EMS Operations & Foundations: Comprehensive Study Guide
Professionalism & Wellness
Characteristics of Professional Behavior: Integrity, empathy, self-motivation, appearance and hygiene, self-confidence, time management, communications, teamwork and diplomacy, respect, patient advocacy, and careful delivery of care.
Maintaining Wellness: Protection from communicable diseases and scene hazards; proper nutrition; sufficient exercise, relaxation, and sleep; refraining from tobacco, drug use, and excessive alcohol consumption; taking time to enjoy life outside of EMS/Fire.
Signs of Provider Stress: Fatigue, anxiety, anger, and feelings of hopelessness, worthlessness, and guilt.
5 Stages of Grief:
Denial: Refusal to accept diagnosis, care, or circumstance.
Anger: Person lashes out with the mindset that "someone must be blamed and punished".
Bargaining: Attempting to negotiate outcome (e.g., "God I promise I'll be a good person if...").
Depression: Internalizing anger, experiencing hopelessness, giving up long before it is time, and having a desire to die.
Acceptance: Accepting the impending death of self or a loved one.
Patient Consent & Legal Definitions
Expressed Consent: Consent given verbally by the patient or their legal guardian.
Informed Consent: Consent obtained after explaining the treatment, its benefits, and the risks of refusing treatment so the patient fully understands.
Implied Consent: Applies when a patient is unconscious, unresponsive, or otherwise incapable of making rational decisions. The law assumes the patient would consent to necessary care and transport.
Consent of Minors: A minor is anyone under 18 years of age and cannot refuse care unless a guardian is present and agrees, or if the minor is legally emancipated.
Emancipated Minor Criteria: A minor who is married, serving in the military, has a child of their own, has court-ordered emancipation, or lives independently without relying on parental support.
DNR (Do Not Resuscitate) Components:
Must state the patient's medical condition/problems.
Must include signatures of the patient (or legal guardian) and the physician/healthcare provider.
Must NOT be expired.
Protocol Note: The valid paper DNR must be present on scene. If in doubt, call medical command. Advanced directives specify treatment should a patient become unconscious, but "DNR" does not mean "Do Not Treat".
Reciprocity: Certification by endorsement where a provider is Nationally Registered and state-certified, allowing them to gain certification in another state.
Definitive Care: The hospital/trauma bay.
Communication Techniques
Effective Communication Steps: Identify yourself; maintain professional body language/uniform; look directly at the patient at eye level (take a knee if the patient is seated); speak slowly and distinctly; ensure only one person speaks at a time; ask one question at a time; do not assume elderly patients are hard of hearing; give patients time to respond; use reflective listening; explain procedures before doing them; never speak about the patient in front of them as if they aren't there.
Deaf/Hard of Hearing Patients: Face the patient so they can read lips; ensure hearing aids are brought with the patient (including after accidents); recognize that hearing-impaired patients have normal intelligence.
Radio Communication Protocol: Always keep your radio with you. Transmit status updates: responding to call (unit enroute), arrival on location, hospital destination, and arrival at hospital (unit available). Dispatch will run safety checks every 10–20 minutes.
Medical Direction:
Online Medical Direction: Direct consultation over the phone/radio with a physician. Protocol: All pharmacological interventions (except oxygen) require online medical command approval.
Offline/Standing Orders: Written orders signed by the agency's medical director outlining specific directions, treatments, and permissions (e.g., protocols, administering oxygen).
HIPAA (Health Insurance Portability and Accountability Act): Protects all private patient information and demographics; details of a call cannot be shared with neighbors, roommates, or unauthorized individuals.
Patient Care Reports (PCRs) & Refusals
6 Functions of a PCR: Continuity of care, compliance and legal documentation, administrative information, reimbursement, education, and data collection for research.
Key PCR Components: Name, gender, DOB, address, dispatch details, chief complaint, initial scene appearance/patient presentation, signs and symptoms, care/treatment provided and patient response, vital signs, SAMPLE history, OPQRST history, and official operational times.
Patient Refusal Protocol:
Assess and confirm the patient is alert, oriented, and fully understands their injury/illness, recommended treatments, and the medical risks of refusal.
Complete and document all physical assessments and findings.
