1. Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Weapons of Mass Destruction and the EMT Chapter 35

2. Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Case History You are dispatched to a local chemical company for a small explosion. You are told that three people are injured. You are the first emergency unit to arrive on scene.

3. Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Weapons of Mass Destruction (WMD)  Extremely toxic material  Designed to kill or debilitate  Potential for mass casualties  Possible need for mass decontamination

4. Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Weapons of Mass Destruction  Terrorists events have occurred and include:  Salmonella food poisoning of salad bars in a small town in Oregon  Nerve agent poisoning on a subway in Japan  Anthrax powder in letters in U.S. mail  The threat today:  Stockpiles of biological, chemical, and nuclear weapons unaccounted for that may be in the hands of terrorists

5. Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. The Threat of NBC Terrorism

6. Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Role of an EMT at a Nuclear, Biological, or Chemical (NBC) Event  Recognize possible NBC scenarios during scene size-up.  Take action to promote safety of self, bystanders, and the victims.  Provide medical care.  Participate within the regional response plans to NBC events.

7. Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. The EMT Who Is “Aware” of WMD  Understands the potential threat of NBC terrorist acts  Has knowledge of signs aiding recognition  Understands that knowledge of specific agents is necessary to appropriately recognize, triage, treat, and transport victims of agents of WMD

8. Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. How WMD Agents are Spread Explosive Rockets or bombs with a “burster” charge surrounded by the agent Spraying Aerosolized can, spraying machine on moving vehicle, crop duster airplane Breaking Light bulbs, bottles that release agent when broken Vectors Letters, packages; insects or animals; contaminated food, water, clothing Ventilation Contamination of ventilation systems within building

9. Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. NBC Agents  Chemical  Biologic  Nuclear

10. Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. NBC DELTA NBC Domestic Preparedness Existing Preparedness Training Incident Command 911 Operations Law Enforcement Emergency Medical Care Firefighting HAZMAT Search and Rescue Emergency Management NBC “Delta”

11. Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Distinguish a HAZMAT Incident from an NBC Terrorist Event HAZMAT NBC Deliberate attack, not accidental X Hazard hidden, recognize by signs/symptoms and investigation X Early identification from placards X Material extremely toxic and potential for mass casualties X May need mass decontamination X Increased risk to rescuers: second device set to kill responders X

12. Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Agent Dissemination Devices Crop dusters. A line of agent spreads downwind.

13. Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Breaking Devices Point Source Common items Moderate downwind hazard Vacuum bottleLight bulb

14. Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Bursting and Exploding Devices Point Source Moderate downwind hazard May destroy agent Detectable Multiple hazard potential Timer Agent reservoir Explosive with igniter

15. Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Vectors Letters/packages Insects/animals Contaminated clothing Contaminated food Contaminated water

16. Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Suspecting an NBC Event Likely targets Large gathering places = many victims Closed or confined spaces = keep agent from dissipating Signs at an event Multiple casualties who were previously well, all with similar complaints Syndrome surveillance Ongoing monitoring by EMS and EDs of possible NBC signs and symptoms such as respiratory problems, flaccid paralysis, bloody sputum

17. Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Likely Targets  Large gathering places = many victims  Closed or confined spaces = keep agent from dissipating

18. Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Signs at an Event  Multiple casualties who were previously well, all with similar complaints

19. Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Syndrome Surveillance  Ongoing monitoring by EMS and EDs of possible NBC signs and symptoms such as respiratory problems, flaccid paralysis, bloody sputum

20. Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Biologic Agents

21. Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Biologic Agents  Learn about a few agents to understand role of EMT.  CDC’s Category A List – (6 Agents)  Easily disseminated or transmitted  High mortality rate  Ability to cause public panic and social disruption  Require special action for public health preparedness

22. Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Anthrax  Bacteria that enter spore form when host dies (e.g., cattle drives)  Cutaneous, gastrointestinal, and pulmonary forms  Pulmonary most fatal  Inhaled (pulmonary) – form from spores spread by aerosolized devices, rockets, or letters

23. Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Anthrax  Clinical illness  If spores inhaled – flu-like symptoms, then respiratory distress, bloody sputum, chest pain  Transmission and personal protection  Not spread from person to person  Standard precautions  Standard disinfection of equipment

24. Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Anthrax  Treatment and postexposure  Early treatment with antibiotics is important.  Can take antibiotics, if exposed to spores  Prehospital considerations  Support care for victims of illness.  Exposed patients (e.g., to suspicious powder) are not ill and do not require transport.  Do need identification and contact with public health authorities for followup.

