Chapter 39 – EMT (Terrorism Response and Disaster Management) – Flashcards

international terrorism (also known as cross-border terrorism)

1. Violent religious groups/doomsday cults -include groups such as Aum Shinrikyo (tokyo subway) -may participate in apocalyptic violence2. Extremist political groups -may include violent separatist groups and those who seek political, religious, economic, and social freedom -e.g. Taliban militant groups3. Technology terrorists -those who attack a population's technological infrastructure as a means to draw attention to their cause, such as cyberterrorists 4. Single-issue groups -these include antiabortion groups, animal rights groups, anarchists, racists, and even ecoterrorists who threaten or use violence as a means to protect the environment

weapon of mass destruction (WMD) or weapon of mass casualty (WMC) -these instruments of death and destruction include biologic, nuclear, incendiary, chemical, and explosive weapons (B-NICE), or chemical, biologic, radiologic, nuclear, and explosive (CBRNE) weaponds -to date, the preferred WMD for terrorists has been explosive devices -WMDs are relatively easy to obtain or create and are specifically geared toward killing large numbers of people -the technical recipes for making B-NICE weapons can be found readily online -chemical warfare may consist of agents in the form of a liquid, powder, or vapor

Chemical agents are manufactured substances that can have devastating effects on living organisms -they can be produced in liquid, powder, or vapor form depending on desired route of exposure and dissemination technique -developed during WWI, used on battlefield and have been used to terrorize civilian populationsChemical warfare agents include: -vesicants (blister agents) -respiratory agents (choking agents) -nerve agents -metabolic agents (cyanides)

Biologic agents are organisms that cause disease -generally found in nature, however for terrorist use they are cultivated, synthesized, and mutated in a lab -the weaponization of biologic agents is performed to artificially maximize the target population's exposure to the germ, thereby exposing the greatest number of people and achieving the desired resultPrimary types of biologic agents that you may come into contact with during a biologic event include: -viruses -bacteria -toxins

weaponization

-includes use of nuclear bombs, such as those used during WWII when Hiroshima and Nagasaki were targeted with nuclear bombs -there are also nations that hold close ties with terrorist groups (known as state-sponsored terrorism) and have obtained some degree of nuclear capability -it is also possible for a terrorist to secure radioactive materials or waste to perpetuate an act of terror --> these materials are easier to acquire and require less expertise to use. Radioactive materials (such as those in radiologic dispersal devices (RDDs) also known as "dirty bombs") can cause widespread panic and civil disturbances

in large-scale terrorist events, it is important to use triage and base patient care on available resources

-most terrorist attacks are covert, meaning the public safety community generally has no prior knowledge of the time, location, or nature of the attack -the Homeland Security Advisory System alerts responders to the potential for an attack, although specifics of the current threat will not be given -on the basis of the current threat level, EMTs should take appropriate actions and precautions while continuing to perform daily duties and responding to calls -The system of colors is used to inform the public safety community of the climate of terrorism and to heighten the awareness of the potential for a terrorist attack -the system is designed to save lives -DHS has not issued specific recommendations for EMS personnel to follow in response to the alert system. Follow local protocols and procedures-it is your responsibility to make sure you know the advisory level at the start of your workday (DHS website, newspaper, TV, etc. all give up-to-date info on the threat level)

1. Type of location -is the location a monument, infrastructure, government building, or a specific type of location like a temple? -is there a large gathering or special event taking place?2. Type of call -is there a report of an explosion or suspicious device nearby? -does the call come into dispatch as someone having unexplained coughing and difficulty breathing? -are there reports of people fleeing the scene?3. Number of patients -are there multiple victims with similar signs and symptoms? ^^this is the single most important clue that a terrorist attack or incident involving WMD has occurred 4. Victim's statements -second best indication of a terrorist or WMD event -are victims fleeing the scene giving statements such as, "Everyone is passing out," "there was a loud explosion," or "there are a lot of people shaking on the ground" -if so, something is occurring that you do not want to rush into, even if it is determined not to be a terrorist event 5. Preincident indicators -is the terror alert level high (orange) or severe (red)? -has there been a recent increase in violent political activism? -are you aware of any credible threats made against the location, gathering, or occasion?

multiple victims with similar signs and symptoms -second best indication of a terrorist or WMD event = victim's statements

Severe (RED) -severe risk of terrorist attackHigh (ORANGE) -high risk of terrorist attackElevated (YELLOW) -significant risk of terrorist attack Guarded (BLUE) -general risk of terrorist attack Low (GREEN) -low risk of terrorist attack

