PEC11 Chap 46 Terrorism.pdf

(1)

Prehospital: Emergency Care

Eleventh Edition

Chapter 46

EMS Response to Terrorism Involving

Weapons of Mass Destruction

(2)

Learning Readiness

• EMS Education Standards, text p. 1340.

• Chapter Objectives, text p. 1340.

• Key Terms, text p. 1340.

• Purpose of lecture presentation versus textbook reading

(3)

Setting the Stage

(1 of 2)

• Overview of Lesson Topics

– Weapons of Mass Destruction

– Prehospital Response to Terrorism Involving WMD

– Conventional Explosives and Incendiary Devices

– Chemical Agents

– Biological Agents

(4)

Setting the Stage

(2 of 2)

• Overview of Lesson Topics

– Personal Protection and Patient Decontamination

– Active Shooter Incident

(5)

Case Study Introduction

EMTs Louis Fine and Alvin Hahn are called to a report of a

sick person at a baseball stadium. Before they arrive, three more calls are reported to dispatch for additional sick

people at the baseball stadium. Dispatch advises all

responding units to use caution and to stage outside the

stadium. An EMS supervisor is en route to establish

(6)

Case Study

(1 of 3)

• Why should arriving units use caution in this situation?

• What could be responsible for several reports of sick

people at an event?

(7)

Introduction

• Weapons of mass destruction (WMD) are a possibility

(8)

Weapons of Mass Destruction

(1 of 4)

• WMD are intended to cause widespread death and

destruction.

• The mnemonics CBRNE and B-NICE can be used to

(9)

Weapons of Mass Destruction

(2 of 4)

• CBRNE is commonly used to remember the types of

WMDs.

– C – Chemical

– B – Biological

– R – Radiological

– N – Nuclear

(10)

Weapons of Mass Destruction

(3 of 4)

• B-NICE is also commonly used to remember the types of

WMDs.

– B – Biological

– N – Nuclear/radiological

– I – Incendiary

– C – Chemical

(11)

Weapons of Mass Destruction

(4 of 4)

• Dissemination means bringing the WMD agent into

contact with its intended target population.

• The general approach to a WMD incident is the same as

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(13)

Prehospital Response to Terrorism

Involving W

M

D

(1 of 8)

• Supplies and Equipment

– To ensure adequate equipment and response, there

must be a community response to the disaster.

– Each type of WMD requires different specialty

equipment and supplies.

– A plan must allow immediate deployment of

(14)

(15)

Prehospital Response to Terrorism

Involving W

M

D

(2 of 8)

• Medical Direction

– There must be a plan to establish medical direction

and verify credentials of responders from outside areas.

– Communications may be unreliable, requiring reliance

(16)

Prehospital Response to Terrorism

Involving W

M

D

(3 of 8)

• Provider Preparation

– As always, EMS provider safety is the highest priority.

– You must be aware of the indications of the weapons

(17)

Prehospital Response to Terrorism

Involving W

M

D

(4 of 8)

• Responding to the Scene

– The earlier a WMD incident is recognized, the better.

– The incident command system is used in WMD

attacks.

– Hazardous materials principles are used if the agent

(18)

Prehospital Response to Terrorism

Involving W

M

D

(5 of 8)

• Issues of Scene Safety

– Signs of a toxic and unsafe environment include:

▪ Respiratory distress.

▪ Dyspnea.

▪ Cough.

▪ Burning chest.

(19)

Prehospital Response to Terrorism

Involving W

M

D

(6 of 8)

• Issues of Scene Safety

– Wear HEPA or N-95 masks, gloves, eye protection,

and gowns for suspected communicable illnesses.

– Approach from upwind.

– Avoid confined spaces.

– Entry must be made only by those with specialized

training and protection.

(20)

Prehospital Response to Terrorism

Involving W

M

D

(7 of 8)

• Role of the EMT at the Terrorist Incident Involving a WMD

– Initial incident command and scene size-up

– Sector leader or officer, such as triage, treatment, or

transportation

(21)

Prehospital Response to Terrorism

Involving W

M

D

(8 of 8)

• Role of the EMT at the Terrorist Incident Involving a WMD

– Recognize locations or events that may be terrorist

targets and use caution when responding to those locations.

– The dead from terrorist incidents are now considered

evidence.

(22)

Conventional Explosives and Incendiary

Devices

(1 of 8)

• Conventional explosives and incendiary devices are the

most widely used WMDs.