Obtain signatures from the patient and an impartial witness on official refusal forms.
Thoroughly document all assessments, explanations, and signed forms in the PCR.
Infection Control & Reporting
Body Substance Isolation (BSI) Protocol: If exposed to blood or body fluids, immediately turn over patient care, clean/wash the exposed area, activate the department infection control plan, and complete an exposure form.
Infection Control Plan Components: Exposure risk determination, education/training, vaccines, PPE requirements, TB/physical testing, post-exposure management, compliance monitoring, and record keeping.
PPE Guidelines:
Patient contacts: Blood- and fluid-impermeable gloves must be worn on all patient contacts.
Tuberculosis (TB): Gloves, N95 respirator, eye protection.
Coughing up blood (Hemoptysis): Gloves, eye protection, N95 respirator.
Hepatitis: Gloves, eye protection.
Handwashing: Wash hands after every call as soon as possible using hot water and soap.
Mandatory Reporting Situations: Gunshot wounds (GSW), dog bites, specific infectious diseases, suspected sexual or physical abuse, and neglect (child or elder).
Crime Scene Management:
Priorities: Responder safety comes first; notify dispatch to request law enforcement.
Care: Provide life-saving emergency medical care while minimizing scene disturbance. Avoid walking in blood or cutting through bullet/knife holes in clothing.
Evidence Handling: All patient clothing and evidence must be placed in paper bags, never plastic bags.
Sexual Assault: Encourage the victim not to shower, urinate, defecate, or clean themselves before examination.
Special Scene Situations:
Hostile Scenes: Immediately back out if a scene becomes unsafe.
Infant Arrest: A grieving mother of an infant in arrest may hold the infant on scene.
Carbon Monoxide (CO): Responsible for the majority of fire-related deaths.
2. Patient Restraints & Air Medical Transport
Patient Restraint Protocol
Indication: Only utilize restraints if the patient is an immediate harm to self or others.
Resource Requirement: Requires 5 providers (1 for each of the 4 limbs, and 1 dedicated to controlling the head).
Positioning Protocol:
NEVER place a patient in the prone (face-down) position.
Never secure anything across the chest or abdomen.
Maintain clear communication and follow a pre-arranged team plan before taking action.
Air Medical Transport Protocol
Indications: Used for critically sick or injured patients where ground transport time/distance would adversely affect patient outcomes, or when specialized resources are required.
Request & Setup: Request air transport through dispatch; local fire departments are typically dispatched to secure the landing zone (LZ).
Landing Zone (LZ) Specifications: Standard LZ size is 100 x 100 feet (absolute minimum 60 x 60 feet). Must be clear of debris, hazards, and bright lights.
Safety Rule: Always approach the aircraft from the front.
3. Incident Command System (ICS) & NIMS
NIMS & ICS Concepts
National Incident Management System (NIMS): Implemented in 2004 to provide a standard framework for federal, state, and local governments, private sectors, and NGOs to work together. Standardizes terminology, resource classification, personnel training, and certification.
Purpose of ICS: Ensures responder and public safety, achieves incident management goals, and ensures efficient resource utilization while eliminating duplication of effort and freelancing.
Span of Control: Maintains a ratio of 1 supervisor to 3–7 workers.
Command Structure & Roles
Incident Commander (IC): In overall charge of the incident scene.
Finance Section: Tracks all expenditures for post-incident reimbursement.
Logistics Section: Secures communications equipment, facilities, food, water, fuel, lighting, and medical supplies.
Operations Section: Manages tactical operations on large scenes (supervises field workers).
Planning Section: Solves problems as they arise and formulates the Incident Action Plan (IAP).
Command Staff Roles:
Safety Officer: Monitors scene operations for safety hazards.
Public Information Officer (PIO): Handles media queries and releases official info.
Liaison Officer: Coordinates with external assisting agencies.
Medical Branch Roles
Triage Supervisor: Oversees patient counting, initial assessment, and prioritization.
Treatment Supervisor: Establishes treatment areas segmented by priority and ensures secondary triage is performed.
Transportation Supervisor: Coordinates hospital distribution and tracks transport units, patient counts, and receiving facilities.
Staging Supervisor: Manages incoming emergency units in an off-scene staging area; units enter the scene only when cleared.