Look at patients' presenting signs and symptoms -the intentional use of a WMD affects multiple persons and these casualties will generally exhibit the same signs and symptoms -it is highly unlikely for more than one person to experience a seizure at any given time

1. Scene safety 2. Responder Safety (personal protection) 3. Notification procedures 4. Establishing command 5. Secondary device or event (reassessing scene safety)

1. Scene Safety -stage your vehicle a safe distance (1-2 blocks) from the incident and wait for law enforcement to advise you that scene has been made secure -in a suspected WMD incident, it's best to stage uphill and upwind of the incident and wait for assistance from those who are trained in assessing and managing WMD scenes -law enforcement will most likely make a perimeterRemember following rules: -always have an escape plan determined beforehand in case scene becomes unsafe -make sure that your vehicle is not blocked in by other emergency vehicles or damaged by a secondary device because then you will be unable to provide victims with transportation or escape yourself2. Responder Safety (Personal Protection) -the greatest threats facing you in a WMD attack are contamination and cross-contamination -contamination with an agent occurs when you have direct contact with a WMD or are exposed to it -cross-contamination occurs when you come into contact with a contaminated person who has not yet been decontaminated 3. Notification Procedures -when you suspect a terrorist or WMD event has taken place, notify dispatcher if communications are functioning properly -inform dispatch of the nature of event, any additional resources that may be required, the estimated number of patients, and the upwind route of approach or optimal route of approach -establish a staging area where other units will converge -trained responders in proper protective equipment are the only persons equipped to handle the WMD incident (HazMat teams typically) and should be requested as early as possible 4. Establishing command -first arriving provider on the scene must begin to sort out the chaos and define his responsibilities under the ICS -as the first person on scene, the EMT may need to establish command until additional personnel arrive -if the initial ICS is already in place when you arrive, immediately seek out the medical staging officer to receive your assignment 5. Secondary Device or Event (Reassessing Scene Safety) -there may be a secondary device that is set to explode after initial bomb and these secondary devices are intended primarily to injure responders and to secure media coverage -secondary devices may include various types of electronic equipment such as cell phones or pagers that are detonated when "answered" -constantly assess and reassess scene for safety -something as subtle as a change in wind direction during a gas attack or an increase in the number of contaminated patients can place you in danger

= liquids or gases that are dispersed to kill or injure -chemical weapons have several classifications -the properties or characteristics of an agent can be described as a liquid, gas, or solid material -persistency and volatility are terms used to describe how long the agent will stay on a surface before it evaporates -persistent or nonvolatile agents can remain on a surface for long periods (usually longer than 24 hours), whereas nonpersistent or volatile agents evaporate relatively fast when left on a surface in the optimal temperature range -an agent that is described as highly persistent (e.g. VX, a nerve agent) can remain in the environment for weeks/months, whereas an agent that is highly volatile (e.g. sarin, a nerve agent) will turn from liquid to gas (evaporate) within minutes to seconds -route of exposure = manner in which toxic substance enters body -chemical agents can have either a vapor or contact hazard -Agents with a vapor hazard enter the body through the respiratory tract in the form of vapors -Agents with a contact hazard (or skin hazard) give off very little vapor or no vapors and enter the body through the skin

evaporates quickly; remains on a surface a long time before it evaporates (possibly weeks to months)

VX, a nerve agent sarin, another nerve agent

1. Vesicants (blister agents) -sulfur mustard (H) -Lewisite (L) -phosgene oxime (CX)2. Pulmonary Agents (Choking Agents) -chlorine (CL) -Phosgene3. Nerve Agents -G agents (sarin, soman, tabun, V agent) 4. Metabolic Agents (Cyanides) -cyanide

