rickettsia, grouped with bacteria, shares features of both bacteria and viruses and causes diseases like Q fever and typhus. Anthrax is a notable bioterrorism agent.
Viruses reproduce only inside living cells and cannot be treated with antibiotics. Toxins are poisons from living organisms, such as ricin from castor beans, which can be lethal in tiny amounts.
Exposure is determined by the dose or concentration of the agent multiplied by the duration of exposure: . Doses are measured in mg or mcg per kg of body weight, and concentration in parts per million. Reducing dose, concentration, or time reduces exposure.
Four major routes of entry for biologic agents are absorption (skin contact), ingestion (mouth), injection (needles or projectiles), and inhalation (breathing). Inhalation is the most likely to cause infection if particles reach the lower respiratory tract. Skin absorption is rare except for certain toxins like T2 mycotoxins.
Factors increasing skin absorption include skin injury, higher skin temperature/blood flow, higher concentration, more hair, longer exposure, and type of agent.
Contamination refers to the presence of harmful material on surfaces, skin, hair, or clothing, and can be in solid, liquid, or aerosol form. Exposure is internal, while contamination is external. Clothing removal is effective for decontamination, and most biologic agents can be washed out.
Types of harm from biologic incidents include:
Chemical harm (secondary hazard, e.g., from clandestine labs)
Etiologic harm (primary hazard, classified as Class 6 Hazardous Materials)
Mechanical harm (secondary hazard from explosives)
Psychological harm (stress and anxiety from perceived exposure, leading to resource strain)
Self-protection measures prioritize respiratory protection, use of PPE, the buddy system, rapid intervention teams, and civilian protection (moving civilians to safe areas). Protect yourself first to avoid becoming a casualty.
Responses to a Radiologic/Nuclear Incident
Nuclear and radiologic threats include both nuclear detonations (such as suitcase bombs) and radiologic dispersion devices ("dirty bombs"), which use conventional explosives to spread radioactive material.
Radiologic materials can also be dispersed by attacking or sabotaging nuclear power facilities, increasing the risk of widespread contamination.
Radiation is undetectable by human senses, and symptoms of exposure (nausea, vomiting, diarrhea) are often delayed, making early diagnosis and treatment critical.
Types of harm from radiologic/nuclear incidents include:
Thermal harm (from nuclear explosions)
Radiologic harm (ongoing hazard from radioactive materials, especially dangerous for children, pregnant women, and the elderly)
Chemical harm (some radiologic substances are also chemical hazards)
Mechanical harm (from the force of explosions)
Psychological harm (emotional and psychological effects from traumatic events)
Self-protection relies on minimizing time of exposure, maximizing distance from the source, and using shielding, with radiologic detection equipment being essential for assessing safety.
All explosive incidents should be treated as potential radiologic, biologic, or chemical threats until proven otherwise, to ensure proper protective measures are taken.
Law enforcement should search all patients for weapons at the scene, as bombers may be among the victims, and any discovered explosives require immediate evacuation and response by specialized personnel.
Responses to an Explosive Incident
Explosive incidents can involve a range of devices, from small pipe bombs to large vehicle bombs, and may target fixed locations or groups of people, including emergency responders.
Explosives may be improvised or commercially manufactured and can be designed to disperse biological, chemical, or radiological materials in addition to causing blast injuries.
Bombs may have various activation mechanisms, such as switches triggered by light, pressure, movement, or remote signals (e.g., radio, cellular phones), making them dangerous to handle without proper training.
Explosives are classified as high-order (HE) or low-order (LE):
High-order explosives (HE) produce a supersonic overpressurization shock wave; examples include TNT, C-4, Semtex, nitroglycerin, dynamite, and ANFO.
Low-order explosives (LE) create a subsonic explosion without a supersonic shock wave; examples include pipe bombs, gunpowder, Molotov cocktails, and aircraft used as guided missiles.
HE and LE explosives result in different injury patterns.
Bombs and explosives are frequently used by terrorists, often alongside small arms like high-capacity handguns and assault-style weapons (e.g., AK-47s).
Types of harm from explosive incidents include:
Thermal harm from heat generated by detonation, primarily a risk during the explosion.
Asphyxiation due to dust and aerosolized toxins (e.g., asbestos) following the blast.