Rehabilitation Supervisor: Provides shelter, food, fluids, and climate protection for responders while monitoring them for stress.
Morgue Supervisor: Coordinates body removal with law enforcement/coroners; ensures the morgue area is completely out of view of survivors and responders.
Extrication/Special Rescue Supervisor: Manages specialized equipment and rescue operations under the EMS branch.
On-Scene Physicians: Assist with difficult triage decisions, secondary triage in treatment zones, on-scene medical direction, and specialized care.
Scene Arrival & Communication Protocol
Scene Size-Up Questions: Evaluate What do I have? What do I need? What do I need to do?
Establish Command: The most senior arriving official establishes command early, notifies dispatch, and requests needed resources.
Communication Protocol: Use face-to-face communication when possible to decrease radio chatter. Do not use 10-codes or signals on radios.
Responder Arrival Protocol: Check in with the IC or assigned sector supervisor upon arrival. Maintain accountability by updating supervisors on your location and tasks.
4. Mass-Casualty Incidents (MCIs) & Triage Protocols
MCI Definition & Transport Rules
Mass-Casualty Incident (MCI): An event involving 3 or more patients that places high demand on the EMS system and exhausts available resources.
Transport Protocol: Never leave the scene with patients if untriaged or untreated victims remain. Transport immediate (red) patients 2 at a time, followed by delayed (yellow) patients 2–3 at a time, then minor (green) patients (which can use a bus), and lastly expectant (black) patients.
Triage Categories & Colors
Immediate (Red Tag): Priority 1; life-threatening injuries needing immediate care/transport.
Delayed (Yellow Tag): Priority 2; serious injuries, but treatment/transport can be delayed briefly.
Minor (Green Tag): Priority 3; "walking wounded" with minimal injuries.
Expectant (Black Tag): Priority 4; deceased or surviving injuries so severe that resuscitation is futile.
[ All MCI Patients ]
|
Can the patient WALK on command?
/ \
(YES) (NO)
/ \
[ GREEN (Minor) ] Assess Respirations
/ \
(ABSENT) (PRESENT)
/ \
Open Airway Is RR > 30?
/ \ / \
(ABSENT) (PRESENT) (YES) (NO)
| | | |
[ BLACK ] [ RED ] [ RED ] Assess Perfusion
(Expectant) (Immediate) (Immediate) (Radial Pulse / CRT)
/ \
(No Pulse / >2s) (Pulse Present / ≤2s)
| |
[ RED ] Assess Mental Status
(Immediate) / \
(Fails Commands) (Follows Commands)
| |
[ RED ] [ YELLOW ]
(Immediate) (Delayed)
START Triage Protocol (Adults)
Step 1: Call out: "Anyone who can walk, move to [designated landmark/green tarp]." Assign all who respond to Green (Minor).
Step 2 (Respirations):
If not breathing: Open airway manually. If still not breathing $\rightarrow$ Black (Expectant). If breathing starts $\rightarrow$ Red (Immediate) (place in recovery position).
If breathing with RR > 30 breaths/min $\rightarrow$ Red (Immediate).
If breathing with RR < 30 breaths/min $\rightarrow$ Move to Perfusion assessment.
Step 3 (Perfusion):
Absent radial pulse OR Capillary Refill Time (CRT) > 2 seconds $\rightarrow$ Red (Immediate).
Present radial pulse AND CRT $\le$ 2 seconds $\rightarrow$ Move to Mental Status assessment.
Step 4 (Mental Status):
Cannot follow simple commands (altered) $\rightarrow$ Red (Immediate).
Follows simple commands $\rightarrow$ Yellow (Delayed).
JumpSTART Triage Protocol (Pediatrics < 8 yrs or < 100 lbs)
Step 1: Direct walking children to green area $\rightarrow$ Green (Minor).
Step 2 (Respirations):
If apneic/not breathing: Immediately check for a pulse.
No pulse $\rightarrow$ Black (Expectant).
Pulse present $\rightarrow$ Give 5 rescue breaths. If breathing resumes $\rightarrow$ Red (Immediate). If child remains apneic after 5 breaths $\rightarrow$ Black (Expectant).