1. Vesicants -primary route of exposure = skin (contact), however if vesicants remain on skin or clothing long enough they produce vapors that can enter resp. tract -cause burn-like blisters to form on patient's skin and in resp. tract -cause the most damage to damp or moist areas of body (i.e. armpits, groin, and resp. tract)Signs of vesicant exposure on skin: -skin irritation, burning, and reddening -immediate intense skin pain (with L and CX) -formation of large blisters -gray discoloration of skin (a sign of permanent damage seen with L and CX) -swollen and closed or irritated eyes -permanent eye injury (including blindness)If vapors were inhaled, the patient may experience: -hoarseness and stridor -severe cough -hemoptysis (coughing up blood) -severe dyspnea a. Sulfur mustard (H) = brownish, yellowish oily substance that is generally considered very persistent (stays on surfaces a long time) -when released, has the smell of garlic or mustard and is quickly absorbed into skin and/or mucous membranes (within seconds) -once absorbed into skin, begins irreversible process of damage to cells (within 1-2 minutes of absorption); eventually cellular death will occur -considered a mutagen -patient won't present with signs/symptoms until 4-6 hours after exposure. Then, patient will develop a progressive reddening of affected area, which will develop into large blisters (similar to those of 2nd degree burns) -although the fluid within the blisters does NOT contain any sulfur mustard agent, the skin is considered contaminated and must be decontaminated -primary complication = second infection (because mustard attacks vulnerable cells in bone marrow and depletes the body's ability to reproduce WBCs, making patient have a decreased resistance to infections) -when vapors are inhaled, causes upper and lower airway compromise, leading to damage and swelling of the airways b. Lewisite (L) and phosgene oxime (CX) -produce blister wounds similar to those caused by mustard -However, they are highly volatile and have a rapid onset of symptoms -produce immediate intense pain and discomfort when contact is made -patient may have grayish discoloration at contaminated site -do not cause secondary cellular injury that mustard does, although tissue damage also occurs Treatment: -No antidotes for mustard or CX, but Bristish anti-Lewisite is the antidote for agent L (not carried by civilian EMS) -ensure patient has been decontaminated before assessing ABCs -transport asap, preferably to burn center that is best equipped to handle wounds and subsequent infections produced by vesicants

2. Pulmonary agents (choking agents) -these are gases that cause immediate harm to exposed patients -primary route of exposure = through respiratory tract (makes them an inhalation or vapor hazard) -once inside lungs, they damage the lung tissue and fluid leaks into lungs; pulmonary edema develops, resulting in difficulty breathing (because of inability for air exchange) -produce respiratory-related symptoms such as dyspnea, tachypnea, and pulmonary edemaa. Chlorine (CL) = first chemical agent ever used in warfare -smells like bleach and creates a green haze when released as a gas -initially produces upper airway irritation and a choking sensation -Later, patient may experience the following signs/symptoms: -shortness of breath -chest tightness -hoarseness and stridor as the result of upper airway constriction -gasping and coughing-with serious exposures, patient may exhibit pulmonary edema, complete airway constriction, and death -household bleach (CL) and ammonia fumes create an acid gas that produces similar effects (common when people try to mix household cleaners) b. Phosgene should NOT be confused for phosgene oxime -phosgene is also a product of combustion (such as might be produced at a fire). Therefore, you may encounter a patient with exposure to this gas during a normal call at a fire scene -potent agent that has delayed onset of symptoms (hours) -unlike CL, it does NOT cause severe irritation that would possibly cause victim to leave the area or hold his/her breath -smells like freshly mown grass or hay -; therefore, much more of the gas is allowed to enter body unnoticed Initially, a mild exposure may include: -nausea -chest tightness -severe cough -dyspnea on exertion -severe exposure patient may present with dyspnea at rest and excessive pulmonary edema (patient will expel large amounts of fluid because of this, possibly becoming hypovolemic and hypotensive) Treatment: -remove patient from contaminated atmosphere -aggressive management of ABCs with focus on oxygenation, ventilation, and suctioning if required -do NOT allow patient to be active (this will worsen patient's condition) -there are no antidotes for pulmonary agents -allow patient to rest in position of comfort with head elevated and rapidly transport

-among the most deadly chemicals developed and are designed to kill large numbers of people with small quantities -can cause cardiac arrest within seconds-minutes of exposure -are a class of chemicals called organophosphates (found in household bug sprays, pesticides, and some industrial chemicals in lower strengths) -organophosphates block an essential enzyme in the nervous system, causing the body's organs to become overstimulated and burn out -nerve agents have similar symptoms but varying routes of entry -these are the only type of chemical agent that has been used successfully in terrorist acta. G agents -came from early nerve agents, the G series, created by a German scientist (hence the G) after WWI and into WWII -there are 3 G agents, all designed with same basic chemical structure with two slight variations: lethality and volatility -listed from high volatility (evaporates easily) to low volatility (evaporates slowly): a. Sarin (GB) b. Soman (GD) c. Tabun (GA) d. V agent (VX)a. Sarin (GB) = highly volatile colorless and odorless liquid -turns from liquid to gas within seconds-minutes -highly lethal with an LD50 of 1,700 mg/70kg (about 1 drop) -LD50 = amount that will kill 50% of people who are exposed to this level -vapor hazard with respiratory tract as main route of entry -dangerous in enclosed spaces (i.e. office buildings, etc.) -when sarin is on clothing, it has the effect of off-gassing, which means that the vapors are continuously released over a period of time (like perfume), making victim and clothing contaminated b. Soman (GD) = twice as persistent (stays on surfaces twice as long) as sarin and five times as lethal -colorless and has fruity odor (due to type of alcohol used in agent) -it's a contact and inhalation hazard that can enter body through skin absorption and through the respiratory tract -it binds to the cells that it attacks faster than any other agent; this irreversible binding is called aging, which makes it more difficult to treat patients who have been exposed -aging = process by which the temporary bond between the organophosphate (nerve agent) and acetylcholinesterase (enzyme) undergoes hydrolysis, resulting in a permanent covalent bond c. Tabun (GA) = half as lethal as sarin and 36 times more persistent -can remain present for several days -also has fruity smell and appearance similar to sarin -components of this nerve agent are easy to acquire and it's easy to manufacture -it's a contact and inhalation hazard that can enter body through skin absorption and respiratory tract d. V agent (VX) = most toxic chemical ever created (small LD50) -clear, oily agent that has no odor and looks like baby oil -developed after WWII and has chemical properties similar to G series -difference = VX is 100 times more lethal than sarin and is extremely persistent (can remain relatively unchanged for weeks-months) -primarily a contact hazard because it lets off little vapor; only residue on the skin after contact is extremely difficult to decontaminate

