1. Terrorism
Dr. Miada Mahmoud Rady

2. Terrorism
Definition : A violent act dangerous to human life to intimidate or force a government, the civilian population, or any segment, in advantage of political or social objectives.

3. Classification
International terrorism : Acts of terror committed by foreign agents.
Domestic terrorism : terrorists are citizens of the same country attacked.

4. Recognizing a Terrorist Event (Indicators)
Acts of terror are usually secret
there are indicator which include locations .

5. Targeted locations of terrorist attacks
High-value targets for terrorists include:
Military bases and centers
Public transportation
Chemical plants or transportation
Government buildings and hospitals
Public gathering places

6. EMT Response to Terrorism
On every call, you must make the following observations:
Type of location
Type of call
Number of patients
Victims’ statements
Preincident indicators

7. Response Actions If you suspect an attack:
Ensure scene safety and personal safety.
Notify dispatch and/or supervisor.
Request additional specialized resources.
Establish command.
Initiate multiple-casualty incident procedures.

8. Scene Safety
Do not enter the scene if there is any doubt that it is not safe
Best location for staging is upwind and uphill
Wait for assistance from trained personnel.
Wait for law enforcement personnel.

9. Responder Safety
Best form of protection is preventing contact with the agent.
The greatest threat in a WMD attack:
Contamination
Cross-contamination

10. Notification procedure and resource requests
As soon as you suspect a terrorist or WMD event, notify the dispatcher.
Establish a safe staging area.
Request HazMat teams as early as possible.

11. Command Is first arriving paramedic
Tasks of first arriving paramedic( incident commander) :
Report to incident command post.
Establish a medical branch.
Determine scope of incident.
Gather and disseminate information to dispatch.

12. Command Assign a supervisor for the following areas: Decontamination
Treatment
Transportation
Staging
Rehabilitation
Report EMS activities to operations chief.

13. Weapons of Mass Destruction
Definition : Any agent designed to bring about:
Mass death
Multiple casualties
Massive damage to property and infrastructure

14. Kinds of Weapons of Mass Destruction
CBRNE is mnemonics for the kinds of WMDs:
Chemical
Biologic
Radiologic
Nuclear
Explosive

15. Explosives/inflammable Weapons
Explosives are most common weapon used by terrorists.

16. Ammonium Nitrate or “Fertilizer” Bombs
Commonly used as an industrial-grade fertilizer
Requires special license for purchase
Can be mixed to create an extremely explosive compound

17. Chemical Agents
Definition : Man-made substances that can have devastating effects on living organisms
Produced in multiple forms:
Liquid
Powder
Vapor

18. Chemical Agents Chemical weapon classifications depends on :
Properties or characteristics of an agent
Persistency and volatility
Route of exposure ( Vapor hazard , Contact hazard )

19. chemical agents Chemical agents are categorized into :
Vesicants (blister agents).
Respiratory agents (choking agents).
Nerve agents.
Metabolic agents (cyanides).
Irritating agents

20. Vesicants (blister agents)
Definition : they are substances that cause burn-like blisters to form on the victim’s skin and in the respiratory tract.
Primary route of exposure of vesicants is skin.
If the substances are left long enough , it can produce vapor that will cause respiratory tract irritation.

21. Vesicants Examples of vesicants : Mustard (H) Lewisite (L)
Phosgene oxime (CX)

22. Signs of vesicant exposure on the skin
Remember normal burn feeling and stages
Immediate, intense skin pain
Skin irritation, burning and reddening
Formation of large blisters
Gray discoloration of skin
Swollen and closed or irritated eyes
Permanent eye injury (including blindness).

23. Management
Rapid removal of the patient by specially trained personnel.
Aggressive decontamination by specially trained personnel wearing PPE.
Address ABCS.
Antidote : there is no known antidote for mustard and phosgene oxime , British antilewisite is used as antidote for lewisite.

24. Pulmonary Agents
Gases that cause immediate harm to persons exposed to them
Primary route is through the respiratory tract.
Produce respiratory-related symptoms:
Dyspnea
Tachypnea
Pulmonary edema

25. Examples of pulmonary agents:
Chlorine.
Phosgene.

26. Chlorine (CL) First chemical agent ever used in warfare
Clinical presentation :
First upper airway irritation and a choking sensation
Shortness of breath
Chest tightness
Hoarseness and stridor
Gasping and coughing\

27. How to identify the presence of chlorine in the scene?
Characteristic smell of chlorine bleach
Green haze it produces in the atmosphere

28. Clinical presentation :
Phosgene
Product of combustion.
Clinical presentation :
Very potent with a delayed onset of symptoms , mild exposure causes :
Nausea
Chest tightness and
Severe cough
Dyspnea on exertion

29. Pulmonary agent treatment
Remove the patient from the contaminated atmosphere.
Manage the ABCs aggressively.
Pay attention to oxygenation, ventilation, and suctioning.
Do not allow the patient to be active.
There are no antidotes.

30. Nerve agents
Definitions : WMDs designed to kill large number of peoples with small quantities , they belong to Organophosphorus class.
Mechanism of action: they block cholinesterase enzymes accumulation of acetylcholine at nerve ending  overstimulation of body organs.

33. Types : four major types ,which vary in their onset of action and lethal dose:
Sarin (GB)
Soman (GD)
Tabun (GA)
V agent (VX)

34. Nerve Agents

35. Clinical presentation
Nerve gases is one of deadliest chemicals known .
Can cause cardiac arrest within seconds to minutes of exposure.
Clinical presentation of nerve gas toxicity is known by two mnemonics military and medical. ( SLUDGEM , DUMBLES).

