1. Response to Terrorism

2. Terrorism Definition A violent act dangerous to human life, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives

3. Domestic Terrorism Directed at government or a population, without foreign direction Often fragmented and leaderless

4. International Terrorism Foreign based Activities cross national boundaries Often religious or politically motivated

5. Types of Terrorism Armed attacks Chemical Biological Radiological Nuclear Explosive Weapons of Mass Destruction

6. September 11, 2001

7. Safety Always remember that responders may be targets of terrorism. Never compromise your own safety during an incident.

8. Responders may be targets. Consider the possibility of secondary devices/events. Utilize SOPs & protocols. Never compromise your own safety.

9. Responder Considerations Identifying the possible threats posed by the event Recognizing the possible harms posed by the event Identifying protection measures based on the possible threats and harms

10. Identify Threat Posed by the Event Occupancy/Location Type of Event Timing of Event On-Scene Warning Signs “OTTO”

11. Occupancy/Location Symbolic/Historic Targets White House IRS offices Public buildings & assembly areas Shopping malls Convention centers

12. Occupancy/Location Controversial businesses Nuclear facilities Family planning offices Infrastructure systems Power plants Hospitals

13. Type of Event Explosions/incendiaries Incidents involving firearms Non-trauma MCIs

14. Timing of Event National holidays Anniversaries of other terrorist events

15. On-Scene Warning Signs Unexplained patterns of illness Chemical containers Unusual items at locations Fires of unusual behavior

16. Recognize the Harms Posed by the Threat Thermal Harm Extreme heat or cold Radiological Harm Nuclear particles “TRACEM-P” Continued…

17. Recognize the Harms Posed by the Threat

18. Recognize the Harms Posed by the Threat Asphyxiation Lack of oxygen in environment Chemical Harm Toxic or corrosive materials “TRACEM-P” Continued…

19. Recognize the Harms Posed by the Threat Etiological Harm Disease causing organisms Mechanical Harm Physical trauma “TRACEM-P” Continued…

20. Recognize the Harms Posed by the Threat Psychological Harm Creation of fear and panic “TRACEM-P”

21. Possible Protection Measures Time Distance Shielding

22. Responses to Chemical Incidents Hazardous Materials Industrial Waste Warfare Agents Inhaled Ingested Absorbed Injected That may be:

23. Specific Types of Harm from Chemical Incidents Thermal Flammability/heat from reactions Asphyxiation Reactions that displace oxygen Chemical Systemic to cardiac, nervous, & respiratory systems

24. Specific Types of Harm from Chemical Incidents Mechanical Corrosives weaken structures Psychological Emotional reaction to exposure

25. Self Protection at Chemical Incidents Be cautious of secondary devices. Ensure victims are not the bomber.

26. Responses to Biological Incidents May be a focused emergency or a public health emergency. Focused emergencies have a point of origin, minimizing spread. Continued…

27. Responses to Biological Incidents Public health emergencies have a sudden demand on public health with no apparent explanation.

28. Agents of Biological Incidents Bacteria Viruses Toxins

29. Exposure The dose or concentration multiplied by time (duration of exposure).

30. Four Biological Agent Routes of Entry 1. Absorption Skin contact 2. Ingestion Through mouth

31. Four Biological Agent Routes of Entry 3. Injection Needles or projectiles 4. Inhalation By breathing

32. Contamination Contact with or presence of a contaminant, which is material that is present where it does not belong and that is somehow harmful to persons, animals, or the environment

33. Exposure vs. Contamination Contamination Substance clings to body or clothing. Exposure Substance enters body through one of the routes of exposure.

34. Specific Types of Harm from Biological Incidents Etiological Poisonous hazardous materials Chemical Secondary events

35. Specific Types of Harm from Biological Incidents Mechanical Secondary events Psychological Emotional reaction to exposure

36. Self-Protection at Biological Incidents Use personal protective equipment. Limit exposure time. Use buddy system/RIT team.