V agent (VX), a nerve agent

Military = SLUDGEM Medical = DUMBELSSLUDGEM: Salivation, Sweating Lacrimation (excessive tearing) Urination Defecation, Drooling, Diarrhea Gastric upset and cramps Emesis (vomiting) Muscle twitching/Miosis (pinpoint pupils)DUMBELS (more useful) Diarrhea Urination Miosis (pinpoint pupils) Bradycardia, Bronchospasm Emesis (vomiting) Lacrimation Seizures, salivation, sweating *seizures will continue until patient dies or until treatment is given with a nerve agent antidote kit (Mark 1 NAAK)

cerebrovascular accident, direct light to both eyes, and drug overdose with cholinergic agents

miosis (bilateral pinpoint constricted pupils) -can remain for days to weeks

respiratory complications, which lead to respiratory arrest -therefore it's important to provide airway and ventilatory support

Treatment: -fatalities from severe nerve agent exposure occur as a result of respiratory complications, which lead to respiratory arrest -therefore, it's important to provide aggressive airway and ventilatory support after patient has been decontaminated -treatment = nerve agent antidote kit; most common is the Mark 1 Nerve Agent Antidote Kit (NAAK) -Mark 1 NAAK contains two medications: 2 mg atropine and 600 mg of pralidoxime chloride (2-PAM) in two separate auto-injectors -an updated version of the Mark 1 is the DuoDote Auto-Injector, which contains 2.1 mg atropine and 600 mg 2-PAM and is delivered in a single dose through one needle -multiple doses may be necessary, used same as EpiPen -atropine is used to block the nerve agent from affecting the body (it's an anticholinergic agent) while 2-PAM is used eliminate the agent from the body -many of the symptoms in DUMBELS/SLUDGEM will be reversed with use of atropine, but many doses may be necessary

-hydrogen cyanide (AC) and cyanogen chloride (CK) are both agents that affect the body's ability to use oxygen -cyanide = colorless gas that has an odor similar to almonds (AC) -effects of cyanides begin at cellular level and are rapidly seen at organ and system levels -besides nerve agents, metabolic agents are the only chemical weapons known to kill within seconds-minutes; however, these agents are commonly found in many industrial settings (gold and silver mining, photography, plastics processing) and are often present in fires associated with textile and plastic factories -cyanide is naturally found in very low doses in the pits of fruits -vapor hazard -binds to body's cells, preventing oxygen from being used -with low doses, signs/symptoms include dizziness, light-headedness, headache, and vomitingSigns/Symptoms (little difference between AC and CK) of higher dose (will appear within several minutes): -shortness of breath and gasping respirations -tachypnea -flushed skin -tachycardia -altered mental status -seizures -coma -apnea (cessation of breathing) -cardiac arrest*death will occur unless patient is treated promptly Treatment: -several medications act as antidotes but most services do not carry them -all of patient's clothing must be removed by HazMat to prevent off-gassing in the ambulance and patient must be decontaminated before you can begin treatment -remove from source of contamination and provide supplemental oxygen -severe exposure will require aggressive oxygenation and perhaps ventilation with supplemental oxygen -always use a BVM device or oxygen-powered ventilator device to ventilate a victim of a metabolic agent (because agent can be easily passed from patient to you through mouth-to-mouth or mouth-to-mask ventilations) -if no antidote is available, initiate transport immediately

