Florida Heart cpr* Terrorism 1 hour

Emergency Medical Services (EMS) often co-manage initial scenes in many medium- to large-scale incidents involving large numbers of casualties. Occasionally, EMS also manages the scene until state or federal agencies arrive. The tragic events of September 11, 2001 underscore the importance of EMS planning and anticipating such events.

Many authorities consider the United States a continuing high-profile target. For all Americans, the attack on the World Trade Center on September 11, 2001, brought home the tragic realization that America is not immune to terrorism. Philip Stern, an expert on terrorism with the Fairfax Group, said, "As an open society and a democracy, this country is particularly vulnerable. We have free passage, coast-to-coast, anyone can apply for a visa to visit and the population is enormous and diversified."

Some feel that such an inviting atmosphere makes terrorist activities inevitable. Many of the terrorist groups of today appear more and more likely to use weapons of mass destruction. Perhaps even more disturbing is the belief that terrorists are leaning toward the use of more technologically advanced weapons and communications. Access to the Internet and information on the World Wide Web facilitates tremendous technological advancement in destructive potential.

All of these issues underscore the importance of proper education in EMS and advance planning. Terrorist activity may have various mechanisms, including chemical or biological weapons and explosives, as well as new methods of destruction. Full response to a terrorist incident requires in-depth interagency planning involving police; fire; EMS; regional, state, and national emergency organizations; as well as a wide array of ancillary services. Assign each agency respective roles as soon as possible, well in advance of potential terrorist acts.

ASPECTS OF TERRORISM

Determining the actual extent of the terrorist threat in the United States is difficult, as it is poorly defined and rapidly changing. James Alan Fox, Dean of Northeastern University's Criminal Justice Program in Boston, believes the 2 current motivations for terrorism are revenge and attention.

Several terrorist incidents in the United States highlight the lethal nature of terrorist acts: the World Trade Center attacks and bombing, the Atlanta Olympic bombing, and the Oklahoma Federal Building bombing.

All Americans remember the tragic events of September 11, 2001. However, not all remember the World Trade Center bombing in 1993, which killed 6 people and injured more than 1000. In April 1995, the Federal Building in Oklahoma City was bombed, killing 168 people. A pipe bomb was detonated in Centennial Park during the 1996 Olympic Games in Atlanta, Georgia, killing 2 people and wounding more than 100. Such events emphasize the potential loss of life and property caused by terrorist activities.

PREPLANNING

Effective response to a terrorist incident hinges on comprehensive planning and interagency cooperation. Address and resolve jurisdictional issues well in advance. After a plan has been devised, update it regularly to reflect changes in resources, population, terrorist activities, or potential targets. Local police, fire, EMS, and Disaster & Emergency Services (DES) agencies should form the first line of response. Other agencies that may be involved include the following:

• 
  Secret Service
  
• 
  Bureau of Alcohol, Tobacco, and Firearms (BATF)
  
• 
  State disaster agencies
  
• 
  Military or reserve units
  
• 
  Specialized medical units
  

An act of terrorism in a metropolitan area may cause major health and medical consequences that could rapidly overwhelm virtually all local health facilities; thus, ongoing contact with state and national agencies is recommended highly. The Federal Bureau of Investigation (FBI) is the federally designated lead agency in a confirmed domestic terrorist event. Depending on location, however, some federal agencies may not be on-site for 24 hours or more.

On a national level, the US Government has established the National Disaster Medical System (NMDS). This organization assists in providing medical care and transportation for disaster victims. The NDMS comprises sections of the Department of Health and Human Resources, the Department of Veterans Affairs, the Department of Defense, and the Federal Emergency Management Agency (FEMA). Any state can enlist the services of NDMS, which provides assistance at the disaster site, evacuates patients, and finds beds for evacuated patients. Congress also has established a Domestic Preparedness Program that provides enhanced training for local first responders and forms metropolitan medical strike teams in major cities.