• Explosives

– Ignition of fuels that burn rapidly, causing hot gases to

displace air, creating a shock wave

– The blast moves out in all directions at supersonic

(23)

Conventional Explosives and Incendiary

Devices

(2 of 8)

• Explosives

– Improvised Explosive Devices

▪ Improvised from easily obtainable products

▪ Vehicle-Borne Improvised Explosive Device (VBIED)

– Car or truck bomb.

– Commonly use an explosive called ANFO

(24)

Conventional Explosives and Incendiary

Devices

(3 of 8)

• Explosives

– Common Explosive Compounds

▪ EGDN

▪ HMTD

▪ PETN

▪ RDX

▪ Semtex

(25)

Conventional Explosives and Incendiary

Devices

(4 of 8)

• Primary, Secondary, Tertiary, Quaternary, and Quinary

Effects

– The explosion blast is the primary effect.

– The secondary effects result from flying debris or

shrapnel.

– Tertiary effects are injuries produced by the

propulsion of the person’s body.

– Quaternary effects include burn, crush, and inhalation

(26)

Conventional Explosives and Incendiary

Devices

(5 of 8)

• Types of Injuries

– Lungs

▪ Blast lung and pneumothorax may occur.

▪ Look for altered mental status, dyspnea, bloody

sputum, chest pain, and stroke-like signs and symptoms.

▪ Use caution with positive pressure ventilation to

(27)

Conventional Explosives and Incendiary

Devices

(6 of 8)

– Abdomen

▪ Bowel may bleed or leak contents into the

abdomen.

▪ Evisceration is possible.

– Ears

▪ The eardrum may rupture and the inner ear bones

may be disrupted.

(28)

Conventional Explosives and Incendiary

Devices

(7 of 8)

– Crush injuries

▪ They may occur from structural collapse and

entrapment.

▪ Complications occur when the pressure on the

crushed area is relieved.

• Shrapnel injuries

– Penetrating injuries can cause bleeding, hollow organ

(29)

Conventional Explosives and Incendiary

Devices

(8 of 8)

• Incendiary Devices

– Be cautious of secondary and undetonated devices.

– They primarily cause burns.

– Assess burns according to the Rule of nine’s

– Pay attention to airway and breathing.

(30)

Chemical Agents

(1 of 16)

• Properties of Chemical Weapons

– Can be dispersed using munitions or aerosol devices

– The tendency of an agent to evaporate and create

vapors is its volatility.

– Agents that do not evaporate are characterized as

persistent.

(31)

Chemical Agents

(2 of 16)

• Types of Chemical Agents

– Nerve agents

– Vesicants

– Cyanide

– Pulmonary agents

– Riot-control agents

(32)

Chemical Agents

(3 of 16)

– Nerve Agents

▪ Potent and easily made

▪ Block the enzyme that breaks down the

neurotransmitter acetylcholine (ACh), allowing

accumulation of ACh

▪ overstimulation of the muscles, smooth muscles,

(33)

Table 46-1 Nerve Agents

• Tabun (GA)

• Sarin (GB)

• Soman (GD)

• GF

• Methylphosphonothioic acid (VX)

(34)

Table 46-2 Signs and Symptoms of Nerve

Agent Exposure

Vapor Small Exposure Large Exposure

Blank Runny nose, mild dyspnea, pupillary constriction

Sudden onset of

unresponsiveness, seizures, apnea, copious secretions, pupillary constriction

Liquid Small Exposure Large Exposure

Blank Localized sweating, nausea, vomiting, fatigue

Sudden onset of

(35)

Chemical Agents

(4 of 16)

– Nerve Agents

▪ Signs and symptoms:

– Respiratory failure from paralysis of respiratory

muscles.

– Copious airway secretions and

bronchoconstriction.

– SLUDGE—salivation, lacrimation, urination,

(36)

Chemical Agents

(5 of 16)

– Nerve Agents

▪ Emergency Medical Care

– Ensure an adequate airway and ventilation; be

prepared to suction.

– The medications atropine and pralidoxime are

antidotes.

– To combat seizures, benzodiazepine

(37)

Chemical Agents

(6 of 16)

– Vesicants

▪ Cause blistering, burning, and tissue damage

▪ Agents include sulfur and nitrogen mustards,

(38)

Chemical Agents

(7 of 16)

– Vesicants

– Burning, redness, blistering, and necrosis.

– Stinging, tearing, and development of ulcers in

the eyes.

– Shortness of breath, coughing, wheezing, and

pulmonary edema.