Chemical hazards from chemicals present at the site or intentionally dispersed by the device.
Mechanical harm from blast overpressure, shock waves, and fragmentation injuries.
Psychological harm such as acute stunned responses or delayed posttraumatic stress.
Self-protection for responders involves preblast and postblast measures:
Preblast: Actions taken after a warning but before an explosion.
Postblast: Actions taken after at least one detonation has occurred.
Dissemination and Weaponization
CBRNE materials (Chemical, Biological, Radiological, Nuclear, and Explosive agents) can be disseminated through various methods, requiring responders to understand these potential routes.
Industrial materials, not just military-grade agents, can be utilized effectively in CBRNE incidents, highlighting the need for broad awareness among responders.
The Respiratory Route
The respiratory tract is the most effective and common route for harmful materials to enter the body, due to its large and delicate surface area exposed during breathing.
Deeper penetration of harmful substances into the lungs increases their effectiveness, especially if the material remains in the lungs for a longer period.
The respiratory system's passageways narrow as they go deeper, affecting where particulates, gases, and vapors are trapped based on particle size, respiration depth and rate, and whether the material is water- or lipid-soluble.
Other exposure routes can be dangerous or lethal, but inhalation is the most efficient way to cause mass casualties.
Other Routes
The effectiveness of the ingestion (alimentary) route for biological agents depends on the agent's ability to survive the acidic environment of the stomach; many bacteria cannot, but some, like anthrax spores, can.
Anthrax is notable for its ability to infect via skin contact, ingestion, or inhalation, with inhalation being the most lethal.
Contaminating domestic water supplies is an unlikely effective dissemination method due to water treatment processes (dilution, filtration, chlorination) and the fact that only about 1% of water is ingested.
The dermal (percutaneous) route is highly effective for chemical blister agents (vesicants) and nerve agents (e.g., sarin, soman, tabun), which can penetrate the skin, but most biological agents are not effective via this route because intact skin is a strong barrier.
Using vectors like fleas to spread biological agents (e.g., bubonic plague) is logistically difficult and thus not a preferred method for terrorists.
Some bacterial and many viral agents can spread efficiently through human-to-human contact, especially when there is a delayed incubation period, allowing widespread infection before detection; this is a major concern for diseases like smallpox, pneumonic plague, and viral hemorrhagic fevers.
Weaponization
Inhalation is the most effective route for weaponizing many agents, as it allows for maximum casualties when the material is delivered in a form that can be easily breathed in.
Particles sized 3–5 microns in diameter are optimal for respiratory uptake, making them the most dangerous for airborne dissemination.
Airborne dissemination can be achieved by applying energy to the material, such as using heat to increase evaporation or using explosives and sprayers to create aerosols.
Characteristics of CBRNE Agents
CBRNE agents are categorized into chemical, biological, radiological/nuclear, and explosive types.
Each type of agent has distinct characteristics that affect how they are identified, managed, and responded to in emergency situations.
Understanding the differences between these agents is essential for effective detection, protection, and treatment strategies.
Chemical Agents
Chemical agents exhibit a wide range of physical properties, including varying states (gas, liquid, solid), vapor pressures, vapor densities, odors, and water solubility, all of which influence their behavior in terms of vapor hazard, persistency, and decontamination methods.
Volatility impacts agent persistency and hazard: Agents with low boiling points and high vapor pressures are more volatile and nonpersistent, leading to higher airborne concentrations but shorter surface duration; agents with high boiling points are more persistent and remain longer on surfaces.
Chemical stability and reactivity vary among agents: All agents are stable enough for dissemination, but their reactivity differs—some degrade quickly, while others require chemical decontaminants like bleach or solid adsorbents (e.g., Fuller’s earth) for inactivation.
Toxicologic effects depend on individual sensitivity and route of entry: Factors such as genetics, race, age, and exposure route (inhalation, skin contact, etc.) influence how individuals respond to chemical agents; physical properties can also modify toxic effects.
Nerve agents disrupt the parasympathetic nervous system by inhibiting acetylcholinesterase, leading to overstimulation and a characteristic set of symptoms remembered by the mnemonic SLUDGEM: Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis, and Miosis.