In evaluating sites of potential terrorist activity, consider the release of chemical or biological agents into crowded and contained areas, such as sports stadiums, office or public buildings, and transportation systems (eg, the Tokyo subway Sarin incident). Such places provide tempting targets despite on-site security. Rapid identification of the chemical or biological agent is critical to proper disposition of patients and to management of affected areas. Disasters of human agency, particularly involving hazardous materials (HAZMAT), radioactive materials, or chemical agents, may produce unfamiliar medical problems that cannot be identified rapidly in readily available emergency medicine (EM) literature. Utilize all possible resources early in the incident to ensure proper identification of the agent and prompt initiation of proper protocols.

INCIDENT MANAGEMENT

Most of the principles of incident management are similar to those of mass casualty incidents. Primary concern in potential terrorist incidents is to secure the area and to ascertain the severity and nature of the threat. Keep in mind that delayed explosives or materials intended to harm rescue workers may have been planted at the site. Primary and secondary perimeters must be established and secured. Determine if a cleared, downwind perimeter is needed, and establish one if required.

Early involvement of support and ancillary services, mutual aid agencies, and local agencies in the planning process is prudent. After identifying the potential threat, determine which type of protective equipment is necessary. Emphasis must be placed on decontamination and protection of rescuers and victims.

After establishing a decontamination and triage area, rescuers should put on appropriate protective clothing before entering the affected area and beginning rescue efforts. The first focus is on supportive care with emphasis on aggressive airway control and decontamination. Issues associated with simultaneous containment, neutralization, and/or decontamination may be addressed by ancillary agencies. Following initial triage, patients are given primary or aggressive aid depending on their presentation and the resources available. Decontaminate and transport patients to a facility that has been informed about the etiology of the incident as soon as feasible. Secure and clean the area to complete the physical response. Record keeping, analysis of the incident, and investigations conclude the complete response.

An explosive is a normally stable material that, when introduced into a chemical reaction, converts rapidly from a solid or liquid to an expanding gas. Explosives are categorized as either low grade or high grade. Low-grade explosives burn quite rapidly. Black powder, the original low-grade explosive, served as the basis for development of smokeless gunpowder and some rocket propellants. Other examples of low-grade explosives are nitrostarch, nitrocellulose, and commercial fireworks.

High-grade explosives, also termed "detonating explosives," are more stable than low-grade explosives, frequently requiring trauma or shock for detonation. Nitroglycerin is the original high-grade explosive. Ammonium nitrate is another example of the early types of detonating explosives. Composition B, C-3, C-4, and TNT were developed later. Other examples include Amatol 80/20, RDX, PETN, and dynamite. Initiating high-grade explosives are a separate class of very sensitive high-grade explosives, such as lead styphnate and lead azide.

The Unabomber, known for constructing and using pipe bombs, is an example of a terrorist who targeted specific victims. The pipe bomb is easy to construct using readily available components and published step-by-step instructions. The Unabomber was very careful in his choice of components used to assemble bombs, complicating the search for his identity.

Chemical agents were first used extensively in World War I with dramatic results against unprepared troops. Although far less lethal than conventional explosives, chemical weapons can affect and incapacitate large numbers of troops in a short time. Chemical warfare agents were defined by the United Nations in 1969 as "chemical substances, whether gaseous, liquid or solid, which may be employed because of their direct toxic effects on man, animals, or plants." The ready availability of precursors of modern chemical weapons and copious documentation on their preparation make the use of chemical weapons for terrorist actions far more likely than use of nuclear or biological weapons. In addition, potential terrorists could easily locate a chemical production facility, sabotage it using chemical or conventional explosives, and allow ambient winds to spread the toxins. The resultant environmental contamination would fulfill many terrorists' objectives of generating fear, trepidation, and panic among the population.

Chemical agents are separated into 2 broad categories, lethal and nonlethal. Lethal agents include cyanides, nerve agents, vesicants, and choking agents. Nonlethal agents include lacrimating, emesis-inducing, and incapacitating agents.

