Paramedic Care: Principles & Practice Volume 5 Special Considerations/ Operations

Chapter 14 Responding to Terrorist Acts

Topics Explosive Agents Nuclear Detonation Chemical Agents Biological Agents General Considerations Regarding Terrorist Attacks

Definition of Terrorism Terrorism is a violent act or an act dangerous to human life, in violation of the criminal laws of the United States or any segment, to intimidate or coerce a government, the civilian population or any segment thereof, in the furtherance of political or social objectives. U.S. Department of Justice

Introduction Impact of September 11, 2001 The weapon of choice is the conventional explosive The twenty-first century will bring new terrorism threats using more unconventional means © Szenes Jason/Corbis Sygma

Introduction Weapons of mass destruction (WMDs) Nuclear, biological, and chemical (NBC) weapons EMS personnel are responsible for maintaining a higher index of suspicion for such an event

Explosive Agents

Explosive Agents Weapon of choice Initial dangers Associated dangers Blast pressure wave Debris Associated dangers Structural collapse Secondary explosions Fire and other hazards

Explosive Agents Incendiary Agents Subset of explosive agents Examples Napalm Molotov cocktail White phosphorus Magnesium Cause severe and extensive burn injuries

Nuclear Detonation

Nuclear Detonation Involves the release of energy that is generated when heavy nuclei split (fission) or light nuclei combine (fusion) Burn injuries are likely to be the most lethal and debilitating injuries associated with a nuclear detonation

Nuclear Detonation Damage associated with a typical nuclear detonation is extreme Results in concentric circles Generates particles of debris and dust that give off nuclear radiation

Nuclear Detonation Nuclear radiation cannot be felt, seen, or otherwise detected Causes cell damage Fallout can produce serious and life-threatening exposure

Nuclear Incident Response First hour post-ignition Move the injured into structures that will protect them Organize, determine the direction of fallout movement, and begin to extricate Care for victims of a nuclear detonation Decontamination Treatment as for a conventional explosion Treatment for thermal burns

Nuclear Incident Response Monitor for radioactive contamination Geiger counter Dosimeter Paramedics may be asked to help distribute potassium iodide (KI) tablets Signs and symptoms of radiation exposure Nausea, fatigue, and malaise

Radioactive Contamination May be spread using conventional explosives “Dirty bomb” Nature of the risk (the radiation) may not be recognized until well after the incident Treatment

Chemical Agents

Chemical Agents Simple to sophisticated chemicals Confined spaces are most common target Physical properties affect distribution Volatility Ease with which a chemical changes from a liquid to a gas Specific gravity Refers to the density or weight of the vapor or gas as compared with air

Chemical Agents Environmental considerations Wind Precipitation Climate controlled environments Classification of chemical agents Nerve agents, vesicants, pulmonary agents, biotoxins, incapacitating agents, and other hazardous chemicals

Nerve Agents Affect nerve impulse conduction Examples Resulting in respiratory failure Examples GB (sarin) VX GD (soman) GA (tabun) Organophosphates

Nerve Agents May be inhaled or absorbed Signs and symptoms Management SLUDGE Management Mark I kit Atropine Pralidoxime chloride Diazepam

Vesicants (Blistering Agents) Damage exposed skin and mucous membranes Examples Sulfur mustard (HD) Nitrogen mustard (HN) Lewisite (L) and phosgene oxime (CX) Assessment Management

Vesicants (Blistering Agents) Assessment Injury to the skin, mucous membranes, and lungs Nausea, vomiting, and fatigue Symptoms may occur slowly Management Decontamination Irrigate with water Treat soft tissue injury

Pulmonary Agents Chemical injury to lungs and mucous membranes Produce inflammation and pulmonary edema resulting in dyspnea and hypoxia Examples Phosgene Chlorine Synthetic by-products

Pulmonary Agents Assessment Management Signs and symptoms related to irritation of the upper airway Rhinorrhea, nasal, oral, and throat irritation, wheezing, cough, eye irritation Pulmonary edema is a late sign Management Remove from environment Exposure to fresh air, high-flow, high-concentration oxygen; and rest Consider albuterol