37. Responses to Radiological Incidents Unlikely to occur May be in the form of an explosive device Difficult to initially detect

38. Specific Types of Harm from Radiological Incidents Thermal Nuclear explosion Radiological Ongoing, varies with substance Chemical Many substances are also chemical hazards Continued…

39. Specific Types of Harm from Radiological Incidents Mechanical Nuclear explosion Psychological Emotional reaction to exposure

40. Self-Protection at Radiological Incidents Use time/distance/shielding. Use decontamination procedures.

41. Responses to Explosive Incidents Vary in size from pipe bomb to car bombs May have suicide bombers May contain chemical or biological agents Most frequent weapon used by terrorists

42. Specific Types of Harm from Explosive Incidents Thermal Heat from detonation Asphyxiation Dusty conditions Chemical & Radiological If present in the device Continued…

43. Specific Types of Harm from Explosive Incidents Mechanical Shockwaves and fragmentation Etiological If biological agents present Psychological Stunned response

44. Self-Protection at Explosive Incidents Be cautious of secondary devices. Ensure victims are not the bomber.

45. Methods of Dissemination of Agents Respiratory/Inhalation Most effective method Ingestion Effectiveness Continued…

46. Methods of Dissemination of Agents Dermal Some agents effective this way, others prevented by logistics/ immunization

47. Weaponization Use of sprayers to disseminate Use of explosives to disseminate

48. Dissemination of Agents

49. Chemical Agent Considerations Physical Considerations Extremely varied Must be gaseous, liquid, or solid Volatility May evaporate quickly

50. Chemical Agent Considerations Chemical Reactivity & stability vary Toxicological Variety of factors influence sensitivity

51. Classification of Chemical Agents Choking agents Vessicating agents (blister agents) Cyanides Nerve agents Riot control agents

52. Classification of Biological Agents Bacterium Can live outside host cell Virus Cannot survive outside of host cell Toxin Poisonous chemical compound

53. Biological Agent Weapon Considerations Infectivity Virulence Toxicity Incubation period Continued…

54. Biological Agent Weapon Considerations Transmissibility Lethality Stability

55. Classification of Biological Agents Infectivity Ease in invading host cell Virulence Severity of disease produced Toxicity Severity of illness from toxin Continued…

56. Classification of Biological Agents Incubation period Time between exposure & symptoms Transmissibility Ease of passing from person to person Continued…

57. Classification of Biological Agents Lethality Ease in causing death Stability Viability to outside influences

58. Biological Weapons Bacteria Single cells, require a host. Easy to grow and spread. Anthrax Naturally occurring. Inhalation is greatest concern. Early treatment with antibiotics is key. Continued…

59. Biological Weapons Cholera Diarrheal disease. Treat dehydration. Plague Transmitted by fleas. Can be highly contagious. Use respiratory precautions. Continued…

60. Biological Weapons Q fever Similar to anthrax. Treat with antibiotics. Tularemia Usually from bites of animals. Fever, headache, weight loss. Treat with antibiotics.

61. Toxin Weapons Do not aerosolize on their own Do not reproduce Do not transmit person to person Generally, intact skin is an effective barrier. Continued…

62. Toxin Weapons Botulism One of the deadliest compounds Ricin Easy to make, common weapon Interrupts cell processes; causes death Most effective through inhalation

63. Biological Weapons Staphylococcal Enterotoxin B (SEB) Similar to food poisoning Treatment is supportive Trichothecene Mycotoxins (T2) Death within 12 hours No vaccine Treat symptoms

64. Virus Weapons Simplest microorganisms Require a host cell Not easy to manufacture Continued…

65. Virus Weapons Smallpox Thought to be eradicated, but may exist Highly contagious Spread by respiratory droplets Encephalitis Naturally occurring Inflammation of the brain More incapacitating than lethal Continued…

66. Virus Weapons Viral Hemorrhagic Fever (VHFs) Ebola, Dengue Fever, Yellow Fever Changes the clotting ability of blood Highly contagious & lethal Liquefies internal organs No vaccines or cures

67. Radioactive / Nuclear Weapons Military / Sabotage Highly unlikely Improvised Easy to gather knowledge, implementation very difficult “Dirty Bomb” Similar issues as improvised device

68. Incendiary Weapons More plausible by using: Molotov cocktails Propane bombs Shaped charges May disseminate other weapons

69. Strategy and Tactics Strategies are broad plans; tactics are specific methods to achieve them. Isolation Notification Identification Protection

70. Isolation – Initial Considerations Determine severity of danger. Control the scene & size it up. Isolate the hazard area. Attempt to evacuate (based on hazards). Establish perimeter control.

71. Isolation – Perimeter Control May be difficult based on resources. Overestimate the size of the perimeter. Continued…

72. Isolation – Perimeter Control Outer perimeter Most distant boundary line Restrict all public access beyond it Inner perimeter Isolates known hazards inside the outer perimeter

73. Perimeter Control Factors Availability of resources Size & configuration of incident Stability of the incident

74. Notification Notify federal & state support agencies during a suspected or known terrorist event (usually done by dispatch centers).

75. Identification May or may not be possible. Do not endanger self to determine. Report obvious signs or indicators. Note placards and labels. Use the Emergency Response Guidebook. Report unusual patterns of illness.