Chemical agents are classified into several categories:
Choking agents: Primarily respiratory irritants (e.g., chlorine), can be weaponized or found in industry, and may act as simple asphyxiants.
Vesicating (blister) agents: Cause immediate chemical changes in tissues, though symptoms may be delayed.
Cyanides: Cellular asphyxiants that prevent oxygen use in cells, not affecting the blood directly.
Nerve agents: Organophosphate compounds that inhibit nerve transmission, often absorbed through the skin, with a petroleum-like odor and milky color, producing SLUDGEM symptoms.
Riot-control agents: Include irritants and lacrimators (e.g., mace, pepper spray, CS gas), typically cause short-lived effects but can trigger severe reactions in asthmatics; used for crowd control and require precautions for responders.
Biologic Agents
Biologic agents include bacteria, viruses, and toxins, each with distinct characteristics affecting their use as weapons, treatment options, and transmission.
Bacteria are free-living microorganisms that can survive outside host cells and are often treatable with antibiotics if detected early. Sudden onset of symptoms in multiple people may indicate a bacterial attack.
Viruses require host cells to reproduce and generally do not respond to antibiotics, though some antiviral treatments exist. They can be highly transmissible and may require strict isolation.
Toxins are poisonous chemical compounds produced by living organisms (plants, animals, or microbes) and are not alive themselves. Examples include botulinum toxin, ricin, and mycotoxins.
Key characteristics influencing the threat of biologic agents:
Infectivity: Ease with which an agent establishes infection; high infectivity means few organisms are needed to cause disease.
Virulence: Severity of disease produced by the agent.
Toxicity: Severity of illness or incapacitation caused by a toxin.
Incubation period: Time between exposure and symptom onset, influenced by dose, virulence, route, replication rate, and host factors.
Transmissibility: How easily an agent spreads from person to person or via vectors.
Lethality: Ease with which an agent causes death, measured by lethal dose (LD) or lethal concentration (LC).
Stability: How environmental factors affect the agent’s viability; measured by decay rate.
Examples of biologic agents and their clinical features:
Anthrax (bacteria): Causes fever, malaise, chest discomfort, progressing to severe respiratory distress and possible death; requires decontamination and supportive care.
Cholera (bacteria): Sudden vomiting, abdominal pain, and severe diarrhea leading to rapid fluid loss; managed with fluid replacement.
Plague (bacteria): Bubonic form causes fever and swollen lymph nodes; pneumonic form leads to severe respiratory symptoms and high mortality; requires isolation and supportive care.
Botulinum toxin: Causes descending paralysis and respiratory failure; requires aggressive respiratory support.
Ricin: Leads to weakness, fever, respiratory distress, and death from hypoxia; managed with airway support and fluid replacement.
Smallpox (virus): Fever, malaise, and characteristic rash; requires strict quarantine and supportive care.
Viral hemorrhagic fevers: Fever, bleeding, shock, and multi-organ involvement; requires decontamination and supportive care.
EMS and prehospital care for biologic agent exposure is primarily supportive, focusing on respiratory and circulatory support, decontamination, and infection control.
Biologic agents can multiply and increase their effect over time, making those capable of self-replication particularly concerning for widespread transmission.
Additional factors for weaponization include ease of production, storage stability, and dissemination potential.* Anthrax can infect humans through open wounds, contaminated meat (rare due to destruction by cooking), or inhalation of spores. Inhalational anthrax is the most lethal form, especially if spores are aerosolized into particles 3–5 microns in diameter. Early antibiotic treatment is effective, but delayed recognition (due to nonspecific symptoms) can lead to death, especially if not started before the "anthrax eclipse"—a deceptive period of apparent recovery followed by rapid decline.
Cholera is a diarrheal disease caused by Vibrio cholera, leading to severe dehydration and electrolyte imbalance due to massive fluid loss ("rice water" stool). Death results from dehydration, but oral rehydration and antibiotics are highly effective. Human-to-human transmission is low; main risk is contact with contaminated fluids.
Plague (Yersinia pestis) is transmitted from rodents to humans by fleas. Bubonic plague presents with swollen lymph nodes, while pneumonic plague (from aerosolized bacteria) is highly contagious and rapidly fatal if untreated. Early antibiotic therapy (within 24 hours) is critical for survival.