Biotoxins Biological agents that act like chemical agents Toxins produced by living organisms Examples Ricin Staphylococcal enterotoxin Botulinum Trichothecene mycotoxins

Biotoxins Management is mainly supportive No antidote is available A special concern is directed to careful decontamination A small amount of biotoxin can endanger rescuers and others

Incapacitating Agents Used by police and military Selected or designed to incapacitate, not injure or harm, the recipient Examples CS CN (mace) Capaicin (pepper spray) CR

Incapacitating Agents Assessment Eye irritation and tearing as well as rhinorrhea Airway irritation and dyspnea Management Removal from source, exposure to fresh air, and oxygen

Incapacitating Agents Anticholinergic agents BZ and QNB Prototype incapacitating agents for the military Method of distribution of these agents is detonation Assessment Effects become apparent after about 30 minutes of inhalation and last for up to 8 hours Physostigmine is the antidote

Other Hazardous Chemicals Any toxic chemical has potential as WMD Industry related Terrorist related Emergency Response Guidebook

Recognition of a Chemical Agent Release Possible cloud or puddle Possible strange or unusual odor Dead or damaged plants and/or animals Potential targets Key: Manifestation of common signs and symptoms occurring rapidly among a large group of individuals

Management of Chemical Agent Release Approach from uphill Maintain distance Evacuate Decontaminate Provide appropriate medical treatment

Biological Agents

Biological Agents Living organisms or toxins Can spread quickly Human-to-human contagious Not human-to-human contagious Can spread quickly Recognition of release Numerous patients with similar signs and symptoms

Pneumonia-Like Agents Biological pulmonary agents Anthrax Most deadly Effective, but not contagious Pneumonic plague Plague most likely used for bioterrorism Incubates over 1 to 4 days and can be spread through droplets and inhalation

Pneumonia-Like Agents Biological pulmonary agents (cont.) Tularemia May be aeresolized Presents with signs and symptoms in 2 to 10 days Q fever May appear in 10 to 20 days More of an incapacitating disease

Encephalitis-Like Agents Smallpox and Venezuelan equine encephalitis Influenza-like diseases Attack the central nervous system Can be aerosolized Signs and symptoms Potential for smallpox as WMD

Other Agents Cholera Viral hemorrhagic fever (VHF) Most commonly transmitted by the fecal–oral route Causes dehydration and shock May be delivered by way of contamination of food or untreated water Viral hemorrhagic fever (VHF) Includes ebola virus Attacks the bloodstream and damages blood vessels Spread through direct contact with infectious material

Protection Against Biological Agent Transmission Employ a more aggressive use of Standard Precautions Take droplet inhalation precautions Immunizations

Protection Against Biological Agent Transmission Emergency Care Limited to supportive care Body temperature, administer oxygen hydration, and, in some cases, IV fluids Use of MDI’s vs nebulizers Antibiotics Role of Public Health

General Considerations Regarding Terrorist Attacks

General Considerations Regarding Terrorist Attacks Scene Safety Secondary explosive devices Analyze a scene to determine the risk to you and other rescuers

Recognizing a Terrorist Attack Relatively easy to recognize a nuclear or conventional explosion Fallout concern Chemical release May or may not be a cloud of gas or aerosolized material Incapacitated small animals, birds, and insects Don nitrile gloves, a well-fitting HEPA filter mask, and a Tyvek® coverall

Recognizing a Terrorist Attack Biological Agent No immediate signs and symptoms from those exposed Likely to be recognized after the incubation period Patients presenting with similar symptoms Don gloves and a well-fitted HEPA filter mask

Responding to a Terrorist Attack Ensure your own safety and that of your patient, other rescuers, and the public Decontaminate patients Once a WMD incident is identified, begin preparing for the casualties Initiate incident management system Follow protocols and SOP’s

Summary Explosive Agents Nuclear Detonation Chemical Agents Biological Agents General Considerations Regarding Terrorist Attacks