Transcript Chapter 50: Terrorism - Jones & Bartlett Learning

Chapter 50
Terrorism
National EMS Education
Standard Competencies
EMS Operations
Knowledge of operational roles and
responsibilities to ensure patient, public, and
personnel safety.
National EMS Education
Standard Competencies
Mass-Casualty Incidents
Due to Terrorism and Disaster
• Risks and responsibilities of operating on
the scene of a natural or man-made
disaster
Introduction
• Terrorist attacks have sharply increased
over the last decade.
− Your personal health and safety should be your
primary concern.
− Additional training and drills can help develop
response skills.
Terrorism
• A violent act dangerous to human life to
intimidate or coerce a government, the
civilian population, or any segment thereof,
in furtherance of political or social objectives
Terrorism
• Terrorism is often
used as a form of
asymmetric
warfare.
• Terrorists tend not
to discriminate
when selecting
their targets.
© ZUMA Wire Service/Alamy Images
International Terrorism
• Acts of terror committed by foreign agents
− International terrorism subgroups:
• Non-state-supported terrorism
• State-sponsored terrorism
• State-directed terrorism
Domestic Terrorism
• Perpetrators are
citizens of the
country attacked
• Example:
− Centennial
Olympic Park
bombing in 1996
© Michael Green/AP Photos
Types of Terrorist
Organizations
• Violent religious groups/doomsday cults
− Seek apocalyptic violence or mass murder
− Eradicate or cleanse a region of people who
don’t practice their faith
Types of Terrorist
Organizations
• Extremist political/social groups
− Looking for political, economic, social freedom
− Influence economic or immigration politics and
geopolitical borders to claim or reclaim land
Types of Terrorist
Organizations
• Technology or “cyber” terrorists
− Attack technologic infrastructure
− “Hack” into systems and introduce corruptive
programs
Types of Terrorist
Organizations
• Single-issue terrorist groups
− Threaten or use violence as a way to advance
their views and goals
• Narcoterrorists
− Goal of manufacturing, distributing, and selling
drugs without prosecution
Types of Terrorist
Organizations
• Other subcategories include:
− Hate groups
− Patriot groups
− Militia groups
−
−
−
−
Common-law groups
Cult groups
Single-issue groups
Lone wolves
Types of Terrorist
Organizations
• Al Qaeda is the most infamous international
terrorist organization.
− Exhibit apocalyptic violence to affect political,
geopolitical, and religious goals
Recognizing a Terrorist Event
(Indicators)
• Acts of terror are usually covert.
• High-value targets for terrorists include:
− Military bases and centers
− Public transportation
− Chemical plants or transportation
− Government buildings and hospitals
− Public gathering places
Recognizing a Terrorist Event
(Indicators)
• The National Advisory System replaced the
Homeland Security Advisory System.
− Alerts responders to potential for attack
− Includes steps to take for protection
− Specifies if the threat is:
• Elevated
• Imminent
Recognizing a Terrorist Event
(Indicators)
• While on duty you should observe:
− Preincident indicators
− Type of location
− Type of call
− Number of patients
− Victims’ statements
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.
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.
Scene Safety
© Dennis MacDonald/Alamy Images
© pbpgalleries/Alamy Images
• Failure to park your
vehicle at a safe
location places you
and your partner in
danger.
Responder Safety
• Responder health and safety can suffer
more than usual during WMD incidents.
− Events can cloud decision making and create
tunnel vision.
Responder Safety
• You need the following:
− Awareness of self-preservation measures
− Culture of safety within your organization
− Previous knowledge and experience with PPE
− Proper PPE
− Self-enforcement of all protective measures
Responder Safety
• Best form of protection is preventing contact
with the agent
− The greatest threat in a WMD attack:
• Contamination
• Cross-contamination
Notification
Procedure/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.
Command
• If Incident Command System (ICS) is in
place, find medical staging supervisor for
assignment.
− Paramedics who arrive first may need to
establish “EMS or Medical Command.”