If respiratory rate is < 15 or > 45 breaths/min $\rightarrow$ Red (Immediate).
Special Triage Considerations: Hysterical/disruptive patients or responders who become injured/ill during operations must be triaged as Red (Immediate).
5. Vehicle Extrication & Specialized Rescue
Definitions & Fundamentals
Extrication: Safe removal of a patient from entrapment or a dangerous situation/position.
Entrapment: Condition where a person is caught in a closed area with no way out, or has a limb/body part trapped.
Primary Roles during Extrication: Ensure personal/team safety, provide emergency medical care, and prevent further patient injury.
Team Responsibilities
EMS: Scene size-up, medical assessment, care, triage, packaging, updates to fire/rescue on criticality, and transport.
Rescue Team: Vehicle stabilization, securing safe entrance/access, and physical patient extrication.
Law Enforcement: Traffic control, scene order, and perimeter security.
Firefighters: Fire suppression, ignition prevention, hazard containment, and fuel spill removal.
10 Phases of Extrication
Preparation: Pre-incident training and daily vehicle/tool checks.
En Route: Safe response procedures.
Arrival & Scene Size-up: Positioning ambulance to block traffic, using essential lights, placing PPE, 360° walk-around.
Hazard Control: Managing lines, fluid, fire, and vehicle stability.
Support Operations: Scene lighting, equipment staging, LZ setup.
Gaining Access: Simple vs. complex access.
Emergency Care: Primary assessment, manual spine stabilization, life-threat management.
Removal of Patient: Coordinating safe removal path.
Transfer of Patient: Moving patient to stretcher/ambulance as a unit.
Termination: Equipment checks, vehicle cleaning/restocking, documentation.
Vehicle Hazards & Safety Protocols
Vehicle Bumpers: Loaded shock-absorbing bumpers can unexpectedly release; approach vehicles from the side, never front/rear.
Airbag Clearance Distances (Undeployed):
Side-impact airbags: Maintain at least 5 inches clearance.
Driver front airbag: Maintain at least 10 inches clearance.
Passenger front airbag: Maintain at least 20 inches clearance.
Airbag Powder: The white haze following deployment is non-harmful cornstarch or talc; wear eye/respiratory protection to prevent irritation.
Vehicle Stabilization & Disconnection: Ensure transmission is in "Park", parking brake is set, ignition turned off, and both battery cables disconnected (negative first) to prevent sparks.
Alternative Fuel / Hybrid Vehicles: High-voltage cables are color-coded orange. High-voltage systems can take up to 10 minutes to de-energize after battery disconnection. Batteries may be under seats or in the trunk. Retreat if you smell unusual odors or feel burning in your eyes/throat.
Downed Power Lines Protocol: Never attempt to move electrical lines. Instruct patients to remain inside the vehicle until power is shut off by utility workers. Responders must remain outside the danger (hot) zone.
Physical Damage Assessment (Visual Clues)
Bent Steering Wheel: High index of suspicion for facial or severe thoracic trauma.
Dashboard Imprints: High suspicion for lower extremity fractures, knee trauma, or hip dislocations/fractures.
Spider-web Glass Pattern (Windshield): Indicates patient head/face impact; suspect head, neck, or cervical spine injuries.
Note: Always lift deployed airbags to check for hidden steering wheel or dashboard deformation.
Gaining Access Protocols
Simple Access: Accessing the patient without using tools or breaking glass (e.g., trying all door handles, asking patient to unlock doors, rolling down windows). Always "Try Before You Pry".
Complex Access: Requires specialized equipment (hydraulic shears, prying tools, hand tools) and advanced technical training (e.g., breaking glass, cutting posts, removing vehicle roofs).
Patient Protection: Cover the patient with a heavy, fire-resistant blanket or use a long backboard as a shield against glass, debris, and noise. Explain all steps clearly to the patient.
Extrication Methods (Rapid vs. Emergency)
Rapid Extrication Protocol:
Indications: Patient has altered mental status, inadequate ventilation, hypoperfusion/shock, or is blocking access to a more critical patient.
Requirements: At least 3 to 4 providers. Manual C-spine precautions and complete spinal immobilization are maintained throughout. Target time is 1 minute or less.