76. Protection EMTs are responsible to protect themselves and their equipment. Perform an initial scene survey. Request security police/military). Establish vehicle staging and treatment areas. Advise EMS command of concerns, suspicious people, and/or activities.

77. Hazardous Materials WMD First responder and Medic personnel may be dispatched when the Charlotte Fire Department Hazardous Materials Team is involved in the management and containment of a radiation incident, biological hazard, or chemical spill. For incidents involving such hazardous materials, strict communication and coordination with the fire department Hazardous Materials Team must be established.

78. 1. At the scene of a hazardous materials incident, firefighters will be in one of three levels of turnout gear for a nuclear, biological, or chemical release or spill: a. Level A Provides the maximal amount of vapor and splash protection. Fully encapsulating and used with a supplied air source (SCBA). Maximum work time is 15 to 20 minutes. b. Level B Resistant against vapor and splash exposure. Partially encapsulating and used with a supplied air source (SCBA). Maximum work time is 1 to 2 hours.

79. c. Level C: Resistant against vapor and splash exposure. Partially encapsulating and used with a charcoal-filtered respirator; either a charcoal- filtered mask or a powered air purifying respirator. Maximum work time is 4 to 6 hours. d. Level D Regular turnout work garment. Respiratory protection not required.

80. 2. For radiation accidents, levels of protective clothing vary depending upon the rescuer's level of exposure to the site. a. Those working in the inner perimeter (hot zone) will be in complete protective suits. 3. All levels and types of protective gear greatly increase an individual's risk for heat-related illness. In addition, rescue personnel will be undergoing profound physical stress due to mobilization of equipment and resources, containment of the incident, and civilian rescue.

81. 4. First responder and Medic personnel should expect fire operations personnel to ensure a systematic rotation from active duty for rehabilitation. 5. No attempt to should be made to access patients or other personnel who have not been properly decontaminated. 6. Complaints related to heat illness may include the following: a. Chest pain b. Shortness of breath c. Headache d. Altered mental status e. Fatigue f. Muscle cramps g. Nausea and vomiting h. Malaise

82. 7. Patients with profound vomiting, diarrhea, and mental status changes should be considered to have suffered an acute exposure and should be rapidly transported to the nearest medial facility after proper decontamination procedures.

83. Basic Medical Care 1. Ensure scene safety and a protective environment for all personnel and patients. Additional precautions (distance and shielding) should be considered when radiological agents are involved. 2. Ensure that fire department resources (Hazardous Materials Team) has been notified and have been dispatched. 3. Attempt to identify exposure (bystander or worker information, incident location, environmental indicators, container description, placards or labels, shipping papers or Material Safety Data Sheets, patient symptoms).

84. 4. Apply appropriate personal protective equipment. The decision for type and level will be made by the scene Incident Command.

85. 5. Immediately remove all patients from the exposure and determine the level of contamination present. Determine the need for decontamination prior to full assessment and treatment. a. Vapor material source: remove from source of contamination. b. Liquid material source: remove contaminated equipment and clothing and perform gross and technical showering decontamination procedures. c. Solid material source: remove material by physical measures of brushing away source, then gross and technical showering decontamination procedures if indicated.

86. 6. If any medical illnesses or traumatic injuries are noted, refer to appropriate protocol. 7. Maintain airway; suction as needed. Provide assisted ventilations with bag-valve mask and 100% oxygen if breathing or ventilatory compromise is apparent. 8. If potential for inhalational injury exists, administer oxygen via non-rebreathing mask at 15 L/min. 9. Consider use of a nasopharyngeal or oropharyngeal airway as an adjunct. 10. Obtain vital signs.

87. 9. Consider use of a nasopharyngeal or oropharyngeal airway as an adjunct. 10. Obtain vital signs. 11. If nausea or vomiting is absent, encourage oral hydration. 12. If patient considered to be heat stroke, cool central body regions with ice packs (scalp, axilla, groin, chest, and abdomen). Keep skin cool and moist by applying cool compresses.

88. 13. If patient considered hypothermic, immediately remove from the environment into a warm setting and protect from further heat loss. Remove cold, wet clothing and apply warm blankets. Massaging extremities is contraindicated. 14. If eye exposure has occurred, irrigate with sterile saline. 15. Continue to monitor vital signs.

89. Advanced Medical Care 1. If airway is clear and spontaneous breathing does not occur, or if patient is hypoventilating or airway compromise is apparent, assist ventilations with bag-valve mask device and 100% oxygen by standard technique.

