Terrorism: A First Responders Overview

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Terrorism A First Responders Overview

• Presented By Bill Milan NREMT-P, CCEMTP

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Terrorism

• An Act intended to create fear and/or Intimidate
  governments or societies in the pursuit of
  political, religious, or ideological ideas.

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How real is the Threat?

• Here are some cases of terrorist attacks that
  have occurred in recent history

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Salmonella in Salad Bars The Dalles, Oregon, 1984

• Most significant biological attack in U.S.
• Salmonella sprayed on 8 local salad bars
• 751 citizens affected
• Attempt to manipulate local election

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February 26th 1993

• 2nd level Parking structure of World Trade Center
• 6 people Dead and injuring thousands
• Blast caused a hole 150 feet in diameter and five
  floors deep

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April 19th 1995

• Murrah Federal Building, Oklahoma City, Oklahoma
• 168 people dead and thousands injured

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March 20th 1995

• Tokyo, Japan Sarin gas attack in subway
• 11 people dead about 5,500 injured

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September 11th 2001

• World Trade Center hit by two planes, Pentagon
  hit by one plane, Another hijacked plane went
  down in Pennsylvania
• Worst Terror attack on American soil

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Now we see the Threat is real!

• So now we have to educate the 1st responders to
  some of the treats that we face as responders.

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Who are the 1st Responders?

• Primary Care Personnel
• Hospital ER Staff
• EMS Personnel
• Public Health Professionals
• Fire Department Personnel
• Law Enforcement
• Other Emergency Preparedness Personnel

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Education is the KEY!
"Education will never become as expensive as
ignorance." Anonymous
Try? There is no "try." There is only "do." Yoda
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Acronym for Terrorism Attacks

• B-NICE
• Biological
• Nuclear
• Incineration
• Chemical
• Explosives

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Bioterrorism
The unlawful use, or threatened use, of
microorganisms or toxins derived from living
organisms to produce death or disease in humans,
animals, or plants.
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Biological Agents of Highest Concern

• Variola major (Smallpox)
• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Francisella tularensis (Tularemia)
• Botulinum toxin (Botulism)
• Filoviruses and Arenaviruses (Viral hemorrhagic
  fevers)
• ALL suspected or confirmed cases should be
  reported to health authorities immediately

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Smallpox

• Malaise
• Fever
• Cough
• Nausea/Vomiting
• Backache
• Hemorrhagic Pox Rash

• Released as Aerosol and spread person to person
  by droplets
• Incubation 12-14 days
• Contagious for first week but still can spread
  till all scabs fall off
• Mortality 30

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Smallpox
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Protective Measures For Smallpox

• Not only is this spread by respiratory but also
  oral secretions and drainage from lesions, so
  strict protective measure must be taken with
  negative pressure room and high efficiency air
  filtration.
• Anyone in contact with these patients must be
  vaccinated.
• Observation of strict contact isolation with
  limited pt interaction.

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Anthrax

• A spore forming bacterium

It has 3 different routes of manifestation Cutane
ous - spore into broken skin Gastrointestinal-
from consumption of raw contaminated meat.
Inhalation - through the respiratory tract.
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Anthrax
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Cutaneous Anthrax

• gt 95 of naturally occurring cases
• Spores enters skin thru break in skin
• Incubation 1-2 days
• Up to 20 fatality rate if untreated
• Mortality rate lt1 with treatment

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Cutaneous Anthrax
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Inhalation Anthrax

• Most likely Bioterrorism form
• Incubation period 1-6 days may be as high as 60
  days
• Non-specific symptoms
• Malaise, fever, fatigue, cough, chest discomfort
• Terminal phase
• Dyspnea, Stridor, Cyanosis, Increased Chest
  discomfort, Chest Wall Edema, Shock, and death
  within 24-36 hours.
• Meningitis seen in up to 50 of cases

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Inhalation Anthrax
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Gastrointestinal Anthrax

• Ingestion of insufficiently cooked meat from
  infected animals
• Nausea, Vomiting, Fever, Diarrhea Abdominal Pain
• Mortality may exceed 50 despite treatment