Emergency Extrication Protocol:
Indications: Immediate threat to life/limb, environmental hazard (e.g., vehicle fire, toxic gas), or inability to perform life-saving care in place due to positioning/threat to XABC.
Action: Rapid "yank and grab" move to pull the patient to safety immediately; C-spine precautions are bypassed due to immediate threat to life.
Specialized Technical Rescue Protocols
Trench Collapse Protocol:
Hazards: Soil weighs ~100 lbs per cubic foot; chest compression prevents lung expansion leading to hypoxia. High risk of secondary collapse.
Parking: Park all response vehicles at least 500 feet away from the scene.
Safety: Turn off all vehicle engines to prevent ground vibration collapse; divert all road traffic outside the 500 ft zone.
Entry Rule: NEVER enter a trench deeper than 4 feet without professional shoring in place.
Search and Rescue (SAR) Protocol:
Staging: Stand by at the command post. Keep heavy/bulky equipment (backboard, wheeled stretcher) in the ambulance protected from weather. Carry jump kit, radio, and flashlight.
Communication: Only the Incident Commander is permitted to give official updates/news to the missing person's family. Keep radio volume low/discreet around family.
Structure Fire Staging: Stage the ambulance where directed by the IC—far enough to give fire trucks room for operations and hydrants, but close enough for rapid transport. Primary EMS role is firefighter safety and rehab.
Tactical Emergency Medical Support (TEMS): Serves SWAT operations. Turn off lights and sirens when approaching. Stage at the command post out of line-of-sight and gun range.
6. Hazardous Materials (Hazmat) Operations
Control Zones & Scene Setup
Approach Protocol: Always approach and park uphill and upwind. Use the ambulance Public Address (PA) system to direct bystanders away from the scene.
Hot Zone: Immediately surrounds the spill/release area; highest contamination. Entry requires specialized PPE. All personnel leaving the hot zone must undergo decontamination.
Warm Zone: Transition area containing decontamination corridors and access control points. Protocol: Decontamination setup belongs between the hot zone and cold zone (before the treatment area).
Cold Zone: Safe area. Houses the Command Post, staging, treatment area, and medical monitoring/rehab. EMTs operate here.
[ WIND DIRECTION: ---> ]
+--------------------------------+
| HOT ZONE | (Contaminated Area / SCBA & Level A/B)
| * Hazard Release Site * |
+--------------------------------+
|
v (Decontamination Line)
+--------------------------------+
| WARM ZONE | (Decon Corridor & Access Control)
+--------------------------------+
|
v (Decontaminated Personnel Only)
+--------------------------------+
| COLD ZONE | (UPHILL & UPWIND)
| - Command Post | (Safe Operating Zone / Standard PPE)
| - EMS Staging |
| - Triage / Treatment / Transport
+--------------------------------+
Hazardous Materials Identification
NFPA 704 Diamond: Standard system identifying Health (Blue), Flammability (Red), Reactivity (Yellow), and Special Hazards (White).
DOT Marking System: Placard (large diamond placed on 4 sides of transport vehicles) and Labels (smaller versions placed on packages/boxes).
Emergency Response Guidebook (ERG): Reference guide providing initial action guidance for ~4,000 hazardous chemicals.
Safety Data Sheets (SDS / MSDS): Chemical documentation detailing makeup, hazards, first aid, and handling guidelines.
CHEMTREC: Technical resource operated by the American Chemistry Council for chemical emergency advice.
Container Classification
Bulk Containers: Large volume horizontal tanks, totes (119 to 703 gallons, no secondary containment), intermodal tanks (5,000–6,000 gallons, shipping/storage).
Non-Bulk Containers: Drums (barrel-like), carboys (glass/plastic containers holding 5–15 gallons of corrosives), bags (solids/powders), compressed gas cylinders.
Toxicity Levels & PPE Levels
Toxicity Levels:
Level 0: Little to no health hazard.
Level 1: Irritation on contact, minor residual injury without treatment.
Level 2: Temporary damage or residual injury unless prompt medical care is provided.
Level 3: Extremely hazardous; requires full chemical protective suit.
Level 4: Minimal contact is rapidly fatal.
Personal Protective Equipment (PPE) Levels:
Level A: Highest protection; fully encapsulating, chemical-resistant suit with SCBA and sealed equipment.