Command
• Tasks of first arriving paramedic:
− Report to incident command post.
− Establish a medical branch.
− Determine scope of incident.
− Gather and disseminate information to dispatch.
Command
• Tasks of first arriving paramedic (cont’d):
− Assign a supervisor for the following areas:
• Decontamination
• Treatment
• Transportation
• Staging
• Rehabilitation
− Report EMS activities to operations chief.
Command
• Expect heavy police presence.
− Provide site security.
− Monitor victims.
− Canvas witnesses.
• Paramedics should fully comply with law
enforcement requests.
Secondary Device or Event
• Terrorists often plant secondary devices to
go off after initial bomb.
− Never become so involved in a task that you do
not look around to reassess the scene.
Weapons of Mass Destruction
• Anything used as a weapon designed to
bring about mass death, casualties, and/or
massive damage to property and
infrastructure
Weapons of Mass Destruction
• Grouped in four major categories:
− Explosives/incendiary devices
− Chemical
− Biologic
− Radiologic/nuclear weapons
Weapons of Mass Destruction
• WMDs are highly desirable.
− Easy to obtain or create
− Geared towards killing large numbers of people.
− Technical recipes are found readily on the
internet.
Explosives/Incendiary
Weapons
• Explosives are
most common
weapon used by
terrorists.
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
Suicide Bombers
(Human Bombs)
• Low-cost, lowtechnology, and
low-risk
© Musadeq Sadeq/AP Photos
• Destructive power
of explosives with
timing/accuracy of
human guidance
Chemical Agents
• Man-made substances that can have
devastating effects on living organisms
• Produced in multiple forms:
− Liquid
− Powder
− Vapor
Chemical Agents
• Categorized as:
− Vesicants or blister agents
− Respiratory or choking agents
− Nerve agents
− Metabolic or blood agents
− Irritating agents
Chemical Agents
• Chemical weapon classifications:
− Properties or characteristics of an agent
− Persistency and volatility
− Route of exposure
• Vapor hazard
• Contact hazard
Vesicants (Blister Agents)
• Primary route of exposure is the skin
• Cause burn-like blisters
• Agents consist of:
− Mustard (H)
− Lewisite (L)
− Phosgene oxime (CX)
Vesicants (Blister Agents)
• Signs of exposure on the skin include:
− Skin irritation, burning, and reddening
− Immediate intense skin pain
− Formation of large blisters
− Gray discoloration of skin
− Swollen and closed or irritated eyes
− Permanent eye injury
Vesicants (Blister Agents)
• Signs of inhalation of vapors include:
− Hoarseness and stridor
− Severe cough
− Hemoptysis
− Severe dyspnea
Vesicants (Blister Agents)
• Sulfur mustard
− Brownish,
yellowish oily
substance
− Persistent
− Distinct smell of
garlic or mustard
− Quickly absorbed
• Considered a
mutagen
Courtesy of Dr. Saeed Keshavarz/RCCI, Research Center of Chemical
Injuries/IRAN
Vesicants (Blister Agents)
• Sulfur mustard (cont’d)
− Patients generally do not show signs or
symptoms for 4 to 6 hours.
− Affected area will progressively redden and
develop into large blisters.
− Attacks cells within bone marrow
Vesicants (Blister Agents)
• Sulfur mustard (cont’d)
− Main complication is secondary infection
− Regarded as a persistent but it does release
vapors.
• Creates upper and lower airway compromise
• Damages and swells airways
Vesicants (Blister Agents)
• Lewisite (L) and phosgene oxime (CX)
− Produce similar blister wounds to sulfur mustard
− Highly volatile
− Immediate and intense pain
− May have grayish discoloration at site
− Tissue damage also occurs.
Vesicants (Blister Agents)
• Vesicant agent treatment
− No antidotes for sulfur mustard or CX exposure
− BAL (British Anti-Lewisite): antidote for agent L
− Ensure patient is decontaminated before ABCs
are initiated.