36. Clinical effects of nerve agent mnemonics

37. Management Decontamination . Address ABCs .
Seizing patient will need nerve gas antidote kit .
DuoDote Antidote Kit contains a single injection of atropine and 2-PAM chloride.

39. Metabolic agents (cyanides)
Include cyanide agent and cyanogen chloride .
Widely used in industry.
Colorless gases with almond odor.
Mechanism of action : impair the body ability to utilize oxygen.

40. Clinical presentation
Low dose symptoms
High dose symptoms
Dizziness
Light-headedness
Headache
Vomiting
Shortness of breath
Tachycardia
Seizures
Cardiac arrest

41. Management of cyanide toxicity
Decontamination :
Patient should be removed from the contaminated area and all their clothes should be removed to prevent off- gasing by trained personnel wearing PPE.
Address ABCs and insert an I.V access :
in case of sever exposure patient will require aggressive oxygenation and ventilation.

42. Biologic terrorism.
Biologic agents are organisms that cause disease.
The primary types are:
Viruses
Bacteria
Toxins

43. Why Biologic Agents are considered extremely dangerous
Almost completely undetectable.
Diseases caused is similar to other minor illnesses.
May be spread in various ways :
Dissemination is the means by which a terrorist will spread the agent.
A disease vector is an animal that spreads disease to another animal.

44. Viruses Special characters :
require a living host to multiply and survive.
Invades healthy cells and replicates itself to spread through the host
Moves from host to host by direct methods or through vectors

45. Examples of viruses used in biological warfare:
Small pox.
Viral hemorrhagic fever e.g. Ebola and yellow fever.

46. Small box Extremely infectious.
The most contagious phase is when blisters begin to form.
Clinical presentation :
Non – specific symptoms : high grade fever , headache and bony aches.
Followed by blisters appearance

47. Small pox blisters

48. Management
You must wear examination gloves, a HEPA-filtered respirator, and eye protection.
Observe the size, shape, and location of the lesions.
Vaccine is offered only to first responders due to its medical complication.

49. Viral hemorrhagic fever (VHF)
Definition : group of disordered that Causes blood to seep out from the tissues and blood vessels.
Examples:
Ebola
Rift Valley
Yellow fever viruses

50. Clinical presentation of viral hemorrhagic fever
First : flu – like symptoms.
Followed by massive internal and external hemorrhage from every organ , tissue and body orifice. ( hall mark )

51. Management
Standard precautions must be strictly followed , this is only available method of protection .
There is no working vaccine for VHF.
Treatment is mainly supportive
Manage ABCS and treat shock and hypotension if present

52. VHF

53. Bacteria Does not require a host to multiply and live
Larger and more complex than viruses
Can be fought with antibiotics
Most infections begin with flulike symptoms.

54. Two types of bacteria are most commonly used :
Anthrax.
Plague .

55. Anthrax
Definition : deadly bacterium that lies dormant in a spore which are released when exposed to optimal temperature and moisture
Routes of entry :
Inhalation
Cutaneous
Gastrointestinal

56. Plague Natural vectors of plague are rodents and fleas.
Two types of plague :
Bubonic.
Pneumonic

57. Types Infects lymphatic system Can lead to sepsis Not contagious
Pneumonic
Infects lymphatic system
Can lead to sepsis
Not contagious
Bubonic
Lung infection
Contagious
Higher death rate

58. Clinical presentation
It starts with flu – like symptoms : headache , fever and bone aches.
Symptoms of pneumonia : cough , shortness of breath .
Painful enlargement of lymph nodes.

59. Management of bacterial biologic agents
Follow standard precautions.
Address ABCS
Patient with respiratory affection may require assisted ventilation.
Rapid transport to specialized facility.

60. plague

61. Neurotoxins Most deadly substances known to humans. Produced from:
Plants
Marine animals
Molds
Bacteria

62. Route of entry:
Ingestion
Inhalation
Injection

63. Botulinum toxin Most potent neurotoxin produced from bacteria
Affects the nervous system’s ability to function :
Leading to muscle paralysis .
Patient will go into respiratory arrest ( cause of death ).

64. Ricin Derived from mash left from the castor bean.
Quite stable and extremely toxic
Causes :
Pulmonary edema
Respiratory and circulatory failure
Death

65. Clinical presentation
Ingestion causes rapid onset of :
Nausea
Vomiting
Abdominal cramps
Severe diarrhea

66. Clinical presentation
Inhalation signs and symptoms:
Irritation of eyes, nose, and throat.
Profuse sweating.
Cyanosis.

67. Management Treatment is supportive: Intubation Ventilation
Positive end-expiratory pressure
Treatment of pulmonary edema as appropriate

68. Radiation
Definition : Energy emitted in the form of rays or particles Found in radioactive material , Radioactive material is unstable.

70. Radiation
Energy emitted from a strong radiologic source and it has four categories.
Alpha
Beta
Gamma (x-rays)
Neutron radiation

71. Effects of radiation on the Body
Effects vary depending on amount and route of entry
Three levels of exposure:
Radioactive exposure
External contamination
Internal contamination

72. Clinical presentation
Radiation can enter through all routes of entry as well as through irradiation
Symptoms of acute radiation sickness divided
Low exposure
Vomiting
Diarrhea

73. Acute radiation sickness