Lethal chemical agents

Cyanide compounds

Although they have been used since World War I, cyanide compounds are highly volatile, rendering them less useful than chlorine. The military designates hydrogen cyanide (AC) and cyanogen chloride (CK) as the substances used in warfare. Cyanide and its compounds are among the most rapidly acting chemical agents. Signs and symptoms include air hunger, hyperpnea, apnea, seizures, coma, and death. Cyanide poisoning is treated with a combination of nitrites and thiosulfates available in commercial kits. Protective masks, gowns, and gloves are necessary until the patient is decontaminated completely.

Nerve agents are chemicals that inhibit acetylcholinesterase irreversibly. They combine with acetylcholine (ACH) to prevent transmission at the neuromuscular junction and affect both the sympathetic and parasympathetic nervous systems. Salivation, lacrimation, urination, defecation, and emesis (SLUDGE) are common signs. Muscarinic effects may cause the most serious complications, including bronchoconstriction, laryngospasm, and respiratory depression or arrest. These nerve agents may be delivered by droplet, vapor, or both. Symptoms of skin exposure appear much more slowly than those from inhalation. Onset of symptoms varies from 1 minute to a few hours. If cyanide compounds are inhaled or absorbed through the mucus membranes, death can occur in 1-10 minutes.

Therapy includes atropine sulfate, with as much as 10-40 mg required in some instances. Currently, the US Army uses 2-PAM (pralidoxime chloride), although it is not completely effective. It is least effective against Soman (GD). Pretreatment with pyridostigmine competitively inhibits the nerve agent. Pyridostigmine combines reversibly with ACH, which can resume neurotransmission after disassociation. However, such pretreatment does not protect against seizures.

Current nerve agents include Tabun (GA), Sarin (GB), Soman (GD), and VX. Local decontamination of these agents includes washing with soap and water. Health care providers should wear full protective gear until the patient is cleared by an environmental health specialist. VX, considered the most toxic of the nerve agents, is also the most difficult to decontaminate because of its low volatility.

Causing pronounced irritation to the upper and lower respiratory tracts, these agents are potentially dangerous because of a period of latency. A victim with dyspnea and mild chest discomfort may deteriorate after several hours to apnea and subsequent death. Chlorine is a widely used chemical that falls into the choking agent class. Chlorine causes upper- and lower-respiratory irritation, lacrimation, chest pain, dyspnea, coughing, laryngeal edema, pulmonary damage, and pulmonary edema.

Treatment is symptomatic with nebulized sodium bicarbonate. Decontaminate by copious flushing of affected areas with water. Medical providers need no special protection from chlorine-exposed patients.

Vesicant agents

Vesicant agents, also termed blistering agents, may be toxic to the lungs, eyes, and mucous membranes. They are named for their tendency to cause blisters. Mustard gas is the best-known vesicant, originally used in World War I. It is a primary tissue irritant and has no significant allergenic component. Lesions are primarily cutaneous, but respiratory, ocular, and GI manifestations may occur, as well as cough, bloody sputum, and dyspnea. Areas of exposure become erythematous and progress to bullae, similar to toxic epidermal necrolysis. Symptoms may not occur for several hours after exposure. No antidote is available.

Other vesicants include sulfur mustard (HD), nitrogen mustard (HN), agent T, and phosgene oxime (CX). Lewisite, unlike mustard and mustard derivatives, causes immediate pain and skin irritation.

Medical providers require protective masks and clothing for patient management. Decontaminate by blotting and cleansing with soap and water. Avoid scrubbing and hot water.

Lacrimator agents (tear gases) are widely used by law enforcement and the military. The most common effects are nasal and ocular discharges, photophobia, and burning sensations in the mucous membranes. Prolonged exposure may produce tightness in the chest, shortness of breath, and malaise and may cause vesiculations or bullae. Physical injuries may be observed from explosive discharge or kinetic effects of projectiles. At least 1 death has been attributed to lacrimator agents.