Pulmonary Agents
(Choking Agents)
• Gases that cause immediate harm to those
exposed
• Primary route of exposure: respiratory tract
− Damages lung tissue, causing fluid to leak
− Produce respiratory-related symptoms
Pulmonary Agents
(Choking Agents)
• Chlorine (CL)
− Distinct odor of bleach
− Creates a green haze when released as gas
− Initially produces upper airway irritation and
choking sensation
Pulmonary Agents
(Choking Agents)
• Chlorine (CL) (cont’d)
− Later symptoms may include:
• Shortness of breath
• Chest tightness
• Hoarseness and stridor
• Gasping and coughing
Pulmonary Agents
(Choking Agents)
• Phosgene
− Produced from chemical welfare but also a
product of combustion
− Potent with delayed symptoms
− Smells similar to freshly cut grass or hay
Pulmonary Agents
(Choking Agents)
• Phosgene (cont’d)
− Symptoms of mild
exposure:
• Nausea
• Chest tightness
• Severe cough
• Dyspnea on
exertion
− Symptoms of
severe exposure:
• Dyspnea at rest
• Excessive
pulmonary edema
Pulmonary Agents
(Choking Agents)
• Pulmonary agent treatment
− Remove patient from contaminated
atmosphere.
− Aggressive management of ABCs
− There is no antidote.
− May include pharmacotherapy
Nerve Agents
• Designed to kill large numbers of people
with small quantities
• Belong to class called organophosphates
• Block cholinesterase from working
− Causes organs to be overstimulated and
burnout
Nerve Agents
• G agents
− Sarin (GB)
• Colorless and
odorless liquid
• Highly lethal
− Soman (GD)
• 5 times as lethal
as GB
• Fruity odor
• No color
− Tabun (GA)
• ¹/₂ as lethal and
36 times as
persistent as GB
• Fruity odor
• Looks like GB
Nerve Agents
• G agents (cont’d)
− V agent (VX)
• Clear oily agent
• No odor
• 100 times more
lethal than GB
• Very persistent
Nerve Agents
• Once the agent
has entered the
body there will be a
pattern of
symptoms.
Nerve Agents
• Nerve agent treatment
− After decontamination, aggressively treat the
patient.
− Manage the ABCs.
• Seizing patients require nerve agent antidote kits in
addition.
Nerve Agents
• Nerve agent treatment (cont’d)
− Antidote for nerve agent exposure:
• DuoDote Antidote Kit contains a single injection of
atropine and 2-PAM chloride.
• Medication is delivered using the same technique as
an auto-injector.
Nerve Agents
Industrial
Chemicals/Insecticides
• Organophosphate is a common chemical in
insecticides.
• Industrial chemicals do not have sufficient
lethality to be effective WMDs.
Industrial
Chemicals/Insecticides
• Metabolic agents (cyanides)
− Hydrogen cyanide (AC) and cyanogen chloride
(CK) affect the body’s ability to use oxygen.
− Cyanide
• Colorless gas
• Odor similar to almonds
Industrial
Chemicals/Insecticides
• Low-dose
symptoms include:
− Dizziness
− Light-headedness
− Headache
− Vomiting
• High-dose
symptoms include:
− Shortness of
breath
− Tachycardia
− Seizures
− Cardiac arrest
Industrial
Chemicals/Insecticides
• Cyanide agent treatments
− Several antidotes
− Trained personnel wearing proper PPE:
• Removes patient from source of exposure
• Removes patient’s clothing to prevent off-gassing
Industrial
Chemicals/Insecticides
• Cyanide agent treatments (cont’d)
− Support the patient’s ABCs and gain IV access.
− Severe exposure requires aggressive
oxygenation and ventilation.
− If there is no antidote, initiate transport
immediately.
Industrial
Chemicals/Insecticides
Biologic Agents
• Organisms generally found in nature and
can cause disease or death
• Primary types found in a biologic event:
− Viruses
− Bacteria
− Neurotoxins
Biologic Agents
• WMD biologic agents pose difficult issues.