Level B: Non-encapsulating suit, but requires SCBA (supplied air) and splash protection.
Level C: Non-permeable clothing with air-purifying filter mask (respirator).
Level D: Basic work uniform (coveralls, safety boots); minimal protection.
Note: Gloves are required across all levels.
7. Weapons of Mass Destruction (WMD) & Terrorism
Terrorism Definitions & Categories
DOJ Definition of Terrorism: Violent acts dangerous to human life violating laws, intended to coerce/intimidate a civilian population, influence government policy, or affect government conduct via mass destruction, assassination, or kidnapping.
Domestic vs. International: Domestic occurs primarily within the US; International occurs primarily outside the US.
Group Classifications: Religious/Doomsday cults (apocalyptic violence), Extremist political groups, Cyber terrorists (attack technological infrastructure), Single-issue groups (anti-abortion, animal rights, eco-terrorists, anarchists, racists).
Lone-Wolf Attacks: Individuals or small groups radicalized independently. Preparatory steps: target reconnaissance, purchasing/manufacturing weapons, researching tactics, releasing manifestos, sudden "farewell" behaviors.
THREAT Protocol: Threat suppression $\rightarrow$ Hemorrhage control $\rightarrow$ Rapid extrication to safety $\rightarrow$ Assessment by medical providers $\rightarrow$ Transport to definitive care.
WMD Acronyms
B-NICE: Biological, Nuclear, Incendiary, Chemical, Explosive.
CBRNE: Chemical, Biological, Radiological, Nuclear, Explosive.
┌─────────────────────────────────────────┐
│ WEAPONS OF MASS DESTRUCTION (WMD) │
└────────────────────┬────────────────────┘
│
┌──────────────────┬───────────────┴───────────────┬──────────────────┐
│ │ │ │
┌────┴─────┐ ┌─────┴──────┐ ┌─────┴──────┐ ┌─────┴──────┐
│ CHEMICAL │ │ BIOLOGICAL │ │RADIOLOGICAL│ │ EXPLOSIVE/ │
│ AGENTS │ │ AGENTS │ │ /NUCLEAR │ │ INCENDIARY │
└────┬─────┘ └─────┬──────┘ └─────┬──────┘ └─────┬──────┘
│ │ │ │
├─ Vesicants ├─ Viruses (Smallpox, VHF) ├─ Dirty Bombs ├─ Primary
├─ Pulmonary ├─ Bacteria (Anthrax, Plague) ├─ SADM Blast (Gas)
├─ Nerve Agents └─ Neurotoxins (Botulinum, └─ Alpha/Beta/ └─ Secondary
└─ Metabolic Ricin) Gamma/Neutron (Debris)
Chemical Agents
Persistence: Persistent/non-volatile agents remain on surfaces > 24 hours. Non-persistent/volatile agents evaporate rapidly.
Routes: Vapor hazard (inhalation via respiratory tract); Contact hazard (skin absorption).
1. Vesicants (Blister Agents)
Route & Action: Contact hazard (skin); causes burn-like blisters on skin and respiratory tract. Targets moist body areas (armpits, groin, airway).
Signs: Intense pain, reddening, large blisters, gray skin discoloration, eye damage/blindness.
Specific Agents:
Sulfur Mustard (H): Brown-yellow oily liquid; persistent. Irreversibly depletes white blood cells in bone marrow.
Lewisite (L) & Phosgene Oxime (CX): Cause immediate intense pain and gray skin discoloration.
Treatment Protocol: Decontaminate prior to treatment. No antidotes exist for Mustard or CX. Provide airway support if inhaled. Transport to burn centers.
2. Pulmonary (Choking) Agents
Route & Action: Inhalation hazard. Damages lung tissue causing pulmonary edema and severe gas exchange impairment.
Specific Agents: Chlorine (Cl) (first used in warfare) and Phosgene.
Signs: Dyspnea, tachypnea, pulmonary edema.
Treatment Protocol: Remove patient from atmosphere, keep patient completely inactive/rested, manage ABCs, oxygenate/ventilate/suction. No antidotes exist; request ALS.