25. Slide 25 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Smallpox  Virus declared eradicated in 1980  Vaccination stopped shortly afterward = most of world’s population is vulnerable  Reports of stockpiles of weaponized smallpox  Very contagious  No treatment, limited vaccine supplies

26. Slide 26 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Smallpox  Clinical illness  Fever and chills, body aches, bedridden, perhaps vomiting  2-3 days later rash appears – especially on face, hands, forearms, then legs and trunk  At first, lesions are round and flat, then raised, then with pus. All in same stage All in same stage

27. Slide 27 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Smallpox  Rash appears – especially on face, hands, forearms, then legs and trunk

28. Slide 28 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Recognizing Smallpox and Chickenpox

29. Slide 29 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Smallpox  Transmission and PPE  Contact and airborne precautions, respiratory isolation, hospital notification about patient with fever and rash, mask patient during movement (treat like chickenpox or measles).  Quarantine exposed patient with droplet and airborne precautions for at least 17 days.

30. Slide 30 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Smallpox  Treatment and postexposure considerations  Supportive treatment  Vaccine for those at high risk Public health investigators, emergency workers, and first responders (on voluntary basis) Public health investigators, emergency workers, and first responders (on voluntary basis) If case identified, then immediate widespread vaccine of population If case identified, then immediate widespread vaccine of population  Early vaccination after exposure may decrease risk of infection and/or severity or illness.

31. Slide 31 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Smallpox  Prehospital considerations  Maintain high index of suspicion  Practice PPE and infection control  Know role in regional plans (e.g., notification of hospitals for care of patients with fever and rash)  Proper disinfection and disposal of vehicle and equipment  Postexposure followup

32. Slide 32 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Plague  Bacteria carried by rodents and prairie dogs, then transmitted to humans by flea bites  Flea bites legs; infection causes swelling of lymph nodes (buboes = bubonic plague)

33. Slide 33 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Plague  If spread to blood and then to lungs, can result in pneumonic plague with nearly 100% fatality if untreated  Pneumonic plague may result from:  Aerosolized exposure (biowarfare)  Droplets from a person with pneumonic plague

34. Slide 34 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Plague  Clinical illness  If exposed to aerosolized or droplets, acute fever, chills, and aches followed by bloody cough in 2-4 days  Need antibiotics early or respiratory death  Transmission and PPE  Droplet transmission  May need to monitor for vectors (rodents, fleas)

35. Slide 35 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Plague  Treatment and postexposure  Antibiotics are effective if given early.  If exposed, take antibiotics.  Prehospital considerations  High index of suspicion Clusters of respiratory illness Clusters of respiratory illness Bloody sputum Bloody sputum  Droplet precautions and postexposure followup

36. Slide 36 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Viral Hemorrhagic Fevers  Viruses that cause fevers and damage to blood vessels and cause bleeding

37. Slide 37 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Viral Hemorrhagic Fevers  Human-to-human transmission usually occurs via direct contact. Animals may carry virus.  Respiratory transmission is possible by aerosolized spread (NBC event).  Some types (e.g., ebola) have high death rates.

38. Slide 38 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Viral Hemorrhagic Fevers  Clinical illness  Variable – fever, aches, and weakness; in severe cases, shock and bleeding  In severe cases, profuse body secretions that are highly infectious Infection control precautions are extremely important. Infection control precautions are extremely important. Without PPE, spread to family and health workers has been reported. Without PPE, spread to family and health workers has been reported. When PPE was reinstituted, epidemic was stopped. When PPE was reinstituted, epidemic was stopped.

39. Slide 39 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Viral Hemorrhagic Fevers  Transmission and PPE  Contact precautions are mandatory.  In severe cases, droplet transmission is suspected, so use respiratory precautions as well.  Treatment  Generally supportive

40. Slide 40 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Viral Hemorrhagic Fevers  Prehospital considerations  Use contact transmission precautions including protective gowns, masks, eyewear, and face shields.  If patient has prominent cough, vomiting, diarrhea, hemorrhage, some recommend a HEPA filter mask.