− Can be completely undetectable
− Symptoms similar to other common illnesses
• Spread in various ways:
− Dissemination
− Disease vector
Biologic Agents
• Communicability
− How easy it is for the disease to be spread from
one human to another
• Incubation
− Time between exposure and start of symptoms
Viruses
• Germs that require a living host to multiply
and survive
− Attacks healthy cells and replicates itself to
spread throughout the host
Viruses
• Smallpox
− Highly contagious
disease
− Before blisters
show, patient has:
• High fever
between 101°F
and 104°F
• Body aches and
headaches
Courtesy of CDC
Viruses
• Smallpox (cont’d)
− The most contagious phase is when blisters
begin to form.
− There is a vaccine.
• Has been linked to medical complications
• Only offered to first responders
Viruses
• Viral hemorrhagic fevers (VHFs)
− A group of diseases
• Ebola
• Rift Valley
• Yellow fever viruses
Viruses
• VHFs (cont’d)
− Causes blood to
seep out from the
tissues and blood
vessels
− Begins with flulike
symptoms
Courtesy of Professor Robert Swanepoel/National Institute for Communicable
Disease, South Africa
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.
Bacteria
• Inhalation and cutaneous anthrax
− Deadly bacterium that lies dormant in a spore
• Germ is released when exposed to optimal
temperature and moisture
Bacteria
• Inhalation and
cutaneous anthrax
(cont’d)
− Routes of entry
• Inhalation
• Cutaneous
• Gastrointestinal
Courtesy of James H. Steele/CDC
Bacteria
Courtesy of CDC
• Plague
− Natural vectors are
rodents and fleas.
− Bubonic plague
• Not contagious
Courtesy of CDC
• Infects lymphatic
system
• Can lead to sepsis
Bacteria
• Plague (cont’d)
− Pneumonic plague
• Lung infection, also known as pneumonia
• Contagious
• Higher death rate
• Easier to disseminate
Neurotoxins
• Most deadly substances known to humans
• Produced from:
−
−
−
−
Plants
Marine animals
Molds
Bacteria
• Route of entry:
− Ingestion
− Inhalation
− Injection
Neurotoxins
• Botulinum toxin
− Most potent neurotoxin
− Produced from bacteria
− Affects the nervous system’s ability to function
• Causes muscle paralysis
• Patient will go into respiratory arrest.
Neurotoxins
• Ricin
− Derived from mash
left from the castor
bean
− Causes:
• Pulmonary edema
• Respiratory and
circulatory failure;
death
Courtesy of Brian Prechtel/USDA
Neurotoxins
• Ricin (cont’d)
− Quite stable and extremely toxic
− Ingestion causes rapid onset of:
• Nausea
• Vomiting
• Abdominal cramps
• Severe diarrhea
Neurotoxins
• Ricin (cont’d)
− Ingestion signs
and symptoms:
• Fever
• Muscle aches
• Nausea
• GI bleeding
− Inhalation signs
and symptoms:
• Irritation of eyes,
nose, and throat
• Profuse sweating
• Cyanosis
Neurotoxins
• Ricin (cont’d)
− Treatment is supportive.
• Intubation
• Ventilation
• Positive end-expiratory pressure
• Treatment of pulmonary edema as appropriate
Other Paramedic Roles During
a Biologic Event
• Syndromic surveillance
− Monitoring of patients presented to emergency
departments and alternative facilities
− Recording of EMS call volume and use of overthe-counter medications
Other Paramedic Roles During
a Biologic Event
• Points of distribution (PODs)
− Strategically placed facilities preestablished for
distribution of:
• Antibiotics
• Antidotes
• Vaccinations
• Other medications and supplies
Other Paramedic Roles During
a Biologic Event
• PODs (cont’d)
− Medications may
be delivered within
12 hours anywhere
in country
− Containers known
as “push packs”
Courtesy of the Strategic National Stockpile/CDC
Radiologic/Nuclear Devices
• Only two publically known incidents
involving the use of a nuclear device
− Hiroshima
− Nagasaki
Radiation
• Energy emitted in the form of rays or
particles
− Found in radioactive material
• Radioactive material is unstable.