-make sure patient is thoroughly decontaminated before you come into contact with them -all of patient's clothing must be removed prior to you providing treatment to prevent off-gassing (chemical agents are primarily a vapor hazard) -NEVER perform mouth-to-mouth or mouth-to-mask ventilations on a victim of a chemical agent exposure because vapors may linger in patient's airway and cross-contamination may occur

1. Viruses -Smallpox -Viral hemorrhagic fevers (VHF)2. Bacteria -Inhalation and Cutaneous Anthrax (Bacillus anthracis) -Plague (Bubonic/Pneumonic)3. Neurotoxins -Botulinum toxin -Ricin -can be almost undetectable and most of the diseases caused by these agents will be similar to other minor illnesses commonly seen by EMS providers -dissemination = means by which a terrorist will spread the agent (e.g. poisoning the water supply or aerosolizing the agent in to the air or ventilation system of a building) -a disease vector = an animal that spreads disease, once infected, to another animal (e.g. bubonic plague can be spread by infected rats, smallpox by infected persons) -communicability = how easily the disease is spread from one human to another human -when communicability is high, such as with smallpox, person is considered contagious -incubation = period of time between the person becoming exposed to the agent and when symptoms begin ? important for EMTs because patient may not exhibit symptoms and yet still be contagious -if the agent is in the form of a powder, HazMat must handle the incident

communicability -when communicability is high, such as with smallpox, person is considered contagious

incubation

=germs that require a living host to multiply and survive -as the virus spreads, so does the disease that it carries -viruses move from host to host by direct methods, such as respiratory droplets or through vectors (act as carriers/transporters) -although some viral agents have vaccines, there is NO treatment for a viral infection other than antiviral medications for some agentsa. Smallpox =highly contagious disease -all forms of standard precautions must be worn to prevent cross-contamination (i.e. examination gloves, HEPA-filtered respirator, and eye protection) -before the rash and blisters show, the illness will start with a high fever and body aches and headaches -patient's temperature is usually in the range of 101 F to 104 F -there is a vaccine to prevent smallpox but it has been linked to medical complications and possible death -should an outbreak occur, the U.S. government has enough vaccine to vaccinate every person in the United States -dissemination = aerosolized for warfare or terrorist uses -communicability = high from infected individuals or items (such as blankets); person-to-person transmission is possible -route of entry = inhalation of coughed droplets or direct skin contact with blisters -no specific treatment for smallpox, simply provide supportive care of ABCsSigns/Symptoms: -severe fever -malaise -body aches -headaches -small blisters on the skin -bleeding of skin and mucous membranes

Observe the size, shape, and location of the lesions -in smallpox, all the lesions are identical in their development, whereas in other skin disorders, the lesions will be in various stages of healing and development -smallpox blisters also begin on the face and extremities and eventually move toward the chest and abdomen

when blisters begin to form

-consist of a group of diseases caused by viruses that include the Ebola, Rift Valley, and yellow fever viruses, among others that cause the blood in the body to seep out from the tissues and blood vessels -the end result is ecchymosis, hemoptysis, and blood in the patient's stool -patients' skin will have severe discoloration, indicating internal bleeding -initially patient will have flulike symptoms, progressing to more serious symptoms such as internal and external hemorrhaging -all standard precautions must be taken when treating these illnesses -mortality rates can range from 5-90% depending on the strain of virus, the victim's age and health condition, and the availability of a modern health care system-dissemination = direct contact with an infected person's body fluids; can also be aerosolized for use in an attack -communicability = moderate from person to person or contaminated items -route of entry = direct contact with an infected person's body fluids -treatment = no specific treatment, provide supportive care of ABCs and treat for shock and hypotension if presentSigns/symptoms: -sudden onset of fever -weakness -muscle pain -headache and sore throat ^^all followed by vomiting, and internal and external bleeding

-unlike viruses, bacteria do NOT require a host to multiply and live -bacteria contain all the cellular structures of a normal cell and are completely self-sufficient -most bacterial infections can be fought with antibiotics and generally begin with flulike symptoms, which can make it quite difficult for providers to identify whether the cause is a biologic attack or a natural epidemica. Inhalation and Cutaneous Anthrax (Bacillus anthracis) -anthrax is caused by a deadly bacterium that lays dormant in a spore. When exposed to the optimal temperature and moisture, the germ will be released from spore -routes of entry for anthrax are inhalation, cutaneous, and gastrointestinal (from consuming food that contains spores) -inhalation form (pulmonary anthrax) is the most deadly and often presents with a severe cold (has 90% death rate if untreated) -antibiotics can be used to treat anthrax successfully, and there is also a vaccine to prevent anthrax infections-dissemination = aerosol -communicability = only in the cutaneous form (rare) -route of entry = through inhalation of spore or skin contact with spores or direct contact with skin wound (cutaneous) -treatment for pulmonary anthrax = oxygen, ventilatory support if in pulmonary edema or respiratory failure, and transport -treatment for cutaneous anthrax = apply dry sterile dressing to prevent accidental contact with wound and fluids Signs/symptoms: -flulike symptoms -fever -respiratory distress with tachycardia, shock, pulmonary edema, and respiratory failure after 3-5 days of flulike symptoms