41. Slide 41 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Tularemia  Bacteria naturally transmitted by bites of insects, such as deerflies, or contact with blood or tissue of infected animals  Known to hunters as “deerfly fever” or “rabbit fever”  Highly infective  Could be spread via respiratory route and aerosolized delivery

42. Slide 42 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Tularemia  Clinical illness  Inhaled form — sudden onset of fever, chills, aches, loss of body fluids 3 days after exposure  Pneumonia can be severe with respiratory difficulty, chest pain, and cough.  Transmission and PPE  Aerosol in NBC  Vectors such as insects and contaminated food and water

43. Slide 43 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Tularemia  Treatment and postexposure  Antibiotics useful and can be taken for prophylaxis  Prehospital considerations  Highly infective, so if there is a cough, closely adhere to PPE is essential

44. Slide 44 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Botulism  Flaccid paralysis  Caused by toxin produced by bacteria  Toxic by oral route, with effects in 24 hours  Also a hazard if inhaled  Death from respiratory muscle paralysis

45. Slide 45 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Botulism  Clinical illness  Classic head downward, descending paralysis Double vision, drooping eyelids, trouble speaking and swallowing Double vision, drooping eyelids, trouble speaking and swallowing Paralysis continues downward to chest and extremities Paralysis continues downward to chest and extremities

46. Slide 46 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Botulism  Transmission and PPE  Not transmissible from person to person  Standard precautions  Treatment and postexposure  Maintain airway and ventilation.  Antitoxin is available.  Prehospital considerations  Look for classic presentation. Support respirations.

47. Slide 47 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Contagious Agents, Appropriate PPE, and Isolation Measures Smallpox Standard, airborne, and contact precautions if EMT may touch patient Respiratory isolation and quarantine Pulmonary Plague Standard and droplet Respiratory isolation Viral Hemorrhagic Fevers Standard and contact. If severe, respiratory precautions as well. Note: Tularemia, anthrax, and botulism are NOT contagious.

48. Slide 48 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Biological Agents Summary  Agent is usually suspected after victims fall ill, days after release of agent.  Decontamination is not usually the issue; victims will have showered; agent is not on patient, it is in them.  Follow principles of infection control and use standard and transmission-based precautions.

49. Slide 49 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Biological Agents Summary  Care of patients is no different than if they acquire the illness naturally.  Preplanning is important since a large outbreak and extended periods of service may be required of EMTs.

50. Slide 50 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents  Mass casualties possible  Require special actions to reduce potential to harm  Knowledge of principles of decontamination important for safety of self, bystanders and victims

51. Slide 51 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents  Two agents, nerve agents and cyanide, can kill quickly after exposure. Antidotes may be needed to save lives.  Mustard agents are absorbed quickly and need to be removed from the skin immediately, if possible.  Pulmonary agents may have lung effects from hours to days after exposure.

52. Slide 52 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents  Used in warfare; extremely toxic  Like organophosphate insecticide only stronger  Death from muscle paralysis and respiratory secretions  Antidotes available that may be needed in minutes after exposure (severe cases)

53. Slide 53 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents Odor Protection First Aid Pinpointing of pupils Vomiting/diarrhea Difficulty in breathing Symptoms Fruity or sulfur Respiratory and skin Decontaminate Salivation Twitching Convulsions Physical Appearance Normally liquid; clear when pure, tan/brown when impure; some may readily vaporize

54. Slide 54 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents  How spread  Aerosol, missiles, sprayers  Vapor  Some agents evaporate at room temperature (e.g., sarin).  Liquid  VX is a nerve agent that remains in liquid form and persists in the environment.

55. Slide 55 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents  Nerve agents act at nerve terminals that release acetylcholine, a chemical that acts as a nerve signal.  Acetylcholine accumulates and there is excessive stimulation of glands, organs, and muscles.

56. Slide 56 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents  Clinical effects  Outpouring of secretions from every organ and orifice Eyes tear, nose runs, secretions in airways, vomiting, urination, defecation, sweating Eyes tear, nose runs, secretions in airways, vomiting, urination, defecation, sweating  Involuntary muscles Bronchoconstriction, constricted pupils, gastrointestinal cramps Bronchoconstriction, constricted pupils, gastrointestinal cramps  Voluntary muscles Twitching (like worms under skin), then weakness, then paralysis Twitching (like worms under skin), then weakness, then paralysis

57. Slide 57 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Small Pupils

58. Slide 58 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Secretions

59. Slide 59 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents  Central nervous system effects  Seizures, loss of consciousness, respiratory arrest

60. Slide 60 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. SLUDGEM  Salivation  Lacrimation  Urination  Diarrhea  Gastrointestinal cramps  Emesis  Miosis and muscular twitching

61. Slide 61 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents  Vapor exposure  First signs – eye complaints, runny nose, and respiratory complaints  Liquid exposure  First signs – local sweating and twitching of contaminated area first, then more general symptoms

62. Slide 62 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents: EMT Actions  Don’t become a victim. Never enter a hot zone unless trained and equipped to do so.  Vapors  Move or direct victim to fresh air; remove outer clothing. Off-gassing of vapor trapped within clothing has been reported. Off-gassing of vapor trapped within clothing has been reported. If transport before definitive decontamination complete, do so only if maximally ventilated ambulance and EMT with patient has suitable respiratory protection. If transport before definitive decontamination complete, do so only if maximally ventilated ambulance and EMT with patient has suitable respiratory protection.