Most patients can be decontaminated fully by undressing, showering, and washing with soap and water. Medical personnel should use protective masks, gowns, and gloves, since lacrimator agents are transmitted by physical contact.

Types of lacrimator agents include bromobenzyl cyanide (CA), ortho-chlorobenzylidenemalonitrile (CS), dibenoxazepine (CR), 2-chloroacetophenone (CN), chloroacetophenone in chloroform (CNC), and chloroacetophenone and chloropicrin in chloroform (CNS).

Emesis agents, also termed nausea gases, are not used routinely in the United States. They produce respiratory and skin irritation effects similar to those of lacrimator agents, as well as profound nausea. Examples of such compounds include adamsite (DM), diphenylcyanoarsine (DC), and diphenylchloroarsinine (DA).

No decontamination is required in the field, and diluted bleach solution has proven effective for definitive cleaning. Ordinary clothing protects against these agents; chemical insert masks and standard gloves are adequate.

Incapacitating agents

The possibility of a nonlethal incapacitating agent has long intrigued military commanders. Several agents have been tested, including lysergic acid diethylamide (LSD), mescaline, psilocybin, and psilocin. The only successful agent in production is benzilate (BZ).

BZ is a delayed onset (1-4 h) agent causing tachycardia, dizziness, vomiting, blurred vision, stupor, confusion, and random activity. Affected persons may be docile, belligerent, stuporous, or confused. They may appear intoxicated.

Decontaminate by washing with soap and water or with dilute bleach solution. Protective masks with charcoal filters provide adequate protection. Gloves are not necessary, since the agent is not absorbed through the skin.

The Biological and Toxin Weapons Convention of 1972 banned the development, production, and stockpiling of biological weapons not required for peaceful intentions. The United States, United Kingdom, Soviet Union, and 67 other nations signed this document. Despite the fact that no biological agents have been used officially in warfare to date, the prospect of their use raises many concerns. Terrorism's history suggests the potential for the use of biological agents. Many authorities fear the use of biological agents more than the use of chemical agents, since antidotes and specific countermeasures are available for some chemical weapons. Use of biological agents in terrorist acts potentially could cause tens of thousands of casualties and cost the US economy billions of dollars.

Caused by Bacillus anthracis, anthrax causes a necrotizing hemorrhagic mediastinitis. Death usually occurs in 24-36 hours. Standard precautions, including masks, gowns, gloves, and isolation, are sufficient. Vaccine is available.

Highly infectious Brucella species are less commonly fatal than anthrax. Fever, malaise, osteomyelitis, and genitourinary (GU) infections may occur. Endocarditis typically is the cause of death. Standard precautions are sufficient. Include precautions against direct contact if draining lesions are present.

Venezuelan, Eastern, and Western equine encephalitis viruses are likely to be used in weapons. Fever, headache, confusion, obtundation, dysphasia, seizures, paresis, and death may be observed. The Eastern variety has the highest mortality rate at 50-75%. A vaccine for Venezuelan equine encephalitis (VEE) is available, and effective vaccines for the others are currently in development. Standard precautions are sufficient; however, mosquito control is suggested, since mosquitoes are a vector.

An epidemic of descending and progressive bulbar and skeletal paralysis in afebrile patients may suggest botulinum poisoning. Respiratory failure is the most frequent cause of death. Since an antitoxin is available, standard precautions are sufficient.

Plague usually manifests as pneumonia, culminating in respiratory failure and shock. A vaccine is available, yet precautions are required against pulmonary and droplet exposure.

A zoonotic disease with domestic livestock as vectors, Q fever varies in its manifestations. Fever, chills, and headache are the most common symptoms, although malaise, diaphoresis, and myalgia often are observed. Mortality rate is low, even when the disease is untreated. A vaccine is under investigation. Standard precautions are sufficient.