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Gastrointestinal Anthrax
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Clinical Progression of Anthrax
Respiratory Distress Stridor, Cyanosis
Chest/Neck Edema
Exposure
DAYS
1
3
4
5
2
Meningitis Respiratory Failure Shock, Death
Fever Fatigue
Myalgia Malaise
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The Anthrax we remember
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The Plaque

• Is classified into 3 catagories Pneumonic,
  Bubonic, Septicemic
• Very Highly Contagious
• Incubation Period 1-6 days
• Untreated Septicemic and Pneumonic plague are
  always fatal

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Pneumonic Plague

• Most likely form of Bioterrorism
• Inhaled from an aerosol cloud and with human to
  human contact thru respiratory contact
• Cough, fever, Extreme weakness, Glandular
  swelling, Pneumonia, Hemorrhages of skin and
  mucous membranes, Collapse
• Requires respiratory isolation for 48 hours
• Mortality 80-90

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Bubonic Plague

• Classic Transmission
• RatgtFleagtMan
• Rapidly Enlarging Lymph nodes( groin, axilla,
  neck) with drainage at area of bite and
  occasionally meningitis
• Mortality 40-70

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Septicemic Plague

• Transmission same as pneumonic plague
• G.I. Symptoms, Spreading to CNS, Respiratory
  System to include ARDS
• Mortality 100

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Tularemia(Rabbit Fever, Deer Fly Fever)

• Transmitted by contact with infected animals or
  bites of infected deerflies, mosquitoes, or ticks
• Viable for weeks in water, soil, carcasses,hides
• Has remained for years in frozen rabbit meat
• Incubation Range 1-14 days
• Fever, Chills, Headache, Malaise
• Ulceroglandular local ulcer, and regional
  lymphadenopathy
• Typhoidal fever, substernal discomfort, weight
  loss, non-productive cough

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Botulinum Toxin

• Most potent lethal substance known to man (Lethal
  dose 1ng/kg)
• Can be contracted by foodborne (poorly packed or
  infected food) or by aerosol
• Symptoms begin 12-36 hours after ingestion and
  24-27 hours after inhalation
• Droopy eyelids, Dry Mouth and Throat, Difficulty
  Talking and Swallowing, Blurred and Double
  Vision, Flaccid Paralysis, Difficulty Breathing,
  Asphyxia
• Will remain stable for weeks in non-moving water
  or food

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Viral Hemorrhagic Fever

• Caused by several different viruses
  Filoviridae(Ebola,Marburg), Arenaviridae
  (Lassa,New World Arenaviridae), Bunyaviridae
  (Crimean-Congo hemorrhagic fever, Rift Valley
  fever) Flaviviridae(Dengue, Yellow Fever, Omsk
  Hemorrhagic Fever, Kyasanur Forest Fever
• Incubation 4-21 days
• Spread via respiratory portal of entry

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Viral Hemorrhagic Fever

• Early Signs severe febrile illness, decreased
  blood pressure, postural hypotension, petechiae,
  easy bleeding, flushing of face and chest,
  non-dependant edema
• Late Signs Headache, photophobia, pharyngitis,
  cough, nausea, vomiting, diarrhea, abdominal
  pain, G.I. bleeding, dizziness, confusion,
  tremor, malaise
• 25 fatality rate

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Nuclear Incidents

• One type is a dirty bomb a explosive bomb that
  has radioactive material in it such as Cesium,
  Cobalt, Iodine, Phosphorous, Strontium
• Three types of Nuclear Radiation (Alpha, Beta,
  Gamma)
• Alpha- Large heavy particles that can be stopped
  by a piece of paper
• Beta- Smaller and can travel faster can be
  stopped by skin but long term exposure can cause
  burns
• Gamma- Are pure energy and can penetrate body and
  attack tissues and organs need at least lead to
  stop
• Radiation sickness includes skin irritation,
  nausea, vomiting, high fever, hair loss, dermal
  burns

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Incendiary Incidents

• Any mechanical, electrical, or chemical device
  used intentionally to initiate combustion and
  start a fire
• Consists of three basic components An igniter or
  fuse, A container or body, And an incendiary
  material of filler
• These devices can be used singularly or in
  combinations
• If they are found only trained personnel should
  handle these devices.