63. Slide 63 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents: EMT Actions  Liquids  Rapid removal; remove clothing, then physically remove (by blotting) any visible agent, and flush with large amounts of water.  Avoid contamination to rescuer. Use suitable protective clothing.

64. Slide 64 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents – Treatment in the Field  Treatment  Severe exposures require antidote treatment with MARKI kits: atropine and pralidoxime.

65. Slide 65 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents – Treatment in the Field  Treatment guided by  Recognition of signs and symptoms  Credible evidence of nerve agent release  Medical direction  EMTs trained in their use

66. Slide 66 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cyanide  Effective and fast killer  Can be lethal if ingested, injected, or inhaled  Major threat in NBC event is vapor.  Cyanide poisons cell’s ability to use oxygen  Most oxygen-dependent organs, the brain and heart, affected first

67. Slide 67 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cyanide  Clinical effects  Victims feel short of breath, initial increase in heart rate and blood pressure  Unconscious, seizures, and respiratory arrest  Heart fails  Initially, may have pink or normal skin color since blood returns from cells with unused oxygen

68. Slide 68 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cyanide  If victims can escape the exposure scene and avoid further exposure, they may survive without treatment.  Move or direct to fresh air, give supportive care (O 2 ).  If victim collapses at scene, may need antidote to survive.  Antidote has side effects and should only given with medical direction.

69. Slide 69 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nerve Agents versus Cyanide  Both can cause respiratory arrest, seizures, and loss of consciousness.  Treatment differs.  Nerve agents are more likely to cause excessive secretions, muscle twitching, and small pupils.

70. Slide 70 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mustard  War agent  More incapacitating than lethal  Effects skin and eyes; may be delayed  Cells are damaged cells shortly after contact, so rapid removal is key.

71. Slide 71 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mustard  May be liquid or vapor  Mustard-like odor  Toxic effects to skin more like radiation injury than thermal burn

72. Slide 72 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mustard Odor Protection First aid Eyes: Burning, gritty Skin: Delayed blisters Lungs: Raspy cough, severe damage Symptoms Garlic or mustard Respiratory and skin Decontaminate Physical Appearance Oily liquid — clear when pure, brownish when impure, freezes at 57 ° F

73. Slide 73 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mustard  Clinical effects  Skin, eyes, and airway most common  Skin from sunburn to blisters  Irritating to eyes

74. Slide 74 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mustard Agent Exposure

75. Slide 75 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mustard  Prehospital considerations  Immediate decontamination is priority Whatever is available Whatever is available  Physical removal  Dry decontamination kits (M291)  Flushing with water or soap and water  Dilute bleach  Supportive care

76. Slide 76 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Pulmonary Agents  Chlorine and phosgene were used in World War I.  Irritating to airway and mucous membranes  Phosgene less irritating than chlorine, so less warning during exposure  Effects on lungs are delayed.

77. Slide 77 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Pulmonary Agents  Suspect exposure from signs of respiratory irritation and pulmonary edema.  Move to fresh air.  Give supportive care and maintain respirations.

78. Slide 78 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents – Summary  Do not enter contaminated zone unless trained to do so and protected appropriately.

79. Slide 79 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Self-Protection Greater Hazard Level A Level B Level C Level D Bunker Gear ? Higher Burden

80. Slide 80 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents – Summary  Recognition  Immediate casualties suggest nerve agent or cyanide.  Other exposures, such as mustard and pulmonary agents, may have delayed effects.

81. Slide 81 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents – Summary  Decontamination  Vapors  Remove to fresh air.  Remove outer clothing, if in closed space or if off- gassing is a concern.