90. 2. If patient exposed to a chemical nerve agent, organophosphate, or carbamate, consider the following: Adult a. Mild effects (miosis, rhinorrhea, nausea, vomiting) i. Atropine 2 mg IM with auto-injector b. Moderate effects (addition of shortness of breath) i. Atropine 2 mg IM with auto-injector Repeat atropine 2 mg in 10 minutes c. Severe effects (addition of seizures, GI effects, apnea) i. Atropine 6 mg IM with auto-injector Repeat atropine 2 mg every 10 minutes ii. 2-Pralidoxime chloride 600 mg with auto- injector

91. Clinical Supplement 1. Hazardous materials incidents may be associated with heat exhaustion. This is distinguished from heat stroke in that diaphoresis will be present with exhaustion, whereas this finding will be absent with stroke. 2. Always ensure that the scene is safe and appropriate resources are available before approaching the scene or patient. Wind direction and fluid run-off should be primary considerations. 3. Toxicity from hazardous materials may be the result of inhalation, ingestion, absorption, or injection. Thus clinical signs and symptoms may be internal or external depending on route of exposure.

92. 4. In any setting involving noxious gas inhalation, high flow oxygenation is paramount for these patients. High levels of SpO2 (including 100%) do not reflect the degree of oxygenation. All patients with potential exposures should be administered 100% oxygen by non-rebreathing mask. 5. The Carolinas Poison Center may provide assistance and is available 24-hours a day at 704-355-4000

93. 6. Specific exposures: Carbon monoxide a. Assessment i. Commonly seen in cold-weather months ii. Toxic manifestations of CO poisoning may include headache, nausea, vomiting, chest pain, dizziness, altered mental status, or a syncopal event iii. There may be multiple patients affected b. Plan i. Administer 100% oxygen by non-rebreathing mask

94. Chemical nerve agents, Organophosphates, Carbamates a. Assessment i. General - SLUDGE syndrome (salivation, lacrimation, urination, defecation, gastric hypermotility, emesis), muscle fasciculations, twitches, weakness, flaccid paralysis, loss of consciousness, seizures, apnea, bradycardia, tachycardia, hypertension,ventricular dysrhythmias ii. Vapor exposure - miosis (blurred vision, eye pain, nausea), rhinorrhea, bronchoconstriction, secretions, loss of consciousness, seizures, flaccid paralysis, apnea iii. Liquid exposure - fasciculations, diaphoresis, nausea, vomiting, diarrhea, loss of consciousness, seizures, flaccid paralysis, apnea, death

95. b. Plan i. Administer 100% oxygen by non-rebreathing mask. Airway protection and ventilation May need to be performed concomitantly with decontamination procedures Ventilations may be difficult due to intense bronchoconstriction and secretions

96. ii. Antidotes Mild effects (miosis, rhinorrhea, nausea, vomiting) Atropine 2 mg IM with auto-injector Moderate effects (addition of shortness of breath) Atropine 2 mg IM with auto-injector Repeat atropine 2 mg in 10 minutes Severe effects (addition of seizures, GI effects, apnea) Atropine 6 mg IM with auto-injector Repeat atropine 2 mg every 10 minutes 2-Pralidoxime chloride 600 mg IM with auto- injector

97. Vesicants a. Assessment i. Skin - erythema, burning, itching, vesicles, blisters, bulla ii. Eyes - conjunctivitis, lid inflammation and edema, blepharospasm, corneal effects (ulceration, perforation, opacification) iii. Respiratory - epistaxis, sinus pain, pharyngitis, cough, laryngitis, dyspnea, pulmonary edema iv. Other system effects - gastrointestinal tract (nausea, vomiting)

98. b. Plan i. Skin exposure standard burn therapy ii. Eye exposure irrigation iii. Respiratory tract exposure oxygen

99. Pulmonary agents a. Assessment i. Eyes - irritation and burning ii. Respiratory - cough, shortness of breath, chestpain b. Plan i. Skin exposure irrigation and standard burn therapy ii. Eye exposure irrigation iii. Respiratory tract exposure oxygen and suction

100. Cyanide a. Assessment i. Mild - no symptoms ii. Moderate - anxiety, nausea, weakness, dizziness iii. Severe - loss of consciousness, seizures, apnea b. Plan i. oxygen

101. Riot control agents a. Assessment i. Skin - burning, redness, blisters ii. Eyes - blepharospasm (eyelid closure), transient blindness, tearing, conjunctival injection, redness iii. Respiratory - nasal discharge, sneezing, burning, cough, shortness of breath, chest tightness, bronchospasm and wheezing

102. b. Plan i. Skin exposure irrigation and standard burn therapy ii. Eye exposure irrigation iii. Respiratory tract exposure oxygen and suction