-plague's natural vectors are infected rodents and fleas -when a person is bitten by an infected flea or comes into contact with an infected rodent (or waste of rodent), the person can contract bubonic plague-Bubonic plague (Black Death) infects the lymphatic system (a passive circulatory system in the body that bathes the tissues in lymph and works with the immune system) -when this occurs, the patient's lymph nodes (area of lymphatic system where infection-fighting cells are housed) become infected and grow. The glands of the nodes will grow large (up to the size of a tennis ball) and round, forming buboes -buboes = enlarged lymph nodes that wre characteristic in people infected with bubonic plague -if left untreated, infection may spread through the body, leading to sepsis and possibly death -this form of plague is NOT contagious and is not likely to be seen in a bioterrorist incident -characterized by acute malaise, fever, and the formation of tender, enlarged, inflamed lymph nodes that appear as lesions, called buboes-Pneumonic plague = a lung infection, also known as plague pneumonia, that results from inhalation of plague bacteria -this form of the disease is contagious and has a much higher death rate than the bubonic form -dissemination = aerosol -communicability: -bubonic = low, only from contact with fluid in buboes -pneumonic = high, from person to person -route of entry = ingestion, inhalation, or cutaneous -treatment = ABCs, provide oxygen, and transport Signs/symptoms: -fever, headache, muscle pain and tenderness -pneumonia -shortness of breath -extreme lymph node pain and enlargement (bubonic)

pneumonic plauge is contagius and has much higher death rate than bubonic form

neurotoxins

= most deadly substances known to humans -strongest neurotoxin is 15,000 times more lethal than VX (most toxic chemical) and 100,000 more lethal than sarin -these toxins are produced from plants, marine animals, molds, and bacteria -route of entry for these toxins is through ingestion, inhalation from aerosols, or injection -unlike viruses and bacteria, neurotoxins are NOT contagious and have a faster onset of symptoms -have not yet been used as WMD even though they have immense destructive potentiala. Botulinum toxin = the most potent neurotoxin -produced by bacteria -when introduced into body, this neurotoxin affects the nervous system's ability to function. Voluntary muscle control diminishes as the toxin spreads. Eventually the toxin causes muscle paralysis that begins at the head and face and travels downward throughout the body -the patient's accessory muscles and diaphragm will become paralyzed and the patient will go into respiratory arrest-dissemination = aerosol or food supply sabotage or injection -communicability = none (not contagious) -route of entry = ingestion, inhalation -treatment = ABCs, provide oxygen, and transport. Ventilatory support in case of paralysis of the respiratory muscles; vaccine is available Signs/symptoms: -dry mouth -intestinal obstruction -urinary retention -constipation -nausea and vomiting -abnormal pupil dilation, blurred vision, double vision, drooping eyelids -difficulty swallowing -difficulty speaking -respiratory failure as the result of paralysis

-while not as deadly as botulinum, ricin is still five times more lethal than VX -derived from mash that is left from the castor bean. These seemingly harmless castor beans contain the key ingredient for ricin, one of the most potent toxins known to humans -when introduced to the body, ricin causes pulmonary edema and respiratory and circulatory failure, leading to death -the clinical picture depends on the route of exposure (ingestion vs. inhalation) -toxin is quite stable and extremely toxic by many routes of exposure, including inhalation -it is likely that 1 to 3 mg of ricin can kill an adult, and the ingestion of one seed can most likely kill a child -although all parts of the castor bean are poisonous, it is the seeds that are the most toxic -castor bean ingestion causes a rapid onset of nausea, vomiting, abdominal cramps, and severe diarrhea, followed by vascular collapse. Death usually occurs on the third day in the absence of medical intervention-ricin is LEAST toxic by the oral route, most likely as a result of poor absorption in the GI tract, some digestion in the gut, and possibly some expulsion of the agent as caused by the rapid onset of vomiting -ingestion causes local hemorrhage and necrosis (cell death) of the liver, spleen, kidneys, and GI tract. Signs and symptoms appear 4-8 hours after exposureSigns/symptoms: -fever, chills, headache -muscle aches -nausea, vomiting -diarrhea -severe abdominal cramping -dehydration -GI bleeding -necrosis of liver, spleen, kidneys, and GI tract -inhalation of ricin causes nonspecific weakness, cough, fever, hypothermia, and hypotension -symptoms occur 4-8 hours after inhalation, depending on the inhaled dose -the onset of profuse sweating some hours later signifies the termination of the symptoms Signs/symptoms of ricin inhalation: -fever, chills -nausea -local irritation of eyes, nose, throat -profuse sweating -headache, muscle aches -nonproductive cough -chest pain -dyspnea -pulmonary edema -severe lung inflammation -cyanosis -seizures -respiratory failure