(39)

Chemical Agents

(8 of 16)

– Vesicant

▪ Emergency medical care

– Irrigation

– Manage chemical burns

– Apply a dry, sterile dressing

– Lewisite, an arsenic-based agent, has an

(40)

Chemical Agents

(9 of 16)

– Cyanide

▪ Rapidly disrupts the ability of the cells to use

oxygen

▪ May be inhaled and ingested

(41)

Chemical Agents

(10 of 16)

– Cyanide

– Anxiety.

– Weakness and dizziness.

– Nausea.

– Muscular trembling.

(42)

Chemical Agents

(11 of 16)

– Cyanide Exposure

▪ Emergency treatment:

– Manage the airway, breathing, and

oxygenation.

– There are antidotes available.

• Nitrites and sodium thiosulfate

(43)

Chemical Agents

(12 of 16)

– Pulmonary Agents

▪ Include phosgene, other halogen compounds, and

nitrogen-oxygen compounds

(44)

Chemical Agents

(13 of 16)

– Pulmonary Agent Exposure

– Tearing and runny nose.

– Throat irritation.

– Dyspnea and wheezing.

– Cough.

(45)

Chemical Agents

(14 of 16)

– Pulmonary agent exposure

▪ Emergency medical treatment:

– Manage the airway and breathing; be prepared

(46)

Chemical Agents

(15 of 16)

– Riot Control Agents

▪ Tear gas and pepper spray

▪ cause extreme irritation of the eyes, nose, mouth,

skin, and respiratory tract.

▪ Emergency medical care is supportive and may

(47)

Chemical Agents

(16 of 16)

– Toxic Industrial Chemicals

▪ They may be obtained from hijacking rail or truck

transportation of chemicals or sabotage of chemical plants.

▪ The approach and treatment depends on the agent

(48)

Case Study

(2 of 3)

(49)

Case Study

(3 of 3)

• What should be the approach to this situation?

• Where should EMS units be located?

(50)

Biological Agents

(1 of 13)

• They consist of living organisms or their toxins.

• Small amounts can cause widespread illness and may

take days to detect.

• Dispersal methods vary.

(51)

Biological Agents

(2 of 13)

• Specific Biological Agents

– Groups of biological agents include:

▪ Pneumonia-like agents.

▪ Encephalitis-like agents.

▪ Biological toxins.

(52)

Biological Agents

(3 of 13)

– Pneumonia-Like Agents

▪ Present with fever and difficulty breathing, and

include:

– Anthrax.

– Plague.

– Tularemia.

▪ Encephalitis-Like Agents include:

(53)

Biological Agents

(4 of 13)

– Biological Toxins

▪ Botulinum

– Descending paralysis

– Double vision

– Blurred vision

– Dry mouth and throat

(54)

Biological Agents

(5 of 13)

▪ Ricin

– Weakness

– Fever

– Cough

– Hypothermia

(55)

Biological Agents

(6 of 13)

▪ Staphylococcus enterotoxin 13

– Fever

– Chills

– Headache

– Body aches

(56)

Biological Agents

(7 of 13)

▪ Epsilon toxin

– Cough, wheezing, and shortness of breath

– Respiratory failure

(57)

Biological Agents

(8 of 13)

▪ Trichothecene myotoxins

– Pain

– Itching and lesions

– Runny nose, and sneezing

– Sloughing skin

(58)

Biological Agents

(9 of 13)

– Other Biological Agents

▪ Cholera

– Vomiting, abdominal distention, and profuse

diarrhea

– Severe dehydration

(59)

Biological Agents

(10 of 13)

▪ Viral hemorrhagic fevers

– Malaise

– Body aches

– Headache

– Vomiting

(60)

Biological Agents

(11 of 13)

▪ Brucellosis

– Fever

– Malaise

– Body aches

– Joint pain

(61)

Biological Agents

(12 of 13)

– Emergency medical care for biological agent

▪ Prehospital care is supportive.

▪ Recognition and contacting public health officials is

crucial.

▪ Smallpox, plague, and Ebola are highly

(62)

Biological Agents

(13 of 13)

– Emergency medical care for biological agent

▪ Hospital care includes antibiotics and antitoxin.

▪ Immunizations and prophylactic treatment are

(63)

Click on the W

M

D Agent Below That is a

Biological Agent

A. Phosgene

B. Nerve agents

C. Ricin

(64)

Nuclear Weapons and Radiation

(1 of 11)

• Three primary mechanisms of death

– Radiation

– Blast

– Thermal burns

• Radiation

– Energy released from radioactive atoms passes

(65)

Nuclear Weapons and Radiation

(2 of 11)

• Radiation

– The cells may die, repair, or produce mutated cells.