Radiation
• Energy emitted
from a strong
radiologic source
has four
categories.
− Alpha
− Beta
− Gamma (x-rays)
− Neutron radiation
Sources of Radiologic Material
• Thousands of radioactive materials found
are generally used to benefit humankind.
− Once it has been used for its purpose the
leftover material is called radiologic waste.
• Remains active but is no longer useful.
Radiologic Dispersal Devices
(RDD)
• Any container designed to disperse
radioactive material
− Generally requires a bomb (dirty bomb)
− Has potential to injure with both radioactive
material and explosives
− Destructive capability is limited by explosives
that are attached to it
Nuclear Energy
• Released by altering or splitting active
atoms
• Results in an immense amount of energy
• Nuclear material gives of all forms of
radiation.
Nuclear Weapons
• Kept in secure facilities
• After the fall of the former Soviet Union
many small devices were lost.
− Special atomic demolition munitions (SADMs)
How Radiation Affects the
Body
• Effects vary depending on amount and
route of entry
• Three levels of exposure:
− Radioactive exposure
− External contamination
− Internal contamination
How Radiation Affects the
Body
• Radiation can enter through all routes of
entry as well as through irradiation
• Symptoms of acute radiation sickness
− Nausea
− Vomiting
− Diarrhea
Medical Management
• Exposure to a radiation source does not
make a patient contaminated or radioactive.
− Occurs when radioactive source is on the body
− Must have initial treatment from HazMat
responder before treatment begins
Protective Measures
• To protect yourself from the source, use:
− Time
− Distance
− Shielding
Summary
• You may be called to respond to a terrorist
event. Prepare yourself mentally and
physically.
• Weapons of mass destruction complicate
the management of an incident.
• Terrorism is a violent act to intimidate or
coerce a group to further political or social
objectives.
Summary
• International and domestic terrorist groups
are categorized as violent religious
groups/doomsday cults, extremist
political/social groups, technology or cyber
terrorists, single-issue terrorist groups, and
narcoterrorists.
• NTAS replaced the color-coded system with
threat levels of elevated or imminent.
Summary
• Based on the threat level take appropriate
actions and precautions.
• Clues as to whether an emergency is the
result of an attack include the type of
location, type of call, number of patients,
patients’ statements, and preincident
indicators.
• If you suspect a terrorist or WMD event,
ensure the scene is safe before entering.
Summary
• Notify the dispatcher and inform of the
nature of the event, additional resources
needed, estimated number of patients, and
upwind or optimal route of approach.
• Establish a staging area, keeping in mind
access and exit routes.
• Constantly assess and reassess the scene
for safety.
Summary
• A weapon of mass destruction is any
nuclear, chemical biologic, or explosive
weapon or agent designed to bring mass
death, casualties, or damage to property
and infrastructure.
• Explosives are the most common weapons
of terrorists.
Summary
• Chemical agents include vesicants or blister
agents, respiratory or chocking agents,
nerve agents, metabolic or blood agents,
and irritating agents.
• Exposure to nerve agents is treated with an
antidote delivered as an auto-injector.
Summary
• Biologic agents include viruses such as
small pox and those that cause viral
hemorrhagic fevers, bacteria, and
neurotoxins.
• Standard precautions are extremely
important when treating patients exposed to
biologic agents.
Summary
• Nuclear or radiologic weapons can create
massive destruction.
• Patients who are potentially exposed to
radioactive material must be
decontaminated before contact.
Credits
• Chapter opener: © Gulnara Samoilova/AP Photos
• Backgrounds: Red—© Margo Harrison/
ShutterStock, Inc.; Green—Jones & Bartlett
Learning; Gold—Jones & Bartlett Learning.
Courtesy of MIEMSS; Purple—Courtesy of
Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.