82. Slide 82 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents – Summary  Decontamination: Liquids and Solids  Physical removal Scrape off bulky material, remove clothing, absorb liquids with powder or dry absorbing material until it can be flushed away. Scrape off bulky material, remove clothing, absorb liquids with powder or dry absorbing material until it can be flushed away.  Dilution and washing Large amounts of water or soap and water Large amounts of water or soap and water Large amounts for the eye Large amounts for the eye Wound irrigation with sterile solutions, if available Wound irrigation with sterile solutions, if available

83. Slide 83 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chemical Agents – Summary  Decontamination  Detoxification Diluted bleach (0.5%) or soap and water Diluted bleach (0.5%) or soap and water Military kits – dry decontamination M-291 Military kits – dry decontamination M-291  Do whatever is most expedient and readily available to accomplish removal as quickly as possible.  Medical care at the scene  Focus on critical interventions.

84. Slide 84 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Radiological and Nuclear Devices

85. Slide 85 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nuclear or Radiological Hazards  Detonation of nuclear weapons  Nuclear reactor sabotage  Explosive dispersal of radiological material  Nonexplosive dispersal of radiological material

86. Slide 86 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Radioactivity  Radioactivity cannot be seen or perceived by our senses.  Measured by:  Survey instrument Measures rate of exposure Measures rate of exposure  Personal monitoring device (dosimeter) Monitors the total accumulation of radiation Monitors the total accumulation of radiation

87. Slide 87 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Detection Radioactive Source 10 mrem/hour NOYES

88. Slide 88 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Ionizing Radiation  Alpha particles  Beta particles  Gamma rays  Neutrons ++

89. Slide 89 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Radioactive Particles Versus Radioactive Waves  Radioactive particles (e.g., alpha and beta particles) are matter and can contaminate or be physically present on a victim.  Radioactive waves (e.g., gamma rays) pass through a victim, like an X-ray, and pose no threat to a rescuer.

90. Slide 90 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Health Effects from Radiation Exposure and Contamination  Radiation exposure can cause irradiation and contamination.  Irradiation is the passing of radiation energy through the body that can alter chemicals and cells in its path. Irradiation is no threat to the rescuer.  Contamination results from radioactive particles being deposited on or in the body. These particles can be spread to the rescuer and others.

91. Slide 91 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Health Hazards in an Incident  Exposure to radiation source (external)  Contamination (possible internal and/or external) External Contamination Internal Contamination S Exposure

92. Slide 92 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Incorporation  Incorporation is the physical binding of a radioactive material or particle within the body’s tissues or organs where it becomes part of the organ and can continue to affect nearby tissue with its radioactive energy.

93. Slide 93 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Exposure to Radiation

94. Slide 94 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Acute Radiation Syndrome  Results from absorption of high doses of radiation over a short time  Signs include nausea, vomiting, and depression of the bone marrow.  In higher doses, cardiovascular and central nervous system effects

95. Slide 95 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Principles of Prehospital Treatment of Radiological Casualties  Self-protection  Remove victims from the source.  Provide emergency care.  Decontaminate the victim, if necessary.

96. Slide 96 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Radiation Self-Protection Time Source Result Alpha Beta Gamma 1 meter Greater Distance = Less Dose Source Distance Shielding PAPERLEAD Less Time = Less Dose

97. Slide 97 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Factors That Affect Severity of Radiation Exposure Should Be Used to Limit Exposure  Time of exposure  Minimize time of exposure by efficiently planning work and sharing time of exposure needed to remove victims with other rescuers.  If the exposure rate is 60 R/hour, then 10 minutes in the work area may result in absorption of 10 R.  Distance from the source  The greater the distance from the source, the less radiation absorbed  If the source is a single point, the radiation absorbed falls inversely with the square of the distance.

98. Slide 98 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Factors That Affect Severity of Radiation Exposure Should Be Used to Limit Exposure  Shielding  Use appropriate shielding. Protective clothing is generally adequate for alpha and beta particles. Protective clothing is generally adequate for alpha and beta particles.  Shielding may be accomplished by using dense materials (lead aprons or a vehicle between the rescuer and the source) or by shielding the source itself.  Different body parts can tolerate different amounts of radiation (e.g., the hands have higher allowable limits than the gonads).

99. Slide 99 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Summary  Preparing for WMD begins with training with special courses from governmental and other agencies.  FEMA, DOJ, and the previous DOD courses (on which this chapter is based) are all recommended.  Participate in regional disaster plans and WMD exercises so you know your role as an EMT.

100. Slide 100 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Summary  Base your approach to WMD events by learning the NBC “delta” difference and building on what you already do everyday as an EMT.  Use the knowledge about WMD agents to make you a better EMT in your everyday care of patients.