– X-ray/gamma radiation is the most penetrating type

and can travel long distances.

– Neutron radiation is a powerful, damaging particle

(66)

Nuclear Weapons and Radiation

(3 of 11)

• Radiation

– Beta radiation is a low-speed, low-energy particle that

is easily stopped by 6 to 10 feet of air, clothing, or the first few millimeters of skin, but poses a serious

hazard if ingested.

– Alpha radiation is heavy, slow-moving, and easily

(67)

Nuclear Weapons and Radiation

(4 of 11)

• Radiation

– Exposure associated with a nuclear explosion

▪ Primary exposure

– Radiation injury that occurs during or shortly

after the detonation

▪ Fallout

– Radioactive dust and particles that can be life

(68)

Nuclear Weapons and Radiation

(5 of 11)

• Blast Injuries

– Nuclear detonation causes a rapid heating of air and

an explosively expanding gas cloud.

– Injuries are the same as those from conventional

explosives.

(69)

Nuclear Weapons and Radiation

(6 of 11)

• Thermal burns

– Cause most deaths and injuries from nuclear

explosion

– Heating is a short duration, but very intense.

(70)

Nuclear Weapons and Radiation

(7 of 11)

• Radiological Dispersal Devices/Radiological Exposure

Devices

– “Dirty Bomb”

▪ A conventional explosive attached to radioactive

materials

▪ Risk of widespread radiation illness and

contamination of the environment

– A Radiological Exposure Device

(71)

Nuclear Weapons and Radiation

(8 of 11)

• Improvised Nuclear Device

– Assembled and built specifically for a terrorist

incident.

– Low-quality materials

(72)

Nuclear Weapons and Radiation

(9 of 11)

• Assessment and Care for Nuclear Detonation and

Radiation Injuries

– Assessment

▪ Most destruction and death is nearest the center of

the blast.

▪ There is less death and injury further from the

blast.

▪ Identify the time after exposure that the patient

(73)

Nuclear Weapons and Radiation

(10 of 11)

Radiation Injuries

– Signs and symptoms:

▪ Nausea, fatigue, malaise, and clotting disorders.

▪ Vomiting, no appetite, diarrhea, and fluid loss.

▪ Reddening of the skin.

▪ Rapid onset of incapacitation, cardiovascular

(74)

Nuclear Weapons and Radiation

(11 of 11)

Radiation Injuries

– Emergency Medical Care

▪ Protect yourself and patients from further

radioactive exposure.

▪ Treat thermal and blast injuries.

▪ Manage airway, breathing, and oxygenation.

▪ Iodine tablets can help protect against long-term

(75)

Personal Protection and Patient

Decontamination

• Personal protective equipment is required for chemical,

biological, and radiological/nuclear exposure.

• Apply the principles of hazardous material response.

• Apply the principles of time, distance, and shielding for

radiation exposure.

• Apply the principles of decontamination as for hazardous

(76)

Active Shooter Incident

• Tactical EMS

– Tactical emergency medicine(TEM) is not normally

taught as part of most EMT or paramedic curriculums.

(77)

Cyberterrorism

• The use of computer network tools to shut down critical

national infrastructure.

• Medical devices and technology rely on networked

computer systems.

• Protected health information (PHI) can be illegally

(78)

Case Study Conclusion

(1 of 4)

Louis and Allan, along with other responding units, are relocated to a position upwind from the stadium.

(79)

Case Study Conclusion

(2 of 4)

(80)

Case Study Conclusion

(3 of 4)

In all, nearly 100 people are decontaminated by hazardous materials personnel at the scene. Hazardous materials

crews confirm that the substance involved was a riot control agent.

(81)

Case Study Conclusion

(4 of 4)

(82)

Lesson Summary

(1 of 2)

• WMD are intended to produce widespread death and

destruction.

• WMD may be chemical, biological, radiological, nuclear,

or explosive agents.

• Conventional explosive agents have the greatest

(83)

Lesson Summary

(2 of 2)

• Preplanning is crucial to management of the incident and

the patients.

• Preplanning must consider supplies and equipment,

(84)

Correct!

Ricin is a biological toxin.

(85)

Incorrect

(1 of 3)

Phosgene is a chemical agent.

(86)

Incorrect

(2 of 3)

Nerve agents are chemical agents.

(87)

Incorrect

(3 of 3)

Hydroxocobalamin is an antidote to cyanide, a chemical agent.

(88)