A hemorrhagic virus infection, Rift valley fever manifests with symptoms such as malaise, fever, prostration, generalized vascular permeability, and abnormal circulatory regulation. Several different varieties of hemorrhagic viruses are documented, including Ebola. Most are highly infectious and cause morbidity. Some carry high mortality rates. Depending on the strain, a vaccine may be available. Precautions against direct contact are recommended. Additional precautions may be necessary if massive hemorrhage is present.

Smallpox may be a viable biological weapon, since the last natural case occurred in 1977 and the smallpox vaccine no longer is produced. Aerosol exposure causes viremia, malaise, fever, headache, delirium, and prolonged rash. Morbidity is caused primarily by secondary bacterial pneumonia. Precautions against aerosol infection are necessary.

Tularemia, a zoonotic disease, occurs in ulceroglandular or typhoidal form. Typhoidal form manifests as fever, prostration, and respiratory symptoms. Mortality rate in typhoidal tularemia is approximately 35%. Standard precautions are sufficient. A vaccine is available as an investigational drug.

Allergic agents come from a variety of sources, including mite and insect particles, feathers, epithelium, hair, urine, feces, and powdered enzymes. Problems caused by these agents may include respiratory symptoms, conjunctivitis, and/or dermatitis.

Responding to a terrorist event can represent a tremendous drain on resources for all agencies involved. The potential for death and destruction is tremendous. Agencies responsible for responding to terrorist events can reduce potential injury, illness, and death only through complete and ongoing planning.

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1. 
   Effective response to a terrorist incident hinges on
   

1. 
   Comprehensive planning
   
2. 
   Interagency cooperation
   
3. 
   Prior knowledge
   
4. 
   A and B
   

2. 
   The first line of response should be formed by:
   

1. 
   Local police
   
2. 
   Disaster and Emergency Services
   
3. 
   EMS
   
4. 
   All of the above
   

3. 
   The _______ is the federally designated lead agency in a confirmed domestic terrorist event.
   

1. 
   CIA
   
2. 
   FBI
   
3. 
   NSA
   
4. 
   FEMA
   

4. 
   Primary concern in potential terrorist incidents is to
   

1. 
   Secure the area
   
2. 
   Evacuate potential victims
   
3. 
   Ascertain the severity and nature of the threat
   
4. 
   A and C
   

5. 
   After establishing ________, rescuers should put on appropriate protective clothing before entering the affected area and beginning rescue efforts.
   

1. 
   A secure perimeter
   
2. 
   Killing the terrorist
   
3. 
   A decontamination and triage area
   
4. 
   A and B
   

6. 
   Lethal chemical agents include choking agents and:
   

1. 
   Cyanides
   
2. 
   Nerve agents
   
3. 
   Vesicants
   
4. 
   All of the above
   

7. 
   Nonlethal chemical agents include
   

1. 
   Lacrimating agents
   
2. 
   Emesis-inducing agents
   
3. 
   Incapacitating agents
   
4. 
   All of the above
   

8. 
   The ________ of 1972 banned the development, production, and stockpiling of biological weapons not required for peaceful intentions. The United States, United Kingdom, Soviet Union, and 67 other nations signed this document.
   

1. 
   Biological Weapons Treaty
   
2. 
   Chemical Warfare Act
   
3. 
   Toxic Weapons Agreement
   
4. 
   Biological and Toxin Weapons Convention
   

9. 
   The list of infectious agents is incredibly extensive and includes:
   

1. 
   Viruses and bacteria
   
2. 
   Protozoa
   
3. 
   Fungi
   
4. 
   All of the above
   

10. 
    Responding to a terrorist event can represent a tremendous drain on resources for all agencies involved. The potential for death and destruction is tremendous. Agencies responsible for responding to terrorist events can reduce potential injury, illness, and death only
    

1. 
   Through open communication
   
2. 
   Through complete and ongoing planning
   
3. 
   With extensive funding
   
4. 
   Government programs