1 to 3 mg of ricin can kill an adult, and the ingestion of one seed can most likely kill a child

seeds

-ricin is LEAST toxic by the oral route, most likely as a result of poor absorption in the GI tract, some digestion in the gut, and possibly some expulsion of the agent as caused by the rapid onset of vomiting -ingestion causes local hemorrhage and necrosis (cell death) of the liver, spleen, kidneys, and GI tract. Signs and symptoms appear 4-8 hours after exposureSigns/symptoms: -fever, chills, headache -muscle aches -nausea, vomiting -diarrhea -severe abdominal cramping -dehydration -GI bleeding -necrosis of liver, spleen, kidneys, and GI tract

profuse sweating

In both, symptoms appear 4-8 hours after exposure Inhalation: -cough, difficulty breathing, chest tightness, nausea, muscle aches, pulmonary edema, and hypoxia Ingestion: -nausea and vomiting, internal bleeding, and death Injection: -no signs except swelling at the injection site and death Treatment is supportive and includes both respiratory support and cardiovascular support as needed -early inubation and ventilation, combined with treatment of pulmonary edema are appropriate -IV fluids and electrolyte replacement are useful for treating the dehydration caused by profound vomiting and diarrhea

-syndromic surveillance -points of distribution (strategic national stockpile)

syndromic surveillance -patients with signs and symptoms that resemble influenza are particularly important -local and state health departments monitor for an unusual influx of patients with these symptoms in hopes of discovering an outbreak early -the EMS role in syndromic surveillance is a small one yet valuable in overall tracking of a biologic terrorist event or infectious disease outbreak -quality assurance and dispatch operations need to be aware of an unusual number of calls from patients with "unexplainable flu" coming from a particular region or community

points of distribution (PODs) -these medications may be delivered in large containers known as "push packs" by CDC and National Pharmaceutical Stockpile --> they can deliver one of many push packs to any location in the country within 12 hours of an emergency ^^push packs contain antibiotics, chemical antidotes, antitoxins, and life-support medications, IV administration supplies, airway maintenance supplies, and medical/surgical items -in some regions, local and state municipalities have started to stockpile their own supplies to reduce the time dealy -EMS workers may be called on to assist in delivery of the medications to the public -your role may include triage, treatment of seriously ill patients, and patient transport to the hospital -most plans for PODs include at least one ambulance on standby for the transport of seriously ill patients

ionizing radiation -this energy can be found in radioactive material, such as rocks and metals -radioactive material = any material that emits radiation. This material is unstable and it attempts to stabilize itself by changing its structure in a natural process called decay -As substance decays, it gives off radiation until it stabilizes (process can take minutes to billions of years, all the while the substance remains radioactive -the energy that is emitted from a strong radiologic source is alpha, beta, gamma (x-ray), or neutron radiation

Alpha Radiation -least harmful penetrating type of radiation -cannot move through most objects (sheet of paper on skin stops it)Beta Radiation -slightly more penetrating -requires a layer of clothing to stop itGamma rays (x-rays) -far faster and stronger than alpha and beta -can easily penetrate through the human body and require lead or several inches of concrete to prevent penetration Neutron particles -one of most powerful forms of radiation -easily penetrate through lead and require several feet of concrete to stop them

