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

2. Chapter 14 Responding to Terrorist Acts

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

4. 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

5. 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

6. 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

7. Explosive Agents

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

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

10. Nuclear Detonation

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. Chemical Agents

18. 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

19. 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

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

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

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

23. 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

24. 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

25. 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

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

27. 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

28. 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

29. 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

30. 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

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

32. 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

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

34. Biological Agents

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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

42. General Considerations Regarding Terrorist Attacks

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

44. 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

45. 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

46. 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

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