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Chemical Incidents

• These fall into 5 different classes
• Nerve Agents- Disrupt nerve impulse transmissions
• Blister Agents- Also called vesicants, which
  cause severe burns to eyes, skin, and tissues of
  the respiratory tract
• Blood agents- Interfere with the ability of blood
  to transport oxygen
• Chocking agents- Severely stress respiratory
  system tissue
• Irritating agents- Cause respiratory distress and
  tearing designed to incapacitate( e.g. riot
  control agents)

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Nerve Agents

• Similar to organophosphate pesticides, but with
  higher degree of toxicity
• Common agents include Sarin(GB), Soman(GD),
  Tuban(GA), and V agent(VX)
• These patients will show signs of Organophosphate
  poisonings(SLUDGE)
• Salivation, Lacrimation, Urination, Defication,
  Gastorintestinal irritation, Emisis

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Nerve Agents

• Other symptoms include
  
• Eyes- pinpoint pupils, dimmed and blurred vision,
  pain aggravated by sunlight
• Skin- excessive sweating and fine muscle tremors
• Muscles- involuntary twitching and contractions
• Respiratory System Runny nose, nasal congestion,
  chest pressure and congestion, coughing and
  difficulty in breathing
• Digestive System- Excessive salivation, abdominal
  pain, nausea and vomiting, involuntary defecation
  and urination
• Nervous System- Giddiness, anxiety, difficulty in
  thinking and sleeping

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Blister Agents

• Referred to as Mustard agents due to smell
• Mustard(H, HD) and Lewisite(L) are common blister
  agents
• Blister agents are oily liquids that are
  dispersed by aerosol or vaporization
• Have a smell of mustard, garlic, or onions
• Outward signs of blister agents include eyes and
  respiratory irritation

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Blister Agents

• Eyes- reddening, congestion, tearing, burning,
  and a gritty feeling, swelling of eyelids,
  severe pain and spasm of eyelids
• Skin- within 1-12 hour, mild itching followed by
  redness, tenderness, and burning pain, followed
  by burns and fluid-filled blisters. The effects
  are enhanced in warm, moist areas such as groin
  and armpits
• Respiratory- within 2-12 hours, burning sensation
  in the nose and throat, hoarseness, profusely
  running nose, severe cough and respiratory
  distress
• Digestive- within 2-3 hours, abdominal pain,
  nausea, blood-stained vomiting, and bloody
  diarrhea

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Blood Agents

• Agents that interfere with transportation of
  oxygen causing asphyxiation
• Common blood agents include Hydrogen
  Cyanide(AC), Cyanogen chloride(CK)
• Cyanide and its compounds are common industrial
  chemicals
• They have the smell of bitter almonds or peach
  blossoms
• CK can cause tearing and irritation of lungs
• Blood agents sometimes cause Respiratory
  distress, vomiting and diarrhea, vertigo and
  headaches

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Chocking Agents

• Stress the respiratory tract which sometimes may
  cause pulmonary edema
• Chlorine and phosgene(CG) are common chocking
  agents
• Phosgene has the smell of newly cut hay
• Common clinical symptoms include eye irritation,
  and respiratory distress

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Irritating Agents

• Also know as riot control agents or tear gas
• These agents can cause pain, sometimes severe, on
  the skin especially in moist areas
• Most people complain of smell of pepper or gas
• Primary route of exposure is inhalation but can
  be absorbed thru skin
• Common irritating agents include Chloropicrin,
  MACE(CN), tear gas(CS), capsicum/pepper spray,
  and dibenzoxazepine(CR)

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Irritating Agents

• Eyes and Throat- burning or irritation, tearing
  of eyes
• Respiratory system- respiratory distress,
  coughing, chocking
• Digestive system- High concentrations may cause
  nausea and vomiting

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Explosive Incidents

• Any substance used to create and explosion(rapid
  release of gas and heat)
• 70 of all terrorist attacks include the use of
  explosives devices
• Only about 4 of terrorist explosions have a
  warning or threat preceding
• In most cases a secondary explosion is set to
  ignite when all emergency workers have had time
  to respond to increase injury toll

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Now I hope you have a little better understanding
of terrorism

• Just Remember YOUR SAFETY IS PARAMOUNT

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Questions?

• Thank you for the opportunity to make this
  presentation
• Hope it helps you to better understand terrorism