Q Fever (Coxiella burnetii) is a zoonotic disease from livestock exposure. The spore form is environmentally resilient. Symptoms include fever, chills, headache, and sometimes pneumonia. Fatality is low, and recovery is typical with antibiotics and supportive care.
Tularemia (Francisella tularensis) is contracted from animal bites or insect vectors and can be weaponized as an aerosol. Symptoms include fever, headache, weight loss, and respiratory issues. Mortality is 5–10% without treatment; antibiotics are effective, and isolation is not required.
Toxins are non-living, non-replicating chemical compounds produced by organisms. They are not volatile and generally not absorbed through intact skin (except T2 mycotoxin). Toxins are not transmissible between humans. Weaponization depends on the toxin's properties (e.g., botulinum by ingestion, T2 by aerosol).
Botulinum toxin is extremely potent, with an LD50 of , making it 15,000–100,000 times more toxic than nerve agents.
Ricin disrupts protein synthesis at the cellular level, causing cell death and tissue necrosis. It is effective by inhalation, ingestion, or injection, and is easily produced from castor beans. Treatment is supportive.
Staphylococcal Enterotoxin B (SEB) causes food poisoning when ingested and severe respiratory illness if inhaled. Early symptoms are nonspecific; severe cases can be fatal, but most are incapacitating. No specific antitoxin exists; treatment is supportive.
Trichothecene Mycotoxins (T2) are fungal toxins that can penetrate skin, are heat-resistant, and cause rapid onset of severe symptoms (vomiting, diarrhea, shock). No vaccine exists; decontamination with soap and water is recommended, and treatment is symptomatic.
Viruses are obligate intracellular parasites containing either DNA or RNA. They require host cells to replicate, making large-scale production difficult. Weaponization is less likely compared to bacteria or toxins.
Smallpox is highly contagious, with a 12-day incubation period and a 30% mortality rate in unvaccinated individuals. Symptoms include fever, rash, and blisters, primarily on the face and extremities. Transmission is via respiratory droplets, requiring strict isolation and quarantine.
Encephalitis (notably Venezuelan Equine Encephalitis, VEE) is a mosquito-borne viral disease causing sudden fever and neurological symptoms. Human-to-human transmission is possible; the disease is more incapacitating than lethal.
Viral Hemorrhagic Fevers (VHFs) (e.g., Ebola, Marburg, Lassa) are caused by viruses that disrupt blood clotting and capillary integrity, leading to systemic hemorrhage and organ liquefaction.* Viral hemorrhagic fevers (VHFs) are highly contagious and lethal diseases that cause rapid onset of fever, weakness, and easy bruising and bleeding.
Early signs often include bleeding in the sclera of the eyes due to capillary leakage, followed by involvement of all mucous membranes.
Transmission to humans occurs through contact with blood and secretions, and more commonly via the respiratory route, making strict Standard and respiratory precautions essential.
There are generally no vaccines or cures for VHFs, and antiviral therapies have limited effectiveness.
Treatment focuses on preventing disease spread and providing supportive care, especially for hypovolemia caused by increased capillary permeability and hemorrhage.
Mortality rates for VHFs vary widely, from 5% to 90% depending on the specific disease, but intravenous serum is available for many VHF strains.
Radioactive/Nuclear Devices
Four main nuclear terrorism scenarios include: use of a military nuclear weapon, use of an improvised nuclear device, use of a radiologic dispersal device (RDD or "dirty bomb"), and sabotage of a nuclear facility.
Military nuclear device use by terrorists is highly unlikely due to extreme difficulty in obtaining, deploying, and activating such a device without detection, as well as the deterrent effect of potential massive retaliation.
Improvised nuclear devices are theoretically possible since basic construction information is accessible, but practical challenges—such as precise assembly, lethal radiation exposure during construction, and likely detection by intelligence agencies—make successful use improbable.
Radiologic dispersal devices ("dirty bombs") are more plausible because they use conventional explosives to spread radioactive material. However, acquiring and handling radioactive sources (from medical waste, industrial processes, etc.) still poses significant risks to perpetrators, and emergency responders can use detection equipment to identify radioactive contamination.
