Terrorism Response for EMS

Terrorism Response Overview

• EMS personnel require terrorism response training to recognize incidents, ensure safety, and administer patient care while maintaining situational awareness.
• Focus is placed on terrorist events, response priorities, and CBRNE (chemical, biological, radiological, nuclear, and explosive) incident management.

Recognizing Terrorist Events

• Terrorist incidents are planned to cause mass casualties, panic, and infrastructure disruption.
• Indicators include unexplained mass casualties; similar symptoms in many patients (respiratory distress, burns, neurological impairment); unusual odors, vapors, or visible clouds; explosions or suspicious devices; multiple sick or dying animals; unusual dissemination methods (aerosols, contaminated food/water); and specific threats or warnings.

Scene Safety and Incident Command System (ICS)

• Ensuring scene safety is the first priority.
• EMS must work within the ICS to coordinate an organized, efficient response.

Scene Safety Guidelines

• Approach cautiously, assuming secondary devices or ongoing threats are present.
• Establish a safe zone, avoiding hazardous areas without proper training.
• Wear appropriate PPE, with the level determined by the agent involved.
• Report findings to law enforcement and hazmat teams.
• Avoid contamination by minimizing exposure and preventing secondary contamination.

ICS Roles in Terrorism Response

• Incident Commander (IC) coordinates response efforts.
• Operations Section directs tactical and medical operations.
• Hazmat Team identifies and mitigates hazardous agents.
• Triage and Treatment Teams manage patient care.
• Logistics and Communication coordinate resource deployment and information flow.

Biological Agents

• Biological attacks use infectious agents, causing widespread disease with potentially delayed symptoms.
• Bacteria examples: Anthrax, Plague transmitted through inhalation, ingestion, or direct contact, causing respiratory distress, fever, or sepsis; treated with antibiotics
• Viruses examples: Smallpox, Viral hemorrhagic fevers spread via aerosolized or person-to-person contact, causing fever, rash, or hemorrhage; treated with supportive care and isolation.
• Toxins examples: Botulinum toxin and Ricin spread via ingestion or inhalation, causing paralysis or respiratory failure; treated with antitoxins and supportive care.
• Recognition is difficult because symptoms can mimic common illnesses.
• Containment is critical, involving infection control, isolation, and PPE (N95 mask, gloves, gown).
• Public Health Authorities must be notified to prevent the spread.

Chemical Agents

• Chemical attacks cause rapid symptoms, requiring immediate decontamination and supportive care.
• Nerve Agents: Sarin, VX, Tabun cause SLUDGE symptoms (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis) and seizures; treated with Atropine & Pralidoxime (2-PAM) and airway management.
• Blister Agents: Mustard gas and Lewisite cause severe burns, blisters, and respiratory distress; treated with airway support, pain management, and irrigation.
• Blood Agents: Cyanide and Arsine cause cellular hypoxia and respiratory arrest; treated with Hydroxocobalamin (Cyanokit) and high-flow O2.
• Choking Agents: Chlorine and Phosgene cause pulmonary edema and dyspnea; treated with oxygen and bronchodilators.
• Decontamination requires clothing removal and skin flushing with water, rapid transport is essential

Radiological/Nuclear Agents

• Radiological/nuclear attacks expose victims to radiation, causing acute radiation syndrome (ARS), burns, and long-term cancer risks.
• Dirty bombs and nuclear reactor incidents cause nausea, vomiting, burns, and pancytopenia.
• Treatment involves decontamination, potassium iodide, and supportive care.
• Limit exposure through time, distance, and shielding.
• Remove clothing and wash with soap/water as part of decontamination.
• Monitor for ARS, as symptoms progress over hours to days.

Explosive and Incendiary Devices

• Explosives cause blast injuries, including blunt trauma, burns, and penetrating wounds.
• Primary Blast Injury: Shockwave causes lung injury (blast lung), eardrum rupture, and bowel perforation.
• Secondary Blast Injury: Shrapnel and debris cause lacerations, fractures, and amputations.
• Tertiary Blast Injury: Body displacement causes blunt trauma and spinal injuries.
• Quaternary Blast Injury: Burns, asphyxiation, and toxic inhalation cause thermal and crush injuries.
• Expect multiple casualties.
• Beware of secondary devices.
• Rapid trauma care involves controlling hemorrhage and providing airway support and transport.

EMS Response and Triage in Terrorist Incidents

• Mass casualty incidents (MCIs) use triage to prioritize treatment.
• Immediate (Red): Respiratory distress, major bleeding, severe burns require immediate attention (high priority).
• Delayed (Yellow): Moderate injuries and closed fractures require delayed treatment (medium priority).
• Minor (Green): Walking wounded and minor cuts require minimal treatment (low priority).
• Expectant (Black): Cardiac arrest and massive head trauma receive no treatment.

START Triage

• Simple Triage and Rapid Treatment:
  • If the patient can walk, they are triaged as Green.
  • If the patient is not breathing, attempt to reposition the airway; if still not breathing, triage as Black

START Triage Continued

• Respiratory Rate >30? Red
• Radial Pulse Absent? → Red
• Unable to follow commands? → Red

Personal Protective Equipment (PPE) and Decontamination

• Proper PPE minimizes responder risk.
• Level A: Fully encapsulated, self-contained breathing apparatus (SCBA) - Highest protection.
• Level B: Non-encapsulated, SCBA - High respiratory protection.
• Level C: Air-purifying respirator (APR), splash protection.
• Level D: Standard PPE (gloves, eye protection).

Decontamination Steps

• Remove clothing (reduces contamination by 80-90%).
• Rinse skin with water/soap.
• Use decon corridors before hospital transport.

Conclusion

• Vigilance in identifying terrorist events, prioritizing scene safety, and delivering effective medical care is crucial for EMS responders.
• Awareness of CBRNE agents, appropriate PPE use, and adherence to ICS protocols ensures an organized and safe response.