3. Nerve Agents (Organophosphates)
Action: Blocks acetylcholinesterase in the nervous system. Extremely lethal within seconds to minutes.
Specific Agents:
Tabun (GA): Fruity odor; 36 times more persistent than sarin.
Sarin (GB): Colorless, odorless volatile liquid. Rapidly turns to gas. High off-gassing hazard (clothing must be stripped).
Soman (GD) & VX: VX is an odorless oily liquid (resembles baby oil), 100x more lethal than sarin, persistent for weeks.
Signs: Miosis (pinpoint pupils; key symptom lasting weeks), excessive secretions, seizures, cardiac arrest.
Treatment Protocol: Seizures will continue until death unless DuoDote (Atropine + Pralidoxime chloride/2-PAM) is administered. Strip clothing to prevent off-gassing.
4. Metabolic Agents (Cyanides)
Action: Impairs cellular oxygen utilization.
Specific Agents: Hydrogen Cyanide (AC) and Cyanogen Chloride (CK). Almond odor; found in industrial fires (burning plastics/textiles).
Signs: Low dose (dizziness, headache, vomiting); High dose (shortness of breath, tachypnea, flushed skin, tachycardia, seizures, coma, apnea, cardiac arrest).
Treatment Protocol: Remove all clothing to prevent off-gassing, support ABCs, rapid transport.
Biological Agents
Definitions:
Dissemination: The means by which a terrorist spreads an agent.
Vector: Animal/insect spreading disease.
Communicability: How easily disease spreads human-to-human.
Incubation: Time between exposure and first symptom appearance.
Viruses (Require host to live):
Smallpox: Highly contagious; starts with high fever, followed by rash/blisters starting on extremities and moving to trunk. Most contagious when blisters form. Requires HEPA respirator and full PPE.
Viral Hemorrhagic Fevers (Ebola, Marburg, Yellow Fever, Rift Valley): Causes systemic blood seepage from vessels; flu-like symptoms progressing to mass internal bleeding.
Bacteria (Do not require host; antibiotic-responsive):
Anthrax: Spore-forming bacterium. Routes: Inhalation, Cutaneous, GI. Pulmonary anthrax is the deadliest. Vaccines and antibiotics available.
Plague: Vectors: Rodents and fleas. Bubonic plague infects lymph nodes (creates swollen buboes); Pneumonic plague is a contagious lung infection.
Neurotoxins (Most deadly substances; non-contagious):
Botulinum Toxin: Most potent neurotoxin known; produced by bacteria. Causes voluntary muscle paralysis leading to respiratory arrest.
Ricin: Derived from castor bean mash; causes organ failure.
Public Health & Dispersal Infrastructure
Syndromic Surveillance: Monitoring emergency department admissions and dispatch calls for unusual clusters of symptoms (e.g., flu-like illness) to detect bio-attacks early.
Points of Distribution (POD): Mass distribution centers for medications, antidotes, and vaccines.
CDC Strategic National Stockpile (Push Packs): Medications and medical supplies capable of delivery anywhere in the US within 12 hours.
Radiological & Nuclear Explosives
Types of Radiation:
Alpha: Least penetrating; stopped by skin/paper.
Beta: Slightly more penetrating.
Gamma (X-ray): Highly penetrating, fast, strong.
Neutron: Most powerful and penetrating particle.
Radiological Dispersal Device (RDD / "Dirty Bomb"): Uses conventional explosives to scatter radioactive waste. Ineffective as a WMD for mass destruction, but causes massive psychological panic.
Nuclear Energy/Weapons: Altering/splitting atoms releasing immense heat/energy. Special Atomic Demolition Munition (SADM) are small portable nuclear units.
Acute Radiation Toxicity: Caused by high radiation exposure.
Protection Protocol: No PPE completely shields radiation. Safety depends on Time, Distance, and Shielding (assume strongest radiation and utilize concrete shielding).
Explosive Devices & Blast Physics
Blast Waves: Chemical detonation rapidly converts solid/liquid into high-pressure gas, creating a spherical blast wave.
Trauma: Flying debris and extreme winds produce severe blunt and penetrating trauma.
Secondary Devices: Additional explosives intentionally set to detonate after initial blast to kill/injure first responders. Always maintain high suspicion for secondary devices.