Sabotage of nuclear facilities is considered the most likely scenario for nuclear terrorism, but large power plants are highly secure and monitored, making successful sabotage difficult. Smaller, less secure facilities (e.g., at universities) are more vulnerable.
Radiation exposure primarily affects three body systems:
At 150 rem: the blood-forming system (bone marrow) is suppressed, leading to immune deficiency, anemia, and clotting problems over days to weeks.
At 500 rem: the gastrointestinal system suffers tissue death, severe nausea, vomiting, fluid loss, and shock, with a poor prognosis if symptoms appear within 2 hours.
At 1,000 rem: the central nervous system is damaged, causing brain swelling, neurological symptoms, and rapid death, with a very poor prognosis.
The rem (roentgen equivalent in man) is the unit used to measure radiation dosage and its biological effects.
Incendiary Devices
Incendiary devices are more accessible and likely to be used by terrorists than nuclear devices, as materials like Molotov cocktails, propane bombs, and shaped charges are relatively easy to obtain and deploy.
Initiation methods for incendiary devices can range from simple to complex, including chemical, electronic, or mechanical triggers, and may involve items such as chemicals, radios, or remote-control devices.
Specialized response teams, often part of the military or law enforcement, are equipped to handle incendiary devices, using tools like robots to safely deactivate explosives and minimize risk to personnel.
Even small incendiary devices can cause significant damage, making it important to know how to quickly contact the appropriate agency responsible for handling such threats in your area.
Blast Injury Patterns
Primary and secondary blast injuries result from high-energy (HE) overpressurization (blast wave) and low-energy (LE) blast wind, with the lungs, ears, abdomen, and brain being especially vulnerable.
Blast lung is the most common fatal primary blast injury among initial survivors, characterized by apnea, bradycardia, and hypotension; symptoms may appear immediately or up to 48 hours post-explosion and should be suspected in anyone with breathing difficulty, cough, hemoptysis, or chest pain after blast exposure.
Ear injuries, particularly tympanic membrane rupture, are common and may present as hearing loss, tinnitus, or bleeding from the ear; these injuries can impair communication, so alternative methods like hand signals or written cards may be necessary.
Abdominal injuries from blast effects often involve gas-containing sections of the GI tract, leading to possible rupture, hemorrhage, mesenteric shear, solid organ lacerations, and testicular rupture; symptoms may include abdominal pain, nausea, vomiting blood, testicular pain, unexplained hypovolemia, or signs of acute abdomen, with clinical findings sometimes delayed.
Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without direct head trauma, with symptoms such as headache, fatigue, poor concentration, lethargy, depression, anxiety, and insomnia; these may overlap with posttraumatic stress disorder.
Treatment protocols for blast and thermal injuries are consistent with standard care for such injuries, and local procedures, including HAZMAT and multiple-casualty incident protocols, should be followed.
Strategy and Tactics
Life safety, incident stabilization, and protection of property are the top priorities for responders at terrorist events involving chemical, biological, or radiological agents.
Critical assets to protect include responders, their equipment, and the continuity of organizational functions, in addition to the general public and property.
Strategies are broad plans aimed at achieving overall goals, while tactics are the specific actions taken to carry out those plans.
Key tactical considerations for responders include:
Isolation of the incident site to prevent the spread of hazards and limit access.
Notification of appropriate authorities and agencies to ensure coordinated response.
Identification of agent indicators to determine the type of threat present.
Protection of critical assets and personnel from harm.
The DOT Emergency Response Guidebook (ERG) provides essential reference information for handling incidents involving terrorist weapons, including safety precautions and agent identification.
Use of an Incident Command System (ICS) is essential for effective management of hazardous materials and multiple-casualty incidents.
Isolation
Approaching a terrorism scene requires rapid and accurate assessment to determine the severity and scope of danger, with immediate efforts to isolate hazards and control the area to protect the public and facilitate medical care.
Establishing control zones early is critical; these include outer and inner perimeters to manage access, isolate hazards, and organize response efforts, especially when resources are limited and large numbers of panicked or contaminated people are present.
Responder safety is paramount; always consider the possibility of secondary attacks, hidden threats, or terrorists among the injured, and strictly follow Incident Command directions rather than acting independently.