-radiologic materials are generally used for purposes that benefit mankind, such as medications, killing germs in food (irradiating), and construction work -once radiologic material has been used for these purposes, it's called radiologic waste, and this remains radioactive but has no more usefulnessThese materials can be found at: -hospitals -colleges and universities -chemical and industrial sites-not all radioactive material is tightly guarded and the waste is often not guarded (appealing to terrorists)

radiologic dispersal device (RDD) --> generally requires use of a bomb -"dirty bomb" = name given to a bomb that is used as a radiologic dispersal device; disperses radioactive material as well as explosive material -destructive ability of a dirty bomb is limited to the explosives that are attached to it -may be long term injuries and illnesses associated with the use of an RDD, yet not much more than the bomb by itself would create (without the radioactive material) overall, the dirty bomb is an effective WMD

nuclear energy -result is an immense amount of energy that usually takes the form of heat -nuclear material is used in medicine, weapons, naval vessels, and power plants -nuclear material gives off all forms of radiation, including neutrons (most deadly type) -like radioactive material, when nuclear material is no longer useful it becomes waste that is still radioactive

special atomic demolition munitions (SADM) (also called "suitcase nuke") -due to collapse of Soviet Union, the whereabouts of many of these is unknown -estimate ~80 are missing -nuclear weapons are very bad (think mutual annihilation)

True -patient can inhale radioactive dust or have radioactive liquid absorbed into the body through the skin -once in the body, the radiation source will irradiate the person from within rather than from an external source (such as x-ray equipment) -the effects of radiation exposure will vary depending on the amount of radiation that a person receives and the route of entry

Low exposure -nausea, vomiting, diarrheaModerate exposure -first-degree burns -hair loss -depletion of the immune system (death of WBCs) -cancerSevere exposure -second- and third-degree burns -cancer -death

-being exposed to radiation --> patient is not contaminated or radioactive -however, when patients have radioactive source on their body (such as debris from a dirty bomb), they are contaminated and must be initially cared for by a HazMat responder -once patient is decontaminated and there is no threat to you, you may begin treatment with the ABCs and treat patient for any burns or trauma

-there are NO suits or protective gear designed to completely shield you from radiation -people who work in high-risk areas wear some protection (lead-lined suits) -best way to protect yourself is to use time and distance and shield yourself using buildings and walls for protectionTime -radiation has cumulative effect on body (less time you're exposed, less the effects will be)Distance -radiation is limited to how far it can travel -alpha radiation can only travel a few inches, whereas gamma rays can travel for hundreds-thousands of meters -make certain that responders are stationed far enough from the incident Shielding -always assume you are dealing with the strongest form of radiation and use concrete shielding (such as buildings or walls) between yourself and the incident

-come in various shapes and sizes (includes IEDs) -need to be able to identify an object you believe is a potential device, notify proper authorities, and safely evacuate the area

-blast injuries from incendiary and explosive devices can occur in a number of ways Primary blast injury -due solely to the direct effects of the pressure wave on the body -seen almost exclusively in the hollow organs of the body (i.e. lungs, intestines, and inner ears) -injury to lungs causes greatest morbidity and mortality Secondary blast injury -penetrating or nonpenetrating injury that results from being struck by flying debris -objects are propelled by the force of the blast and strike the victim, causing injury Tertiary blast injury -results from whole body displacement and subsequent traumatic impact with environmental objects (e.g. trees, buildings, and vehicles) -other indirect effects include crush injury from collapse of structures and toxic effects from the inhalation of combustion gases

-when a substance is detonated, a solid or liquid is chemically converted into large volumes of gas under high pressure with resultant explosive energy release -propellants like gunpowder are explosives designed to release energy slowly compared to high energy explosives which are designed to detonate very quickly -this generates a pressure pulse in the shape of a spherical blast wave that expands in all directions from the point of explosion

-hollow organs such as middle ear, lung, and GI tract are most susceptible to pressure changes -junction between tissues of different densities and exposed tissues such as head and neck are also prone to injury

ear

primary pulmonary blast injuries --> occur as contusions and hemorrhages -patient may complain of tightness in chest or pain in chest -may cough up blood and have tachypnea or other signs of resp. distress -subcutaneous emphysema over chest can be palpated, indicating air in the thorax -pneumothorax is common and may require emergency needle decompression -subarachnoid and subdural hematomas are common -permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism -instant but transient unconsciousness, with or without retrograde amnesia, may be initiated not only with head trauma but also by cardiovascular problems -bradycardia and hypotension are common after an intense pressure wave from an explosion --> this is a vagal nerve-mediated form of cardiogenic shock without compensatory vasoconstriction (for example, vasovagal syncope) -extremity injures are common and are often associated with tertiary blasts -patients with traumatic amputation are likely to sustain fatal injuries secondary to the blast

petechiae (pinpoint hemorrhages) to large hematomas

neurologic injuries and head trauma -subarachnoid and subdural hematomas are common

neurologic injuries and head trauma -subarachnoid and subdural hematomas are common

neurologic injuries and head trauma -subarachnoid and subdural hematomas are common