Multiple hazard locations and scattered patients may require complex perimeter setups, with both outer perimeters (to restrict public access) and inner perimeters (to isolate specific hazards or suspicious areas).
Perimeter control is resource-intensive and may require significant law enforcement support; request additional assistance early, especially for security and crowd management.
Access to the scene may be hindered by debris, police activity, or uncontrolled movement of contaminated individuals, increasing the risk of secondary contamination in chemical, biological, or radiological/nuclear incidents.
Law enforcement should use standard procedures to establish and maintain perimeters, with an initial preference for overestimating perimeter size, as it is easier to reduce than expand once operations are underway.
Key factors influencing perimeter control include available resources, responder training and self-protection capabilities, incident size and configuration, and scene stability; actions should not exceed the training or protective abilities of personnel.
The behavior of hazardous materials is independent of whether the release was accidental or intentional, so response protocols should focus on the material's properties and risks.
Notification
Notification of response and support agencies is essential during a terrorism event, and is mandated by directives, procedures, or statutes at local, state, and federal levels.
Local EMS or emergency management plans should specify the appropriate agencies and points of contact for notification in such events.
On-scene EMTs are not responsible for performing notification functions; this is typically handled by dispatch centers or emergency operations centers.
An initial radio report from an EMT can serve as the trigger for the notification process, especially when specific threats, such as a possible improvised explosive device (IED), are identified, prompting notification of federal law enforcement agencies.
Identification
Identify indicators of hazardous agents by noting chemical containers, lab materials, or items that appear out of place or lack proper documentation such as safety data sheets or shipping manifests.
Observe placards and labels on storage tanks or vehicles from a safe distance, using binoculars if necessary, to gather information about potential hazards.
Record the exact spelling of any chemical or biologic agent to ensure accurate identification and communication.
Consult authoritative resources like the Emergency Response Guidebook and contact poison control centers or hotlines (CHEMTREC, CHEM-TEL) for assistance in identifying and managing the substance.
Document unusual illness patterns by recording the number of affected individuals, their signs and symptoms, and any relevant negatives (such as the absence of an obvious cause).
Communicate all gathered information promptly to the appropriate authorities for effective incident management.
Protection
Critical asset protection in EMS involves safeguarding people, vehicles, and equipment/supplies, especially during terrorism or criminal incidents.
Force protection is the concept of ensuring EMS personnel and resources are secure so that missions can be completed.
Effective protection requires collaboration between EMS responders and security agencies such as law enforcement, private security, and National Guard units.
Security agencies handle perimeter protection, entry control, and traffic control to maintain safety at the scene.
EMTs are not armed or trained for direct security operations and should not engage in security tasks.
Your responsibilities as an EMT include: conducting an initial scene size-up for security threats, considering the possibility of multiple hazardous devices, requesting security support via radio promptly, setting up vehicle staging and triage/treatment areas in secure locations, informing EMS Command of any security concerns, and immediately reporting suspicious individuals or activities.
Decontamination
Gross decontamination is the initial phase of decontamination for EMS personnel, aimed at significantly reducing surface contamination.
This process typically involves mechanical removal of contaminants and an initial rinsing to quickly decrease the amount of hazardous material present on individuals.
Gross decontamination is a critical first step before more thorough decontamination procedures are performed, helping to limit the spread of hazardous substances.
Self-Protection at a Terrorist Incident
Self-protection and safety awareness are essential when responding to a terrorist event.
You must prioritize your own safety and remain vigilant about potential hazards in the environment.
Being prepared and aware of your surroundings can help you effectively protect yourself during a terrorist incident.
Protect Yourself First
Your safety is the top priority; if you are injured, you cannot assist others. Use your knowledge of multiple casualty incidents, the Incident Management System, PPE, crime scenes, hazardous materials, and decontamination to protect yourself.
Scene size-up and situational awareness are critical during potential terrorist incidents. Continuously reassess for hazards and unusual conditions.
Key signs to watch for in patients include: symptoms of hazardous substance exposure, unconsciousness without trauma, SLUDGEM signs (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal upset, Emesis, Miosis), seizures, skin blistering or irritation, and respiratory distress.
Look for physical and environmental warning signs: mass casualties with little or no trauma, injured responders, dead animals or plants, and unusual odors, smoke colors, or vapor clouds.
Terrorist incidents may involve unique risks: emergency responders can be targets, unusual illness patterns may indicate a biological agent, and explosive devices may be used to disperse chemical, biological, or radiological agents as well as cause physical harm.
How to Protect Yourself
Recognize possible terrorist events by using OTTO clues: Occupancy/location, type of event, timing, and on-scene clues (such as suspicious containers or unexplained illness patterns) help you identify potential terrorist involvement.
Do not rush into a potentially dangerous scene: Wait for authorities to declare the area safe, follow Incident Command protocols, wear appropriate PPE, and be alert for multiple devices or booby traps. Search patients for explosives or weapons, or wait for police to do so; evacuate immediately if an explosive device is found.
Understand TRACEM-P harms: Be aware of the seven types of harm—Thermal, Radiologic, Asphyxiation, Chemical, Etiologic (disease-causing), Mechanical, and Psychological—to guide your protective actions.
Apply time, distance, and shielding to reduce exposure: Minimize time spent in hazardous areas, maximize distance from the source, and use appropriate shielding (protective gear, barriers) for all types of terrorist agents.
At chemical incidents: Chemical harm is primary; minimize exposure time, stay outside contaminated areas unless properly trained and equipped, and use protective clothing and respiratory protection (e.g., SCBA).
At biologic incidents: Etiologic harm (disease) is primary; limit exposure, decontaminate promptly, maintain distance, and shield yourself with vaccinations, inoculations, and protective equipment (e.g., HEPA or N-95 mask).
At radiologic/nuclear incidents: Radiologic harm is primary, with possible thermal and mechanical harm; limit time in contaminated areas per local protocols, decontaminate promptly, maintain distance, and shield yourself with structures or materials that block radiation.
At explosive incidents: Thermal and mechanical harms are primary; etiologic and chemical harms are possible if agents are dispersed. Limit time in hazardous areas, maintain distance until declared safe, and shield yourself with turnout gear and PPE suitable for chemical, biologic, or radiologic threats if indicated.
Resources
The Strategic National Stockpile (SNS) provides essential pharmaceuticals and medical supplies when local resources are depleted during national disasters or terrorist incidents, including chemical, biologic, radiologic/nuclear, or explosive events.
The SNS was established in 1999 to ensure rapid delivery of disaster medical supplies to affected communities that request assistance.
The SNS is managed by the Administration for Strategic Preparedness and Response (ASPR) within the U.S. Department of Health and Human Services, ensuring federal oversight and coordination during emergencies.
Future Trends
Active shooter and mass shooting incidents are a significant and evolving threat, defined as situations where an individual is actively attempting to kill people in populated areas; these can result in multiple casualties regardless of the shooter's motivation.
Effective response to active shooter incidents requires close coordination between emergency medical providers and law enforcement, with joint training exercises being essential for successful mitigation; NFPA 3000 provides best practices for training and response to such events.
Cyberterrorism poses a growing risk to healthcare systems and patient safety, as hospital computer systems and medical devices (such as pacemakers and insulin pumps) are vulnerable to hacking, which can lead to operational disruption, ransom demands, identity theft, and direct threats to patient health.
EMTs play a role in safeguarding patient health information (PHI) by practicing secure handling of data, helping to prevent unauthorized access and cyberattacks.
Drugs of abuse, particularly potent opioids like fentanyl, can be weaponized as chemical agents, posing a risk for mass casualty incidents if disseminated intentionally; fentanyl's high potency and availability make it a potential tool for terrorism, as demonstrated in historical events.
Awareness of these emerging threats and their potential impact on emergency medical response is crucial for EMTs to remain current and proficient in their roles.
Think Like an EMT
Terrorism can present itself in various forms and scales, ranging from local incidents to nationwide threats, requiring you to be vigilant about different types of hazards.
Suspicious substances, such as white powder in an envelope, may indicate chemical, biological, or radiological threats; you should suspect possible hazardous materials and take precautions like avoiding direct contact, isolating the area, and using personal protective equipment (PPE).
Explosions in public places can result in multiple hazards, including structural damage, secondary devices, fire, and mass casualties; you should be alert for ongoing dangers, ensure scene safety, and coordinate with law enforcement and fire services before providing medical care.